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Columbia  ^mbersiitp 
inttcCitpof^etogorfe 


department  of  ^urgerp 
^uU  iilemonal  Jf  unD 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/americantextbookOOkeen 


AN  AMERICAN 


TEXT-BOOK  OF  SURGERY, 


FOR 


PRACTITIONERS  AND  STUDENTS. 


BY 

PHIXEAS  S.  CONNER,  iM.  D.,  FREDERIC    S.  DENNIS.  M.  D., 

WILLIAM    W.    KEEN,   M.  D.,   CHARLES   B.    NANCREDE,    M.  D. 

ROSWELL  PARK,  M.  D..  LEWIS  S.  PILCHER,  M.  D  . 

NICHOLAS   SENN,  M.  D.,  FRANCIS  J.  SHEPHERD.  M.  D., 

LEWIS   A.    STIMSON,    M.  D..    J.    COLLINS    WARREN,    M.  D., 

AND   J.  WILLIA:\I    WHITE.  M.D. 


EDITED  BY 

WILLIAM   W.  KEEN,  M.  D.,  LLD., 

AND 

J.   WILLIAM   WHITE,    M.  D.,    Ph.D. 


THIRD  EDITION,  THOROUGHLY  REVISED. 


PHILADELPHIA: 

W.    B.    SAUNDERS, 

925  Walnut  Street. 

1899. 


Copyright,  1899,  by 
W.      B.     SAUNDERS. 


ELECTROTVPED  BY  PRESS  OF 

WESTCOTT  A  THOMSON,  PMILAD^  ^,   B.   SAVNDERS,   PHILADA. 


TO  THE 


MEDICAL  PROFESSION  AND  MEDICAL  STUDENTS  OF  AMERICA 


THEIR  CO-WORKERS   AND  FELLOW  STUDENTS, 


THE    AUTHORS. 


LIST   OF   AUTHORS. 


PHINEAS  S.  CONNER,  M.  D.,  LL.D., 

Professor  of  Surgery,  Medical  College  of  Ohio  and  Dartmouth  Medical  College;  Surgeon 
to  the  Cincinnati  and  Good  Samaritan  Hospitals. 

FREDERIC  S.  DENNIS,  M.  D.,  F.  R.  C.  S., 

Professor  of  Clinical  Surgery,  Cornell  University,  New  York  City ;  Attending  Surgeon  to 
the  Bellevuc  and  St.  Vincent  Hospitals  ;  Consulting  Surgeon  to  the  Montefiore  Home,  New 
Yoi-k  City. 

WILLIAM  W.  KEEN,  M.  D.,  LL.D., 

Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College, 
Philadelphia:  Surgeon  to  the  Jefferson  Medical  College  Hospital;  Consulting  Surgeon  to 
the  Philadelphia  Orthopedic  Hospital  and  Infirmary  for  Nervous  Diseases,  to  St.  Agnes' 
Hospital,  and  to  the  Woman's  Hospital;  Membre  correspondant  etranger  de  la  Societ^  de 
Chirurgie  de  Paris  ;'  Membre  honoraire  de  la  Societe  Beige  de  Chirurgie. 

CHARLES  B.  NANCREDE,  M.  D.,  LL.D., 

Professor  of  Surgery  and  of  Clinical  Surgery,  University  of  Michigan  ;  Surgeon  to  the 
University  Hospital,  Ann  Arbor;  Emeritus  Professor  of  General  and  Orthopedic  Surgery  in 
the  Philadelphia  Polyclinic  and  School  for  Graduates  in  Medicine ;  late  Major  and  Chief 
Surgeon,  U.  S.  V. 

ROSWELL  PARK,  M.  D., 

Professor  of  Surgery,  Medical  Department  of  the  University  of  Buffalo;  Attending  Sur- 
geon to  the  Buffalo  General  Hospital ;  Consulting  Surgeon  to  the  Fitch  Accident  Hospital. 

LEWIS  STEPHEN  PILCHER,  M.  D., 

Surgeon  to  the  Methodist  Episcopal  Hospital,  New  York  City. 

NICHOLAS  SENN,  M.  D.,  Ph.D.,  LL.D., 

Professor  of  Surgery,  Rush  Medical  College,  in  affiliation  with  the  Chicago  University ; 
Professor  of  Surgery,  Chicago  Polyclinic ;  Attending  Surgeon  to  the  Presbyterian  Hospital ; 
Surgeon-in-Chief  to  St.  Joseph's  Hospital. 

FRANCIS  J.  SHEPHERD,  M.  D.,  C.  M., 

Professor  of  Anatomy  and  Lecturer  on  Operative  Surgery,  McGill  University;  Senior 
Surgeon  to  the  Montreal  General  Hospital. 

LEWIS  A.  STIMSON,  B.  A.,  M.  D., 

Professor  of  Surgery  in  Cornell  University  ;  Attending  Surgeon  to  the  New  York  and 
Hudson  Street  Hospitals ;  Consulting  Surgeon  to  Bellevue  Hosjiital,  New  York  City ;  Cor- 
responding Member  of  the  Societe  de  Chirurgie,  Paris. 

J.  COLLINS  WARREN,  M.  D.,  LL.D., 

Professor  of  Surgery,  Harvard  University ;  Surgeon  to  the  Massachusetts  General 
Hosi>ital. 

J.  WILLIAM  WHITE,  M.  D.,  Ph.D., 

Professor  of  Clinical  Surgery,  University  of  Pennsylvania;  Surgeon  to  the  University 
Hospital ;  Consulting  Surgeon  to  the  Maternity  and  Samaritan  Hospitals. 


PREFACE  TO  THE  THIRD  EDITION. 

Of  the  two  former  editions  of  the  Ameriraii  Text-book  of  Surgery  there 
have  been 'sold  nearly  29,000  copies.  This  and  its  adoption  as  a  text-book 
in  over  100  medical  colleges  have  been  gratifying  evidences  of  the  approval 
of  the  profession  and  a  stimulus  to  the  authors  to  keep  the  work  abreast  of 
the  times  by  another  careful  revision ;  indeed,  to  all  copies  of  the  second 
edition  printed  during  the  last  two  years  a  chapter  on  the  use  of  the  Ront- 
gen  rays  and  a  number  of  illustrations  were  added  without  waiting  for  an 
entirely  new  edition.  This  chapter  has  now  been  brought  up  to  date  throuc^h 
the  kindness  of  Dr.  C.  L.  Leonard. 

In  the  present  edition,  among  the  new  topics  introduced  are  a  full  con- 
sideration of  orrho-  (serum-)  therapy  ;  leucocytosis  ;  post-operative  insanity  ; 
the  use  of  dry  heat,  at  high  temperatures ;  Kronlein's  method  of  locating 
the  cerebral  fissures ;  Hoffa's  and  Lorenz's  operations  for  contrenital  disloca- 
tions of  the  hip;  Allis's  researches  on  dislocations  of  the  hip-joint;  lumbar 
puncture;  the  forcible  reposition  of  the  spine  in  Pott's  disease;  the  treatment 
of  exophthalmic  goitre;  the  surgery  of  typhoid  fever;  gastrectomy  and 
other  operations  on  the  .stomach;  several  new  methods  of  operating  upon  the 
intestines;  the  use  of  Kelly's  rectal  specula;  the  surgery  of  the  ureter; 
Schleich's  infiltration-method  and  the  use  of  eucaine  for  local  anesthesia; 
Krause's  method  of  skin-grafting;  the  newer  methods  of  disinfecting  the 
hands ;  the  use  of  gloves,  etc. 

The  sections  on  Appendicitis,  on  Fractures,  and  on  Gynecological  Opera- 
tions have  been  revised  and  enlarged,  and  many  other  changes  and  improve- 
ments have  been  introduced  throughout  the  book. 

A  considerable  number  of  new  illustrations,  including  a  colored  plate 
of  several  specimens  of  appendicitis  (which  we  owe  to  the  courtesy  of  Dr. 
Maurice  H.  Richardson,  of  Boston),  have  been  added,  and  enhance  the  value 
of  the  work. 

Our  thanks  are  due  to  our  co-authors  for  their  willing  aid,  to  Prof.  J. 
Chalmers  DaCosta  and  Dr.  Alfred  C.  Wood  for  much  assistance  in  the  revis- 
ion, and  to  Mr.  W.  B.  Saunders,  the  Publisher,  for  valuable  services  ren- 
dered through  his  Editorial  Department. 

The  increasing  specialization  of  the  surgery  of  the  eye  and  the  ear,  and 
the  growth  of  the  American  Text-hook  in  size,  have  compelled  the  editors 
to  omit  these  two  chapters.  This  has  been  done  with  great  reluctance,  and 
in  spite  of  the  mo.st  sincere  appreciation  of  the  admirable  work  of  Drs. 
Burnett  and  Thomson. 

William  W.  Keen,  \ 
J.  William  White.) 


PREFACE  TO  THE  SECOND  EDITION. 


The  success  of  the  American  Text-Book  of  Surgery,  as  evinced  by  its 
extraordinary  sale  and  its  adoption  as  a  text-book  in  over  one  hundred  medical 
schools  in  this  country,  as  well  as  by  a  large  sale  abroad,  has  been  most  grati- 
fvin<T  both  to  the  editors  and  to  their  colleagues.  Tiie  three  years  that  have 
elapsed  since  the  first  edition  was  published  have  been  years  fruitful  in  sur- 
gical progress,  and,  accordingly,  a  number  of  topics  have  been  added  to  the 
text,  as  well  as  others  expanded  which  seemed  to  have  had  inadecjuate  treat- 
ment in  the  first  edition.  An  endeavor  has  been  made  to  take  advantage  of 
the  kindly  criticism  in  the  medical  press  to  make  good  many  deficiencies 
and  to  correct  some  errors.  It  is  impossible  to  enumerate  all  of  the  many 
changes  in  the  text,  but  among  others  may  be  mentioned  the  effect  of 
modern  small-arms  in  military  surgery ;  a  new  section  on  Acromegaly ;  the 
Ilartlev-Krause  method  of  removing  the  Gasserian  ganglion ;  the  osteo- 
plastic method  of  resection  of  the  skull,  with  a  number  of  additions  to  ope- 
rations and  methods  in  endocranial  and  spinal  surgery ;  in  the  surgery  of 
the  chest,  a  description  of  Schede's  operation  ;  in  the  surgery  of  the  digestive 
tract,  Witzel's  method  for  gastrostomy ;  the  use  of  Murphy's  button  in 
intestinal  anastomosis :  the  consideration  of  retro-peritoneal  tumors  and  of 
castration  for  enlarged  prostate ;  a  chapter  on  Symphyseotomy ;  Macewen's 
method  of  compressing  the  aorta  in  amputation  at  the  hip-joint,  etc. 

The  sections  dealing  with  Fractures  and  Dislocations,  Appendicitis,  the 
Radical  Cure  of  Hernia,  and  the  more  recent  methods  in  Ampirtations  of  the 
Breast  have  been  especially  enlarged,  particularly  in  the  matter  of  treat- 
ment. Displacements  of  the  Uterus  have  been  also  regrouped  and  the  chap- 
ter largely  rewritten.  A  new  section  on  the  use  of  the  Rontgen  rays  in 
surgery  ha.^  also  been   a<lded. 

Many  of  the  illustrations  have  been  redrawn,  and  a  number  of  new  ones 

have  been  substituted  for  old  ones.     In  the  present  edition  each  illustration 

that  is  not  original  has  been   credited  to  its  author   immediately  under  the 

cut,  instead  of  the  credit  being  given  in  a  List  of  Illustrations.     The  names 

of  instrument-makers  have  been  removed  from  the  cuts,  and  credit  has  been 

given  to  the  makers  in  a  separate  list,  which  Avill  be  found  at  the  end  of 

the  Index. 

WiLLi.AM  W.  Keen, 

J.  "WiLLiA.M  White, 

Editors. 


PREFACE. 


The  great  advances  which  have  been  made  in  the  Science  and  Art  of 
Surgery  within  the  last  few  years  have  created  a  need  for  new  sources  of 
reference,  both  for  the  student  and  the  practitioner — a  need  which  has  been 
met  to  some  extent  abroad,  but  not  so  thoroughly  in  this  country.  For 
this  reason  the  present  Text-Book  has  been  prepared  by  American  authors 
who  are  teachers  of  surgery  in  leading  medical  schools  and  hospitals.  Many 
of  the  most  important  subjects  are  considered  from  a  new  standpoint,  and 
especial  prominence  has  been  given  to  Surgical  Bacteriology,  and  to  the 
most  recent  methods  of  treatment,  particularly  in  relation  to  Asepsis  and 
Antisepsis,  and  to  the  newer  methods  in  those  departments  in  which  of  late 
such  notable  progress  has  been  made,  as  in  cerebral,  spinal,  abdominal,  and 
pelvic  surgery,  etc. 

The  entire  book  has  been  submitted  in  proof-sheets  to  all  of  the  authors 
for  mutual  criticism  and  revision.  As  a  whole,  the  book  may  therefore  be 
said  to  express  upon  important  surgical  topics  the  consensus  of  opinion  of 
the  surgeons  who  have  joined  in  its  preparation.  Minor  differences  of 
opinion  necessarily  exist,  and  are  recognized  in  the  text. 

The  Editors  assume  the  responsibility  for  the  orthography,  for  the  general 
plan  of  the  book,  and  for  the  method  of  mutual  criticism  and  of  unsigned 
chapters. 

Very  many  of  the  illustrations  are  original,  among  them  the  bacterio- 
logical colored  plates  and  the  numerous  half-tone  plates,  which  are  reproduced 
with  great  fidelity  from  photographs  of  patients  or  of  specimens,  and  which  it 
is  believed  add  to  the  value  of  the  work  both  artistically  and  surgically.  A 
large  number  of  the  wood-cuts  and  some  of  the  colored  plates  have  been  taken 
from  other  authors,  and  are  credited  to  them  in  the  List  of  Illustrations ;  and 
the  Editors  desire  to  express  their  thanks,  not  only  to  the  authors,  but  to  the 
publishers  of  the  various  works,  both  xlmerican  and  foreign,  from  which  these 


X  PREFACE. 

illustrations  have  been  taken,  for  their  uniform  courtesy  and  li])crality  in  aid- 
ing their  work  as  far  as  possible. 

The  Editors  desire  also  especially  to  thank  Dr.  J.  Chalmers  DaCosta  for 
preparing  the  index  and  for  valuable  aid  in  other  -ways,  and  Mr.  Joseph 
McCreery  for  his  very  careful  revision  of  the  proof-sheets,  and  to  express 
their  appreciation  of  the  unvarying  courtesy  and  efficient  co-operation  of 

Mr.   Saunders. 

William  W.  Keen, 

J.  William  White, 

PHiLADELrniA,  Augiist  1,  1892.  Ediion. 


CONTENTS. 

BOOK   I. 
GENERAL   SURGERY. 


CHAPTER   I. 

PAGE 

Surgical  Bacteriology 1 

CHAPTER  II. 
Inflammation 10 

CHAPTER  III. 
The  Process  of  Repair 25 

CHAPTER  IV. 
The  Traumatic  Fevers 34 

CHAPTER  V. 
Suppuration  and  Abscess 40 

CHAPTER  VI. 
Ulceration  and  Fistula 48 

CHAPTER  VII. 
Gangrene 52 

CHAPTER  VIII. 
Thrombosis  and  Embolism ,     58 

CHAPTER  IX. 
Septicemia 60 

CHAPTER  X. 
Pyemia 63 

CHAPTER   XI. 
Erysipelas 66 


xii  CONTENTS. 

CHAPTER  XII. 

TAOE 

Tetanus 70 

CHAPTER  XIII. 
Scurvy 72 

CHAPTER    XIV. 
Tuberculosis 74 

CHAPTER  XV. 
Rhachitis 85 

CHAPTER    XVI. 
Contusions  and  Wounds 87 

CHAPTER  XVII. 

Syphilis 139 

CHAPTER  XVIII. 
Hereditary  Syphilis 176 

CHAPTER  XIX. 
Tumors 194 


BOOK   II. 
SPECIAL   SURGERY. 


CHAPTER   I. 
Surgery  of  the  Vascular  System 221 

CHAPTER  II. 
Surgery  of  the  Osseous  System 2H2 

CHAPTER  III. 
Fractures 282 

CHAPTER  IV. 
Diseases  and  Injuries  of  the  Muscles,  Tendons,  and  Burs^ 333 

CHAPTER  V. 
Orthopedic  Surgery 346 


CONTENTS.  xiii 

CHAPTER  VI. 
Surgery  of  the  Nerves 

CHAPTER  VII. 
Surgery  of  Joints ^  ' 


PAGE 

359 


CHAPTER  VIII. 


Dislocations 


423 


CHAPTER  IX. 
Diseases  and  Injuries  of  Lymphatics 463 

CHAPTER  X. 

Surgical  Diseases  of  the  Skin  and  its  Appendages 475 


BOOK  III. 
REGIONAL   SURGERY. 


CHAPTER  I. 
Diseases  and  Injuries  of  the  Head 489 

CHAPTER  II. 
Surgery  of  the  Spine ^^' 

CHAPTER  III. 
Surgery  of  the  Respiratory  Organs 589 

CHAPTER  IV. 
Diseases  and  Injuries  of  the  Neck ^^^ 

CHAPTER    V. 

CCA 

Surgery  of  the  Digestive  Tract    ....       

CHAPTER  VI. 
Diseases  and  Injuries  of  the  Abdomen 701 

CHAPTER  VII. 
Surgery  of  the  Genito-urinary  Tract 


XIV  cnxThwrs. 

CHAITER   VIII. 

PAfiE 

Surgery  of  the  Female  Generative  Oimjaxs wo 

CHAPTER    IX. 
Diseases  axd  Injuries  of  the  Breast ln40 


BOOK   IV. 
OPERATIVE   SURGERY. 


CHAPTER  I. 
General  Principles 1071 

CHAPTER  II. 
Anesthesia 1092 

CHAPTER   III. 
Plastic  Surgery 1104 

CHAPTER  IV. 
Ligation  of  Arteries 1113 

CHAPTER  V. 

Operations  on  Bones  and  Joints 1132 

CHAPTER  VI. 
Amputations 1151 

CHAPTER  VII. 
Minor  Surgery     11"5 

CHAPTER  VIII. 
The  Use  of  the  X  011  Rontgen  Rays  in  Surgery 1101 


INDEX 1107 


LIST    OF   PLATES. 


I.  Fig.  1.  Staphylococcus  Pyogenes  Aureus  and  Albus  (Original)    •    .  opposite 

Fig.  2.  Streptococcus  Pyogenes  (Original) " 

II.  Fig.  1.  Bacilli  of  Tuberculosis  in  Sputum  (Original) " 

Fig.  2.  (4onococcus  (Original) " 

Fig.  3.  Bacillus  Tetani  (Original) " 

III.  Fig.  1.   Bacillus  of  ^lalignant  OOdenia  (Original) " 

Fig.  2.  Bacillus  Anthracis  (Original) " 

IV.  Fig.  1.  Giant  Cells  of  Tuberculosis  (Original) " 

Fig.  2.  Giant  Cells  of  Tuberculosis  (Original) " 

V.  Wound  healing  by  First  Intention  (third  day)  (Original) " 

VI.  Moist  Gangrene  from  Laceration  of  Feinoral  Artery  (by  permission 

of  the  Surgeon-General  U.  S.  A.) " 

VII.  Large  Chondroma  of  Ilium  (Original) " 

VIII.  Large  Sarcoma  of  Buttock  (Original) " 

IX.  Fig.  L  Ulcerated  Epithelioma  of  Neck  and  Chin  (Original)    ...  " 

Fig.  2.  Malignant  Lymphoma  (Hodgkin's  Disease)  (Original)    .    .  " 
X.  Sequestrum  of  Entire  Shaft  of  Femur;  Involucrum  riddled  with 

Cloacse;  the  result  of  Acute  Osteo-Myelitis  (Original)    ....  " 

XI.  Fig.  1.  Central  Sequestrum  and  Osteo-sclerosis  (Original)     ....  " 

Fig.  2.  Tubercular  Foci  in  lower  Epiphysis  of  Fenuir  (Original)   .  " 

XII.  Fig.  1.  Abscess  in  the  Great  Trochanter  (Original) " 

Fig.  2.  Impacted  Fracture  of  i^eck  of  Femur  (Original) ** 

XIII.  Fig.  1.  Linear  Fracture  of  Vault  of  Skidl  (Original) " 

Fig.  2.  Depressed  Fracture  of  Vault  of  Skull  (from  within)  (Orig- 
inal)      " 

Fig.  3.  Depressed  Fracture  of  Vault  of  Skull  (from  without)  (Orig- 
inal)     •  .    .  " 

XIV.  Fig.  1.  Fracture  of  Base  of  Skull  (Original) " 

Fig.  2.  Gunshot  Fracture  of  Lower  Jaw  and  Cranium  (Original)  .  " 

XV.  Lateral  Curvature  of  Spine  (Scoliosis)  (Original) " 

XVI.  Pott's  Disease  of  the  Spine  (Spondylitis)  (Original) " 

XVII.  Fracture  of  the  Spine  (Original) " 

XVIII.  Various  Forms  of  Appendicitis  (Richardson) " 

XIX.  Fig.  1.  Inguinal  Hernia  (Original) " 

Fig.  2.  Femoral  Hernia  (Original) " 

XX.  Fig.  ].  Large  Scrotal  Hernia  (Original) " 

Large  Labial  Hernia  (Original) " 

XXI.  Fig.  1.  Diverticulum  of  the  Bladder  (Original) " 

Fig.  2.  Hypertrophy  of  the  Median  Lobe  of  the  Prostate  (Wat- 
son)      

XXII.  General  Enlargement  of  the  Prostate  (White  and  Wood)    ....  " 

XXIII.  Fig.  1.  Sarcoma  of  Breast  (Original) " 

Fig.  2.  Scirrhus  of  Breast  (Original) 

XXIV.  Fig.  1.  Ulcerated  Scirrhus  of  Breast  (Original) " 

Fig.  2.  Recurrent  Scirrhus  of  Breast  (Original) ** 

XXV.  Surgical  Anatomy  of  the  Neck  (Maclise) 

XXVI.  Surgical  Anatomy  of  the  Neck  (Maclise) 

XXVII.  Surgical  Anatomy  of  the  Axilla  (Maclise) " 

XXVIII.  Surgical  Anatomy  of  the  Arm  (Maclise)  _. " 

XXIX.  Surgical  Anatomy  of  the  Forearm  (Maclise) 

XXX.  Surgical  Anatomv  of  the  Hand  (Maclise) " 

XXXI.  Surgical  Anatomv  of  the  Pelvis  and  Thigh  (MacliBe) " 

XXXII.  Surgical  Anatomy  of  the  Leg  (Maclise) " 

XXXIII.  Surgical  Anatomy  of  the  Leg  (Maclise) " 

XXXIV.  Bandages  (Original) 

XXXV.  Bandages  (Original) " 

XXXVI.  Bandages  (Original) " 

XXXVII.  Bandages  (Original) 

XXXVIII.  Rontgen  Rays  (Original)      || 

XXXIX.  Rontgen  Rays  (Original) 


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AN   AMERICAN 
TEXT-BOOK  OF  SURGERY. 


*BOOK  I. 

GEJYERAL   SURGERY. 


CHAPTER    I. 

SUEGICAL    BACTERIOLOGY. 

Bacteria  or  micro-organisms,  or  microbes,  as  they  are  variously 
called,  belong  to  the  lowest  order  of  the  vegetable  kingdom,  and  are  closely 
allied  to  the  algae.  They  derive  their  name  from  j^axrijpiov,  a  rod,  which 
some  of  them  resemble  in  shape.  The  developed  organism  is,  in  form,  a  cell, 
consisting  of  a  membrane  enclosing  a  protoplasm.  This  protoplasm  can  be 
strongly  stained  by  aniline  dyes.  The  membrane,  with  difficulty  separated 
from  the  contents,  consists  of  a  substance  closely  allied  to  cellulose.  There 
is  a  gelatinous  intercellular  substance  present  in  varying  amounts  and  at 
times  forming  a  distinct  demonstrable  capsule  surrounding  the  microorgan- 
ism. During  the  process  of  division  this  holds  the  organisms  together,  and 
as  they  multiply  may  form  the  zooglea  or  glue-like  mass  in  which  they  are 
sometimes  grouped.  Many  bacterial  growths  are  highly  colored,  being  red, 
yellow,  or  blue ;  according  to  some  observers,  the  coloring-matter  is  in  the 
protoplasm ;  according  to  others,  it  lies  in  granules  which  have  been  exuded 
— both  observations  are  true.  Many  bacilli  and  spirilla  have  the  power  of 
motion,  which  is  attained  either  by  means  of  flagella  or  by  serpentine  move- 
ments of  the  protoplasm.  Micrococci  and  some  bacilli,  as  the  bacilli  of 
tuberculosis  and  of  anthrax,  have  no  motility. 

The  principal  forms  of  bacteria  are  the  micrococcus  or  globular 
form  (xoxxoc,  a  berry),  the  bacillus  or  staff  shape  (bacillus,  a  little  rod  or 
staff),  and  spirillum  or  spiral  shape. 

The  micrococci,  when  developing  rapidly,  are  seen  often  in  the  stage  of 
division,  and,  being  grouped  in  "pairs,"  are  called  diplococci.  When 
arranged  in  rows  or  "  chains  "  they  are  called  streptococci  (azpsTZTO^,  a 
chain);  when  bunched  together  in  "grape-like"  masses  they  are  called 
staphylococci  {(rraifuhj,  a  bunch  of  grapes).  Bacterial  forms  undergo  no 
essential  changes,  although  under  differing  conditions  of  soil,  warmth,  and 
moisture  they  may  have  an  altered  appearance.    They  multiply  by  fission,  the 


2  AN  AMKRKAy    TEXT- HOOK    OF  SURGERY. 

process  bcitii;  more  rcutlily  observed  in  the  eoeei  than  in  tht,"  ])aeilli.  A 
number  of  the  baeilli  and  a  few  spirilhi  undergo  germination,  spore-formation 
taking  phice  within  the  eell  before  it  is  finally  destroyed.  There  may  be  only 
one  spore  to  oaeh  cell,  the  spore  thus  formed  ])ossessing  an  extremely  dense 
enveloj)ing  meml»rane,  which  protects  it  from  external  influences  until  it  can 
find  conditions  favorable  for  future  growth.  The  cell  is  usually  distended  either 
in  the  middle  or  at  one  end  by  the  spore,  and  when  the  latter  has  reached  its 
full  developuient  the  cell-membrane  undergoes  a  gelatinous  softening,  the  cell 
breaks  up.  and  the  spore  is  free.  When  the  spore  begins  to  develop  into  a 
bacillus  it  loses  its  tough  envelope,  and  is  then  nmch  more  readily  destroyed. 

Bacteria  are  to  be  found  everywhere,  even  occasionally  in  the  interior  of  the 
healthy  living  tissues.  They  exist  in  the  air,  the  soil,  the  water,  in  our  clothing, 
on  the*  surface  of  our  bodies,  and  on  the  mucous  membrane  of  the  intestinal  and 
respiration  tracts.  They  grow  best  in  alkaline  or  neutral  media.  They  multiply 
under  favorable  conditions  with  great  rapidity  :  according  to  Cohn,  a  bacillus 
divides  into  two  in  the  space  of  an  hour,  into  four  at  the  end  of  a  second  hour, 
and  so  on.  In  twenty-four  hours  the  nuui])er  of  bacteria  derived  from  a 
single  bacillus  will  amount  to  sixteen  and  a  half  millions.  It  is  chiefly  in 
dead  organic  substances  that  they  find  a  favorable  soil,  and  it  is  through 
them  that  the  process  of  decomposition  is  carried  on.  Those  concerned  in 
this  process  are  called  saprophytic  or  saprogenic.  A  certain  number 
grow  in  the  living  body,  causing  by  their  presence  morbid  conditions,  and 
are  known  as  the  pathogenic  or  disease-producing  bacteria,  among  which 
those  producing  pus,  the  pyogenic  bacteria,  are  of  the  greatest  surgical 
importance. 

Pasteur  divided  bacteria  into  aerobic,  or  those  which  live  best  in  the  pres- 
ence of  oxygen,  and  anaerobic,  or  those  Avhich  live  without  oxygen.  The 
greater  portion  of  the  l)acteria  are  aerobic.  Some  are  so  sensitive  that  a  slight 
diminution  in  the  amount  of  oxygen  is  sufficient  to  prevent  their  development. 
These  are  called  the  oblijjate  aerobic  bacteria.  Others,  however,  can  grow 
well  in  media  rich  in  oxygen,  but  are  also  able  to  grow  where  there  is  no  oxy- 
gen. These  are  called  the  facultative  aerobic  bacteria.  Most  of  the  pathogenic 
bacteria  belong  to  this  variety,  the  oxygen  of  the  body  not  being  found  in 
large  quantities  and  being  soon  consumed  by  the  micro-organisms  in  their 
growth.  It  is  rare  that  we  find  a  strictly  anaerobic  pathogenic  form.  An 
example  of  this  variety  is  the  bacillus  of  tetanus.  The  presence  of  sunlight 
is  unfavorable  to  the  growth  of  bacteria. 

The  growth  of  the  saprophytic,  and  particularly  the  anaerobic,  bacteria 
upon  albuminoid  nuitter,  whether  animal  or  vegetable,  causes  the  jirocess  of 
decomposition,  in  the  course  of  which  the  complex  organic  material  is  broken 
up  and  new  chemical  comjtounds  are  formed,  some  of  whicii  have  been  iso- 
lated and  are  called  ptomaines  {-ribna,  a  dead  body).  They  are  the  animal 
bases  derived  from  the  direct  action  of  the  bacteria  on  albuminoid  bodies, 
and  have  an  excess  of  hydrogen  and  little  or  no  oxygen  in  their  make-up, 
and  are,  therefore,  oxidizable.  The  sepsin  of  Bergmaiin  and  the  cadaverin 
and  putrescin  of  Brieger  are  examples  of  these  chemical  substances.  The 
ptomaines  are  frequently  very  poisonous.  Thus  bacteria,  harmless  if  intro- 
duced into  the  living  animal,  may  by  their  growth  in  articles  of  food 
develop  poisons  which  can  cause  the  severest  toxic  symjjtoms  (])tomaine- 
poisoning). 

The  pathogenic  bacteria,  having  gaineil  entrance  into  an  organism  and 
multiplying  there,  cause  disease  in  virtue  of  toxini<  which  they  produce  dur- 
ing their  development.     These  toxins  are  set  free  or  secreted  by  the  bacteria, 


SURGICAL    IIACTERIOLOGY.  3 

and  are  analogous  to  the  active  principle  of  the  venom  of  snakes  and  to  the 
so-called  extractives  from  our  excreta.  They  apj)ear  to  be  of  an  albuminoid 
nature  and  are  more  closely  allied  to  the  nueleo-albumins,  though  often  ap- 
pearing to  belong  to  the  class  of  nucleins  or  proteids.  From  a  physiological 
point  of  view,  it  is  necessary  to  compare  them  with  soluble  ferments  or 
enzymes,  as  they  act  by  their  power  to  split  up  or  peptonize  proteid  bodies. 
If  this  action  takes  place  locally,  there  is  an  inflammatory  reaction  devel- 
oped ;  if  the  toxin  becomes  diffused  through  the  body,  constitutional  svmp- 
toms  apjiear.  through  the  ferment-like  action  of  the  toxin  upon  the  tissues  of 
the  boily  and  upon  the  thermic  centers.  In  the  most  localized  conditions, 
however,  there  is  usually  "septic  absorption  "  enough  to  cause  some  general 
disturbance. 

It  has  been  observed  that  while  some  animals  are  very  susceptible  to  a 
given  form  of  pathogenic  bacteria,  otliers  are  much  less  so.  and  still  others 
are  immune,  and  it  has  been  found  that  immunity  can  be  conferred  upon  sus- 
ceptible animals  in  various  ways — by  vaccines,  by  the  injection  of  gradually 
increasing  doses  of  the  bacteria  or  their  toxins,  or  by  the  blood-serum  either 
of  a  naturally  immune  animal  or  of  one  that  has  been  made  immune.  This 
immunity  is  probably  due  to  cell  activity  in  the  organism.  When  the  tissues 
are  threatened  by  any  pathogenic  organisms  and  their  toxins,  new  cells  are 
called  to  the  seat  of  the  invasion  by  what  is  known  as  the  chemotactic  action  of 
the  bacteria.  Some  of  the  cells  probably  actually  destroy  the  bacteria  by  a 
phagocytic  action ;  but  by  far  the  most  important  action  of  these  cells  is  to 
furnish  to  the  organism  a  material,  the  antitoxin,  which  is  capable  of  neu- 
tralizing the  toxin.  In  bacterial  diseases  these  plasma,  connective-tissue 
cells,  and  leucocytes  by  their  action  enable  the  organism  to  overcome  the 
poisonous  effect  of  the  bacteria ;  but  in  fatal  cases  the  amount  of  toxin  is 
sufficient  to  overcome  the  organism  before  these  cells  either  make  their 
appearance  or  develop  in  sufficient  quantities  to  neutralize  the  toxins.  For 
the  consideration  of  Orrhotherapy  (Serumtherapy)  see  page  81. 

The  question  of  the  direct  transmission  of  microbic  disease  from  parent 
to  offspring  is  one  not  susceptible  of  easy  demonstration.  There  are  two 
routes  through  which  hereditary  disease  may  be  communicated :  through  the 
placenta  during  intra-uterine  life,  or  during  the  act  of  conception  through  the 
semen  as  a  vehicle.  Placental  infection  has  been  observed  in  small-pox, 
erysipelas,  typhoid,  and  intermittent  fever.  Glanders  has  been  transmitted 
in  this  wav  from  mare  to  foal,  and  the  bacilli  of  anthrax,  glanders,  and  malicr- 
nant  oedema  have  been  shown  by  experiment  to  pass  through  the  placenta  to  the 
foetus.  The  tubercle  bacillus  has  been  found  in  the  seminal  fluid  of  consump- 
tives not  suffering  from  tuberculosis  of  the  genital  organs:  Tubercular  lesions 
have  been  found  in  the  human  foetus  at  varying  periods  of  intra-uterine  life. 
There  is  therefore  no  doubt  that  this  disease  may  be  transmitted  from  parent 
to  child :  it  is  merely  at  the  present  time  a  question  of  the  frequency  and 
method  of  transmission  of  the  disease  (Baumgarten).  It  is  also  well  known 
that  syphilis  may  be  acquired  through  both  the  semen  (by  impregnation) 
and  the  placenta,  although  the  fact  that  no  specific  organism  has  as 
yet  been  discovered  renders  it  impossible  to  furnish  the  bacteriological 
proofs. 

Most  bacteria  grow  best  at  a  temperature  varying  from  86°  to  104°  F. 
The  saprophytic  or  putrefactive  organisms  prefer  a  temperature  of  about  75°  F., 
or  the  ordinary  house  temperature.  The  pathogenic  bacteria  grow  best  at  a 
temperature  of  from  95°  to  104°  F.  Subjecting  solutions  containing  bacteria 
to  freezing  temperatures  does  not  generally  kill  the  micro-organisms.     They 


4  AX  A  mi:  RICA  X  TEXT-BOOK  OF  SURGERY. 

all  lose  the  power  of  movement  and  reproduction  at  this  temperature,  but  may 
preserve  the  power  to  resume  their  activity  at  a  higher  temperature.  Cohn 
has  reduced  the  tc-mperature  of  liquids  containing  bacteria  as  low  as  — 186°  F. 
without  destroying  their  vitality.  Cold  is  therefore  an  agent  which  can- 
not be  employed  to  destroy  these  organisms.  Experiments  show  that  organ- 
isms containing  aporen^  like  the  bacilli  of  anthrax,  are  much  more  difficult 
to  kill  than  the  micrococci,  which  do  not  contain  spores.  If  dry  heat  is 
used  as  a  means  of  sterilization,  it  is  necessary  to  expose  the  latter  to  a 
temperature  of  212°  F.  for  an  hour  and  a  half  in  order  to  destroy  them. 
Bacilli  containing  spores,  however,  must  be  subjected  to  a  temperature  of 
284°  F.  for  three  hours  before  they  are  rendered  incapable  of  further  growth. 
The  dry  heat,  moreover,  does  not  always  penetrate  easily  to  the  centre  of  arti- 
cles subjected  to  this  process,  and  most  materials,  and  particularly  instruments, 
are  permanently  injured  by  such  high  temperatures. 

The  fact  that  boiling  ivater  will  kill  all  kinds  of  organisms  and  spores  in  a 
few  minutes  suggested  the  application  of  hot  steam  for  the  purpose  of  disinfec- 
tion. Experiments  showed  that  moist  heat  had  in  fact  a  much  greater  germicidal 
value  than  dry  heat.  In  Koch's  sterilizer  all  kinds  of  bacteria  are  destroyed 
in  half  an  hour  when  subjected  to  a  temperature  of  212°  F.,  even  in  those  cases 
where  the  organisms  were  surrounded  by  voluminous  dressings  and  materials 
of  different  kinds.  Most  of  the  ordinary  pyogenic  bacteria  are  micrococci,  and 
therefore  produce  no  spores.  They  are  not  tenacious  of  life,  but  are  easily 
destroyed  by  heat.  The  bacilli  of  anthrax,  malignant  oedema,  and  tetanus, 
spore-bearing  surgical  bacteria,  can  practically  be  left  out  of  consideration 
in  the  sterilization  of  surgical  instruments.  The  following  experiment  shows 
how  readily  the  ordinary  surgical  bacteria  can  be  destroyed :  Agar-agar  tubes 
planted  with  a  mixed  growth  of  cocci  were  exposed  to  the  action  of  steam  in 
the  Arnold  sterilizer,  and  one  tube  was  removed  at  the  end  of  five  minutes, 
a  second  tube  at  the  end  of  ten  minutes,  and  so  on.  A  second  series  of  tubes 
"was  inoculated  from  the  first  tube  removed,  and  all  of  them  remained  sterile. 
No  further  growth  occurred  in  the  original  tubes,  showing  that  the  micrococci 
were  destroyed  by  the  action  of  the  steam  for  the  minimum  length  of  time,  five 
minutes  (A.  K.  Stone), 

The  Arnold  sterilizer,  which  is  cheap  and  convenient,  and  is  in  common 
use  in  America  at  present,  furnishes  a  rapid  and  easy  method  of  generating 
steam,  by  which  surgical  dressings  and  instruments  may  be  sterilized.  The 
best  method,  however,  for  the  sterilization  of  instruments  is  to  boil  them  for 
five  minutes  in  water  to  which  sodium  bicarbonate,  in  the  proportion  of  a 
teaspoonfnl  to  a  quart,  has  been  added.  This  prevents  rusting  by  neutraliz- 
ing the  carbonic  acid  in  the  water. 

The  most  powerful  of  bactericidal  drugs  is  corrosive  sublimate.  A  solution 
of  1  :  1,000,000  exercises  a  marked  retarding  influence  upon  the  develop- 
ment of  bacteria.  A  solution  of  1  :  20,000  kills  the  spores  of  bacilli  in  ten 
minutes,  and  a  solution  of  the  strength  of  1  :  1000,  according  to  Koch,  destroys 
the  most  powerful  organism  in  a  few  minutes,  without  any  previous  preparation 
of  the  object  to  be  disinfected.  Aqueous  solutions  of  carbolic  acid,  in  the 
strength  of  1  :  100,  destroy  in  two  minutes  sporeless  anthrax  bacilli,  and  in 
the  strength  of  1  :  30  is  sufficient  for  all  ordinary  surgical  purposes,  as  it  retards 
the  development  of  the  spores  and  kills  the  mature  organisms.  But  solu- 
tions in  oil  have  not  the  least  influence  upon  the  life  of  micro-organisms. 
Boric  acid  and  salicylic  acid  have  been  regarded  as  useful  antiseptic  drugs, 
but  their  gennicidal  power  is  now  known  to  be  almost  nil.  Iodoform  is  not  a 
germicide,  but  markedly  retards  the  growth  of  bacteria ;  used  as  a  powder,  it 


SURGICAL  BACTERIOLOGY.  Plate  I. 


m. 


1.  staphylococcus  pyogenes  aureus  and  albus :  a,  pus-cell  with  nuclei ;  b,  free  nuclei. 
[Camera  Lucida.    Zeiss  Apochromalic  objective  2.0  mm.  ocular  6.] 


WM 


2.  Streptococcus  pyogenes  in  pus  :  a,  pus-cell  with  nuclei ;  b,  free  nuclei. 
[Same  power  as  fig.  1.] 


SURGICAL  BACTERIOLOGY.  5 

has  a  tendency  to  stop  serous  oozhi>f,  a  condition  favorable  to  bacterial  growth. 
When  moistened  it  liberates  iodine,  which  has  a  certain  antiseptic  value.  It 
does  not  procure  asepsis  of  material,  instruments,  or  wounds. 

The  inicroseo/jicdl  stiuh/  of  bacteria  has  been  greatly  facilitated  by  the  use 
of  the  Abbd  condenser,  which  is  placed  Ijeneath  the  object-glass  and  throws  a 
cone  of  ravs  Avith  a  very  broad  base,  thus  giving  powerful  illumination  of  the 
section  and  making  it  possible  to  use  higher  powers  wdiich  would  otherwise  cut 
off  the  light.  By  this  means  the  section  is  flooded  with  light  and  the  structure 
of  the  tissues  is  made  quite  transparent.  If  now  we  use  aniline  dyes,  which 
stain  the  micro-organisms,  and  wash  the  sections  afterward  in  alcohol  or  acetic 
acid,  the  coloring  matter  will  be  in  great  part  removed  from  the  tissues,  and  the 
bacteria  alone  will  retain  the  dye.  In  this  way  the  bacteria  are  readily  dis- 
tinguished from  other  objects,  when  examined  Avith  suitable  lenses.  For  this 
purpose  immersion  lenses  alone  are  reliable.  Furthermore,  contrast-stains 
can  be  often  advantageously  employed,  by  means  of  which  the  tissues  are  given 
a  decidedly  different  though  paler  hue.  Fragments  of  tissue  which  it  is  desired 
to  examine  for  bacteria  should  be  cut  in  pieces  half  an  inch  square  and  placed 
immediately  in  absolute  alcohol.  This  should  be  changed  once  or  twice,  and 
in  tAvo  days  the  specimen  is  ready  for  cutting.  The  sections  are  placed  for  five 
to  fifteen  minutes  in  dilute  solutions  of  fuchsin  or  gentian-violet.  They  are 
then  decolorized  in  acidulated  Avater,  and  afterAvard  washed  in  water;  after 
alcohol  has  been  used  to  remove  the  water  from  the  specimen  it  is  mounted  in 
Canada  balsam. 

It  is  often  necessary  to  examine  the  tirine  or  the  sjnifa  for  tubercle  bacilli, 
for  the  purposes  of  diagnosis.  The  urine,  Avhich  should  be  collected  in  con- 
siderable quantity,  is  alloAved  to  deposit  a  compact  sediment.  A  small  portion 
of  this  sediment  is  spread  upon  a  thin  cover-glass  held  by  a  pair  of  forceps. 
It  is  best  to  let  this  become  nearly  or  completely  dry,  and  then  to  pass  the 
cover-glass  three  times  gently  through  the  flame  of  an  alcohol  lamp  in  order 
better  to  fix  upon  the  glass  the  material  it  is  proposed  to  examine.  If  the 
sediment  is  light,  a  second  or  even  a  third  drop  is  added,  and  each  time 
evaporated  to  dryness.  The  cover-glass  is  noAV  placed  in  the  following  solution, 
(Ziehl),  Avhich  has  been  slightly  warmed,  for  from  five  to  ten  minutes :  ^ 

Fuchsin,  1  gram ; 

Carbolic  acid  solution  (5  ^),     80  c.c. ; 
Alcohol  (95  %),  20  c.c. 

It  is  then  decolorized  by  placing  it  in  a  5  per  cent,  solution  of  strong  sul- 
phuric acid,  Avhich  removes  the  fuchsin  from  all  but  the  bacilli.  The  length 
of  time  necessary  for  the  bleaching  process  must  be  determined  by  experi- 
ment, and  is  hastened  by  transferring  to  60  per  cent,  alcohol.  The  coA^er- 
glass  is  next  Avashed  thoroughly  Avith  distilled  Avater,  and  is  then  placed 
in  a  strong  Avatery  solution  of  methyl-blue  for  about  five  minutes.  The 
glass  is  finally  washed  in  distilled  Avater,  dried  thoroughly,  and  mounted  in 
Canada  balsam  upon  a  glass  slide.  The  bacilli  appear  under  the  micro- 
scope as  minute  red  rods  scattered  about  upon  a  blue  background.     The  same 

1  Koch-Ehrlich  Stain  for  the  Barjlltis  of  Tuberculosis.— 1.  Sections  or  cover-glass  preparations  are 
left  in  aniline-water  fuchsin  (or  gentian-violet)  solution  for  twenty-four  hours  in  the  cold.  2. 
Transfer  to  a  solution  of  nitric  acid  (1  part  to  3  of  water  if  sections,  1  part  to  4  of  water  if 
cover-glasses)  for  two  to  three  seconds  (just  long  enough  to  pass  them  through).  3.  Then  transfer 
to  60  per  cent,  alcohol  for  a  moment,  to  complete  the  decolorization.  4.  Wash  in  water.  5.  A 
contrast-stain  may  be  made  with  a  watery  solution  of  methylene-blue  (if  fuchsin  be  the  first 
stain)  or  vesuvin  (if  gentian-violet  be  first"  used).  6.  Wash  thoroughlv  in  water,  dry,  and  mount, 
if  cover-glasses.     Dehydrate,  clear  in  oil  of  cedar,  and  mount,  if  sections. 


6  AN  AMA'BICAX  TEXT-JiOOK  OF  SUltGERY. 

method  of  staininj^  is  applicable  to  the  detection  of  tlie  tu])ercle  bacillus  in  the 
sputa  of  jihtiiisical  jiaticnts.  A  drop  of  the  sputum  is  selected  from  one  of  the 
tough  yello^v  clumj)s  Hoatiiig  in  the  sputum  and  placed  upon  the  cover-glass; 
a  second  cover-glass  is  then  placed  on  top  of  it,  and  the  sputum  is  pressed  out 
into  a  thin  layer.  The  glasses  are  then  separated  and  dried,  and  furnish  two 
specimens  for  the  coloring  process. 

Bacteria  are  not  usuaUy  found  in  the  healthy  tissues  of  the  body,  although 
occasionally  they  may  be  concealed  in  certain  structures  "which  show  no  symp- 
toms of  disease,  and  first  make  themselves  manifest  after  the  infliction  of  an 
injury  or  during  the  course  of  some  intlamnuitory  process.  Cocci  and  spores  may 
remain  latent  in  cicatrices  for  a  considerable  length  of  time,  awaiting  a  suitable 
opportunity  for  development.  It  is  not  uncommon  to  discover  the  presence  of 
tubercle  bacilli  in  individuals  apjiarently  healthy.  An  injury  or  a  slight  bruise 
under  such  circumstances  "would  offer  an  opportunity  for  their  development 
either  as  a  local  or  a  general  tul)erculosis.  Micrococci  are  often  found  tem- 
porarily in  the  blood  of  individuals  "whose  vital  powers  are  enfeebled.  They 
may  disappear  quite  rapidly — even  in  a  tew  hours — without  having  given  rise 
to  any  Avell-defined  pathological  process. 

Bacteria  are  found  in  all  kinds  of  true  inflammations.  The  term  ''  sim- 
ple inflammation"  is  intended  to  designate  that  variety  in  which  no  micro- 
organisms are  found.  This  form  of  inflammation  is  a  more  limited  one  than 
was  formerly  supposed,  and  is  confined  chiefly  to  those  jjrocesses  "which  follow 
injury  and  are  concerned  in  repair  if  bacteria  are  excluded  (Senn). 

The  forms  of  bacteria  most  frequently  met  "with  in  surgical  diseases  are 
those  "which  produce  suppuration.  These  organisms  are  known  as  the  pus 
microbes  or  pyogenic  cocci. 

The  Pus  microbes  consist  of  several  varieties,  but  the  most  common 
form  is  the  staphylococcus  pyogenes  aureus  (PI.  I,  Fig.  1),  so  called 
from  the  grouping  of  the  cocci  in  clusters.  Its  shape  is  globular,  and  it  meas- 
ures from  0.7  to  0.87  micromillimeters  in  diameter.  It  multiplies  by  division, 
but  the  line  of  fission  is  difficult  to  see.  It  is  a  very  resistant  organism,  and 
requires  several  minutes'  boiling  or  steaming  to  destroy  its  power  of  gro"wth.  It 
is  readily  stained  by  all  the  coloring  agents.  It  grows  well  at  the  ordinary  house 
temperature,  but  is  more  active  "when  growing  at  a  temperature  nearer  that  of 
the  body.  It  does  not  need  a  large  amount  of  oxygen  for  its  growth.  When 
cultivated  in  the  test-tube  upon  beef  gelatin  it  forms  at  first  a  yellowish-white 
layer,  which  later  changes  to  an  orange  color ;  hence  the  last  part  of  its  name 
— aureus.  If  thrust  deeply  into  the  gelatin,  the  upper  surface  softens  as  the 
growth  forms,  and  becomes  liquefied  in  virtue  of  peptonizing  action  exerted  by 
the  organism.  It  has  a  peculiar  odor  of  sour  paste.  The  aureus  is  found  abun- 
dantly outside  of  the  human  body.  It  can  be  obtained  from  dirty  dish-water, 
the  soil,  or  the  air,  particularly  in  foul  hospital  wards,  but  its  most  conmion 
seat  is  the  superficial  layers  of  the  skin,  particularly  of  the  axill»  and  other 
moist  parts,  and  also  under  the  ends  of  the  finger-nails.  It  is  also  found  in 
the  mucus  of  the  pharynx  and  digestive  tract. 

Other  forms  of  the'])yogenic  cocci,  but  less  frequently  seen  than  the  aureus, 
are  the  staphylococcus  pyogenes  albus  and  the  staphylococcus  pyo- 
genes citreus.     These  may  occur  alone  or  be  combined  with  the  aureus. 

The  Streptococcus  pyogenes  (PI.  I,  Fig.  2),  is  an  important  variety 
of  the  pus  cocci.  The  arrangement  of  the  organism  is  in  chains  or  rows,  six 
to  ten  being  usually  attached  together.  These  cocci  measure  about  one  micro- 
millimeter  in  diameter.  On  culture-media  the  growth  reaches  its  development 
in  four  or  five  days,  and  has  at  first  a  transparent  whitish  look,  but  later  a 


SURGICAL  BACTERIOLOGY.  Plate  II. 


1.  Bacilli  of  tuberculosis  in  sputum. 
[Camera  Lucida.    Zeiss  apochrornatie  objective  2.0  mm.  ocular  6.] 


T  ; 


/ 


2.  Gonococcus  from  gonorrheal  pus.  3.  Bacillus  tetani.    Cover-glass  preparation 

[Sawie  power  as  fig.  1.]  from  culture  by  Kitasato. 

[Same  power  as  fig.  1.] 


SURGICAL  BACTERIOLOGY.  7 

brownish  color.     Tlie  streptococci  are  found  under  normal  conditions  in  the 
saliva,  socrctions  dt"  the  nostrils,  vaj^ina,  and  urethra. 

The  Bacillus  pyocyaneus  is  an  organism  wiiieh  is  found  in  green  or  blue 
pus.  It  is  a  small,  thin  rod  with  distinctly  rounded  ends.  It  has  no  spores, 
has  a  flagellum  at  one  end,  and  is  actively  motile.  The  pigment  is  deposited 
from  the  bacilli  when  in  contact  with  oxygen,  and  is  then  seen  principally  on  the 
exposed  edges  of  dressings.      The  substance  thus  found  is  termed  injocyanine. 

The  pyogenic  cocci  are  found  in  all  acute  abscesses.  I'he  staphylococci  are 
found  in  circumscribed  abscesses,  as  boils,  carbuncles,  suppurating  glands,  em- 
pveraa,  osteomyelitis,  etc.  The  streptococci  are  more  frequently  seen  in  the 
spreading  inflammations,  as  phlegmonous  cellulitis,  erysipelas,  ulcerative  endo- 
carditis, and  metastatic  abscesses  such  as  are  seen  in  pyemia. 

In  order  that  suppuration  should  take  place  it  is  not  simply  necessary  that 
the  pyogenic  cocci  sliould  be  introduced  into  the  living  tissues.  It  is  found 
that  other  conditions  are  of  ecjual  imj)ortance.  Cheyne  has  shown  by  experi- 
ment that  the  number  of  bacteria  injected  is  an  important  factor.  The  dose 
must  be  sufficiently  large.  It  is  owing,  probably,  to  this  fact  that  many  cases 
of  imperfect  asepsis  in  surgical  operations  often  heal  well.  Doses  of  less  than 
18,000,000  of  the  Proteus  vulgaris  when  injected  into  the  muscular  tissue  of 
a  rabbit  seldom  cause  any  result,  and  it  rec^uires  so  large  a  number  as 
250,000,000  to  produce  a  circumscribed  abscess. 

But  the  Htate  of  tKe  tissues  in  Avhich  the  organisms  are  arrested  is  also  a 
matter  of  great  importance.  Tissues  which  have  been  damaged  by  injury  or 
inflammation  are  not  so  resistant  to  tlie  action  of  bacteria  as  Avhen  in  a  state 
of  health.  A  healthy  peritoneum  may  receive  and  absorb  a  large  number  of 
bacteria,  but  if  damaged  during  a  laparotomy,  so  that  a  considerable  portion 
of  its  secreting  surface  has  been  destroyed  and  at  the  same  time  considerable 
oozing  of  blood  and  serum  has  taken  place  from  the  injured  surfaces,  a  soil 
favorable  for  the  growth  of  the  organisms  is  provided  and  a  septic  peritonitis 
may  result.  Tense  sutures  are  more  likely  to  be  followed  by  "  stitch  abscesses  " 
than  where  the  sutured  margins  of  the  wound  come  easily  together. 

The  question  has  arisen.  Can  sujJjniration  take  place  without  the  presence 
of  bacteria  ?  Steinhaus  has  shown  that  calomel,  and  also  nitrate  of  silver, 
when  injected  into  the  tissues  can  produce  pus  in  certain  animals.  Even  the 
chemical  substances  formed  by  the  pyogenic  cocci,  when  separated  from  them 
and  injected,  can  produce  non-bacterial  pus.  But,  as  Senn  remarks,  the  matter 
remains  practically  where  it  was  before,  as  clinically  we  do  not  meet  Avith 
examples  of  acute" suppuration  without  the  introduction  of  the  pyogenic  cocci 
into  the  system.  Foreign  bodies  or  mechanical  irritation  cannot  produce  pus 
without  the  aid  of  bacteria.  The  pus-producing  power  of  the  cocci  lies  in  their 
ability  to  liquefy  the  fibrinous  exudation  of  inflammation. 

The  pyogenic  cocci  are  not  usually  found  in  cold  abscesses.  It  was  sup- 
posed that  this  form  of  abscess  was  produced  by  the  tubercle  bacillus  only,  but 
Ernst  and  others  have  found  the  aureus  and  albus  in  several  cases  of  psoas 
abscess.  It  is  possible  that  the  failure  to  obtain  cultures  from  this  kind  of  pus  is 
due  to  the  dying  out  of  the  organism  owing  to  the  age  of  the  abscess. 

The  Streptococcus  erysipelatis  resembles  closely  in  all  respects  the 
streptococcus  pyogenes,  and  the  weight  of  evidence  is  at  present  strongly  in 
favor  of  their  identity.  In  all  cases  it  is  the  cause  of  the  disease,  and  direct 
proof  has  been  given  of  its  power  by  inoculation  of  open  wounds  in  the  human 
subj  ect. 

The  Gonococcus  (PI.  II,  Fig.  2)  is  the  specific  organism  which  pro- 
duces  gonorrhea.      It  measures  1.25   micromillimeters    in    diameter,  and   is 


8  AN  AMERICAN  TEXT- HOOK  OF  SURGERY. 

usually  arran^iod  as  a  dijilococcus.  One  of  the  most  striking  peculiarities 
■which  distinguishes  it  from  nearly  all  other  forms  of  micrococci  is  its  ability  to 
penetrate  cells  and  multiply  rajiidly  within  them.  In  this  way  it  may  he  read- 
ily recognized  under  tiie  microscope.  It  is  difficult  to  cultivate,  as  it  will  oidy 
grow  on  blood-serum  ami  when  isolated  from  other  cocci.  The  gonococci  are 
stained  well  with  methyl-blue,  and  may  be  prepared  for  examination  by  the 
cover-glass  method  mentioned  previously.  The  organisms  grow  more  readily 
on  those  mucous  membranes  which  possess  a  cylinder  epithelium  or  one  closely 
allied  to  it,  as  the  membranes  of  the  male  and  female  urethra,  the  uterus,  and 
the  conjunctiva.  It  does  not  penetrate  below  the  epithelial  layer,  the  more 
deep-seated  suppuration,  such  as  bubo,  being  due  to  the  presence  of  the  pyo- 
genic cocci. 

The  Tetanus  bacillus  (I'l.  II,  Fig.  3)  is  a  large,  slender  rod  with  somewhat 
rounded  ends.  Spore-formation  takes  place  at  the  end  of  the  bacillus,  and,  as  it 
enlarges  the  cell  considerably,  gives  it  the  so-called  drumstick  shape.  It  is  mov- 
able, belongs  to  the  strictly  anaerobic  organisms,  and  rapidly  dies  when  exposed 
to  the  air.  It  is  readily  colored  by  methyl-blue  and  fuchsin.  It  can  be  culti- 
vated in  cultures  of  gelatin  mixed  with  grape-sugar,  and  grows  well  at  the 
bottom  of  the  inoculation  puncture,  whence  it  sends  out  innumerable  little  pro- 
longations, giving  the  growth  the  appearance  of  the  fir  tree.  It  is  difficult  to 
separate  from  other  organisms,  but  improved  laboratory  techniijue  has  made 
it  comparatively  easy  to  obtain  pure  cultures.  The  spores  are  found  in 
garden  soil,  in  masonry,  in  decomposing  liquids,  and  in  manure.  Hence  the 
frequency  of  the  disease  in  those  employed  about  stables.  It  is  quite  frequently 
met  with  in  the  dust  of  the  streets,  but  owing  to  its  anaerobic  nature  is  not  easily 
inoculated  into  the  living  tissues.  Brieger  has  obtained  from  cultures  a  number 
of  toxines,  to  one  of  which  he  has  given  the  name  tetanin,  and  inasmuch  as  the 
same  group  of  symptoms  are  obtained  experimentally  by  the  toxines  as  by  the 
bacilli,  and  as  the  latter  are  hard  to  find  in  the  blood  and  internal  organs  in 
individuals  who  have  died  of  tetanus,  it  has  been  thought  probable  that  the 
symptoms  of  the  disease  are  produced,  in  a  great  measure,  by  this  substance. 

The  Tubercle  Bacillus  (PI.  II,  Fig.  1). — This  organism  was  first  seen 
under  the  microscope  by  Bauingarten,  but  Koch  cultivated  and  fully  identified 
the  organism  with  the  disease  in  1882.  The  bacilli  are  small,  thin  rods,  two 
to  four  micromillimeters  in  length — that  is,  about  one-half  the  diameter  of  a 
red  blood-corpuscle.  The  rod  is  slightly  bent  in  the  middle  and  its  ends  some- 
what rounded.  The  longest  rods  are  usually  seen  in  phthisical  sputa.  They 
are  usually  single,  occasionally  being  found  in  pairs  or  arranged  in  the  form  of 
the  letter  V.  They  do  not  possess  the  power  of  motion.  The  bacillus  possesses 
great  powers  of  resistance  to  destructive  agencies,  the  organisms  in  tuberculous 
sputa  being  destroyed  only  after  twenty  minutes'  boiling.  The  expectoration 
can  be  kept  for  months  and  even  years  in  a  dried  state  without  destruction  of 
the  bacilli.  They  are  stained  by  the  ordinary  aniline  dyes  with  far  greater  dif- 
ficulty than  any  other  bacteria,  and,  in  common  with  the  bacilli  of  leprosy,  which 
they  closely  resemble,  do  not  yield  to  bleaching  fluids  like  all  other  bacteria. 
The  bacilli  are  found  between  the  leucocytes  in  the  tubercles,  in  the  epithelioid 
cells,  and  also  in  sm:dl  numbers  in  the  giant  cell,  being  generally  seen  at  its 
periphery.  The  organism  is  very  difficult  to  cultivate,  and  grows  well  only  on 
a  hardened  blood-serum  or  a  combination  of  the  ordinary  nutrient  media  with 
glycerin,  for  which  latter  agent  it  appears  to  have  a  special  predilection.  When 
cultivated  on  agar  the  first  signs  of  the  growth  appear  at  the  end  of  fourteen  days, 
and  one  to  two  weeks  more  pass  before  full  development  has  taken  place.  It 
appears  then  as  thick  scales  of  a  dull  grayish-white  color,  which  are  very  dry 


SURGICAL  BACTERIOLOGY.  Plate  111. 


\ 
\ 


/ 

\ 


/ 


1.  Bacillus  of  malignant  oedema.    Cover-glass  preparation  from  spleen  of  white  mouse. 
[ Camera  -Lucida.    Zeiss  apochrmnatic  objective  i.O  mm.  ociilar  h.] 


/ 


x' 


\ 


2.  Bacillus  anthracis.    (/'over-glass  preparation  from  spleen  of  white  mouse. 
[iSame  p(/wer  as  Jig  J.J 


SURGICAL    llM'TFJUOUKiY.  9 

and  brittle.  The  material  lor  culture  is  usually  obtained  by  inoculatin<r  a 
iTuinea-pi<^  with  tuberculous  material.  The  experiment-anitnals  are  killed  in 
from  four  to  six  weeks  and  cultures  made  from  the  enlar«^ed  lymj)h-<i;lands. 

The  tubercle  bacilli  are  true  parasitic  organisms,  as  they  are  unable  to  grow 
outside  of  the  living  tissues  of  man  and  animals.  Inoculation  may  take  place 
through  the  skin,  tVdlowing  slight  bruises  or  cuts.  The  organism  is  very  re- 
sistan"  to  the  action  of  the  digestive  fluids,  and  animals  fed  experimentally 
with  tubercle  bacilli  have  develoj^ed  general  tuberculosis.  It  is  probable, 
therefore,  that  they  can  penetrate  the  mucous  membrane,  and  may  be  carried 
into  the  svstem  with  the  food.  H.  C.  Ernst  has  shown  that  ^ix  dropn  of  the 
milk  from' a  tuberculous  cow,  injected  subcutaneously  into  a  guinea-pig,  may 
develop  a  tuberculosis.  The  milk  of  tuberculous  cows  is  therefore  a  very  dan- 
gerous article  of  food.  The  breathing  of  infected  air  is  the  most  frequent  mode 
of  acquiring  the  disease.  The  frequency  of  pulmonary  tuberculosis  is  sugges- 
tive of  this'' mode  of  infection.  Cornet  has  shown  that  the  dust  of  infected 
localities  is  dangerous.  The  organisms  are  distributed  through  the  air  when 
in  a  dry  state,  and  are  found  in  the  dust  of  hotels  or  hospitals  occupied  by 
consumptives,  and  in  Victories  and  prisons.  The  tuberculous  sputa  should  not 
be  allowed  to  dry,  being  harmless  when  kept  moist.  All  tuberculous  patients 
therefore  shouhrexpectorate  into  a  cup  containing  an  antiseptic  solution. 

Bacillus  of  Malignant  CZdema  (PI.  HI,  Fig.  1).— This  bacillus  was 
first  described  by  Pasteur,  but  its  present  name  was  given  to  it  by  Koch.  It 
is  occasionally  found  in  traumatic  gangrene.  It  is  a  saprophytic  organism, 
and  is  found  in  decomposing  substances  and  in  rich  garden  soil.  The  bacilli 
have  an  active  motion  and  contain  large  spores.  The  cultivation  is  attended 
with  the  evolution  of  gas,  and  when  the  bacilli  are  inoculated  into  animals  they 
produce  a  gangrenous  oedema  as  in  man.  This  bacillus,  like  that  of  tetanus, 
is  strictly  anaerobic 

In  noma,  a  gangrenous  inflammation  of  the  mouth  and  female  genitals  in 
young  children,  LirTgard  has  found  long  bacilli,  and  Ranke  has  found  strepto- 
cocci. No  specific  organism  for  traumatic  gangrene  has  yet  been  found.  It  is 
probable  that  the  ptomaines  play  an  important  part  in  the  process.  No  bacte- 
rial examinations  have  been  made  of  hospital  gangrene,  as,  thanks  to  antisepsis, 
it  is  now  almost  an  historical  disease  only.  Studies  made  as  early  as  1872 
show  the  presence  of  enormous  numbers  of  streptococci,  but  these  are  unreli- 
able from  a  more  modern  standpoint. 

The  Syphilis  Bacillus, — It  is  very  probable  that  syphilis  is  of  bacterial 
origin,  but  the  organism  has  not  yet  been  satisfactorily  identified.  Lustgarten 
des'cribed  a  bacillus  in  1884  which  is  slightly  curved  or  S-shaped  and  is  found  in 
the  tissues  and  discharges  of  syphilitic  ulcers,  but  he  was  unable  to  cultivate  it. 
It  has  been  grown  upon  a  gelatin  prepared  from  the  bladder  of  the  Russian 
sturgeon.  Similar  bacilli  have  been  found  in  the  preputial  and  vulvar  smegma. 
Bacilli  and  also  micrococci  have  been  found  in  the  blood  and  tissues  of  syphi- 
litic patients  by  other  observers.  Fragments  of  chancres  have  been  placed  in 
nutrient  bouillon,  and  the  bacilli  thus  obtained  have  been  inoculated  into 
monkeys,  and  eruptions  resembling  those  of  syphilis  have  been  observed.  All 
these  observations  require  repetition  and  confirmation. 

Bacillus  Mallei. — This  organism  was  discovered  in  1882  by  Lofiler  and 
Schutz  in  the  tissues  of  animals  afllicted  Avith  glanders.  They  cultivated  it 
artificially,  and  made  successful  inoculations  in  animals,  reproducing  the  disease. 
It  is  shorter  and  thicker  than  the  bacillus  of  tuberculosis.  Grown  on  boiled 
potato,  these  bacilli  form  a  characteristic  yellow,  transparent,  honey-like  layer 
which  appears  on  the  second  day.     Later'  the  border  acquires  a  greenish  hue. 


10  AX  AMERICAN  TEXr-HOOK  OF  SURGERY. 

The  bacilli  are  found  ^roupeil  in  the  centre  of  tlie  diseaf^ed  nodules.  Horses 
acfjuire  the  disease  by  inhalation,  but  man  is  usually  inoculated  through  cuts  or 
scratches. 

Bacillus  Anthracis. — This  ])aeillus  (Pi.  111.  Fi^'.  2)  produces  the  dis- 
ea.se  known  in  man  as  inali;:;nant  pustule  and  wool-sorters  disease,  and  in  animals 
a.s  anthrax.  It  was  discovered  Ity  Davaine  in  lHr>0,  and  has  been  called  the 
keystone  to  the  arch  of  bacteriolofry.  It  is  very  large,  being  1.5  micromilli- 
meters  in  thickness  and  3  to  G  micromillimeters  in  length.  The  spores  when 
forming  are  seen  as  bright,  glistening  bodies  in  the  centre  of  the  rods.  The 
bacilli  are  comj)aratively  delicate,  but  the  spores  belong  to  the  most  durable  of 
bacterial  organisms,  and  are  therefore  generally  used  as  a  standard  test  of  the 
values  of  disinfectants.  In  animals,  chieHy  cattle,  they  produce  the  disease 
known  as  anthra.x  or  splenic  fever,  and  are  found  in  immense  numbers  in 
the  caj)illaries  of  the  internal  organs.  Pasteur  succeeded  in  weakening  the 
strength  of  these  bacilli  by  cultivating  them  at  high  temperatures  or  for  a 
long  time,  and  thus  produced  an  attenuated  virus  by  means  of  which  he  was 
able  to  protect  animals  from  the  disease  by  "vaccination."  The  immunity, 
however,  is  not  permanent,  and  does  not  protect  against  infection  through 
the  intestinal  canal. 


CHAPTER     II. 
INFLAMMATION. 


Inflammation  is  a  disturbance  of  the  mechanism  of  nutrition,  and  affects 
the  structures  concerned  in  this  function.  It  is  "the  response  of  living  tissue 
to  injury."  It  was  formerly  supposed  to  be  an  increased  nutrition  of  the  palt, 
but  the  more  modern  view,  as  expressed  by  Sanderson,  is  that  the  condition 
is  the  result  of  damage  which,  if  not  severe  enough  to  cause  death  of  the  part, 
will  be  followed  by  a  series  of  characteristic  changes  in  the  blood-vessels  and 
the  surrounding  connective  tissue.  As  the  result  of  this  disturbance,  however, 
we  have  conditions  favorable  for  the  process  of  repair  or  for  the  neutralization 
or  removal  of  the  primary  microbic  cause.  These  changes  give  rise  to  tlie  Jive 
cardinal  HjimptoniH  of  inflammation — pain,  heat,  redness,  swelling,  and 
Impaired  function  (dolor,  calor,  rubor,  tumor,  functio  l;csa). 

In  an  acute  inflammation  of  the  connective  tissue  (cellulitis)  we  find  the 
part  greatly  swollen  and  sensitive.  The  tissues  also  become  much  firmer  than 
they  were  before.  The  skin  is  not  only  redder  than  natural,  but  is  much 
warmer  to  the  touch.  The  patient  complains  of  a  thro]tl)ing  pain  in  the  part, 
and  if  an  incision  is  made  through  the  skin  the  flow  of  blood  is  unusually  I'apid 
and  copious.  The  function  of  the  limb  affected  for  the  time  being  is  impaired, 
and  the  muscles  in  the  immediate  neighborhood  become  more  or  less  rigid. 
As  the  disease  progresses  all  these  symptoms  are  intensified,  and  finally  at  the 
point  of  severest  pain  the  part  becomes  softer,  an  examination  shows  that  fluid 
is  collecting  beneath  the  skin,  and  we  recognize  that  suppuration  has  taken 


SURGilCAL  liACTElllOLOCJY. 


Plate  IV. 


Isjc^^*  «™. 


.-^^^   ^SSS!^J^ 


0  e  B    o 


m 


o^»' 


I 


hi  i'  i'-o 


i-^-k 


/ 


1.  Section  of  human  tonarue  showing  priant-cells  of  tuberculosis,  aurronnded  with  inflammatory 
tissue  [submiliary  tubercle]:  a,  muscular  liber     [^Vamera  Lucida.    Zeiss  ohjeclive  Ul)  ocular  U] 


"^ 


V 


2.  Giant-cell  of  tuberculosis  of  human  tongue  before  stage  of  cheesy  degenerations  showing  bacilli. 
[Camera  Lucida.    Zeiss  apochromatic  objective  2.0  mm.  octUar  6'.] 


INFLAMMA  TION. 


11 


place.  The  symptoms  may,  however,  hegin  to  abate  before  this  stage  is 
reached,  and  the  part  may  gradually  return  to  its  normal  condition.  The 
intianimation  is  then  said  to  have  terminated  by  resolution. 

In  order  to  understand  the  meaning  of  these  symptoms  a  study  of  the 
patliology  of  inflammation  is  necessary. 

The  changes  seen  in  the  blood-vessels  claim  our  first  attention. 
The  experiments  of  Cohnheim  in  18G7  greatly  increased  our  knowledge  of 
this  part  of  the  process.  Previous  to  that  time  the  great  number  of  cells 
found  in  an  inflamed  part  were  supposed  to  be  due  to  the  proliferation  of  the 
cells  of  the  connective  tissue,  but  Recklinghausen  showed  that  many  of  the 
connective-tissue  cells  possessed  the  power  of  motion  and  wandered  into  the 
inflamed  tissues.  They  are  called  amoeboid  cells  from  their  resemblance  to 
the  amoeba.  Following  this  discovery  came  that  of  Cohnheim,  who  identified 
the  cells  in  the  inflamed  tissue  with  the  white  corpuscles  of  the  blood  or  the 
leucocytes. 

If  Ave  paralyze  a  frog  with  curare,  and  draw  a  loop  of  his  intestine  through 
an  incision  made  on  one  side  of  the  abdomen,  we  obtain  in  the  exposed  mesen- 


FlG.  1. 


Fig.  2. 


Normal  Vessels  and  Blood-Stream 
(original). 


Dilatation  of  the  Vessels  in  Inflammation 
(original). 


tery  a  thin,  transparent  membrane,  in  which  the  circulation  can  be  studied 
with  ease  under  the  microscope.  It  may  also  be  readily  observed  in  the  web 
of  a  frog's  foot  or  in  the  frog's  tongue.  The  exposure  of  the  mesentery  is 
sufficient  in  itself  to  produce  an  inflammation,  but  an  application  of  a  caustic 
will  be  necessary,  in  the  case  of  the  web  or  the  tongue,  to  bring  about  the 
same  result.  If  we  examine  such  an  area  under  the  microscope,  we  can  gen- 
erally see  an  arteriole  with  its  rapid  pulsating  current  of  blood,  and  near  by 
a  small  vein  in  Avhich  the  blood  flows  with  a  more  steady  movement.  The 
red  blood-corpuscles  occupy  the  axis  of  the  blood-vessel,  and  the  few  white 
corpuscles  which  are  seen  float  i«  the  more  sluggish  stream  of  plasma  which 
occupies  the  borders  of  the  lumen  and  appears  as  a  transparent  layer 
(Fig.    1).     The    capillaries   are  not   readily   seen,   but   careful    observation 


12 


AN  AMERICAN  TEXT-BOOK  OF  SURGERY 


will  detect  the  elianiiels  through  wliieh,  occasionally,  a  few   hlood-corpnscles 
pass. 

At  the  beginning  of"  the  inHaniniatory  process  the  rajiidilif  of  the  fliiiv  of 
blood  is  iireatli/  iiicrcascd  and  a  greater  amount  of  blood  is  observed  in  the 
part.  Tlie  Imiuni  of  the  artcn/  is  yreater  than  before,  and  the  column  of  red 
corpuscles  is  much  broader  and  fills  a  comparatively  greater  portion  of  the 
lumen  of  the  vessel.  The  capillaries  are  now  quite  distinctly  seen,  and  nre 
crowded  with  blood-corpuscles.  They  appear  to  be  considerably  larger  than 
they  were  before.  The  tlow  of  blood  is  also  more  rapid  in  the  veins,  and  it  is  of 
a  brighter  and  more  arterial  color.  This  condition  of  the  circulation  is  known 
as  Jiypi'vemia  (Fig.  2),  and  is  presently  succeeded  by  a  slowing  of  the  current, 

which  soon  becomes   much   more 
^"^•-  '^  sluggish  than  in  the  normal  state. 

This  is  first  noticed  in  the  capilla- 
ries, and  soon  after  in  the  veins. 
The  })ulsation,  however,  continues 
in  the  arteries.  As  a  result  of  this 
diminution  of  speed  the  column  of 
blood-corpuscles  becomes  broader, 
and  almost  completely  fills  the  in- 
terior of  the  vessels.  In  the  veins 
a  great  aceuriiulation  of  tvhite  cor- 
puscles takes  place  on  the  interior 
of  the  walls.  Being  of  a  lower 
specific  gravity  than  the  red  cor- 
puscles, the  leucocytes  are  not 
forced  onward  with  the  same  mo- 
mentum, and  are  drop])ed,  as  it 
were,  here  and  there  on  the  vessel- 
wall.  Finally  they  are  so  greatly 
increased  in  numbers  that  the 
entire  Avail  of  the  vessel  appears 
to  be  lined  Avith  leucocytes.  The 
Avhite  corpuscles  also  accunmlate 
in  the  capillaries,  but  not  to  the 
same  extent.  In  the  arterioles  these  corpuscles  cling  more  readily  to  the 
Avail  during  the  diastole,  but  they  are  soon  swept  aAvay  again  into  the  blood- 
current. 

Another  step  in  the  process,  beginning  concurrently  Avith  the  sloAving  of  the 
blood-stream,  is  the  emigration  of  the  leucocijtes  from  the  interior  of  the  veins 
(diapedesis)  (Figs.  3  and  4).  Many  leucocytes,  b}'  a  change  of  shape,  send 
out  little  prolongations  of  protoplasm  into  the  substance  of  the  Avail,  and  slight 
protuberances  are  soon  seen  projecting  from  its  outer  surface.  These  enlarge, 
and  Ave  noAv  see  the  corpuscles  presenting  an  hour-glass  appearance.  The  por- 
tions Avithin  the  vessel  soon  folloAv  those  Avithout,  and  the  leucocytes  escape 
from  all  contact  Avith  the  vessel.  Many  corpuscles  appear  to  folloAv  one  another 
through  the  same  point  in  the  wall.  AVhether  there  are  actual  holes  (stomata) 
between  the  endothelial  cells  of  the  vessel  through  Avhich  the  leucocytes  escape 
or  not  is  still  a  disputed  question.  The  amoeboid  movements  of  the  leuco- 
cytes are  effected  by  a  poAver  of  those  cells  to  change  their  shape.  Processes 
(pseudopodia)  are  throAvn  out  from  the  protoplasm  of  the  cell,  Avhich  noA\' 
becomes  elongated  or  fiask-shaped.  As  the  ])rotoplasmic  mass  resumes  its 
more  or  less  globular  form,  the  main  portion  folloAvs  the  protruded  mass,  and 


stasis  of  Blood  and  Diapedesis  of  White  Corpuscles  in 
Inflammation  (original). 


INFLAMMA  TION. 


13 


a  change  iu  the  position  of  the  cell  results.     The  white  corpuscle  is  a  minute 
mass  of  granular,  or,  according  to  some  authors,  reticulated,  protoplasm,  con- 


FiG.  4. 


10.30   P.M. 


10.40. 


11. 


11.15. 


11.40. 


12.20. 


Stages  of  the  Migration  of  a  Single  White  Blood-corpuscle,  through  the  Wall  of  a  Vein  in  One  Hour  and 
Fifty  Minutes  (mesentery  of  the  frog  ;  Caton). 

taining  one  or  more  nuclei,  and  without  any  limiting  membrane.     The  cells 
which  accumulate  in  large  numbers  outside  the  walls  of  the  blood-vessels  in 


Fig.  5. 


Changes  seen  in  the  Leucocyte  of  a  Frog  during  Ten  Minutes  (original). 


inflammation  have  the  same  appearance.  Migration  takes  place  to  a  limited 
extent  also  from  the  capillary  vessels,  but  no  such  process  is  observed  in  the 
walls  of  the  arteries. 

Leucocytosis. — In  most  local  inflammatory  processes,  as  well  as  in  most 
acute  infectious  diseases  and  in  many  toxemic  conditions,  the  number  of 
polynuclear  leucocytes  in  the  circulating  blood  is  greatly  increased.  This  is 
usually  considered  to  be  due  to  what  is  known  as  chemotaxis,  by  which  is 
to  be  understood  an  attraction  exerted  by  the  products  of  bacterial  activitv 


14  ^iV^   AMERICAN    TEXT-BOOK    OF   SURGERY. 

upon  the  leucocytes  in  tlie  blood-iuiikinf];  organs,  which  arc  probably  stimu- 
lated to  an  increased  rate  of  production.  The  number  of  leucocytes  jier 
c.cm.  of  blood  is  thus  increased  from  HUGO  ±  (the  normal  number)  up  to 
20,000-40,000  or  even  100,000,  according  to  the  severity  of  the  infection 

and  the  resisting  power 
'"'^*-  ^-  ^"■'  '^-  of  the  organism.     Viru- 

lent infections  well  re- 
sisted cause  the  greatest 
leucocytosis.  Where  the 
infection  is  very  mild, 
or  where  it  is  so 
overwhelmingly  violent 
that  the  resistance  of 
the  system  is  easily 
overpowered,  the  leuco- 
,  T.,     ,  rrv.   1,1     ,      1  .    ■         cyte  count  may  be  nor- 

Normal  Blood.  The  Blood  in  Leucocvtosis.  "^   ,  ,  -^      , 

mal  or  subnormal. 

Any  suppurative  process,  such  as  appendicitis,  felon,  osteomyelitis,  ischio- 
rectal abscess,  perinephric  abscess,  etc.,  usually  gives  rise  to  leucocytosis. 
In  a  general  way,  the  course  of  the  leucocytosis  follows  that  of  the  tem- 
perature ;  but  the  leucocytes  may  increase  while  the  temperature  falls,  and 
in  some  cases  {e.  ^.,  in  appendicitis)  the  increasing  leucocytosis  may  be 
evidence  of*  a  spreading  peritonitis  which  temperature  and  other  signs 
would  not  indicate. 

In  the  diagnosis  of  deep-seated  suppurative  processes,  septicemia,  and 
pyemia  the  leucocyte  count  is  not  infre(|uently  of  value. 

After  free  drainage  of  an  abscess  cavity  has  been  established  by  incision 
or  otherwise,  the  leucocyte  count  falls  rapidly  to  normal  and  remains  so, 
despite  a  free  purulent  discharge.  If,  however,  the  proper  drainage  is  in 
any  Avay  interfered  with,  the  leucocyte  count  again  rises.  "Nervousness" 
never  increases  the  leucocyte  count.  The  examinations  should  always  be  made 
directly  before  a  meal,  since  a  slight  increase  (up  to  15,000  or  17.000)  may 
be  caused  by  the  influence  of  proteid  digestion. 

The  blood-plaques  probably  comprise  several  different  elements,  into 
the  nature  of  Avhich  it  is  not  profitable  here  to  enter.  They  are  colorless, 
irregularly  oval  or  grape-like  masses,  from  1.5  to  3.5  fx  in  diameter,  and 
usually  cling  together  in  masses.  No  nucleus  can  be  made  out.  In  various 
inflammatory  conditions  they  may  be  increased  in  number.  Normally,  they 
are  about  200,000  per  c.mm. 

The  changes  seen  in  the  circulation  account  for  two  of  the  cardinal  symp- 
toms— viz.  heat  and  redness.  The  rapid  return  of  color  seen  after  pressing 
the  finger  on  an  inflamed  surface  indicates  the  increased  amount  of  blood. 
The  copious  bleeding  from  incisions  in  an  inflamed  tissue  shows  the  increased 
detei'mination  of  blood  to  the  part  and  the  distention  of  even  the  smallest 
capillaries.  The  bright  scarlet  redness  is  also  an  indication  of  the  active 
hyperemia  Avhich  exists  in  acute  inflammation.  In  the  more  chronic  forms, 
or  in  those  in  which  the  congestion  is  very  intense  and  the  flow  of  blood  is 
consequently  not  so  rapid,  there  is  a  bluish  tinge  to  the  reddened  surface. 
If  the  color  cannot  be  entirely  pressed  away  Avith  the  finger,  this  is  due  either 
to  decomposition  of  the  coloring  matter  of  the  blood,  which  leaves  a  yellowish 
tinge  behind,  or,  if  a  reddish  tint  remains,  it  is  caused  by  the  presence  of 
red  blood-corpuscles  which  have  been  forced  out  of  the  vessels  by  the  inten- 
sity of  the  pressure.     This  "hemorrhagic"  form  of  inflammation  has  often 


INFLA  MM  A  TION.  \  5 

a  much  deeper  and  more  irregular  coloring  than  is  usually  seen  in  acute 
inflammation.  Redness  is  entirely  absent  in  bloodless  parts,  as  in  the  cor- 
nea, but  in  this  case  we  find  a  hyperemia  of  the  vessels  of  the  conjunctiva, 
and  later  an  actual  development  of  vascular  loops  in  the  direction  of  the 
inflamed  spot.  It  was  at  one  time  su])posed  that  the  increased  warmth  of  the 
part  was  due  to  a  local  production  of  heat.  It  is  now  known  that  the  local 
rise  of  temperature  is  due  to  the  greater  amount  of  blood  which  flows  throu'^h 
the  vessels. 

One  of  the  most  constant  symptoms  of  inflammation  is  the  swelling.  This 
is  rarely  absent,  and  is  seen  even  in  non-vascular  parts.  The  increase<l  amount 
of  blood  in  the  vessels  of  the  part  does  not  add  materially  to  its  size.  We 
must  seek  for  an  explanation  of  this  phenomenon  in  the  altered  condition  of 
the  tissues  of  the  part.  On  making  an  incision  into  an  inflamed  spot  we  find 
the  meshes  of  tissue  distended  with  an  abundant  exudation  of  blood-serum  and 
leucocytes  escaping  through  the  walls  of  the  dilated  blood-vessels.  The  tissues 
are  saturated  with  this  material  often  to  such  an  extent  that  it  may  be  difticult  for 
the  surgeon  to  recognize  the  difference  between  muscles,  fasciie,  and  vessels.  The 
exudation  consists  not  only  of  leucocytes,  but,  in  addition,  of  a  certain  amount 
of  fluid  which  closely  resembles  the  liquor  sanguinis,  and  from  which  fibrin  is 
formed  giving  a  certain  firmness  to  the  part.  The  tissues  are  also  crowded  with 
leucocytes.  The  increased  number  of  cells  in  the  part  was  at  one  time  attributed 
to  the  division  or  "proliferation"  of  the  pre-existing  cells  of  tlie  inflamed 
tissues,  but  Cohnheim  maintained  tliat  the  new  cells  were  the  escaped  Avhite 
blood-corpuscles,  and  that  the  so-called  fixed  connective-tissue  cells  played  no 
part  in  the  process,  being  incapable  of  proliferation.  This  doctrine  he  illus- 
trated by  experiments  upon  the  cornea.  The  opacity  produced  by  an  artificial 
inflammation  was  found  to  be  due  to  the  presence  of  numberless  leucocytes, 
while  the  corneal  corpuscles  were  found  to  be  unchanged.  Subsequent  obser- 
vations have,  however,  shown  that  the  fixed  cells  of  the  cornea  also  undergo 
proliferation  and  take  part  in  the  process.  Cohnheim  thought  that  the  immense 
number  of  cells  found  in  an  inflamed  part  were  all  derived  from  the  white  cor- 
puscles, and  that  by  subsequent  proliferation  they  were  increased  in  number 
and  formed  what  is  known  as  granulation-tissue^  which  he  assumed  played  a 
prominent  part  in  the  healing  process.  It  is  a  well-known  fact,  however,  at 
the  present  time,  that  the  fixed  connective-tissue  corpuscles  and  other  cells  in 
tissues  of  the  body  are  capable  of  division.  According  to  the  latest  views  on  the 
origin  of  the  granulation-tissue,  the  round  cells  with  single  nuclei  are  mostly 
formed  by  the  proliferation  of  connective-tissue  and  other  fixed-tissue  cells. 
Later,  many  of  these  cells,  as  also  the  leucocytes,  become  polynuclear  cells,  and 
as  such  are  incapable  of  taking  any  further  active  part  in  the  process.  Accord- 
ing to  Ziegler,  the  polynuclear  leucocytes  appear  to  be  taken  up  and  destroyed 
by  the  proliferating  connective-tissue  cells,  the  leucocytes  apparently  serv- 
ing simply  as  nutriment  for  these  cells.  The  process  of  multiplication  by 
cell-division  is  now  much  better  understood  than  formerly,  and  the  mode  of 
indirect  division  (karyokinesis,  p.  29)  in  which  the  nucleus  plays  a  prominent 
part  is  the  one  most  frequently  observed. 

The  meshes  of  the  tissue  are  distended  with  coagulated  lymph,  and  the 
connective-tissue  fibres  are  swollen  and  softer  than  usual,  and  here  and  there 
terminate  suddenly,  as  if  broken  off",  giving  them  a  club-shaped  appearance. 
In  the  organs  afl"ected  we  find  the  epithelial  cells  altered  in  appearance,  being 
in  the  condition  known  as  that  of  "cloudy  swelling;"  that  is,  their  protoplasm 
is  granular  and  more  opaque,  and  containing  frequently  fatty  granules.  Dur- 
ing the  development  of  the  inflammatory  process  the  leucocytes  are  seen  infil- 


16 


AN  AMERICAN  TEXT-BOOK  OF  SURGERY. 


A  Phagocyte  destroying  a  Bacillus  (Landcrer). 


trating  the  tissue  between  the  pre-existing  cells,  arranged  in  rows  or  irregular 
masses  or  scattered  about  singly.  They  are  more  numerous  in  the  immediate 
neighborhood  of  the  small  veins  and  capillaries.  At  the  height  of  the  inflam- 
mation the  part  may  be  completely  filled  with  small  round  cells,  many  of  them 
leucocytes  and  many  of  them  derived  from  the  cells  of  th-e  inflamed  part. 

Various  views  are  held  as  to  the  function  of  the  leucocytes.  Cohnheim 
regarded  them  as  the  active  agents  in  the  process  of  repair.     By  others  they 

have  been  regarded  as  the  scaven- 
^^^'  °'  gers  which  appropriate  to  themselves 

the  broken-down  materials  which 
result  from  inflammation,  and  thus 
aid  in  the  process  of  absorption. 
Fragments  of  dirt  or  blood-clots  or 
carmine  granules,  when  used  experi- 
mentally, are  found  in  the  proto- 
plasm of  these  cells.  MetschnikoflF 
has  advanced  the  theory  known  as 
phagocytosis,  according  to  which 
the  cells  of  the  inflamed  part,  in  virtue  of  their  al)ility  to  consume  foreign  sub- 
stances, attack  and  destroy  the  invading  bacteria  (Fig.  8).  These  cells  are  called 
phagocytes  {(fdyco,  to  eat,  and  xuto(:,  a  cell).  If  they  are  able  to  destroy 
the  bacteria,  the  system  is  protected  from  the  invading  organisms.  The 
leucocytes  are  called  micro-phagocytes  (or  microphages),  and  the  larger  cells 
developed  from  the  fixed  connective-tissue  cells  are  called  the  macro-phagocytes 
(or  macrophages).  The  latter  may  consume  the  smaller  cells  after  their 
struggle  with  the  bacteria,  and  thus  assist  in  the  process  of  absorption.  A 
large  number  of  experiments  were  performed  by  Metschnikoff  in  support 
of  this  theory.  Other  writers  have,  however,  shown  that  the  leucocytes 
may  be  the  vehicles  by  which  the  bacteria  are  conveyed  to  distant  portions 
of  the  body,  and  that  they  are  therefore  capable  of  spreading  infection. 
The  doctrine  has  not  been  generally  accepted  as  an  explanation  of  the 
immunity  which  certain  animals  or  individuals  possess  against  the  attacks  of 
certain  diseases.  The  rich  cell-infiltration  of  an  inflamed  part  may,  however, 
exert  a  protective  influence  in  other  ways.  The  lymph-spaces  of  inflamed 
tissue  are  usually  crowded  Avith  leucocytes,  and  absorption  of  chemical  or 
bacterial  poison  is  thus  prevented.  The  mechanical  protection  which  the  gran- 
ulating surface  of  a  wound  afibrds  is  in  striking  contrast  to  the  rapidity  Avith 
which  a  freshly-exposed  tissue  Avill  absorb  a  virus. 

Returning  to  the  microscopical  changes  to  be  seen  in  inflamed  tissues,  we 
find  that  when  granulation-tissue  has  formed  the  intercellular  substance  is  not 
so  easily  seen  as  before,  and  the  part  appears  to  be  composed  almost  exclusively 
of  cells.  It  is,  however,  rich  in  blood-vessels,  as  can  be  easily  demonstrated  by 
special  methods  of  preparation.  Much  of  the  intercellular  substance  and  many 
of  the  fibers  have  disappeared,  and  a  granular  intercellular  substance  has  taken 
their  place.  This  condition  exists  usually  in  the  more  indurated  j)ortions  of  the 
inflamed  part,  and  gives  rise  to  the  characteristic  "cake-like"  hardening  so 
often  felt.  In  the  surrounding  softer  and  more  pulpy  structures  Ave  find  a 
large  amount  of  coagulated  fibrin  and  serum,  Avhich  latter  substance  may  at 
times  be  excessive  in  quantity,  and  then  produces  a  condition  that  is  knoAvn 
as  inflammatory  oedema.  Such  collections  of  the  fluid  products  of  inflamma- 
tory transudations  are  most  marked  in  loose  connective  tissues,  as  in  the  eyelids 
and  the  prepuce.  When  an  oedematous  SAvelling  of  this  character  takes  place 
in  the  mucous  membrane  of  the  larynx  fatal  complications  may  arise. 


INFLAMMATION.  17 

When  mucous  membranes  are  inflamed  the  exudation  usually  shows  itself 
in  the  form  of  an  increased  and  altered  secretion  on  its  surface,  in  certain  con- 
ditions even  assuming  the  consistence  of  a  false  membrane.  When  serous 
surfaces  are  inflamed  the  transudation  will  take  the  form  of  an  effusion  into 
the  serous  cavity  involved,  as  in  the  pleura  or  the  cavity  of  the  knee-joint. 
The  cells  which  are  a  part  of  the  exudation  may,  however,  form  a  membrane 
on  the  walls  of  these  cavities,  and  give  rise  to  adhesions  which  interfere  with 
the  motion  of  the  two  surfaces  upon  each  other. 

The  next  symptom  of  inflammation  is  pain,  which  is  due  to  the  pressure 
or  tension  produced  by  the  swelling  upon  the  terminal  branches  of  the  nerves ; 
it  may  also  be  due  to  exalted  sensibility  from  hyperemia,  and  to  the 
chemical  irritation  of  ptomaines.  It  is  most  severe  in  the  early  stages 
of  the  inflammation,  before  the  tissues  have  had  an  opportunity  to  accom- 
modate themselves  to  the  pressure  exerted  by  the  exudation.  It  will  vary 
greatly  with  the  anatomical  nature  of  the  part.  In  bone,  where  the  tis- 
sues yield  less  rapidly  than  elsewhere,  it  will  be  very  severe,  and  even  in 
the  chronic  forms  of  inflammation  the  pain  will  be  of  a  boring  character, 
which  is  proverbially  hard  to  bear.  The  throbbing  pain  is'^due  to  the 
pulsation  of  the  hyperemic  vessels  of  the  part,  and  the  peculiar  lancinating 
pain  which  pus  causes  in  its  efforts  to  escape  is  characteristic  of  an  abscess 
which  is  about  to  discharge.  Pain  may,  however,  be  entirely  wanting.  This 
is  the  case  in  nerveless  tissues,  and  also  in  severe  inflammations  which  rapidly 
destroy  the  vitality  of  a  part. 

The  fifth  symptom  of  inflammation,  disturbance  of  function,  will  show 
itself  in  various  ways,  according  to  the  part  affected :  an  inflamed  muscle  will 
become  rigid  and  contracted;  an  inflamed  gland  will  cease  to  give  forth  its 
natural  secretion.  The  special  senses  may  also  be  impaired,  or  even  perma- 
nently affected,  by  the  inflammatory  process. 

Inflammation  does  not  begin  spontaneously.  Old  writers  recognized  an 
idiopathic  form  of  inflammation,  but  the  term,  if  intended  to  mean  more  than 
non-traumatic,  should  be  discarded.  Inflammation  is  due  to  some  cause  which 
acts  in  an  injurious  or  destructive  manner  upon  the  tissues,  such  as  heat,  cold, 
chemical  action,  injury  or  trauma,  the  temporary  removal  of  blood  from  a  part', 
as  m  laboratory  experiments  or  in  frost-bite,  and,  finally,  infection,  or  the  action 
of  micro-organisms  and  their  products  upon  the  tissues.  There  is  a  tendency 
at  the  present  time  to  ascribe  all  inflammation  to  the  action  of  bacteria. 
According  to  Senn,  inflammation  proper  should  be  made  to  embrace  patho- 
logical conditions  which  are  caused  by  the  action  of  micro-organisms  or 
ptomaines  upon  the  histological  elements  of  the  blood  and  fixed  tissue-cells. 
Hueter  also  believed  in  the  universal  agency  of  bacteria  in  inflammation,  and 
regarded  it  as  an  epidemic  and  contagious  disease  existing  everywhere.  All 
other  forms  of  inflammation  would,  according  to  this  view,  be  regarded  as  the 
phenomena  accompanying  the  process  of  repair. 

The  question  of  the  action  of  the  nerves  in  inflammation,  at  one  time  dis- 
carded, has  been  recently  revived  by  Lister.  It  is  claimed  that  the  most 
striking  clinical  example  of  this  type  of  inflammation  is  the  so-called  urethral 
fever  which  follows  the  use  of  the  catheter.  The  inflammation  of  the  genito- 
urinary tract  thus  brought  about,  and  the  accompanying  chill  and  fever,  are 
supposed  to  be  due  to  a  reflex  action  of  the  nerves  of  the  part.  Doubtless 
many  of  these  cases  may  be  ascribed  to  a  septic  infection  by  the  instrument 
or  to  injury  of  already  infected  organs.  The  value  of  counter-irritation  as  a 
method  of  treatment  is  brought  forward  to  show  the  probability  of  an  abnormal 
action  of  the  nerves.     The  so-called  trophic  action  of  the  nerves  in  inflam- 


18  ^1-V  A.VERICAX  TEXT-BOOK  OF  SURGERY. 

mation  was  at  one  time  regarded  with  favor.  Division  of  the  vagus  nerve  in 
animals  was  found  to  be  followed  by  pneumonia.  These  cases  are,  however, 
now  explained  satisfactorily  by  bacterial  infection  following  removal  of  the 
protective  nerve  influence  of  the  part.  The  list  of  inflammations  to  be  ascribed 
to  the  action  of  the  bacteria  and  their  products  is  no  doubt  constantly  enlarging, 
but  we  are  not  yet  in  a  position  to  discard  all  other  supposed  inflammatoiy 
agencies. 

Cohnheim  believed  that  all  these  agencies  acted  upon  the  walls  of  the 
blood-vessels  and  produced  a  molecular  change  in  them  by  means  of  which  the 
phenomena  of  inflammation  were  produced.  Virchow  advanced  the  '-abstrac- 
tion ""  theory,  in  which  the  cells  of  the  tissues  played  a  prominent  part.  Lan- 
derer  does  not  think  we  ought  to  separate  the  capillaries  from  the  tissues  in 
which  they  lie  in  considering  the  seat  of  inflammation.  When  the  cause  of 
inflammation  acts  upon  the  tissues  they  become  relaxed,  the  equilibrium  between 
blood  and  tissues  is  disturbed,  and  we  have  a  leakage  or  exudation  into  the 
inflamed  part. 

Most  traumatic  inflammations  take  their  origin  in  the  tissues,  as  these  are 
acted  upon  directly  by  the  inflammation-producing  agent.  Other  inflammations, 
as  the  more  deep-seated  foiTns.  are  produced  by  an  agent  acting  through  the 
blood-vessels  or  the  lymph-channels.  In  this  way  those  types  of  inflammation 
known  as  parenchymatous  or  interstitial  are  produced. 

From  a  study  of  the  pathology  of  this  aff"ection  we  are  justified  in  assuming, 
therefore,  that  the  phenomena  of  inflammation  are  evidences  of  injury  to  the 
nutrition  of  the  part,  while  the  consequent  flushing  of  the  part  with  increased 
blood-supply,  by  preventing  mural  implantation  of  bacteria,  and  exudation, 
assist  in  the  removal  of  injurious  substances,  and  leave  the  tissues  in  a  condi- 
tion favorable  to  a  return  to  tlie  normal  state. 

There  are  several  varieties  of  inflammation  to  be  considered.  For- 
merly the  terais  traumatic  and  idiopatJdc  were  used  to  designate  respectively 
inflammation  caused  by  injury  and  that  which  arises  spontaneously ;  but  we 
hear  little  of  the  idiopathic  form  at  the  present  time.  Inflammation  may  be 
simple  or  infective.  The  simple  inflammations  are  limited  in  extent,  and  tend 
to  recovery  as  soon  as  the  inflammatory  agent  ceases  to  act.  The  infective 
inflammations  are  caused  by  bacteria,  and  have  a  tendency  to  spread. 

Inflammations  are  said  to  be  sthenic  or  asthenic  according  to  the  severity 
of  the  symptoms.  The  sthenic  type  is  seen  in  a  young  and  vigorous  subject 
when  affected  with  acute  inflammation.  The  asthenic  fonns  occur  cliiefly  in 
old  and  feeble  individuals.  In  the  parenchymatous  inflammations  the  part 
attacked  is  the  specific  cells  of  an  organ  or  its  parenchyma.  These  cells  undergo 
a  ''cloudy  swelling,"  and  later  proliferation  may  occur,  or  even  destnaction  of 
the  cells  may  result.  An  inflammation  is  called  interstitial  when  the  connective- 
tis.sue  stroma  which  supports  the  parenchyma  appears  to  be  the  part  principally 
affected.  We  see  then  a  cellular  infiltration  in  the  stroma  of  the  organ.  There 
is  no  essential  difference  in  these  two  types,  as  the  connective  tissue  is  usually 
increased  in  direct  proportion  to  the  destruction  of  the  parenchyma. 

When  an  inflammation  affects  the  walls  of  a  serous  cavity,  we  may  have 
considerable  accumulation  of  fluid.  The  term  serous  inflammation  is  then 
used  to  denote  the  type  which  produces  a  collection  of  fluid  in  the  joints  or  the 
pleural  cavity.  The  amount  of  serum  discharged  from  a  wound  may  at  times 
be  very  large,  and  drainage-tubes  are  often  employed  to  conduct  away  the  fluid. 
Adhesive  or  iihrinous  inflammations  are  seen  best  in  the  peritoneal  cavity 
when  two  surfaces  of  peritoneum  are  quickly  united  by  the  process.  The 
rapidity  with  which  this  membrane  may  become  united  to  itself  exceeds  that 


INFLAMMA  TION.  \  9 

of  any  other  in  the  body.  In  a  few  liours  the  adhesion  will  already  have 
formed,  and  the  peritoneal  cavity  may  in  this  way  be  protected  from  the  intru- 
sion of  poisonous  substances  such  as  pus  or  feces.  The  same  result  may  be 
obtained  in  the  interior  of  joints  or  the  pleural  cavity.  The  motion  of  the  parts 
will  stretch  these  new  adhesions,  which  may  thus  be  drawn  out  into  bands  of 
considerable  length.  When  extensive  adhesions  occur  between  the  opposing 
surfaces  of  a  joint  or  in  the  folds  of  its  capsule,  anchylosis  or  great  impairment 
of  motion  will  result. 

When  bacteria  are  present,  particularly  the  pyogenic  cocci,  these  organisms 
exert  a  solvent  action  upon  the  exudation,  and  fibrin  does  not  form ;  the 
tendency  is  therefore  to  a  liquefaction  of  the  tissues,  and  suppuration  takes 
place.  This  we  call  suppurative  inflammation,  or,  less  correctly,  phlegmonous 
inflammation. 

Hemorrhagic  inflammations  occur  when  the  red  blood-corpuscles  are  present 
in  unusual  numbers  in  the  exudation-fluid.  This  condition  is  found  in  very 
intense  forms  of  inflammation,  when  the  congestion  has  been  extreme  and 
large  numbers  of  corpuscles  are  forced  through  the  Avails  of  the  vessels  by  the 
unusual  pressure.  Black  measles  and  hemorrhagic  small-pox  are  familiar 
types,  as  are  also  some  of  those  extremely  septic  forms  of  inflammation  which 
the  surgeon  meets  with.  Small  hemorrhages  may  occur  in  the  inflammations 
of  the  aged  and  feeble  or  those  affected  with  cardiac  disease,  or  in  scorbutic 
patients.  The  presence  of  blood  in  a  serous  exudation  is  suggestive  of  intense 
congestion  of  a  part,  as  in  strangulated  hernia,  or  of  the  existence  of  malignant 
disease. 

When  a  false  membrane  forms  upon  the  surface  of  an  inflamed  mucous 
membrane  the  inflammation  is  called  croupous.  The  exudation-cells  and 
newdy-formed  cells  of  the  part  are  caught  in  a  fine  reticulum  of  fibrin.  Avhich 
forms  on  the  surface  and  prevents  their  escape  in  the  mucous  discharges. 
There  is  more  or  less  destruction  of  the  epithelial  cells  which,  when  intact,  exert 
a  preventive  influence  against  the  formation  of  such  a  membrane.  This  form 
of  inflammation  is  due  to  the  presence  of  bacteria,  which,  as  they  invade  the 
tissues  more  deeply,  produce  a  sort  of  coagulation-necrosis  of  the  more  super- 
ficial layers  of  the  tissues,  and  form  what  is  known  as  a  diphtheritic  membrane. 
The  principal  distinction  between  a  ci'oupous  membrane  and  a  diphtheritic 
membrane  lies  in  their  anatomical  situation.  The  former  is  on  the  surface  of 
the  mucous  membrane,  the  latter  is  situated  in  the  mucous  membrane  itself. 
There  is  probably  no  important  etiological  diff'erence  between  the  two  pro- 
cesses. 

Coagulation-necrosis  is  caused  by  arrested  nutrition  or  by  the  action  of 
chemical  or  thermal  agencies.  The  changes  seen  in  the  dead  tissues  are  due 
partly  to  a  coagulation  of  lymph  which  flows  into  the  part,  and  partly  to  a 
change  in  the  cells  of  the  part,  the  nuclei  of  which  lose  their  power  to  be 
stained  by  dyes.  The  cells  and  intercellular  substance  become  subsequently 
transformed  into  a  more  or  less  homogeneous  tissue. 

G-angrenous  inflammations  belong  to  the  most  malignant  types.  Death  of 
a  part  may  occur  either  from  the  virulence  of  the  poison  which  invades  it  or 
from  the  great  distention  of  the  tissues  by  swelling,  and  a  consequent  stasis  of 
the  blood-current.  The  anatomical  character  of  the  tissues  aff'ected  will  serve 
as  an  important  factor.  In  bone,  which  is  unyielding,  we  frequently  see  death 
or  necrosis  of  the  tissue  in  acute  inflammation. 

The  non-bacterial  forms  of  inflammation  have  no  tendency  to  spread.  In 
simple  inflammation  the  disease  is  confined  to  the  part  originally  affected.  In 
the  infective   inflammations   we  find   the  tissues  involved  for  a   considerable 


20  AN  AMERICAN  TEXT-BOOK  OF  SURGERY. 

distance  from  the  original  starting-point.  In  mucous  membranes  the  inflam- 
mation has  a  tendency  to  spread  ahjng  the  surface  rather  tlian  to  deeper  parts, 
and  the  same  is  true  of  inflammation  of  the  skin.  In  the  phlegmonous  types 
of  inflammation  the  process  will  involve  deeper  parts,  and  the  subcutaneous 
connective  tissue  may  become  the  seat  of  abscesses.  Dense  fasciae  and  bone 
may  resist  the  invasion  of  the  inflammatory  process,  but  the  softer  tissue  of  the 
interior  of  bones  is  a  frequent  seat  of  infective  inflammations. 

Not  only  will  the  part  attacked  feel  the  influence  of  the  inflammatory  agent, 
but  the  whole  system  may  be  affected,  and  we  then  have  what  is  known  as 
constitutional  disturbance — i.  e.  fever.  The  nature  and  extent  of  the  febrile 
process  depends  upon  the  materials  which  are  taken  up  and  absorbed  from  the 
inflamed  area. 

In  chronic  inflammations  the  symptoms  are  much  less  marked.  The  swell- 
ing is  only  moderate  in  amount,  and  there  is  very  little  increase  of  temperature. 
There  Avill  be  some  pain,  of  a  neuralgic  or  boring  character  according  to  the 
locality  of  the  part,  but  it  will  not  be  continuous,  as  in  the  acute  form.  Micro- 
scopically we  find  an  abundant  connective-tissue  growth,  containing  a  large 
amount  of  fibers,  but  comparatively  few  cells.  Many  degenerative  changes  are 
seen  in  such  tissues :  the  fibers  are  often  transformed  into  a  gelatinous  trans- 
parent tissue,  and  they  appear  to  have  been  absorbed  or  destroyed.  The  num- 
ber of  leucocytes  in  such  forms  of  inflammation  is  probably  small,  and  the  new 
cells  found  in  the  tissue  are  probably  derived  chiefly  from  the  fixed  cells  of  the 
part.  We  find  degenerative  changes  in  their  nuclei  and  protoplasm,  and  also 
evidences  of  proliferation  of  the  cells  going  on  at  the  same  time.  Here  and 
there  we  see  clusters  of  granulation-cells  with  epithelioid  and  giant  cells.  In 
other  cases  a  dense  fibrous  tissue  is  formed,  or,  in  bone,  bony  growths  which 
lead  to  a  hypertrophy  of  the  part.  The  causes  of  this  form  of  inflammation 
are  malnutrition  of  the  part  and  a  continuous  .action  of  the  inflammatory  agent. 
Loss  of  nerve-supply  by  section  of  the  nerve  or  injury  to  the  spinal  cord  so 
diminishes  the  vitality  of  the  tissues  that  the  slightest  injuries  give  rise  to 
Inflammation.  Repeated  slight  injuries  will  also  produce  a  chronic  inflam- 
matory process.  The  most  frequent  causes  are  the  chronic  forms  of  bacterial 
disease,  such  as  syphilis  or  tuberculosis.  The  results  of  sucli  inflammation 
may  lead  to  adhesion  in  joints  or  thickening  and  deformity  of  bones.  A 
class  of  swellings  known  as  the  granulomata  are  produced  by  the  bacterial 
growths.  Chronically  inflamed  parts  are  often  much  discolored  and  pigmented, 
and  slight  injuries  may  lead  to  ulceration  which  heals  with  difficulty. 

Subacute  inflammation  is  a  term  used  to  denote  a  type  intermediate,  in 
regard  to  the  severity  of  its  symptoms,  between  acute  and  chronic. 

Inflammation  may  terminate  by  resolution,  suppuration,  gangrene,  or  tissue- 
production.  Resolution  implies  that  the  various  symptoms  gradually  subside, 
and  the  part  Avill  return  to  its  normal  condition  without  any  appreciable  altera- 
tion of  its  tissues.  The  granulation-tissue  which  has  formed  will  gradually 
disappear  by  absorption  of  the  leucocytes  and  eff'used  lymph.  Many  of  the 
leucocytes  return  into  the  circulation  through  the  lymphatic  vessels  and  the 
capillaries  and  veins ;  others  are  broken  down  and  disintegrated.  The  same 
fate  meets  also  the  proliferated  cells  of  the  j)art.  New  fibres  are  formed  in  the 
place  of  those  which  have  been  destroyed  during  the  inflammatory  process,  and 
the  injury  done  to  the  tissues  is  thus  repaired.  With  the  al)Sorption  of  the 
products  of  inflammation  the  inflammatory  agents  also  disappear. 

When  suppuration  takes  place  there  is  a  loss  of  substance,  and  after  the 
pus  has  been  discharged  a  more  extensive  process  of  repair  is  needed  to  produce 
a  healing  of  the  wound  and  the  formation  of  the  cicatrix. 


INFLAMMATION.  21 

Very  severe  forms  of  inflammation  will  lead  to  gangrene.  The  dead  tissue 
is  gradually  separated  from  the  living,  to  which  it  is  attached,  by  the  formation 
of  a  line  of  demarcation — that  is,  by  suppuration — and  Avhen  the  slough  has 
separated  healing  by  granulation  takes  place.  As  absorption  takes  place,  the 
red  blood-corpuscles  found  in  the  exudation  are  broken  up  and  part  with  their 
coloring  matter,  which  remains  behind  and  frequently  produces  pigmentation. 
Many  of  the  cellular  elements  undergo  fatty  degeneration,  which  may  occasion- 
ally occur  on  so  extensive  a  scale  that  the  material  is  not  all  absorbed,  but 
remains  behind  as  masses  of  cheesy  degeneration.  In  some  cases  lime-salts 
are  eventually  deposited  in  the  unabsorbed  material,  and  calcareous  concre- 
tions are  formed.      Tissue-production  is  considered  in  the  next  chapter. 

Treatment. — The  principal  method  of  treating  inflammation  a  generation 
ago  Avas  the  so-called  antiphlogistic  treatment.  This  was  based  on  the  theory 
that  inflammation  was  an  inflammable  condition  of  the  part,  which,  like  a  fire, 
must  be  subdued  by  appropriate  measures.  It  did  not  take  into  account  the 
causes  of  the  process,  which  are  now  so  much  better  understood.  This  method 
consisted  in  the  use  of  emetics,  venesection,  cupping  and  leeching,  and  the 
administration  of  drugs,  like  mercury,  which  were  supposed  to  have  an  anti- 
phlogistic tendency.  This  method  has  given  place  to  antiseptic  treatment, which 
has  the  important  advantage  of  dealing  directly  with  the  cause  of  disease. 
Some  of  the  older  measures  are,  however,  still  retained,  and  may  occasionally 
be  used  to  advantage  in  relieving  some  of  the  symptoms  of  inflammation. 

Local  Treatment. — This  varies  according  to  the  different  stages  of 
inflammation.  In  the  first  stage  congestion  may  be  relieved  by  local  blood- 
letting. The  use  of  leeches,  wet  cups,  or,  rarely,  venesection,  is  then  indi- 
cated. In  cases  of  extreme  congestion  the  withdrawal  of  blood  and  serum 
by  a  free  incision  will  relieve  tension  and  may  prevent  stasis  and  gangrene. 

When  there  is  not  so  much  tension  of  the  part  applications  of  heat  or 
cold  favor  absorption  of  the  exudation  and  relieve  pain,  which  is  greatest  at 
this  period.  In  cases  of  virulent  sepsis  a  prompt  and  deep  incision  may 
prevent  extension  of  the  septic  process.  An  early  incision  into  an  inflamed 
mass  may  prevent  the  formation  of  pus. 

In  the  later  stages  of  inflammation,  when  suppuration  has  been  estab- 
lished, the  abscess  should  freely  be  laid  open  and  the  walls  of  the  abscess 
cavity  scraped  or  scrubbed  clean  with  gauze  sponges  to  arrest  the  further 
progress  of  the  bacteria.  Free  drainage  is  then  important  to  prevent  the 
formation  of  pus  and  to  favor  a  rapid  healing  of  the  wound.  In  case  sup- 
puration does  not  occur  the  products  of  inflammation  may  be  absorbed  by 
counter-irritation,  which  stimulates  the  absorbent  vessels  to  conduct  off"  the 
exuded  material.     This  can  be  accomplished  by  leeching  or  blistering. 

As  the  majority  of  surgical  inflammations  are  of  a  septic  nature,  the  anti- 
septic treatment  is  the  more  rational  method  to  pursue  in  most  cases.  This 
method  is  described  in  its  appropriate  place,  as  also  the  aseptic  treatment, 
Avhich  may  be  regarded  as  the  prophylactic  treatment  of  surgical  inflammation. 

Counter-irritation  was  another  of  the  weapons  of  the  antiphlogistic 
system,  but,  although  much  less  used  at  the  present  time  than  formerly,  has 
not  been  wholly  discarded.  It  is  a  remedy  of  more  value  in  chronic  inflamma- 
tions than  in  those  of  an  acute  type,  and  may  act,  possibly,  through  the  nerves 
of  the  part  by  a  reflex  process,  and  thus  produce  a  change  in  its  nutrition 
and  promote  absorption.  The  actual  cautery  is  still  occasionally  used  in  deep- 
seated  inflammation  of  the  joints.  It  should  be  lightly  applied  at  a  white 
heat  over  a  considerable  extent  of  skin  near  the  inflamed  part,  and  should 
act  only  on  the  superficial  layers  of  the  skin.     Repeated  blistering  is  also  of 


22  AN  AMERICAN    TEXT- HOOK    OF  SUJldEltY. 

benefit  in  producing  absorption  in  an  enbirged  gland  or  a  "'weeping  sinew,"  (jr 
of  an  exudation  which  is  slow  to  disappear.  Iodine  may  be  used  for  the  same 
purpose,  but  probably  acts  in  virtue  only  of  its  power  to  produce  a  local  irrita- 
tion on  the  surface,  not  from  any  special  sorbefacient  (juality  ])ossessed  by  it. 

Compression  is  a  valuable  agent  ki  the  treatment  of  both  the  eai'iy  and  the 
late  stages  of  inflaunnation.  In  the  acute  stage  it  restrains  the  tendency  to  exces- 
sive swelling  of  the  part  and  the  collection  of  serous  or  bloody  discharges  between 
the  lips  of  a  wound.  It  must  be  applied,  however,  with  great  care  during  this 
period,  as  sloughing  or  even  gangrene  may  be  the  result  of  tight  bandages  on 
a  part  when  the  circulation  is  enfeebled  by  injury.  In  the  later  stages  com- 
pression may  be  employed  with  great  advantage,  and  is  one  of  the  most  val- 
uable agents  which  the  surgeon  possesses  to  promote  absorption  and  resolution. 
It  is  most  useful  in  chronic  inflammation.  The  beneficial  effect  of  pressure 
upon  a  varicose  ulcer  by  plaster  or  a  rubber  bandage  is  an  admirable  illustra- 
tion of  this  power,  as  is  also  the  effect  produced  upon  the  serous  eff'usion  in  a 
knee-joint  by  elastic  bandages  made  of  rubber  or  flannel.  A  most  efficient 
ttieans  of  obtaining  compression  of  the  knee-joint  is  with  compressed  sponge : 
two  coarse  sponges  may  be  flattened  over-night  under  a  heavy  piece  of  furni- 
ture ;  one  is  put  on  either  side  of  the  joint,  which  is  placed  on  a  posterior 
splint ;  a  long  cotton  bandage  is  now  firmly  applied,  after  which  a  stream  of 
water  is  allowed  to  trickle  into  the  sponges.  This  dressing  may  be  left  on  for 
one  or  two  days,  sufficient  moisture  being  supplied  to  keep  the  bandages  tight. 

Cold  and  heat  are  used  for  the  purpose  of  reducing  the  hyperemia  and  to 
relieve  pain.  Cold  may  be  applied  either  by  evaporating  lotions  or  by  the 
use  of  ice.  Evaporating  lotions  can  be  used  on  exposed  parts,  but  must  be 
changed  very  frequently  to  have  the  desired  eff'ect.  They  are  less  used  than 
formerly.  Ice  may  be  applied  in  thin  rubber  bags.  Cold  can  also  be  applied 
by  the  "ice-coil,"  by  means  of  which  a  current  of  ice-water  is  allowed  to  flow 
through  a  coil  of  rubber  or  metal  tubing  over  the  part.  Care  must  be  taken  to 
avoid  freezing  the  superficial  layers  of  the  skin  if  a  prolonged  use  of  the  remedy 
is  intended.  The  ice-bag  is  comforting  in  cases  of  rapid  swelling  folloAving 
injury,  to  a  tender  and  swollen  knee-joint,  or  to  an  inflamed  throat.  It  is 
dangerous  in  cases  of  extreme  congestion,  as  in  strangulated  hernia. 

Heat  may  be  applied  in  the  form  of  fomentations,  hot-water  bags,  or  the  hot 
douche.  It  acts,  doubtless,  in  various  Avays.  A  hot  fomentation  when  first  used 
produces  a  powerful  counter-irritation  ;  later,  it  acts  through  the  circulation, 
relieving  stasis  and  favoring  an  absorption  of  exudation.  If  the  heat  be  main- 
tained at  a  high  point  by  frequent  application  of  the  hot  douche,  a  constriction 
of  the  blood-vessels  takes  place,  and  congestion  is  thus  diminished.  The  flax- 
seed poultice  is  now  discarded  in  the  treatment  of  wounds,  but  may  still  be 
used  with  advantage  Avhen  no  wound  exists.  The  antiseptic  poultice,  now  used 
for  wounds  in  certain  cases,  is  practically  a  hot  fomentation  to  which  some  anti- 
septic agent  has  been  added. 

Incisions  are  often  of  great  value  in  certain  types  of  inflammation,  even 
when  suppuration  has  not  taken  place.  In  cases  of  intense  congestion  of  the 
inflamed  part,  Avhen  the  integuments  are  thick  and  brawny,  one  or  more  incis- 
ions are  followed  by  a  free  gush  of  blood  and  serum  which  greatly  relieves  the 
tension  of  the  part  and  wards  off'  not  only  threatening  deep-seated  supjiuration, 
but  also  gangrene  of  the  parts.  The  incision  should  be  made  completely  through 
the  skin  and  cellular  tissue,  but  should  not  be  over  two  inches  in  length  in 
most  cases.  Early  interference  of  this  kind  is  imperatively  needed  in  the 
rapidly  spreading  forms  of  inflammation  such  as  occur  often  in  the  hand  and 
forearm,  which  may  not  only  ruin  a  hand,  but  endanger  a  life. 


INFLAMMATION.  23 

Elevation  of  the  inflamed  part,  combined  with  rest  by  splints,  etc.,  is  of 
the  utmost  importance  in  controlling  the  progress  of  an  inflammation.  Other 
remedies  will  be  of  little  use  if  the  congestion  is  favored  by  allowing  the  limb 
to  be  dependent,  and  if  motion  is  permitted  to  interfere  with  the  natural  tend- 
encies toward  resolution  and  repair. 

Pliifsiological  rest  of  injured  as  well  as  of  internal  organs  is  also  indicated, 
to  enable  the  disturbed  function  to  be  restored.  The  importance  of  absolute 
rest  after  injuries  to  the  brain  has  long  been  recognized.  A  chronic  cystitis 
may  be  cured  by  cystotomy  when  all  other  remedies  have  failed. 

Parenchipnatous  injections  were  proposed  at  one  time  to  arrest  the  prog- 
ress of  bacterial  infection.  Hueter  employed  3  per  cent,  solution  of  carbolic 
acid  in  this  way  around  the  area  of  erysipelatous  inflammation.  This  method, 
in  general,  has  not  met  with  favor.  It  is  possible,  however,  that  the  hypo- 
dermatic  syringe  may  have  a  future  in  surgical  diseases  which  is  not  yet 
apj)arent. 

The  results  of  inflammation  which  remain  in  the  shape  of  stiifened  joints, 
contracted  or  enfeebled  muscles,  and  thickened  integuments  can  best  be  dealt 
with  by  massage^  Avhich  not  only  favors  absorption,  but  is  a  powerful  restora- 
tive of  the  physiological  action  of  the  part. 

Constitutional  Treatment. — It  is  essential  to  remember  that  local 
treatment,  whatever  its  nature  may  be,  is  not  the  only  method  to  be  employed 
to  restore  the  patient  to  health.  The  careful  surgeon  will  always  pay  due 
attention  to  the  general  condition  of  the  patient.  The  presence  of  organic 
disease  elsewhere  must  not  be  allowed  to  pass  undiscovered. 

Stimulants  may  be  used  during  the  progress  of  the  fever  to  sustain 
strength.  Alcohol  can  be  used  freely  in  all  cases  where  there  is  an  abnormal 
consumption  of  tissue,  whether  the  result  of  acute  febrile  disturbance  or  of 
chronic  wasting  disease.  Here  alcohol  becomes  a  food,  and  one  of  the  most 
valuable  kind."  Patients  who  cannot  bear  the  usual  doses  of  alcohol  often 
experience  benefit  from  minute  quantities.  Dram  doses  of  whiskey  are  often 
well  borne,  and  are  of  service  in  such  cases.  In  the  "  typhoidal "  state  which 
accompanies  profound  septic  infection  astonishingly  large  quantities  will  be 
assimilated  even  by  patients  unaccustomed  to  its  use.  Flushing  of  the  face  is 
an  indication  that  the  dose  should  be  diminished  in  quantity.  Champagne  is 
a  good  substitute  for  whiskey  or  brandy  wdiere  the  stomach  is  sensitive.  Beer 
and  ale  are  useful  during  convalescence  or  in  chronic  types  of  inflammation. 

The  use  of  antipyretics  has  little  permanent  influence  on  the  pyrexia,  and 
does  not  appear  to  give  that  relief  to  symptoms  which  is  obtained  by  it  in 
so-called  medical  diseases.  A  much  more  reliable  method  of  controlling  the 
constitutional  disturbance  is  careful  attention  to  the  local  conditions  of  the 
wound  or  inflamed  part. 

A  large  variety  of  medicines  have  been  used  in  former  times  on  account  of 
their  supposed  virtues  in  arresting  or  shortening  the  inflammatory  process. 
Among  these  may  be  mentioned  quinine  and  mercury.  Quinine  is  still 
much  used,  on  account  of  its  tonic  action  even  during  the  febrile  state.  Its 
employment  in  large  doses  of  20  grains  or  more  is  confined  chiefly  to  malarial 
regions,  where  perhaps  there  is  a  tendency  to  use  it  to  excess.  In  doses  of 
5  grains  it  may  be  given,  three  times  a  day,  in  any  form  of  fever  in  which  a 
tonic  effect  is  desired.     It  is  still  used  largely  in  erysipelas. 

Mercury  was  formerly  used  internally  in  every  form  of  inflammatory 
process;  on  the  theory  that  it  had  a  powerful  antiphlogistic  action.  It  was 
supposed  to  dissolve  the  fibrinous  exudation.  Much  of  its  reputation  was 
probably  due  to  the  eff'ect  it  had  upon  unrecognized  forms  of  syphilis.      Calo- 


24  AN  AJfERICAN  TEXT-BOOK  OF  SURGERY. 

mel,  in  whicli  form  it  -was  usually  adiiiinistt'red,  has  now  «riven  place  to  corro- 
sive sublimate,  -which  as  an  antiseptic  takes  the  highest  rank.  Calomel  may 
also  have  exerted  a  beneficial  effect  in  virtue  of  its  cathartic  action. 

Purgatives  were  used  freely  as  part  of  the  antiphlogistic  system  of  treat- 
ment, and  are  still  valuable  in  certain  forms  of  inflammation.  They  are  part 
of  the  routine  treatment  of  head  injuries,  and,  if  administered  promptly  in 
coma  following  these  injuries  or  in  apoplexy,  are  snpi)()si'd  to  remove  sources  of 
irritation  and  to  leave  the  system  in  a  condition  unfavorable  to  meningeal  or 
cerebral  inflammation.  Six  grains  of  calomel  placed  upon  the  tongue  is  an 
easy  means  of  acting  upon  the  bowels  under  these  circumstances.  The  dose 
may  be  followed  in  two  hours  by  an  aloes  enema  (one  dram  of  powdered 
aloes  to  a  pint  of  hot  soapsuds).  Such  a  mode  of  treatment  is  suj)posed  to 
exert  a  "derivative"  action,  by  means  of  which  irritation  is  removed  from 
the  brain  and  its  coverings  to  distant  parts  of  the  economy.  The  tendency  to 
hyperemia  is  in  this  way  diminished.  The  treatment  of  peritonitis  by  purga- 
tives, particularly  after  laparotomy,  has  lately  come  into  vogue.  It  seems  to 
be  based  upon  the  power  of  the  cathartic  to  remove  gas,  and  consequently  to 
relieve  the  tympanites,  and  by  its  production  of  watery  stools  also  to  relieve 
the  engorgement  of  the  intestinal  vessels,  and  eliminate  germs  or  ptomaines 
by  causing  the  emptier  vessels  to  absorb  the  peritoneal  exudates.  A  Seidlitz 
powder  or  a  dose  of  Epsom  salts  will  often  promptly  remove  alarming  symptoms. 
Smaller  doses  of  salts,  repeated  every  hour  or  half  hour,  may  be  substituted 
for  the  single  larger  dose. 

DiapJioretics,  although  but  little  used  in  surgery,  may  occasionally  be 
found  of  value,  owing  to  their  antipyretic  action.  AVater  can  almost  always 
be  given  freely  if  taken  in  small  quantities  from  time  to  time.  Sweet  spirits 
of  nitre  in  dram  doses,  when  largely  diluted  in  water,  will  favor  diaphoresis, 
and  at  the  same  time  is  useful  as  a  sedative  and  also  as  a  diuretic. 

The  importance  of  diuretics  in  inflammation  of  the  bladder  need  not  be 
insisted  upon  here.     Their  value  will  be  discussed  in  another  chapter. 

Emetics  have  long  since  been  discarded  as  a  means  of  controlling  inflam- 
mation, though  they  are  useful  when  the  stomach  is  overloaded.  They  were 
formerly  used  in  connection  with  venesection. 

Anodynes  are  of  the  greatest  value  in  the  treatment  of  inflammation. 
They  relieve  the  most  disagreeable  symptom  of  inflammation — namely,  pain — 
and  also  the  malaise  and  nervous  disturbance  Avhich  are  the  accompaniments 
of  fever.  First  among  these  is  opium,  which  not  only  relieves  pain,  but  con- 
tracts the  peripheral  vessels.  The  crude  drug  is  rarely  given  except  in  a  sup- 
pository. Morphine  is  on  the  whole  the  most  useful  of  its  derivatives.  The 
subcutaneous  injection  of  morphine  should  be  reserved  for  the  more  acute  forms 
of  pain.  It  is  well  to  avoid  the  habit  of  giving  the  alkaloid  in  this  way  too 
freely,  as  it  is  a  powerful  remedy,  acting  with  double  the  power  of  the  same 
doseVhen  given  by  the  mouth,  and  is  sometimes  followed  by  symptoms  of  col- 
lapse or  opium  narcosis.  The  liquor  morphiniTe  sulphatis  (gr.  j  to  5J)  can  be 
given  by  the  mouth  in  teaspoonful  doses,  and  repeated  every  hour  or  half  hour 
until  pain  is  relieved.  If  it  is  desired  to  avoid  the  disagreeable  eff'ects  of  mor- 
phine upon  the  stomach,  it  can  be  given  by  suppository.  This  is  an  exceed- 
ingly convenient  way  of  administering  opium  for  pain  in  any  part  of  the  body. 
The  relief  from  pain' brings  with  it  rest — a  most  important  element  in  the  treat- 
ment. The  production  of  obstinate  vomiting  by  even  the  smallest  dose  of 
opium  or  its  derivatives  is  of  occasional  occurrence.  It  is  usually  a  personal 
idiosyncrasy.  In  important  cases  its  possible  existence  should  not  be  lost  sight 
of.     The  nervous  disturbance  will   be  also  relieved  by  this  drug,  but  we  must 


THE  PROCESS  OF  REPAIR.  25 

rely  more  upon  chloral,  the  bromides,  sulphonal,  or  other  hypnotics  for  the 
relief  of  this  symptom  and  to  obtain  sleep. 

The  diet  is  of  the  greatest  importance  in  all  forms  of  inflammation.  The 
fallacy  that  low  diet  is  necessary  under  these  circumstances  is  now  well  exposed. 
The  stomach  should  be  supplied  with  food  of  the  most  nutritious  character,  but 
in  a  form  that  can  be  easily  digested.  Milk  is  the  most  valuable  of  all  liquid 
forms  of  food.  It  may  be  given  pure,  mixed  with  lime-water,  peptonized,  or 
sterilized,  or  it  may  be  taken  in  the  form  of  gruel.  Alcohol  may  be  given 
with  it.  A  very  excellent  combination  is  wine-whey.  Clear  beef-tea  has  but 
little  nourishing  power.  Meat-broths  are,  however,  nutritious  and  valuable 
articles  of  diet  for  the  sick.  Pure  beef-juice  is  a  most  reliable  form  of  concen- 
trated and  digestible  nourishment.  When  food  cannot  be  taken  by  the  stomach, 
enemata  may  be  given  by  the  rectum.  These  may  consist  of  beef-broths,  with 
or  without  brandy.  Some  of  the  various  peptonized  forms  of  meat  may  be 
found  useful  for  this  purpose.  A  few  drops  of  laudanum  may  be  given  Avith 
the  enema  when  there  is  any  difficulty  in  retaining  it. 

After  the  inflammation  and  fever  subside  the  solid  forms  of  food  may  be 
used  more  freely.  Light  wines  or  beer  can  be  used  if  any  alcohol  be  needed 
at  this  period.  Tonics  are  now  indicated,  as  iron,  quinine,  calisaya-bark,  and 
the  phosphites.  They  improve  the  appetite  and  favor  the  local  process  of 
repair  and  the  return  of  the  system  to  a  normal  condition. 


CHAPTER    III. 

THE  PEOCESS  OF  EEPAIK. 


It  was  formerly  supposed  that  inflammation  was  necessary  for  the  healing 
of  a  wound,  but  from  the  present  point  of  view  the  processes  of  inflammation 
and  repair  are  regarded  as  distinct  from  one  another.  Under  the  condition  of 
asepsis  we  are  now  able  to  see  wounds  heal  without  the  usual  phenomena  of 
inflammation.  The  symptoms  of  inflammation  are  brought  about  by  the  dis- 
turbed functions  of  tissues  which  have  been  damaged.  Repair,  on  the  other 
hand,  is  the  result  of  an  active  process  by  means  of  which  the  cells  of  the  part 
are  enabled  to  replace  tissues  which  have  been  destroyed. 

Healing  of  a  wound  is  said  to  take  place  either  by  first  intention  or  by 
second  intention. 

In  healing  by  first  intention,  or  primary  union,  repair  takes  place  without 
suppuration.  When  an  incision  is  made  through  the  skin  and  superficial  tissues, 
the  edges  of  the  wound  separate  from  one  another  according  to  the  elasticity 
of  the  different  structures  which  have  been  divided :  the  wound  is  said  to  gape. 
The  bleeding  of  the  smaller  vessels  soon  ceases  spontaneously,  owing  to  the  con- 
traction of  their  lumen  and  to  the  retraction  of  the  arterioles  into  their  sheaths, 
where  they  are  soon  obstructed  by  the  formation  of  a  clot.  The  largest  vessels 
are  controlled  by  pressure,  torsion,  or  ligature.  When  the  blood  has  been 
washed  or  wiped  away  the  edges  of  the  wound  are  carefully  adjusted  by  means 
of  sutures.  If  such  a  wound  has  been  kept  perfectly  aseptic — that  is,  if  no 
bacteria  have  been  allowed  to  gain  access  to  it — we  shall  see  but  little  change 
in  the  appearance  of  its  edges  during  the  healing  process.  There  will  be  a 
slight  swelling  of  the  lips  of  the  wound,  and  the  tissues  in  the  immediate 
neighborhood  of  the  linear  incision  and  around  the  stitch  holes  will  be  some- 


2G  A^y  AMERICAN  TEXT-BOOK  OF  SURGERY. 

what  firnier  than  in  the  natural  state.  This  is  due  to  the  (iistiiiliance  in  the 
circulation  owing  to  division  of  the  vessels,  and  to  the  injury  done  to  the 
tissues.  There  is  no  redness,  as  hyperemia  is  usually  absent,  ))ut  a  moderate 
amount  of  exudation  occurs,  which  results  in  the  formation  of  fibrin,  by  means 
of  which  the  surfaces  brought  in  contact  are  tem])orarily  glued  together.  In 
large  wounds  the  amount  of  exudation  may  be  considerable,  and,  unless  it 
be  conducted  off  by  a  drainage-tube,  may  accumulate  in  spaces  which  have  not 
been  accurately  brought  in  contact,  and  thus  separate  the  o])posing  surfaces. 
In  order  to  avoid  this  either  buried  sutures  or  pressure  must  be  employed  to 
keep  the  raw  surfaces  of  the  wound  in  contact,  or  a  drainage-tube  must  be 
inserted  to  conduct  off  the  exudation,  and  thus  allow  the  raw  surfaces  to 
adhere. 

It  was  at  one  time  thought  that  the  edges  of  a  Avound  might  unite  by  what 
was  called  immediate  union — that  is,  by  an  adhesion  of  the  microscoj)ical 
structures  of  the  part,  without  any  reparative  effort.  It  is  now  known  that 
such  a  union  is  merely  the  temporary  adhesion  of  fibers  to  fibers  by  means  of 
fibrin,  which  is  preliminary  to  final  union  l)y  the  formation  of  new  tissue. 

In  all  large  wounds,  no  matter  how  careful  the  adjustment  of  the  parts  has 
been,  there  are  always  places  where  the  Avails  have  not  come  accurately  in 
contact.  If  we  examine  under  the  microscope  a  wound  healing  by  first  inten- 
tion, we  find  these  small  spaces  occupied  by  blood-corpuscles  and  masses  of 
coagulated  fibrin.  There  will  also  be  found  some  fragments  of  bruised  and 
injured  tissue,  and  here  and  there  small  portions  of  tissue  which  have  under- 
gone a  necrosis  owing  to  the  impairment  of  their  blood-supply.  At  the 
end  of  the  first  twenty-four  hours  there  Avill  be  an  accumulation  of  leucocytes 
along  the  line  of  the  wound.  The  number  of  these  cells  is  usually  small,  but 
when  inflammation  is  present  to  any  extent  they  may  accumulate  in  sufficient 
numbers  to  obscure  the  pre-existing  elements  of  the  tissue.  At  this  period  the 
vessels  are  not  seen  near  the  margins  of  the  Avound,  but  Thiersch  has  shoAvn 
by  injection  preparations  that  a  system  of  plasma-canals  exists,  Avhich  com- 
municate directly  Avith  the  adjacent  vessels,  and  that  many  of  the  red  blood- 
corpuscles  and  masses  of  fibrin,  apparently  extravasated  in  the  tissues,  lie  in 
these  spaces,  Avhich  thus  are  able  to  provide  nutriment  to  the  part  until  new 
blood-vessels  are  formed.  As  the  process  of  repair  proceeds  the  number  of 
cellular  elements  of  the  part — indifferent  cells,  as  they  are  called — increases 
perceptibly  (PI.  V). 

As  the  cells  increase  the  fibers  of  the  old  tissue  become  more  obscure,  and 
many  of  them,  and  of  other  elements  Avhich  have  undergone  retrograde  changes, 
disappear,  and  the  cells  seem  soon  to  be  supported  in  a  ncAv  granular  or  fibril- 
lated  or  reticulated  intercellular  substance,  and  the  so-called  granulation  or 
embryonic  tissue  is  formed.  At  first  this  is  composed  of  round  cells ;  in 
the  course  of  a  few  days,  hoAvever,  a  large  number  of  spindle-shaped  cells  are 
found  mingled  Avith  these,  and  other  large  cells  Avith  one  or  more  nuclei,  Avhicb 
are  called  e])ithelioid  cells.  A  high-poAver  microsco))e  Avill  shoAV,  in  fact,  the 
greatest  variety  of  shapes  at  this  time.  Later  the  sj^indle-shaped  cells  become 
more  numerous,  and  the  ncAv  tissue  begins  to  present  a  fibrous  appearance. 
The  origin  of  the  cells  of  the  granulation-tissue  is  a  subject  about  Avliich  there 
has  been  much  dispute.  According  to  Cohnheim,  these  cells  are  the  emigrated 
leucocytes,  Avhich  are  able  by  proliferation  to  produce  other  cells  like  them- 
selves, and  are  the  active  agents  in  the  formation  of  the  ncAv  tissue.  The  vicAV 
that  the  fixed  cells  of  the  connective  tissue  and  the  parenchyma  cells  of  organs 
are  able  to  proliferate  and  form  ncAV  cells  during  the  process  of  repair  has  been 
gradually  regaining  its  lost  position,  and  the  very  latest  views  are  as  folloAA's : 


PROCESS  OF   REPAIR, 


Plate  ^^ 


P- 


■5  t! 

0' 

i 

5 

^^•._ 

1/ 

,v 


u. 


Left  margin  of  wound  healing  by  first  intention  on  the  3d  day:  a,  epidermic  layer  showing  cells 
undergoing  karyokinesis  ;  b,  leucocytes  accumulating  on  the  edge  of  the  wound ;  c,  blood-cloi  filling 
dead  space— commencing  "  organization  ;"  d,  vein  from  which  leucocytes  are  emigrating. 


THE  PROCESS  OF  REPATR.  27 

Granulation-tissue  contains  many  leucocytes,  ])ut  they  take  no  active  part  in 
the  healing  process,  serving  simply  as  food  for  the  other  cells  as  soon  as  they 
have  reached  a  certain  stage  in  their  career,  known  as  the  polynuclear  stage, 
a  point  beyond  Avhich  they  are  unable  to  develop.  The  cells  coming  from  the 
proliferating  tissue-cells  are  the  constructors  of  the  new  tissue,  and  they  have 
in  early  life  amoeboid  movements  (Ziegler).  It  is  not  possible  to  distinguish 
the  two  kinds  of  cells  in  granulation-tissue,  and  Avhen  cells  of  either  kind 
become  polynuclear  they  are  no  longer  able  to  take  an  active  part  in  the 
growth  of  tissue  (Grawitz).  It  is  proposed  by  Marchand  to  call  the  leucocytes 
found  in  granulation-tissue  "  exudation-cells,"  and  the  proliferating  connective- 
tissue  cells  the  "formative  cells."     Soon  after  the  first  day  of  the  healing 


Fig.  9. 


\my- 


-y^Yf^ 


■aiiim  \>\  i.raiuilaii' 


ia'ocess  new  vessels  begin  to  form  in  loops  which  develop  from  the  pre-exist- 
ing vessels.  On  the  surface  of  a  capillary  loop  a  mass  of  granular  protoplasm 
is  seen,  which  gradually  increases  in  size  and  grows  to  an  elongated  mass  of 
solid  nucleated  protoplasm  which  projects  toward  the  edge  of  the  wound. 
These  prolongations  either  become  attached  to  the  wall  of  another  vessel,  or 
unite  with  similar  outgrowths  from  other  vessels  or  with  the  cells  of  the  sur- 
rounding tissue.  Later,  the  central  portion  of  these  newly-formed  structures 
melts  away,  and  they  become  hollow  and  establish  a  communication  with  the 
vessels  from  which  they  spring.  The  wall  of  the  new  vessel  is  at  first  homo- 
geneous, but  later  becomes  nucleated  and  lined  with  endothelium.  In  this  w^ay 
a  mass  of  capillary  loops  form  on  either  side  of  the  wound,  eventually  becoming 
united  and  forming  an  exceedingly  rich  capillary  network  in  the  new  tissue. 
As  cicatrization  completes  itself  many  of  the  spindle  cells  and  round  cells  dis- 
appear. Some  undergo  granular  degeneration  and  are  absorbed ;  others  wander 
into  the  adjacent  lymph-spaces,  and  are  taken  up  again  into  the  circulation; 
many,  after  reaching  a  certain  stage  of  development,  are  destroyed  by  the  more 
active  cells  in  the  reparative  process.  As  the  cells  vanish  new  fibers  make 
their  appearance,  and  the  wound  becomes  thus  firmly  united.  In  the  mean 
time,  on  the  surface  a  clot  or  crust  of  broken-down  blood-corpuscles,  epithelial 
scales,  and  exudation-material  has  formed,  underneath  w^hich  new  epithelium 
develops  from  the  deeper  layers  of  the  rete  mucosum  which  covers  in  the  sur- 
face of  the  wound. 

When  from  loss  of  tissue  or  other  cause  it  has  not  been  possible  to  close  a 
wound,  and  the  lips  are  separated  widely  from  one  another,  union  can  only  take 
place  by  the  process  of  healing  by  granulation,  or  second  intention  (Fig.  9). 
If  we  watch  such  a  wound  with  the  naked  eye  we  shall  observe,  in  the  course  of 
an  hour,  that  a  film  has  formed  upon  the  surface  ;  the  wound  has  become  glazed 
by  the  deposition  of  a  thin  layer  of  coagulated  fibrin.  This  layer,  at  first  trans- 
parent, soon  becomes  stained  with  masses  of  coagulated  blood  and  fragments  of 


28  AN  AMERICAN  TEXT-BOOK  OE  SURGERY. 

fibers  torn  from  their  surroun(lin<^s  and  lyin^  upon  tlie  surface.  This  hiyer  is 
also  soon  occupied  by  numbers  of  emigrated  leucocytes.  In  this  way  the  wound 
is  covered  over  so  that  the  structures  beneath  can  no  longer  be  recognized.  The 
discharge  which  flows  from  the  wound  is  at  first  of  a  reddisli  liue,  and  consists 
chiefly  of  bloody  serum  in  which  are  floating  fragments  of  broken-down  tissue. 
This  gradually  changes  to  a  grayish  color,  and  is  found  to  contain  more  white 
corpuscles  and  fewer  red  corpuscles  as  time  goes  on.  In  a  few  days  the  dirty 
layer  covering  the  surface  of  the  wound  is  washed  away  by  the  discharge, 
which  has  now  assumed  the  yellowish-white  or  creamy  color  of  pus,  and  the 
wound  is  said,  in  surgical  parlance,  to  clean  off".  As  the  d6bris  is  swept  away 
we  find  underneath  a  surface  of  bright  and  irregular-shaped  nodules  wliich  are 
called  granulations.  The  time  which  granulations  take  to  form  may  vary 
from  two  or  three  days  to  a  week,  according  to  the  health  of  the  individual  or 
the  nature  of  the  tissue  involved.  Microscopically,  tbe  tissue  consists  chiefly 
of  small  round  cells  mingled  with  epithelioid  or  larger  cells,  such  as  are  seen  in 
the  so-called  granulation-tissue,  the  origin  of  which  has  already  been  described. 
The  velvety  appearance  of  a  granulating  surface  is  due  to  the  little  elevations 
on  the  surface  produced  partly  by  growth  of  colls  near  the  blood-vessels  and 
partly  by  the  oedema  of  certain  portions  of  the  tissue. 

The  cavity  of  the  wound  is  gradually  obliterated,  partly  by  the  growth  of 
the  granulations  and  partly  by  cicatricial  contraction  by  wdiich  the  edges  of  the 
wound  are  approximated.  In  the  mean  time  the  epidermic  cells  by  prolifera- 
tion begin  to  cover  in  the  margins  of  the  open  surfiice  of  the  wound,  and  a 
thin  bluish-white  border  indicates  the  presence  of  a  fresh  epithelial  cell-growth. 
New  formation  of  epithelial  cells  cannot  occur  in  the  center  of  the  wound 
unless  some  fragment  of  epithelial  structure,  such  as  a  portion  of  a  papilla, 
sweat-ducts,  or  hair-follicles,  may  have  remained,  from  which  such  an  outgrowth 
could  take  place;  hence  cicatrization  always  progresses  from  the  circumference 
toward  the  centre.  Occasionally  the  growth  of  granulations  is  so  exuberant 
that  they  project  above  the  surface  of  the  skin,  and  the  epithelium  may  then  be 
unable  to  cover  in  all  the  surface.  This  "proud  flesh,"  as  it  is  popularly 
called,  must  be  removed  with  the  knife  or  caustic  before  the  healing  process 
can  be  completed.  Healing  may  take  place  by  direct  union  of  granulating 
surfaces,  or  healing-  by  third  intention.  It  readily  occurs  in  wounds  ren- 
dered aseptic  and  kept  so  by  the  use  of  iodoform  or  sterilized  gauze.  The 
gauze  being  removed  on  the  second  or  third  day,  the  surfaces  from  which  little 
or  no  secretion  exudes  are  brought  in  apposition  and  unite. 

After  the  cicatrix  has  freely  developed,  it  consists  of  fibers  interwoven  in 
various  directions  possessing  great  contractile  powers,  which  cause  many  of 
the  delicate  vessels  to  disappear  and  the  red  scar  to  grow  pale.  In  extensive 
scars  this  contraction  gives  rise  to  groat  deformities,  particularly  Avhen  the 
wound  is  situated  in  regions  where  two  adjacent  portions  of  the  body  may  be 
thus  bound  together  by  a  dense  scar.  Examples  of  tliis  may  be  seen  after 
burns  on  the  neck  or  at  the  flexures  of  the  joints  (see  Burns). 

Granulations  are  not  always  firm  and  red:  occasionally  they  are  pale  and 
flabby,  which  appearance  is  due  to  an  unusually  oedcmatous  condition.  These 
are  often  seen  in  tubercular  processes.  Erothistic  granulations  bleed  easily 
and  are  excessively  painful.  They  appear  to  be  caused  by  some  mechanical 
disturbance  of  the  wound.  The  surface  of  the  wound  will  sometimes  be 
found  covered  with  a  membrane  which  has  a  diphtheritic  appearance,  and  is 
caused  by  imperfect  development  of  the  capillary  vessels  or  is  due  to  their 
obstruction  by  inflammation.  A  coagulation-necrosis  of  the  upper  layers  of 
the  granulation  is  thus  produced. 


THE  PROCESS  OF  REPAIR. 


29 


The  healing  of  subcutaneous  wounds  does  not  differ  essentially  from 
the  j)rocess  already  described.  Kejjair,  however,  usually  takes  place  without 
suppuration.  In  this  case  we  find  the  seat  of  the  wound  occupied  by  a  blood- 
clot,  sometimes  of  considerable  size.  As  repair  progresses  the  extravasated 
blood  is  gradually  absorbed,  and  granulations  j)usli  out  from  the  surrounding 
connective  tissue  and  ramify  in  the  clot,  which  furnishes  a  favorable  culture 
soil  for  the  new  cell-growth.  The  amount  of  inflammation  which  will  accom- 
pany this  process  depends  upon  the  degree  of  injury  or  upon  bacterial  infec- 
tion. In  the  case  of  infection  by  sloughing  of  the  integuments  or  of  intra- 
vascular infection,  suppuration  will  take  place  and  an  abscess  will  form. 

The  same  mode  of  healing  under  a  blood-clot  occurs  when  an  open 
sterile  wound  has  been  filled  with  an  ase})tic  blood-clot  which  is  allowed  to 
remain.  The  layer  of  clot  which  covers  the  surface  becomes  hard  and  dry, 
and  gradually  loses  its  dark  color.  As  the  clot  shrinks  the  epithelial  margins 
follow  close  upon  its  edges,  while  the  connective  tissue-growth  beneath  has 
been  substituting  itself  for  the  fibrin  and  blood-corpuscles  which  are  gradually 
absorbed.  When  the  wound  has  healed  the  remains  of  the  surface  clot  break 
up  and  come  away  with  the  dressings,  and  a  firm  cicatrix  is  disclosed.  If 
infection  of  the  wound  has  taken  place,  the  clot  will  break  down  and  be  swept 

Fig.  10. 


6- 


Process  of  Repair  of  a  Wound :  a,  cells  forming  connective-tissue ;  6,  leucocytes ;  c,  newly-formed  blood- 
vessels (original). 

away  with  pus  which  forms,  and  the  wound  Avill  then  heal  by  granulation. 
This  method  of  healing  by  organization  of  the  blood-clot,  as  it  has  been 
called,  is  the  one  which  usually  occurs  in  ruptures  of  the  internal  organs,  such 
as  the  liver  or  the  kidneys. 

The  formation  of  fibrillar  connective  tissue  is  accomplished  by  the  prolifera- 
tion of  the  fixed  cells  of  the  connective  tissue.  Cell-division  takes  place  either 
directly  or  indirectly.  Direct  cell-division  (Fig.  10),  which  is  simply  a  segmen- 
tation of  the  nucleus  followed  by  a  division  of  the  whole  cell,  was  thought  to  be 
the  ordinary  mode  of  cell-growth,  but  the  indirect  method  is  the  one  which 
usually  occurs.    This  latter  is  known  as  karyokinesis  (Fig.  11).    When  such 


30 


AN   AMi:i!I('AX    Ti:XT-lU)OK    OF  SLRUKllY 


a  mode  of  cell-division  is  iil)oiit  tf)  take  ])lacc,  the  delicate  reticulum  of  fiber  of 
which  the  nucleus  is  composed  when  in  the  (juiescent  state — an<l  which  is  called 
chromatine  substance,  from  its  capacity  to  take  staining  fluids — becomes  con- 


Fk;.  1 1. 


Karyokinesis,  or  Iiulirect  Cell-division  (Zieglon :  «,  cell  with  nucleus  in  iiwiescent  state.  The  nucleus 
contains  nucleoli  and  a  network  of  threads  ;  h,  formation  of  coarse  chromatine  threads  in  nucleus  ; 
f,  disappearance  of  nucleolus  and  membrane  of  nucleus ;  arrangement  of  threads  in  loops  forming 
the  "  rosette  "  ;  </,  angles  of  loops  directed  toward  the  poles  of  the  cell,  which  are  formed  of  achro- 
matic threads;  c,  beginning  division  of  the  cell;  this  is  followed  by  a  gradual  return  of  the  nucleus 
to  the  quiescent  state  (a). 

verted  into  a  skein  of  contorted  filaments,  wliicli  rrradually  assumes  the  shape  of 
a  rosette,  and  subsequently  a  star.  Mean-vvhile  the  wall  of  the  nucleus  has  dis- 
appeared. In  a  later  or  equatorial  starje  of  the  process  the  star-shaped  mass  of 
filaments  separate  into  two  groups,  which  dispose  themselves  around  the  two  poles 
of  the  nucleus,  leaving  a  clear  space  in  the  plane  of  the  equator.  When  the 
nucleus  has  thus  divided  the  filaments  return  to  their  former  quiescent  state.  The 
protoplasm  is  contracted  along  the  line  of  equatorial  division,  and  the  division 
of  the  cells  becomes  complete  (Quain).  The  new  cells,  or  fihrohlasis,  as  they  are 
called,  become  elongated  by  the  formation  of  prolongations  from  their  extremi- 
ties, and,  as  shown  above,  develop  fibrillse  by  a  differentiation  of  their  proto- 
phism. 

Examples  of  ivoimds  of  hJoodlcKn  tissues  are  seen  in  the  cornea  and  in  car- 
tilage. When  the  cornea  is  divided  and  the  wound  gapes,  it  is  filled  in  at  first 
partly  by  a  coagulum  of  fibrin,  and  partly  by  a  growth  of  e])ithelial  cells.  At 
the  end  of  a  few  days  the  corneal  corpuscles  begin  to  proliferate  and  push  aside 
the  elements  which  occupy  the  cleft,  and  thus  permanently  close  the  wound. 
In  cartilage,  owing  to  the  poor  supply  of  nutriment,  the  cells  appear  to  take  but 
a  feeble  ])art  in  the  process  of  repair.  Incised  wounds  of  joint-cartilage  are 
found  many  weeks  after  the  injury  filled  with  a  clot  of  fibrin,  which  eventually 
is  replaced  by  connective  tissue.  The  cartilage-cells  near  the  wound  become 
polynucleated,  and  the  intercellular  substance  becomes  fibrillated,  but  this  is 
probably  only  a  retrograde  metamorphosis. 

Neiv  epidermis  is  formed  by  proliferation  of  the  epithelial  cells.  New 
epithelial  cells  possess  amoeboid  movements,  and  may  wander  a  short  distance 
from  ilie  margin  of  the  wound.  The  deep  layers  of  the  rete  mucosum  furnish 
cells  which  multiply  rapidly,  and  it  is  this  layer  of  the  skin  which  is  utilized 
by  Reverdin  in  transplanting  small  grafts  to  the  granulations.  The  success 
of  the  Thiersch  method,  which  consists  in  the  transplantation  of  portions  of 
skin  several  inches  in  length  to  the  freshly-cut  surface  of  open  wounds,  is  due 
to  this  fact.  The  grafts  are  cut  with  the  razor  and  are  exceedingly  thin,  so 
that  only  the  most  superficial  portions  of  the  skin  are  removed. 

Refjeneration  of  striped  muscular  liher  occurs  to  some  extent  in  slight  injuries. 
The  cicatrix  following  a  wound  in  the  muscle  is,  however,  usually  composed  of 
connective  tissue,  and  the  fragments  of  the  muscle  are  thus  united  by  a  tendin- 
ous mass.     At  first  an  increase  in  the  size  and  number  of  the  muscular  nuclei 


THE   PROCESS    OF  REPAIR.  31 

are  seen.  Some  observers  have  noticed  karyokinetic  changes  in  tliese  nuclei. 
These  new  cells  or  sarcoblasts  assume  a  spindle  shape  and  are  arranged  in  rows, 
and  at  the  end  of  the  third  week  begin  to  show  striations.  Each  spindle  cell 
elongates,  and  finally  forms  a  muscular  fiber.  Regeneration  of  muscular  fiber 
has  been  observed  in  myocarditis,  and  has  also  been  produced  experimentally 
in  animals.  Attempts  to  graft  the  muscle  of  a  dog  into  a  wound  of  the 
biceps  following  extirpation  of  a  tumor  did  not  succeed.  Large  loss  of 
substance  of  muscle,  ho^^ever,  may  not  be  followed  by  much  impairment  of 
motion. 

Refieneration  of  nerve-tissue  is  sufficiently  perfect  to  unite  the  ends  of 
divided  nerves  which  have  been  sutured,  and  to  restore  even  the  continuity 
of  nerves  which  have  been  resected  in  their  trunks  for  the  cure  of  pain. 
Views  differ  as  to  the  histological  changes  which  occur  during  the  process  of 
repair.  Gi'owth  appears  to  be  more  active  from  the  central  end,  although 
it  may  take  place  from  the  peripheral  end  also.  The  axis-cylinders  become 
elongated  and  divide  into  several  fibers,  which  later  are  covered  by  the  medul- 
lary sheaths.  According  to  another  view,  the  axis-cylinders  may  be  formed 
by'^a  growth  of  spindle  cells,  neuroblasts,  which  takes  place  from  both  ends 
of  the  divided  nerve  and  unites  the  two  fragments.  Around  these  cylinders 
medullary  substance  is  deposited  later,  and  new  sheaths  are  thus  produced. 
The  completion  of  the  process  takes  several  months.  When  the  ends  of  the 
nerve  are  separated  by  a  distance  of  over  one  inch  in  length,  repair  can  rarely 
take  place  spontaneously.  The  ends  of  the  nerves  have  then  a  club-shaped 
enlargement,  due  chiefly  to  a  growth  of  the  neurilemma,  and  many  of  the  fibers 
become  degenerated.  Suturing  of  the  ends  of  a  divided  nerve,  with  restora- 
tion of  function,  has  been  accomplished  over  a  year  after  the  injury. 

When  a  tendon  is  divided  the  two  ends  are  separated  from  each  other  in 
the  tendon-sheath,  and  a  flow  of  blood  fills  the  intervening  space  with  clot. 
A  growth  of  cells  takes  place  from  the  sheath  and  surrounding  tissue,  and 
granulations  force  their  way  into  the  clot,  which  is  absorbed.  The  new  tissue 
gradually  assumes  the  appearance  of  a  fibrous  tissue  running  parallel  with  the 
fibers  of"^the  tendon.  The  tendon  does  not  at  first  appear  to  take  any  part  in 
the  process  of  repair ;  later  it  is  difficult  to  distinguish  between  the  old  and  the 
new  fibers.  The  new  tissue  appears  to  be  derived  chiefly  from  the  connective 
tissue. 

When  a  hone  is  broken  the  new  tissue  which  unites  the  fragments  is  usually 
bone  (Fie.  12).  A  true  regeneration  of  bone,  therefore,  does  take  place.  The  tis- 
sue Avhich  first  forms  around  and  between  the  ends  of  the  bone  is  of  a  temporary 
character,  and  is  called  the  provisional  callus  ;  that  formed  from  the  periosteum 
is  called  the  external  callus :  and.  that  from  the  medullary  tissue,  the  internal 
callus.  The  intermediate  callus  lies  between  the  ends  of  the  bone,  and  is  at 
first,  in  part,  a  growth  from  both  of  these  regions ;  but  it  is  here  that  the  per- 
manent cicatrix  is  finally  developed  from  the  bone-forming  tissue.  The  size 
of  the  callus  will  depend  upon  the  amount  of  traumatism  and  the  amount  of 
displacement  and  of  motion  during  the  process  of  repair.  Later  the  provisional 
callus  is  absorbed,  and  cicatrization  is  sometimes  so  perfect  that  it  is  difficult 
to  detect  the  precise  seat  of  an  old  fracture.  In  groicing  hone  the  cells  which 
are  most  active  in  the  process  of  development  are  found  in  the  deeper  layers  of 
the  periosteum.  Here  an  active  cell-growth  takes  place,  and  medullary  spaces 
containing  the  bone-forming  cells  or  osteoblasts  are  developed.  A  growth  of 
bone  also  occurs  in  the  deeper  layers  of  the  cartilage.  Bone-salts  are  deposited 
between  the  cartilage-cells,  and  the  spaces  occupied  by  them  are  converted  into 
jaedullary  spaces,  and  the  medullary  cells,  and  probably  also  cartilage-cells, 


32 


AN  AMERICAN   TEXT- BOOK   OF  SURGERY. 


become  converted  into  osteoblasts.  The  osteoblasts  form  new  bone  by  a  chanf^e 
of  their  protoplasm  into  a  finely  fibrillated  or  homogeneous  material,  -which  by 
a  deposit  of  lime-salts  is  transformed  into  bony  lamellnc.  Absorption  of  bony 
substance  is  accomplished  by  giant  cells,  now  known  as  osteoclasts,  which  are 
derived  from  the  protoplasm  of  the  various  kinds  of  cells  which  come  in  contact 
with  bony  tissues  (Tillmans).  These  cells  are  said  to  form  carbonic  dioxide, 
■which  dissolves  the  lime-salts. 

The  ossification  of  the  external  callus  is  accomplished  by  the  osteoblasts. 
These  cells  are  observed  developing  in  the  granulation-tissue  Avhich  has 
formed  between  the  bone  and  the  periosteum.  The  osteoblasts  develop  an 
osteoid  tissue  which  subsequently,  by  deposit  of  lime  salts,  becomes  true  bone ; 
or  the  bone-formation  may  be  preceded  by  the  development  of  cartilage  from 
these  formative  cells.  In  the  second  week  an  osteophytic  growth  is  already 
seen  on  the  surface  of  the  bone,  and  by  the  end  of  the  third  week  the  peri- 
osteal callus  usually  consists  of  firm,  spongy  bone.  A  similar  formation  of 
bony  tissue  occurs  in  the  medullary  cavity  in  the  development  of  the  internal 
callus  (Fig.   13).     The  amount  of  this  growth  varies   greatly  in  different 

Fig.  13.  Fig.  14. 


Fracture  One  Week  :  blood- 
clot  contain^  fragment 
of  bone  (original). 


Callus  of  Fracture  (dog)  Four 
Weeks :  commencing  ossi- 
fication of  external  callus 
(original). 


Femur  of  a  Child  Fifth  Week  after 
Fracture  (original). 


cases.  Formation  of  cartilage  also  occurs  here  near  the  seat  of  fracture,  but 
is  not  so  constant  or  extensive  as  in  the  periosteal  callus.  The  provisional 
callus  becomes  converted  into  a  permanent  cicatrix  by  a  condensation  of  its 
tissue.  An  absorption  of  its  more  superficial  and  deeper  portions  also  takes 
place — a  process  which  is  brought  about  mainly  by  the  action  of  the  osteo- 


THE  PROCESS   OF  REPAIR. 


33 


Fig.  15. 


clasts.  Tlio  dense  cortical  bone  at  the  point  of  fracture  shows  at  first  no 
change,  but  subsecjuently  becomes  porous  and  finally  unites  with  the  adjoining 
fragment.  It  is  eventually  changed  again  into  dense  bone  by  the  action  of 
the  osteoblasts.  Tlie  medullary  cavity  of  the  bone,  sometimes  completely 
broken  in  its  continuity  by  an  overlapping  of  the  fragments,  is  finally  more 
or  less  completely  restored  (Fig.  14). 

The  healing  of  arteries  after  ligature  is  not  unlike  that  of  bone  in  the 
sequence  of  events.  We  liave  here  also  a  provisional  growth  Avhich  forms 
around  the  ligature  and  encloses  the  two  ends  of  the  vessel ;  as  in  the  bone, 
the  size  of  the  ''callus,"  as  it  may  be  called,  will  depend  upon  the  amount  of 
traumatism.  In  the  interior  of  the  vessel  a  thrombus  forms,  which  in  purely 
aseptic  operations  is  exceedingly  small,  and  it  has  been  maintained  by  some 
observers  to  be  absent  altogether  under  these  conditions.  The  proximal 
thrombus  is  usually  larger  than  the  distal  one.  The  external  growth  or 
"callus"  is  composed  of  granulation-tissue,  and  as  the  walls  about  the  ligature 
are  infiltrated  with  leucocytes,  the  ligature  loosens  its  hold  upon  the  vessel, 
and  the  two  ends  retract  and  separate  slightly  from  one  another,  but  are  still 
held  enclosed  in  the  external  callus.  The  ends  of  the  vessel  now  open  slightly, 
and  admit  a  growth  of  granulation-tissue  which  infiltrates  the  thrombus. 
Subsequently  this  granulation-tissue  is  absorbed,  and  as  it  disappears  it 
becomes  apparent  that  a  growth  has  taken  place  from 
the  walls  of  the  vessel  which  forms  the  permanent  cica- 
trix. In  the  interior  a  formation  of  new  tissue  has 
taken  the  place  of  the  thrombus,  which  now  has  disap- 
peared. If  the  thrombus  has  been  a  large  one,  there 
will  be  a  considerable  growth  of  connective  tissue  filled 
with  vascular  spaces.  A  new  growth  of  endothelium 
covers  this  tissue  and  lines  the  new  vessels  contained  in 
it.  In  aseptic  wounds  the  amount  of  connective-tissue 
growth  is  small,  and  we  then  find,  when  the  process  is 
completed,  a  crescent-shaped  cicatrix  at  the  end  of  the 
cul-de-sac  formed  by  the  ligatured  vessel.  The  surface 
of  this  cicatrix  is  covered  with  a  new  endothelium ; 
below  this  is  a  new  layer  of  muscular  cells  which  have 
developed  from  the  media,  and  externally  is  a  connec- 
tive-tissue growth  from  the  adventitia  (Warren).  The 
two  ends  of  the  vessel  are  now  united  by  a  ligamentous 
bond.  The  usual  method  of  ligature  is  to  apply  a 
single  thread  around  the  vessel  with  sufficient  force  to 
rupture  the  internal  coats.  Unless  this  is  done  there 
is  a  possibility  that  the  lumen  of  the  vessel  may  not 

be  obliterated.  According  to  Senn,  however,  two  ligatures  can  be  applied 
near  each  other,  without  sufficient  force  to  rupture  the  coats,  with  speedy 
obliteration  of  the  vessel.  Ballance  and  Edmunds  believe  that  the  cicatrix 
is  composed  of  ordinary  scar -tissue  formed  from  the  connective-tissue  elements 
in  the  vessel-walls.  They  also  recommend  a  double  ligature,  the  material 
being  tendon  or  peritoneum.  Their  sta^  knot,  recommended  for  large  vessels, 
is  tied  as  follows :  The  first  hitch  of  a  reef  knot  should  be  made  on  each 
ligature  separately,  and  the  ligatures  should  be  so  tightened  that  the  loop  lies 
in  contact  with  the  vessel  without  constricting  it.  Then,  taking  the  corre- 
sponding ends  of  the  two  ligatures  in  the  two  hands,  constrict  the  vessel  so  as 
to  occlude  it.  Then  complete  the  reef  knot,  treating  the  two  ends  in  each 
hand  as  if  they  were  a  single  thread.     In  amputation-stumps  the  ligatured 


Carotid  Artery  of  Horse, 
Two  Months  after  Liga- 
ture :  a,  thrombus ;  6, 
callus  :  r,  arterial  wall; 
d,  ligature  sinus  (orig- 
inal). 


34 


AN  AMERICAN  TEXT-BOOK   OF  SURGERY, 


artery  does  not  terminate  abruptly  in  a  cul-de-sac  at  the  point  of  ]if];ature, 
but  is  partially  obliterated  for  some  distance  from  the  ligature  by  a  growth 
from  the  intima  and  other  coats  of  the  vessel.  This  compensatory  end- 
arteritis ada])ts  the  vessel  to  the  greatly  diminished  blood-suj)ply  needed  for 
the  stump.  After  ligature  in  continuity  the  branches  given  off  above  and 
below  the  ligature  become  enlarged,  and,  anastomosing  with  one  another, 
establish  a  collateral  circulation. 


CHAPTER    IV. 


THE  TRAUMATIC  FEVERS. 

The  fever  which  occurs  after  the  infliction  of  a  wound  may  be  aseptic  or 
septic,  according  to  the  conditions  which  prevail  at  the  time  of  the  trauma  or 
injury. 

Clinically,  surgical  fevers  may  be  divided  into  two  main  groups,  the 
benign  and  the  malignant  types  of  fever.  It  is  the  former  group  only  which 
is  considered  in  this  chapter. 

The  benign  group  includes  those  forms  which  are  described  usually 
as  traumatic  fever,  and  includes  aseptic  fever,  septic  or  "  surgical "  fever, 
as  it  was  formerly  called,  and  suppurative  fever.  To  these  may  be  added 
certain  special  forms,  such  as  surgical  scarlet  fever  and  urethral  fever. 

The  malignant  group  comprises  septicemia,  sapremia,  and  pyemia.'  Sep- 
ticemia and  sapremia  may  be  regarded  as  malignant  types  of  surgical  fever, 
and  pyemia  the  malignant  type  of  suppurative  fever. 

Aseptic  fever  is  characterized  by  a  pyrexia  which  accompanies  wounds 
healing  by  first  intention.     It  was  formerly  supposed  that  fever  was  a  symp- 

FlG.  1«. 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

II 

12 

13 

107° 
106° 
IOS° 
104* 
103* 
102' 
101* 
100° 

99* 

98° 

A 

y\ 

/\ 

1 

/ 

/     ^ 

v 

^^ > 

^. 

,^ 

^ 

Temperature  Chart  of  a  case  of  Aseptic  Fever  (original). 

torn  necessarily  associated  with  infection  of  the  wound,  but  after  the  anti- 
septic treatment  of  wounds  was  perfected  it  was  discovered  that  many  wounds 
thus  treated  were  accompanied  by  a  considerable  rise  of  temperature,  par- 

1  See  pp.  60  and  63. 


THE    TRAUMATIC  FEVERS.  35 

ticularly  those  in  whicli  a  large  amount  of  blood-clot  existed  between  the  lips 
of  the  wound,  or  in  large  wounds  where,  necessarily,  more  or  less  bruising 
of  the  tissues  has  occurred    (Fig.  16). 

It  has  been  shown  by  experiment  that  a  large  number  of  chemical  sub- 
stances when  introduced  into  the  circulation  will  produce  a  rise  of  tempera- 
ture. Among  them  is  the  fluid  obtained  from  defibrinated  blood,  which 
contains  a  substance  known  as  fibrin-ferment.  When  injected  into  animals 
this  ferment  produces  extensive  coagulation  of  blood  in  the  vessels  and  death. 
Other  substances,  as  pepsin,  and  even  water,  when  injected  will  produce 
febrile  disturbance. 

During  the  healing  of  a  large  wound  there  is  necessarily  a  breaking  down 
of  minute  portions  of  tissue  and  blood-clot,  which,  Avith  eifused  serum,  are 
absorbed  in  greater  or  lesser  quantity.  These  chemical  substances  are  but 
slightly  altered  from  their  normal  condition,  but  when  absorbed  appear  to 
have  what  is  known  as  a  pyrogenous  or  fever-producing  action. 

The  normal  temperature  of  the  body  is  98.4°  F.,  or  37°  C.  During  this 
form  of  constitutional  disturbance  the  temperature  may  rise  to  102°  F.,  and 
not  return  to  normal  for  several  days.  Beyond  the  pyrexia  there  are  but  few 
symptoms  in  aseptic  fever.  The  patients  thus  affected  do  not  suffer  from 
malaise  or  delirium,  and  are  rarely  conscious  of  feeling  ill.  They  may  be 
able  to  sit  up  in  bed  or  to  move  about  the  room. 

This  form  of  fever  is  seen  during  the  healing  of  simple  fractures  and  of 
wounds  in  which  no  drainage  has  been  employed,  or  in  very  large  wounds 
which  are  healing  by  first  intention. 

Traumatic,  Septic,  or  Surgical  Fever. — Before  the  introduction  of  the 
antiseptic  method  of  treatment  all  wounds  healed  with  more  or  less  inflam- 
mation, even  when  suppuration  did  not  occur,  and  this  Avas  supposed  to  be  a 
part  of  the  process  of  repair.  The  amount  of  constitutional  disturbance  was 
considerable,  and  was  called  surgical  or  traumatic  fever.  Examples  of  this 
type  are  seen  to-day  in  Avounds  that  have  not  been  treated  antiseptically,  partic- 
ularly those  Avhich  are  d\ie  to  injuries  and  have  been  exposed  to  septic  infection. 
The  presence  of  bacteria  of  various  kinds  in  the  secretions  of  such  wounds 
gives  rise  to  a  fermentative  process  during  Avhich  ptomaines  are  developed 
and  are  absorbed,  producing  fever.  Very  fcAv  bacteria  are  found  in  the  blood 
during  this  type  of  fever,  and  if  present  they  are  rapidly  eliminated.  There 
is  no  progressive  development  of  bacteria  in  the  system,  as  in  septicemia. 

Surgical  fever  is  not  to  be  confounded  with  suppurative  fever,  for,  although 
suppuration  may  occur  in  inflammations  Avhich  produce  the  former,  the  tem- 
perature falls  when  suppuration  takes  place,  and  the  decomposing  fragments 
of  tissue,  together  with  the  ptomaines  they  produce,  are  Avashed  aAvay.  Sur- 
gical fever  is  produced  by  the  products  of  decomposition  rather  than  by  those 
of  suppuration. 

The  constitutional  symptoms  correspond  pretty  accurately  with  the  con- 
dition of  the  wound  and  the  amount  of  inflammation.  There  is  a  sharp  rise 
of  temperature  a  day  or  tAvo  after  the  operation  or  injury ;  the  skin  is  hot 
and  dry,  the  pulse  rapid,  and  the  tongue  coated.  The  subjective  symptoms 
are  also  more  marked;  the  patient  suffers  greatly  from  heat,  thirst,  and  rest- 
lessness, and  there  may  be  delirium.  The  urine  is  scanty  and  highly  colored. 
On  the  evening  of  the  second  day  the  thermometer  indicates  a  temperature 
of  102°  or  more  in  the  axilla.  The  folloA\dng  morning  the  temperature 
drops  a  degree,  to  rise  higher  than  before  in  the  evening.  On  the  third  or 
fourth  day,  when  suppuration  is  established,  the  wound  cleans  off,  granula- 
tions spring  up,  the  chemical  substances  which  have  caused  the  pyrexia  are 


36  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

no  longer  absorbed,  and  the  temperature  falls.  Surgical  fever  does  not  last 
over  a  week,  by  the  end  of  uhich  time  the  symptoms  of  fever  liave  entirely 
disappeared. 

ihe  constitutional  disturbance  in  this  form  of  fever  usually  corresponds 
pretty  accurately  with  the  local  condition  of  the  wound.  Wlien,  therefore, 
all  symi)toms  are  well  marked,  infection  of  the  Avound  siiould  be  suspected 
and  the  dressing  should  be  removed  for  a  thorough  examination.  The  lips  of 
the  wound  are  usually  found  red,  swollen,  and  tender,  and  on  pressure  decom- 
posed blood-clot,  and  perhaps  pus,  may  ooze  at  one  or  two  points  from  between 
the  lips  of  the  wound.  The  stitches  should  be  removed,  the  wound  opened 
and  disinfected,  and  a  moist  dressing  in  the  form  of  antiseptic  fomentations 
should  be  applied. 

In  slight  disturbances  such  a  dressing  may  suffice  to  carry  off  all  decom- 
posing secretions  without  removing  the  stitches,  and  the  wound  may  heal 
after  all  by  first  intention.  Experience  only  will  enable  the  surgeon  to 
decide  whether  to  interfere  or  to  leave  the  wound  undisturbed. 

Suppurative  fever,  or,  as  it  is  sometimes  called,  secondary  fever, 
is  a  term  employed  to  denote  that  febrile  condition  which  prevails  after  sup- 
puration has  been  established.  It  occurs  only  in  those  cases  in  which  pus  is 
retained,  so  that  some  of  its  constituents  are  absorbed. 

If  at  the  usual  period  of  defervescence  of  surgical  fever  we  find  the  tem- 
perature remains  high,  or  there  is  a  rise  after  the  usual  fall,  it  is  highly 
probable  that  an  accumulation  of  pus  has  taken  place  between  the  lips  of  the 
wound  and  is  unable  to  escape.  The  pyrexia  is  probably  produced  by  the 
absorption  of  a  chemical  substance  which  has  been  formed  by  the  pyogenic 
organisms.  The  micrococci  are  not  found  to  any  extent  in  the  blood  or 
tissues,  and  the  fever  curve  drops  as  soon  as  the  pus  is  evacuated.  It  is 
evident,  therefore,  that  there  is  no  progressive  infection  of  the  system  by 
virus  already  absorbed,  as  in  pj^emia. 

When  pus  is  confined  in  a  wound  the  constitutional  disturbance  is  usually 
well  marked.  There  is  a  sharp  rise  of  temperature,  accompanied  perhaps  by 
a  chill.  If  the  pus  is  evacuated  promptly,  the  suppurative  process  may  be 
arrested,  but  occasionally  the  surrounding  tissues  become  affected  and  the 
pus  burrows  in  various  directions. 

The  fever  corresponds  pretty  accurately  Avith  the  degree  of  local  inflam- 
mation. During  the  acute  stage  the  fever  remains  high  with  slight  diurnal 
variations ;  later,  when  a  state  of  chronic  suppuration  has  been  established 
and  pus  is  to  be  found  accumulating  at  the  bottom  of  numerous  sinuses,  the 
fever  curve  assumes  a  remittent  type,  falling  in  the  morning  to  the  normal 
point,  to  rise  again  several  degrees  in  the  evening.  This  is  the  type  of  the 
so-called  hectic  fever  (Ixr^zor,  a  habit),  accompanying  the  chronic  suppura- 
tions Avhich  are  so  marked  a  complication  of  the  tubercular  process.  ^^  ith 
the  continuance  of  the  fever  there  are  marked  emaciation  and  prostration. 
The  pulse  becomes  weak  and  rapid.  Diarrliea  and  night-sweats  are  often 
prominent  symptoms,  and  unless  the  sup])uration  is  checked  the  patient  may 
succumb  to  septic  poisoning  or  to  exhaustion.  In  the  more  chronic  form  the 
emaciation  is  gradual.  Enlargements  of  the  lymphatic  glands  and  amyloid 
degeneration  of  the  internal  organs  are  often  found. 

The  treatment  of  acute  suppuration  consists  in  the  establishment  of 
thorough  drainage  with  disinfection  of  the  entire  suppurating  surface.  For 
this  purpose  free  incisions  should  be  made  in  order  to  lay  open  the  pus-cavity 
and  render  its  walls  accessible  to  the  curette.  After  all  the  infected  material 
that   can   be   removed  is  scraped  away,  the  remaining  surfaces  should  be 


THE    TRAUMATIC  FEVERS.  37 

thonnighlv  cleansed  with  peroxide  of  ljydro«ren  or  sulphurous  acid  (1  :  30)  and 
disinfected  with  solutions  of  carbolic  acid,  corrosive  sublimate,  or  zinc  chloride. 

When  joints  are  involved  the  question  of  resection  must  be  considered. 
The  presence  of  an  amyloid  degeneration  of  the  kidneys,  as  revealed  by  an 
examination  of  the  urine,  is  a  contraindication  to  resection,  and  in  these 
cases  amputation  may  offer  a  better  chance  of  saving  life. 

Free  stimulation  and  a  nutritious  diet  are  indispensable.  In  many  cases 
placing  the  patient  in  the  open  air  for  several  hours  daily  may  bring  about 
a  decided  improvement,  even  in  serious  cases.  When,  however,  those  pro- 
cesses are  associated  with  tuberculosis  the  prognosis  is  most  unfavorable. 

Surgical  Scarlet  Fever. — A  scarlet  rash  may  occur  after  surgical  opera- 
tions, and  the  eru))tion  may  bo  followed  by  desquamation.  In  many  of  these 
cases  there  has  been  an  infection  of  the  system  through  the  wound^  with  the 
virus  of  scarlet  fever.  Such  infections  are  more  likely  to  occur  if  the  wound 
involves  a  mucous  membrane,  as  in  cases  of  lithotomy.  The  appearance  of  the 
symptoms  of  surgical  scarlet  fever  are,  according  to  Paget,  quite  "disorderly," 
the  period  of  incubation,  for  instance,  being  much  shorter  than  usual. 
Scarlet  rashes  may  occur  also  as  the  result  of  vaso-motor  disturbances,  or 
from  the  absorption  of  a  chemical  poison  from  the  wound,  or  from  bacterial 
invasion,  as  in  pyemia  and  septicemia. 

Urethral  fever  is  a  term  given  to  the  chill  and  pyrexia  which  often 
folloAv  the  introduction  of  a  catheter  or  sound  into  the  bladder.  It  has  been 
cited  as  an  example  of  the  purely  nervous  origin  of  fever. 

Many  of  these  cases  are  probably  due  to  the  infection  of  a  wound  of  the 
mucous  membrane  caused  by  the  instrument,  but  some  cases  are  not  to  be 
accounted  for  in  this  way,  but  are  to  be  explained  only  by  reflex  nervous 
action. 

Traumatic  Delirium. 

This  term  is  used  to  denote  those  forms  of  delirium  which  occur  as  the 
result  of  injury,  and  are  not  due  to  alcoholism. 

The  anatomical  seat  of  delirium  is  in  the  cortical  gray  matter  of  the  brain. 
The  delirium  is  due  either  to  functional  disturbance  or  anemia  of  that  region  or 
to  inflammations  of  the  cortex  and  meninges — more  particularly  of  the  middle 
and  posterior  lobes  (Hunt).  The  causes  of  delirium  are  as  numerous  almost  as 
the  injuries  which  give  rise  to  constitutional  disturbance,  but  there  are  certain 
lesions  which  seem  more  prone  to  this  form  of  functional  disturbance  than 
others.  In  some  cases  of  shock  there  is  considerable  mental  exaltation  and 
excitement  which  are  quite  characteristic,  the  condition  being  known  as  "pros- 
tration with  excitement."  There  is  usually  no  marked  delirium,  but  at  times 
a  temporary  mental  aberration  of  a  well-defined  character.  It  may  precede 
and  accompany  cerebral  lesions,  such  as  hemorrhage  from  trauma,  or  throm- 
bosis and  embolism. 

Delirium  is  often  noticed  in  children  and  the  aged  after  capital  operations, 
after  operations  for  cataract,  and  also  in  many  forms  of  chronic  inflamma- 
tion in  aged,  anemic,  and  feeble  patients.  Among  other  surgical  lesions, 
severe  burns  and  scalds  and  facial  erysipelas  may  be  mentioned  as  par- 
ticularly liable  to  be  accompanied  by  delirium.  In  some  individuals  pain 
alone  is  often  sufficient  to  produce  a  temporary  mental  aberration,  which  dis- 
appears immediately  upon  the  subsidence  of  the  pain.  This  form  of  delirium 
is  allied  to  the  so-called  delirium  nervosum  of  the  German  writers — a  condition 
of  nervous  disturbance  which  comes  on  after  injuries  in  hysterical  subjects.  It 
may  occur  in  the  stage  of  convalescence  following  erysipelas  and  other  inflam- 


38  AN  AMERICA y    TEXT-BOOK    OF  SURGERY. 

matory  diseases  in  nervous  patients.  It  is  characterizetl  by  considerable  mental 
depression.  Transitory  psychical  disturbances  may  also  follow  sur<^ical  opera- 
tions, and  there  may  be  developed  at  times  not  only  melancholia,  but  a  suicidal 
mania.  A  nervous  delirium  without  fever  is  occasionally  noticed  after  opera,- 
tions  upon  portions  of  the  body  supplied  with  unusually  sensitive  nerves.  The 
operation  for  phimosis,  with  an  unusual  am(»unt  of  irritation  of  the  ;^lans  penis, 
is  an  example.  Severe  nervous  disturbance  and  delirium  following  operations 
or  injuries,  without  a  corresponding  amount  of  inflammation  or  fever,  should 
cause  the  surgeon  to  inquire  as  to  the  possibility  of  poisoning  by  iodoform  or 
carbolic  acid — conditions  readily  shown  by  an  examination  of  the  urine. 

The  treatment  of  this  form  of  delirium  consists  in  the  removal  of  all  local 
sources  of  irritation,  in  the  application  of  ice  to  the  head  in  some  ca,ses,  and  in 
the  use  of  the  bromides  and  hyj)notics.  If  due  to  cerebral  anemia  from  loss  of 
blood,  suitable  stimulation  is  indicated.  Opium  is  usually  not  well  borne,  and 
should  be  reserved  for  those  violent  cases  which  cannot  be  controlled  in  any 
other  way. 

Post-operative  Insaxity. 

Occasionally  after  an  operation  or  an  accident,  even  when  the  head 
was  not  the  part  involved,  a  condition  of  genuine  insanity  develops.  This 
condition  is  afebrile,  occurs  in  those  who  are  weak  and  exhausted,  is 
especially  common  in  persons  who  possess  a  hereditary  tendency  toward 
the  development  of  psychoses,  and  is  similar  to  and  identical  with  post- 
febrile insanity. 

The  most  common  form  encountered  is  characterized  by  great  mental 
confusion  (confusional  insanity  of  Wood),  but  either  mania,  melancholia,  or 
delusional  insanity  may  arise.  The  prognosis,  as  a  rule,  is  favorable  if  sys- 
tematized delusions  are  not  present.  The  treatment  consists  in  the  adminis- 
tration of  large  amounts  of  nourishment,  the  use  of  tonics,  and  proper  men- 
tal exercise.  Most  of  these  cases  should  be  treated  in  a  hosj)ital  for  the 
insane. 

Delirium  Tremens. 

This  disease  is  a  form  of  mental  disturbance  characterized  by  delirium, 
and  accompanied  by  a  peculiar  tremor  of  the  muscles,  occurring  in  individuals 
habitually  intemperate  in  the  use  of  alcoholic  stimulants.  It  follows  either 
a  debauch  or  some  injury  which  suddenly  confines  such  a  patient  to  bed; 
hence  its  consideration  here.  It  is  said  to  be  much  less  common  in  countries 
where  wine  and  beer  are  the  national  beverages  than  in  those  in  which  spiritu- 
ous liquor  is  consumed.  The  habitual  use  of  various  drugs  is  said  to  produce 
it,  as  opium,  tobacco,  and  cannabis  indica,  and  even  tea  and  coffee.  The 
term  mania-a-potu  is  used  to  denote  an  acute  type  of  delirium  following  a 
debauch,  in  which  the  patient  may  become  maniacal. 

Delirium  tremens  was  formerly  supposed  to  be  due  to  an  inflammation  of 
the  brain.  Usually,  however,  the  post-mortem  appearances  indicate  no  sign 
ef  active  inflammation  beyond  some  thickening  of  the  meninges.  According 
to  Hunt,  there  is  a  condition  so  characteristic  that  it  has  been  called  "wet 
brain,"  consisting  of  a  passive  congestion  with  serous  exudation  in  and  under 
the  pia  mater,  filling  the  ventricles  and  following  the  convolutions.  Chronic 
gastric  catarrh  is  also  found  to  exist,  and  atheromatous  degeneration  of  the 
arteries,  fotty  liver,  and  Bright's  disease. 

The  symptoms  of  delirium  set  in  gradually.  The  patient,  removed 
from  his  ordinary  surroundings,   complains  of  feeling  uncomfortable ;    he  is 


THE    TRAUMATIV   FEVERS.  ;i9 

restless  and  tremulous;  there  is  inueli  depression  of  spirits,  and  his  sleeji  is 
disturbed  with  nightmares  ;  he  talks  in  his  sleep,  and  may  wander  about  during 
the  night,  but  the  next  morning  asserts  that  he  has  slept  well.  When  it  fol- 
lows an  injury,  the  onset  of  the  disease  is  usually  sudden.  With  the  full 
develoj>nient  of  the  disease  there  is  complete  insomnia,  with  a  muttering  delir- 
ium fre((uently  broken  by  loud  cries,  and  a  peculiar  tremor  of  all  the  mus- 
cles. The  patient  is  constantly  employed  pulling  the  bed-clothes  about,  tear- 
ing off  dressings  and  splints,  and  endeavoring  to  get  out  of  bed.  He  appears 
to  be  more  or  less  insensible  to  pain,  and  may  walk  upon  a  broken  leg  Avithout 
showing  any  signs  of  suffering.  He  is  the  victim  of  all  manner  of  delusions, 
usually  of  a  horrible  nature.  The  hallucinations  take  the  form  of  hideous 
animals  and  insects ;  occasionally  they  are  obscene  in  cliaracter.  The  patient 
may  be  momentarily  recalled  to  himself  sufficiently  to  give  an  intelligent 
answer,  but  relapses  immediately  into  his  previous  condition.  There  is  little 
fever,  although  occasionally  there  may  be  a  marked  rise  of  temperature.  The 
pulse  is  weak  and  quick,  and  there  is  rapid  loss  of  strength,  due  to  the  small 
amount  of  nourishment  taken  during  the  debauch  and  the  later  inability  to 
retain  food. 

In  favorable  cases,  after  two  or  three  days  of  insomnia  sleep  comes  sud- 
denly, and  on  awakening  the  delirium  is  found  to  have  disappeared.  In  severe 
or  fatal  forms  the  prosti^tion  increases  rapidly  and  is  a  marked  feature,  the 
pulse  foiling  greatly  in  strength.  The  patient  may  die  suddenly  from  heart 
failure.  Pneumonia,  a  complication  unusually  frequent  in  alcoholic  subjects, 
may  supervene,  and  bring  about  a  fatal  issue.  The  prognosis  of  the  disease  is, 
however,  usually  favorable.  Among  the  most  reliable  symptoms  which  give  a 
clue  to  the  patient's  condition  are  the  pulse  and  temperature.  The  weak  and 
rapid  pulse  is  a  measure  of  the  prostration,  and  the  rise  of  temperature  is  a 
warning  of  complications  such  as  pneumonia  or  septic  infection  of  the  wound. 

The  prophylactic  treatment  consists  in  the  employment  of  alcoholic  stim- 
ulants in  moderate  quantities,  of  capsicum  and  digitalis,  and  of  nourishing  food. 
The  last  is  only  secondary  in  importance  to  sleep.  By  these  means  the  nervous 
system  is  steadied  and  the  strength  of  the  patient  maintained.  Any  indica- 
tion of  nervousness  or  insomnia  should  be  met  Avith  a  free  use  of  the  bromides. 
An  attack  may  in  this  way  be  warded  oif.  During  the  attack  mild  stimulation 
with  liquor  or  beer  is  usually  advisable,  although  the  use  of  stimulants  must 
be  determined  by  the  circumstances  of  each  case.  The  drugs  which  are  most 
frequently  used  at  the  present  time  are  chloral  hydrate  and  the  bromides.  It 
is  probable  that  sulphonal  in  sufficient  doses  to  cause  sleep  has  rather  too  depress- 
ing an  influence  upon  the  heart's  action.  The  question  of  the  use  of  opium  in 
this  disease  has  been  much  discussed.  In  mild  cases  it  is  not  necessary,  but  it 
may  be  of  much  value  in  quieting  restlessness  when  it  is  of  great  importance 
that  splints  or  dressings  should  not  be  disturbed,  or  when  the  delirium  is  of  so 
acute  a  type  that  all  other  remedies  fail  to  control  the  patient. 


40  AN  AMERICAN    TEXT-HOOK    OF   SIJROEHY. 

CHAPTER  V. 

SUPPURATION  AND  ABSCESS. 
SECTION   I— SUPPURATION. 

Suppuration  is  due  to  the  action  of  the  pyogenic  cocci  upon  the  tissues, 
•ind  is  the  usual  termination  of  infective  infianiniation.  It  is  the  process  by 
means  of  which  the  exudate  and  the  tissues  involved  become  liquefied  and  con- 
verted into  pus.  The  organisms  most  frequently  found  in  pus  are  the  staphylo- 
coccus pyogenes  aureus  and  albus.  They  have  a  tendency  to  accumulate  in 
clusters,  and  when  growing  in  the  tissues  produce  circumscribed  forms  of 
sup];uration.  The  streptococcus,  which  is  sometiuies  present,  on  the  other 
hand,  shows  less  tendency  to  cause  local  suppuration,  but  spreads  rapidly 
through  the  tissues  by  the  lymphatics,  and  eventually  gives  rise  to  a  diffused 
form  of  suppuration.  When  grown  on  beef  gelatin  the  staphylococcus  causes  a 
liquefaction  of  the  culture  medium  in  virtue  of  its  peptonizing  action,  which  is 
due  to  the  presence  of  a  soluble  peptonizing  ferment,  and  it  is  in  consequence 
of  this  action  that  the  fibrinous  exudate  and  the  inflamed  tissues  become 
converted  into  pus. 

That  the  pyogenic  cocci  are  the  cause  of  suppuration  has  been  abundantly 
shown  by  microscopical  investigation  and  experiment.  They  are  found  in  the 
pus  of  all  acute  abscesses,  and  sometimes  in  cold  abscesses.  The  failure  to 
find  them  in  the  latter  class  of  abscess  has  been  explained  in  various  ways.  By 
some  these  abscesses  are  supposed  to  be  caused  by  the  bacillus  of  tuberculosis 
alone,  but  the  most  probable  explanation  is  the  dying  out  of  the  organisms  and 
the  deposition  of  their  remains  as  a  sediment.  Experiments  on  animals  show  that 
these  organisms  when  injected  in  sufficient  quantity  under  the  skin  will  produce 
suppuration.  When  absorption  takes  place  rapidly,  however,  a  larger  (juantity 
can  be  injected  without  producing  suppuration.  In  man  inoculation  through 
abrasions  or  Avounds,  and  even  through  the  uninjured  skin,  will  cause  suppu- 
ration. Garre  produced  furuncles  of  the  forearm  by  rubbing  in  a  culture  of 
the  aureus.  The  question  of  suppuration  without  the  agency  of  bacteria  has 
been  carefully  studied  recently.  Ex})criments  on  animals  with  the  injection  of 
calomel,  mercury,  turpentine,  and  croton  oil  show  that  certain  drugs  can  produce 
in  certain  animals  pus,  or,  as  it  would  be  better  called,  "  puruloid  material," 
containing  no  bacteria.  Non-bacterial  pus  can  also  be  produced  by  introducing 
cultures  of  cocci  which  have  been  sterilized  by  heat.  In  this  case  the  organ- 
isms have  been  removed,  but  their  chemical  products  still  remain,  and  are 
undoubtedly  important  factors  in  the  production  of  inflammation  and  suppu- 
ration. Practically,  however,  the  surgeon  never  has  to  deal  with  non-bacterial 
suppuration. 

Among  the  predisposing  causes  of  suppuration  may  be  mentioned  diminished 
vitality  of  the  tissues.  The  healthy  body  is  intolerant  of  bacteria,  and  will 
resist  the  invasion  of  a  mass  of  organisms  which  an  inflamed  or  diseased  part 
may  be  unable  to  withstand.  The  milder  types  of  inflammation  seem  partic- 
ularly well  adapted  to  encourage  bacterial  growth.  Some  of  the  severest  types 
of  suppuration,  such  as  acute  osteo-myelitis,  follow  often  slight  blows  or  inju- 
ries. The  delicate  reticulum  of  blood-vessels  found  in  the  medullary  cavities 
of  bones  furnishes  a  convenient  lodging-place  for  swarms  of  bacteria,  owing  to 
the  slowness  of  the  blood-current  and  tlie  tortuous  course  of  the  blood-channels. 
When  the  circulation  has  been  impaired  or  arrested  by  an  extravasation  of 
blood  or  a  congestion  of  the  part,  the  conditions  are  favorable  for  an  intravas- 


SUPPURATION  AND    ABSCESS.  41 

cular  infection  if  organisms  happen  to  be  circulating  in  the  l^lood  at  the  time. 
As  we  have  seen,  micro-organisms  may  from  time  to  time  be  found  in  the  cir- 
culating blood,  particularly  in  individuals  of  feeble  constitutions.  The  ana- 
tomical nature  of  the  part  will  therefore  fjivor  suppuration  in  certain  localities. 
A  most  familiar  example  is  the  lymphatic  gland  tissue.  There  the  organisms 
which  have  invaded  the  tissues  through  a  wound,  and  have  found  their  way 
into  the  lympliatic  vessels,  are  arrested,  and  a  glandular  abscess  results.  The 
condition  of  tlie  blood  is  also  a  predisposing  cause,  as  tlie  tendency  to  carbun- 
cular  inlianniKition  in  dia])etes  shows. 

The  material  which  forms  as  the  result  of  suppurative  inflammation  is 
pus. 

Pus  is  a  yellowish-white  fluid  of  the  consistency  of  milk  or  cream,  of  an 
alkaline  reaction,  and  commonly  nearly  odorless.  It  has  a  specific  gravity  of 
about  1030,  and  when  allowed  to  stand  it  separates  into  a  clear  fluid  known 
as  pus  serum,  and  a  sediment  which  averages  from  10  per  cent,  to  20  per  cent, 
of  the  whole  amount. 

The  liquor  puris,  or  pus  serum,  is  a  pale  greenish-yellow  fluid  which  does 
not  coagulate  spontaneously,  and  contains  an  albuminous  substance  known  as 
peptone.  The  salts  which  it  contains  are  present  in  about  the  same  proportion 
as  in  the  blood. 

The  sediment  consists  of  pus-corpuscles,  the  pyogenic  cocci  and  the  other 
forms  of  micro-organisms  that  may  be  present,  and  fragments  of  broken-down 
tissue. 

Most  of  the  pus-corpuscles  are  the  altered  leucocytes  which  have  escaped 
from  the  blood-vessels  with  the  exudation;  others  are  derived  from  the  prolif- 
erated fixed  connective-tissue  cells.  When  first  taken  from  a  fresh  abscess 
many  of  them  are  found  to  possess  amoeboid  movements.  They  are  a  little 
larger  than  the  white  blood-corpuscles.  Their  protoplasm  is  somewhat  gran- 
ular, and  when  acetic  acid  is  added  to  them  they  are  found  to  contain  several 
nuclei.  This  polynuclear  condition  was  supposed  to  be  evidence  of  an  ability 
of  the  pus-corpuscles  to  proliferate,  but  it  is  now  recognized  as  a  sign  of  degen- 
eration.  They  also  occasionally  contain  drops  of  fat ;  others  are  full  of  large 
granules,  which,  Avhen  they  break  up,  liberate  a  granular  detritus  Avhich  may 
be  seen  suspended  in  the  fluid. 

The  color  of  pus  is  occasionally  blue.  This  is  due  to  the  presence  of  the 
bacillus  pyocyaneus,  ordinarily  considered  a  harmless  organism,  but  the  presence 
of  which  indicates  slowness  of  repair.  Orange-colored  pus  is  caused  by  the 
presence  of  hematoidin  crystals,  and  is  found  in  some  forms  of  inflammation. 
It  is  probably  due  to  the  fact  that  many  red  corpuscles  in  the  exudation  have 
been  broken  up  by  the  septic  process, 

The  peculiar  foul  odor  of  pus  which  comes  from  the  neighborhood  of  the 
vagina  or  rectum  is  due  to  the  presence  of  the  bacillus  pyogenes  foetidus.  The 
thick  creamy,  odorless  pus  which  flows  from  an  acute  abscess  was  formerly 
known  as  healthy  or  laudable  pus.  It  contains  comparatively  few  bacteria. 
Pus  may  occasionally  undergo  decomposition ;  in  this  case  the  micro-organisms 
of  putrefaction  also  are  found  in  it,  and  the  pus-corpuscles  are  broken  down  and 
much  diminished  in  number.  This  is  known  as  ichorous  pus,  and  Avhen  mixed 
with  blood  which  is  seen  flowing  from  a  rapidly-spreading  abscess  is  called 
sanious  pus.  These  unhealthy  forms  of  pus  are  very  acrid  and  give  an  acid 
reaction. 

A  microscopical  examination  of  the  connective  tissue  in  suppurative  inflam- 
mation shows  that  in  the  early  stages  of  the  process  the  stellate  cells  of  the 
tissue  lose  their  prolongations,  become  rounded,  and  undergo  karyokinesis,  and 


42  .l.V   AMElilL'Ay    TEXT-BOOK    <jT   .)iLB(JTJn'. 

multiply  in  this  way.  In  the  mean  time  the  intercellular  su})stance  underfrocs 
a  softenin;;  process,  is  transformed  into  a  homo^ieneoiis  sulistance,  and  the 
proliferated  connective-tissue  cells  are  in  a  state  of  jiolynuclear  defeneration. 
This  sta<re  is  the  one  immediately  preceding  that  of  pus  formation.  Many  of 
these  degenerated  cells  are  therefore  of  connective-tissue  origin,  and  under 
some  circumstances  they  may  even  outnumber  the  leucocytes.  When  the 
polynuclear  stage  has  been  reached,  it  is  impossible  to  tell  the  origin  of  these 
cells. 

Suppuration  is  always  to  be  regarded,  as  it  has  been  aptly  described  as  a 
"battle  of  cells,"  the  bacteria  exerting,  in  all  probability,  a  clicmotactic 
attraction   which  for  weakened  cells  is  irresistible. 

When  acute  suppuration  takes  place  the  symptoms  of  inflammation  all 
become  more  marked.  There  is  great  increase  in  redness  and  swelling,  and 
the  part  is  exceedingly  hot  and  is  the  seat  of  a  throbbing  pain.  The  formation 
of  pus  is  often  ushered  in  by  a  chill  or  rigor,  and  a  change  in  the  conditions 
of  the  part  will  indicate  the  locality  of  the  pus.  The  skin  at  this  spot  becomes 
adherent  to  the  parts  beneath,  and  later  presents  to  the  touch  the  sense  of 
fluctuation.  A  deeper  color  is  also  present  at  this  point,  and  in  the  centre  of 
the  focus  a  whiter  zone  indicates  the  stage  immediately  preceding  the  breaking 
down  of  the  abscess  and  the  discharge  of  pus. 

The  diffused  forms  of  suppuration  in  connective  tissue  are  called 
phlegmonous  injirimmations.  This  variety  is  usually  seen  after  compound 
fracture  when  septic  infection  has  occurred,  and  may  involve  the  greater  portion 
of  the  limb,  as  the  forearm,  the  arm,  or  the  leg.  An  acute  swelling,  with 
oedema  of  the  connective  tissues,  ushers  in  the  process,  and  areas  of  bogginess  or 
fluctuation  will  make  themselves  manifest  later.  The  constitutional  disturbance 
will  usually  be  great.  A  sharp  rise  of  temperature,  accompanied  perhaps  with 
a  chill,  will  mark  the  beginning  of  the  suppuration,  and  the  pyrexia  will 
remain  until  free  incisions  and  thorough  drainage  have  arrested  the  progress  of 
the  pus.  The  route  which  pus  takes  under  these  circumstances  depends  upon 
the  anatomical  structure  of  the  part,  upon  gravity,  and  also  upon  the  nature 
of  the  organisms.  In  many  cases  pus  will  continue  to  burrow  until  the  integu- 
ments have  been  freely  divided  and  the  margins  of  the  suppurating  area  have 
been  fully  exposed.  The  improvement  following  such  free  incisions  is  due  to 
the  fact  that  the  bacteria  growing  in  the  wall  of  the  abscess  are  thus  freely 
exposed  to  the  air,  a  condition  less  favorable  for  their  growth,  and  are  more 
readily  reached  by  antiseptic  agents.  Small  incisions  are  of  little  use  in  the 
more  rapidly-spreading  forms  of  cellulitis,  and  incisions  from  six  to  twelve 
inches  in  length  are  sometimes  required  to  arrest  the  progress  of  the  disease. 
If  the  treatment  adopted  fail  to  arrest  suppuration,  it  may  pass  into  a  chronic 
stage ;  the  pus  will  then  burrow  slowly  and  make  its  appearance  at  many 
different  spots.  There  will  also  be  considerable  constitutional  disturbance, 
marked  by  a  progressive  emaciation  and  gradual  exhaustion  of  the  patient. 
The  febrile  disturbance  will  be  of  the  remittent  type  known  as  hectic  fever. 

Purulent  infiltration  of  a  limb  is  a  still  more  malignant  form  of  inflam- 
mation. Originating  in  a  suppuration  perhaps  at  first  trivial,  it  will  spread 
rapidly,  and  its  involvement  of  the  lymphatics  of  the  limb  will  be  plainly  indi- 
cated by  red  lines  extending  up  to  the  axilla  or  the  groin.  The  protective 
influence  of  the  lymphatic  glands  will  be  shown  by  their  filtration  from  the 
lymph-stream  of  the  cocci  and  their  ptomaines.  This  leads  to  the  fonnation 
of  an  abscess  just  above  the  elbow  or  in  the  axilla  or  groin,  which  temporarily 
arrests  further  progress  of  the  supj)uration.  More  rarely  the  entire  limb  will 
be  involved  in  an  acute  inflammatory  swelling  with  little  tendency  to  suppura- 


SUI'I'  I  7.'.  1  riOX    .  I  M>    .  1 BSCKSS.  43 

tion.  In  this  ease  the  whole  part  is  apt  to  become  gangrenous.  Free  incisions 
are  foHowod  by  the  escape  of  a  sero-punileiit  iliiid.  There  is  profound  constitu- 
tional disturbance  with  perhaps  acute  septicemia.  Probaldy  in  these  cases  there 
is  a  mixed  infection,  and  bacilli  of  putrefaction  are  mingled  with  the  micrococci. 

When  infection  of  a  wound  takes  place  the  slight  swelling  which  ordi- 
narily accompanies  the  healing  process  is  much  increased  at  some  portion  of 
the  wound,  and  is  accompanied  by  reddening  and  induration.  This  will  usually 
occur  around  one  of  the  stitches  which  has  been  the  source  of  infection,  or  pus 
may  collect  in  some  part  of  the  wound  Avhere  the  surfaces  were  not  accurately 
brought  in  apposition  and  where  the  Avound  fluids  have  accumulated  from 
imperfect  drainage.  The  rise  of  temperature  will  give  speedy  warning  of  the 
approach  of  suppuration  in  such  cases. 

The  general  plan  of  treatment  to  be  adopted  in  cases  of  spreading 
suppuration  is  the  emploA'ment  of  free  incisions  which  expose  the  extreme 
limits  of  the  suppurating  area.  This  operation  should  be  accompanied  by  a 
thorough  curetting  of  the  surface  of  the  pus-cavity  to  remove  the  bacteria 
from  the  surrounding  tissues  and  by  thorough  disinfection  with  appropriate 
antiseptic  drugs.  In  the  case  of  an  extremity  this  can  best  be  accomplished  by 
immersion  of  the  limb  in  an  antiseptic  bath.  The  agent  used  should  be  largely 
diluted  (sublimate  1  to  10,000,  or  carbolic  acid  1  to  500)  to  prevent  poisoning 
by  the  drug.  Following  the  bath  antiseptic  fomentations  may  be  applied. 
For  this  purpose  some  of  the  milder  drugs  containing  carbolic  acid,  as  sulpho- 
naphthol,  may  be  used.  When  other  methods  fail,  irrigation  is  often  successful. 
Sterilized  water  may  be  used  for  this  purpose  or. extremely  Aveak  solutions  of 
disinfectants.  If  a  dry  dressing  is  preferred,  iodoform  or  aristol  or  boric  acid 
may  be  dusted  freely  upon  the  part,  and  the  Avound  may  then  be  packed  with 
an  antiseptic  gauze.  The  use  of  stimulants  and  careful  feeding  should  be  the 
chief  feature  of  the  general  treatment  of  the  case. 

SECTION  II.— ABSCESS. 

An  abscess  is  a  circumscribed  collection  of  pus,  and  is  caused  usually  by 
the  presence  of  the  staphylococci  in  the  tissues.  When  these  organisms  invade 
a  part,  Ave  find  even  at  the  end  of  tAventy-four  hours  an  enormous  number  of 
leucocytes  in  the  exudation  which  takes  place.  The  connective-tissue  fibers  are 
SAA^ollen  and  the  lymph-spaces  are  distended  and  filled  with  cells.  As  we  have 
already  seen,  the  fixed  cells  of  the  tissue  undergo  changes  of  an  active  nature, 
and  form  nucleated  cells  Avhich  cannot  be  distinguished  from  the  leucocvtes  : 
they  are,  however,  usually  much  less  numerous  than  the  latter.  The  small 
vessels  are  dilated  and  distended  with  blood,  and  in  many  cases  with  leucocytes. 
The  cocci  in  the  mean  time  inci^ease  in  number  and  tend  to  group  in  masses. 
As  they  exert  a  peptonizing  action  upon  the  intercellular  substance  and 
the  fibrin  of  the  exudation,  liquefaction  takes  place  in  the  center  of  the 
inflamed  tissue,  and  an  abscess  is  formed.  The  walls  of  the  pus-cavity  are 
formed  by  a  zone  of  granulation-tissue,  the  cells  and  intercellular  substance 
of  which  have  not  been  broken  down  by  the  action  of  the  bacteria,  and  remain 
to  form  a  protecting  layer  betAveen  the  infected  area  and  the  surrounding  healthy 
tissues.  This  is  the  mode  of  development  of  an  abscess  in  some  of  the  looser 
tissues  like  connective  tissue.  In  the  denser  structures  and  in  the  internal 
organs  when  a  plug  of  microccocci  becomes  arrested  at  some  point  in  the  circu- 
laton,  as,  for  instance,  in  a  glomerulus  of  the  kidney  or  in  a  lymphatic  gland  or 
in  the  cutis  vera,  Ave  find  that  the  tissue  immediately  surrounding  it  undergoes 
a  chemical  change  due  to  the  action  of  the  ptomaines   upon   its  cells,  the 


44  AX   AMKRICAX    TKXT-li( )<)k'    OF  SURGERY. 

result  of  which  is  that  coaofulation-nccrosis  of  the  tissue  takes  plaee.  This 
ring  of  dead  tissue  is  readily  seen  in  sections  taken  for  microscopic  })ur- 
poses,  as  the  necrosed  area  does  not  take  any  of  the  staininjr  fluids  ■\\hicii 
act  upon  the  surrounding  tissues.  Outside  of  this  area  a  ring  of  granulation- 
tissue  forms.  Eventually  the  necrosed  area  is  invaded  both  by  the  bacteria 
and  the  leucocytes,  and  becomes  liquefied  by  the  action  of  the  cocci.  An 
abscess  of  this  type,  when  examined  microscopically,  will  show  a  mass  or 
plug  of  bacteria  in  the  center,  around  which  is  a  layer  of  pus  and  shreds  of 
tissue  enclosed  in  a  zone  of  granulation-tissue,  the  miscalled  pyogenic  membrane 
of  the  older  ])athologists,  who  thouglit  that  the  wall  of  an  abscess  was  a  sort  of 
secreting  surface  from  which  pus  was  formed. 

The  symptoms  of  an  acute  abscess  are  usually  well  marked.  The  large 
amount  of  local  swelling,  Avith  a  varying  amount  of  pain  according  to  the 
density  of  the  tissues  which  lie  between  the  cavity  of  the  abscess  and  the 
surface,  is  accompanied  frequently  by  a  chill  or  a  gradual  rise  of  temperature 
as  pus  begins  to  form.  As  the  abscess  forms  a  progressive  softening  of  the 
integuments  takes  place  until  the  pus  reaches  the  surface.  Considerable  resist- 
ance will  be  offered  by  certain  tissues,  as  fascia,  a  joint  capsule,  or  bone,  and 
the  pus  may  take  a  devious  path  before  the  abscess  begins  to  point.  Fluctua- 
tion will  now  be  distinctly  felt,  and  redness  witli  oedema  of  the  skin  and  subcu- 
taneous tissue  will  indicate  the  near  approach  of  pus.  The  skin  becomes 
stretched  and  thin  and  its  vessels  compressed,  and  over  a  certain  area  the 
blood  Avill  not  circulate ;  death  of  this  area  occurs,  and  the  abscess  then  easily 
breaks  through  it. 

It  is  not  usually  difficult  to  diagnosticate  the  presence  of  an  acute  abscess. 
Acute  forms  of  inflammation  may  occur,  however,  in  which  the  sensation  of 
fluctuation  is  apparently  well  marked  when  an  incision  fails  to  reveal  the  pres- 
ence of  pus.  No  harm  is  done,  the  inflammation  may  be  relieved  by  such  an 
operation,  and  the  impending  abscess  prevented. 

Deeply  seated  abscesses  under  a  dense  fascia,  as  in  the  neck,  may  be  over- 
looked, as  no  fluctuation  can  be  felt.  The  local  oedema  and  brawny  feel,  with 
other  signs  of  suppuration,  are  always  a  sufficient  warrant  for  a  deep  but  care- 
ful exploratory  incision  at  an  early  date  to  prevent  wide  and  dangerous  burrow- 
ing of  the  pus  under  the  fascia.  An  aneurysm  may,  however,  be  mistaken  for 
abscess,  particularly  when  its  presence  is  obscured  by  the  symptoms  of  inflam- 
mation, and  the  use  of  the  knife  in  such  a  case  Avould  be  a  grave  error.  An 
aneurysm  will  declare  itself  by  its  less  acute  history,  by  the  thrill,  bruit,  and 
expansile  pulsation,  and  can  exist  only  in  connection  Avith  a  large  vessel. 
Some  forms  of  rapidly-growing  malignant  tumors  may  also  simulate  suppura- 
tive processes.  In  all  such  cases  the  use  of  the  aspirator  or  of  the  hypoder- 
matic needle  is  of  great  value.  The  heat  of  the  part,  the  sense  of  fluctuation, 
the  local  oedema,  and  the  rise  of  temperature,  as  shown  by  the  thermometer, 
are  all  important  diagnostic  symptoms,  and  will  usually  be  sufficient  to  estab- 
lish the  presence  of  an  abscess. 

When  an  acute  abscess  breaks  the  pus  which  is  discharged  is  of  a  thick 
cream-like  consistency,  and  is  frequently  mingled  with  soft  sloughs  of  con- 
nective tissue  or  fascire,  or  fragments  of  lymphatic  glands  Avhich  have  under- 
gone a  necrosis  due  either  to  the  great  tension  of  the  part  or  to  the  formation 
of  destructive  chemical  substances  by  the  pyogenic  cocci. 

The  treatment  of  acute  abscess  consists  in  incision  as  soon  as  it  can  be 
definitely  ascertained  that  pus  has  formed,  and  sometimes  even  earlier. 
Nothing  is  to  be  gained  by  delay,  and  extensive  injury  may  be  inflicted  upon 
the  surrounding  tissues  if  the  abscess  is  not  opened  early.     In  some  regions 


SUPPURATION  AXI>    ABSCESS.  45 

the  (lan^'crs  of  delay  are  very  great.  An  abscess  in  tlie  neighborhood  of  the 
appendix  verniifonnis  may  produce  a  fatal  peritonitis  if  allowed  to  remain 
unopened.  ])eep-seated  abscesses  of  the  neck  may  burrow  widely,  and  mav 
seriously  interfere  with  res])iration  by  pressure  upon  the  trachea.  An  abscess 
near  the  rectum  should  be  opened  as  soon  as  induration  is  discovered,  in  order 
to  prevent  a  fistula.     If  no  pus  has  formed  the  incision  may  prevent  it. 

The  incision,  as  a  rule,  should  be  a  free  one,  and  so  made  as  to  favor  drainage 
and  to  leave  the  least  conspicuous  scar.  The  finger  should  then  be  introduced  to 
determine  the  size  and  situation  of  the  various  pockets.  In  case  of  abscesses 
near  large  vessels  or  other  important  structures  Hilton's  method  may  be  used 
to  advantage.  This  consists  in  making  an  incision  through  the  skin  and  deep 
fascia  by  the  knife.  The  seat  of  the  pus  can  be  ascertained  by  pushing  in  a 
pair  of  closed  hemostatic  forceps  or  blunt  scissors  or  a  sinus  dilator,  and  the 
opening  so  made  can  be  easily  enlarged  by  drawing  them  out  open.  If  neces- 
sary, to  facilitate  the  escape  of  the  pus  by  gravity,  a  counter-opening  can  often 
be  made  by  pushing  the  hemostatic  forceps  entirely  through  the  tissues  to  the 
opposite  skin,  and  cutting  between  its  partly  opened  blades.  The  cavity  of 
the  abscess  should  be  thoroughly  emptied,  curetted,  and  syringed  out  with  anti- 
septic solutions.  These  may  consist  of  corrosive  sublimate  1 :  5000  or  carbolic 
acid  1 :  100,  or  if  a  milder  antiseptic  fluid  is  needed  phenyl  (sulpho-naphthol) 
1 :  250.  When  the  pus.  and  sloughs  have  been  thoroughly  removed  in  this 
way,  a  drainage-tube  of  a  sufficient  size  should  be  inserted,  and  retained  either 
by  a  safety  pin  inserted  through  its  extremity  or  by  stitching  it  to  the  skin  to 
avoid  its  falling  out  of  the  abscess,  or,  still  worse,  of  being  lost  in  its  cavity. 
An  antiseptic  poultice  (made  of  aseptic  cotton  and  cheese-cloth  and  wrung  out 
of  a  weak  antiseptic  solution)  may  be  applied,  or  a  dry  absorbent  dressing  may 
be  used.  In  freely-discharging  abscesses  the  dressing  should  be  changed  at 
the  end  of  twelve  hours  or  less,  and  the  cavitv  Avashed  out  again.  The  fountain 
syringe  fitted  with  a  tube  ending  in  a  conical  glass  point  is  well  adapted  for 
this  purpose.  It  gives  a  continuous  stream,  and  causes  but  little  pain  to  the 
patient  in  its  application.  In  a  few  days  the  inner  surface  of  the  abscess-wall 
"cleans  off"  and  healthy  granulations  make  their  appearance.  The  tube  can 
be  shortened  daily  as  the  cavity  shrinks,  but  the  time  of  its  removal  will  depend 
entirely  upon  the  length  and  ramifications  of  the  cavity. 

Cold  abscess  is  caused  in  the  great  majority  of  cases  by  tubercular 
infection,  although  occasionally  it  may  be  of  syphilitic  origin.  In  the  ordinary 
tubercular  cold  abscess  we  find  a  peculiar  membranous  wall  formerly  called 
the  "pyogenic  membrane"  (the  "  pyophylactic  membrane"  of  Park),  which 
is  readily  scraped  off  and  is  infiltrated  Avith  tubercles.  In  the  syphilitic 
abscess  no  such  condition  exists.  This  membrane,  as  also  the  pus  of 
cold  abscess,  is  more  fully  described  in  the  chapter  on  Tuberculosis.  The 
organisms  found  in  the  contents  of  the  abscesses  before  they  are  opened 
are  the  bacilli  of  tuberculosis.  Sometimes  before,  and  always  after  they 
have  opened  spontaneously  or  have  been  opened  without  due  antiseptic 
precautions,  there  is  added  the  infection  with  pyogenic  cocci,  or  the  bacteria 
of  putrefaction.  This  is  an  example  of  what  is  called  mixed  infection. 
Clinically,  we  find  few  of  the  symptoms  of  acute  abscess.  There  is  in  most 
cases  no  redness  of  the  part  until  the  abscess  is  about  to  break.  Pain  and 
heat  are  usually  wanting.  The  swelling  is  frequently  quite  large  and  fluctua- 
tion is  distinct.  Such  abscesses  may  exist  for  months  before  they  burst.  Dur- 
ing their  formation  the  constitutional  disturbance  is  usually  slight.  There  may 
be,  however,  considerable  emaciation  due  to  the  progress  of  the  tuberculosis. 
The  temperature  is  usually  slightly  raised,  and  in  cases  of  doubtful  diagnosis 


46  A\  AMi:i:icAX  'nixr-nooK  of  surgery. 

the  tlieruiometer  ■will  give  valuable  inroriuation.  (.)iie  of  the  most  coniiuon 
seats  of  cold  abscess  is  the  vicinity  of  the  spinal  colunin,  and  such  abscesses 
are  due  to  tubercular  disease  of  the  vertebra}  (Pott's  disease).  The  \)\\^  bur- 
rowino;  along  the  psoas  muscle  (])soas  abscess)  points  above  or  below  J*(»uj»art's 
lig;»ment  or  on  the  thiixh  external  to  the  vessels,  or  it  may  ))oint  in  the  lumbar 
region  near  the  margin  of  the  (juadratus  lumborum  muscle  (lumltar  abscess). 

Treatment. — These  abscesses  should  be  opened  with  every  antiseptic 
precaution,  otherwise  true  suppuration  with  hectic  fever  will  follow  from  the 
mixed  infection  which  inevitably  occurs.  They  must  lie  tlioioughly  scraped 
out  and  the  wound  stuff'ecl  with  iodoform  gauze.  Such  treatment  is  best 
adapted  to  those  abscesses  which  have  few  ramifications,  and  the  walls  of  which 
are  evervAvhere  accessible  to  the  curette.  Treves  treats  psoas  abscess  by  an 
opening  in  the  loin  which  passes  external  to  the  latissimus  dorsi  and  erector 
spinas  muscles  and  through  the  quadratus  lumborum  and  psoas  muscles.  The 
diseased  vertebra  is  first  explored,  and  fragments  of  bone  are  removed,  and 
the  abscess-wall  is  repeatedly  scraped  and  wijied  out,  and  also  washed  out 
with  a  douche  of  corrosive  sublimate,  1  :  5000,  at  100°  F.  The  wound  is 
then  closed  and  dressed  with  an  iodoform  dressing  retained  by  a  bandage. 
The  patient  should  be  kept  at  rest  in  the  recumbent  position  for  many 
months.     If  the  abscess-cavity  refills,  the  operation  should  be  repeated. 

In  many  cases  of  cold  abscess  it  is  well  to  evacuate  the  contents  with  the 
aspirator  and  to  inject  some  preparation  of  iodoform.  A  large  canula  is 
sometimes  necessary,  owing  to  the  thick  plugs  of  cheesy  matter  which  obstruct 
the  flow  of  pus.  The  cavity  is  now  washed  out  with  a  3  per  cent,  solution  of 
boric  acid.  Among  the  preparations  of  iodoform  recommended  is  a  5  per 
cent,  ethereal  solution,  but  not  more  than  three  ounces  should  be  injected 
for  fear  of  iodoform-poisoning.  It  causes  considerable  pain.  A  10  per 
cent,  emulsion  of  iodoform  in  olive  oil  can  be  introduced  safely.  The  fol- 
lowing emulsion  is  also  sometimes  used,  and  is  considered  safe  so  far  as  poi- 
soning is  concerned :  Iodoform  10  parts ;  glycerin  20  ;  mucilag.  gum.  Acac. 
5  ;  carbolic  acid  1  ;  and  Avater  100  parts.  From  one  to  three  ounces  should  be 
injected,  and  the  abscess-cavity  should  be  carefully  manipulated  so  as  to  intro- 
duce the  drug  into  all  the  pouches.  Tavo  or  three  such  injections  are  made  at 
intervals  of  three  or  four  weeks.  A  cure  may  not  be  obtained  for  several 
months.  Equal  parts  of  iodoform  and  olive  oil  may  be  injected  freely  into 
tubercular  sinuses  which  have  resulted  from  the  burstinff  of  such  abscesses. 
If  this  treatment  fails,  recourse  may  be  had  to  incision,  as  above  described. 

The  general  treatment  consists  of  good  food,  cod-liver  oil  and  other  tonics, 
and  a  careful  selection  of  climate.  Mechanical  contrivances  may  be  needed 
for  the  support  of  joints  or  bones. 

Abscesses  of  different  regions  of  the  body  ])ossess  characteristic 
peculiarities.  The  most  common  form  of  abscess  in  the  integuments  is  the 
furuncle  or  boil.  This  is  caused  by  a  growth  of  the  cocci  from  the  deeper 
layers  of  the  epidermis  doAvnward  along  the  sheaths  of  the  hair-follicles,  and  a 
final  accumulation  near  the  root  of  a  hair.  If  the  cocci  are  arrested  in  their 
groAvth  at  the  mouth  of  the  follicle,  a  pustule  is  formed,  but  in  many  cases  the 
development  contiimes  doAvnAvard  and  a  true  furuncle  is  developed.  The  boil 
in  its  early  stages  appears  as  a  pustule.  The  amount  of  coagulation-necrosis  is 
considerable,  and  the  result  is  a  '"core"  Avhich  is  discharged  Avhen  the  abscess 
breaks.  A  crucial  incision  Avill  promptly  arrest  the  groAvth  of  a  boil  in  its  early 
stages,  or  an  application  of  the  liquefied  crystals  of  carbolic  acid  may  be  used 
if  it  is  desired  to  avoid  a  scar.  A  carbuncle  is  a  suppuration  and  necrosis 
of  the  subcutaneous  tissue,  and  is  situated  most  frequently  under  the  thick 


srrrrRATioN  and  abscess.  47 

skin  of  the  back  of  the  neck.  Like  tlie  ])oil,  it  is  at  first  superficial,  ])ut 
rapidly  spreads  to  the  deeper  parts.  It  has  erroneously  been  called  a  collec- 
tion of  boils,  owing  to  the  fact  that  numerous  points  of  })us  a]»))ear  on  the 
surface,  and  when  opened  it  ])resents  a  honevcond)ed  appearance.  This 
peculiarity  of  the  carbuncle  is  due  to  the  anatomical  structure  of  the  skin 
and  subcutaneous  tissues  of  this  part  of  the  body.  The  pus  forms  in  the 
dense  fibrous  reticulum  -which  underlies  the  thick  cutis,  and  makes  its  Avay  to 
the  surfiice  through  the  columniie  adipostc,  in  which  the  fine  lanugo  hairs  are 
situated,  causing  disintegration  of  the  parts  and  sloughing  of  the  tissues  and 
the  formation  of  a  central  crater  (Warren).  ^Phe  carbuncle  should  be  freely 
incised  and  all  the  sloughs  removed  by  the  sharp  spoon  or  scissors,  and  the 
part  disinfected  as  thoroughly  as  possible.  Complete  excision  of  the  car- 
buncle with  thorough  disinfection  of  the  parts  will  often  lead  to  an  arrest  of 
the  process  and  a  speedy  convalescence.  Abscess  of  the  lymjjhatic  glands 
may  form  in  the  groins,  as  the  result  of  suppuration  complicating  venereal 
disease;  in  the  neck,  following  inflammation  of  an  adjacent  mucous  membrane; 
in  the  axilla,  as  the  result  of  suppuration  in  the  fingers  or  hand ;  or  in  the 
saphenous  glands,  from  suppuration  in  the  toes  or  foot.  A  deep  abscess  of 
the  neck  should  be  opened  by  Hilton's  method.  A  retropharyngeal  ab- 
scess should  be  opened  through  the  neck,  the  incision  being  made  at  the 
anterior  or  posterior  edge  of  the  sterno-cleido-mastoid  muscle.  Felons  and 
palmar  abscesses  are  often  supposed  to  be  caused  by  direct  local  trauma, 
but  are  more  frequently  due  to  indirect  infection  by  pyogenic  cocci  which 
probably  follows  an  injury  of  some  kind.  The  precise  seat  of  the  suppura- 
tion will  vary  according  to  the  situation  of  the  infection.  Nowhere  is  an 
early  incision  of  more  importance,  as  the  usefulness  of  the  finger  or  hand  is 
at  stake. 

When  abscesses  form  in  and  around  the  internal  organs  they  are  usually 
designated  by  special  names  derived  from  the  parts  with  which  they  are  asso- 
ciated, as  perinephric,  psoas,  or  subdiaphragmatic  abscesses.  Sub- 
phrenic abscess,  as  the  latter  is  sometimes  called,  is  usually  due  to  a  circum- 
scribed peritonitis  caused  by  a  perforating  ulcer  of  the  stomach,  duodenum, 
or  appendix,  and  more  rarely  of  some  other  portion  of  the  intestinal  tract 
or  to  inflammation  of  the  liver,  spleen,  or  kidney.  The  abscess  sometimes 
contains  air  and  may  resemble  pyopneumothorax.  It  may  be  treated  by  an 
intercostal  or  an  abdominal  incision  (Mason).  Abscesses  of  the  liver  are 
occasionally  observed  in  America.  They  are  caused  by  inflammations  in  the 
intestinal  tract  and  contain  a  brown  grumous  material,  in  which  is  found  the 
amoeba  coli  {vide  infra). 

Abscess  is  found  in  bones  near  the  epiphyseal  line  ("  Brodie's  abscess  ") 
in  acute  inflammation  (osteomyelitis),  and  tuberculous  abscesses  are  often 
seen  near  the  ends  of  long  bones  in  connection  with  joint-disease  {vide  infra). 
Abscesses  in  the  brain  are  occasionally  observed  as  metastatic  abscess  or  in 
connection  with  middle-ear  suppurations  or  after  injuries. 

Pus  in  the  thorax  is  most  frequently  found  in  the  pleural  cavity,  consti- 
tuting empyema.  An  empyema  can  rarely  be  cured  by  aspiration,  but 
should  be  promptly  opened  and  drained.  A  cure  may  be  retarded  by  the 
mechanical  difficulty  of  bringing  the  abscess  walls  together,  owing  to  the 
contraction  of  the  lung  and  the  rigidity  of  the  chest  Avail.  In  these  cases 
resection  of  several  ribs  is  necessary  to  allow  the  thoracic  wall  to  come  in 
contact  with  the  lung  (Estlander's  or  Schede's  operation).  Tuberculosis  is 
often  a  complication  of  this  variety  of  suppuration.  Abscesses  occur  also, 
but  much  more  rarely,  in  the  lung  itself.     These  can  be  opened  and  drained 


48  AN  AMERICAN   TEXT- BOOK   OF  SURGERY. 

by  ail  incision  bet^vceii  tlio  ribs  or  by  resection  of  one  or  more  ril)s.  The 
operation  is  much  simplified  if  adhesion  of  the  lung  to  the  thoracic  wall  has 
already  taken  place. 

Details   regarding   abscesses   of  special   regions   will   be   found   in   their 
appropriate  places. 


CHAPTER    VI. 
ULCERATION   AND   FISTULA. 

SECTION     I. ULCERATION. 

An  ulcer  is  a  loss  of  substance  due  to  inflammation  of  a  superficial 
structure.  There  is  also  a  tendency  to  necrosis  or  death  of  the  granulations 
which  are  formed  by  the  tissues  in  an  effort  at  repair.  If  the  retrograde 
changes  equal  the  reparative,  the  ulcer  will  remain  stationary  ;  but  if  the  for- 
mer exceed  the  latter,  the  ulcer  will  constantly  increase  in  size. 

The  causes  of  ulceration  are  of  widely  different  origin.  Some  develop 
during  the  course  of  certain  infectious  diseases,  particularly  those  of  a  chronic 
type,  as  syphilis,  tuberculosis,  leprosy,  and  glanders.  Another  kind  of  ulcer 
depends  upon  widespread  disturbances  in  nutrition.  These  are  known  as 
dyscrasic  or  constitutional  ulcers.  To  this  class  belong  the  scorbutic  ulcers, 
which  appear  to  form  as  a  result  of  disease  of  the  blood-vessels  brought  about 
by  the  absence  of  a  sufficient  variety  of  nutriment ;  also  the  cachectic  ulcers, 
due  to  exhaustion  of  the  system  from  starvation,  exposure,  or  disease. 

Ulceration  may  also  be  ftivored  by  certain  local  conditions.  A  passive 
hyperemia  due  to  retardation  in  the  venous  circulation  may  be  the  cause  of 
the  varicose  ulcer.  Decubitus,  or  bed-sore,  is  due  to  a  feeble  circulation,  which 
is  easily  arrested  by  continuous  pressure  from  lying  in  bed,  causing  death  of 
the  part.  Neuro-paralytic  ulcers  are  caused  by  diminished  innervation. 
The  so-called  trophic  disturbance  belongs  in  this  class.  A  striking  example 
of  this  variety  is  the  ''mal  perforant,"  or  perforatm;/  ulcer  of  the  foot,  for 
which  the  nerves  of  the  leg  have  been  stretched  with  success.  We  may  also 
have  ulceration  as  the  result  of  the  breaking  down  of  maJif/uaut  (/rowt/is,  as 
sarcoma  and  carcinoma,  particularly  in  the  epithelial  forms  of  the  disease. 

Finally,  ulcerations  occur  which  are  the  result  of  certain  mechanical  dif- 
ficulties obstructing  the  healing  process.  Extensive  loss  of  substance,  burns 
of  the  skin,  or  avulsion  of  the  scalp  may  result  in  the  existence  of  a  permanent 
granulating  surface  constantly  contracting  or  enlarging,  but  never  fully  healing. 
Sloughing  of  the  flaps  of  an  amputation-stump  may  be  followed  by  an  adhe- 
sion of  the  integuments  to  the  ends  of  the  bones,  which  protrude  slightly  and 
are  covered  with  granulations.  Wounds  may  be  prevented  from  healing  by 
mechanical  irritation,  such  as  chafing  or  rubbing  or  the  application  of  irritating 
ointments  or  acids. 

A  section  taken  from  an  ulcer  and  examined  microscopically  shows 
generally  a  thickening  of  the  tissues  around  the  ulcer  due  to  a  hypertrophy 
of  the  papilli^J  and  an  accumulation  of  the  epidermic  cells,  which  sometimes 
form  an  overhanging  mass,  giving  the  appearance  of  "  callous  edges.  In  the 
deep  layers  of  the  rete  mucosum  and  in  the  papillary  layer  of  the  true  skin 
deposits  of  blood  pigment  are  often  seen.  The  surface  of  the  ulcer  is  covered 
with  a  layer  of  granulation-tissue.     This  tissue  may  resemble  the  type  seen  in 


ULCERATION  AND    FISTULA.  49 

healthy  granuhitions,  being  composed  of  roiuul  cells  closely  packed  together 
and  supplied  with  a  rich  capillary  network  of  blood-vessels,  or  we  may  find 
a  condition  of  coagulation-necrosis  due  to  breaking  down  of  portions  of  the 
granulations.  In  old  ulcers  the  cell-growth  is  much  less  abundant,  and  a  gelat- 
inous intercellular  substance  is  seen  in  which  clusters  of  cells  are  scattered 
here  and  there.  The  granulation  layer  is  quite  superficial,  and  beneath  it  we 
see  either  the  nearly  normal  tissue  or  a  mass  of  fibrous  cicatricial  tissue. 

Ulcers  are  either  acute  or  chronic.  An  acute  ulcer  is  a  spreading  ulcer, 
in  and  about  which  acute  destructive  inflammation  exists.  Such  an  ulcer  is 
of  irregular  outline,  its  floor  is  sloughy,  its  discharge  is  purulent,  and  the 
parts  about  are  inflamed.  In  such  a  case  the  ulcer  is  rendered  aseptic  and 
the  parts  about  it  are  treated  as  is  any  case  of  acute  inflammation. 

A  chronic  ulcer  is  an  ulcer  which  does  not  tend  to  heal  or  which  heals 
very  slowly.  In  treating  a  chronic  ulcer  it  is  necessary  to  discover  the  cause 
which  prevents  healing  and  remove  it.  Such  ulcers  occasionally  develop 
epithelioma  at  their  margins,  but  this  is  very  rare.  In  such  cases  they 
should  be  freely  excised  at  an  early  date,  together  with  any  enlarged  glands. 

Ulcers  are  classified  not  only  on  the  basis  of  their  mode  of  origin,  but  also 
according  to  certain  peculiarities  which  are  characteristic.  Thus  an  ulcer  may 
be  healthy,  fungous,  erethistic,  callous  or  atonic,  phagedenic,  etc. 

A  liealtluf  ulcer  is  one  in  which  the  granulations  are  small  and  florid  and 
the  edges  show  a  bluish  border  of  cicatrization.  If  it  be  small,  it  may  be 
allowed  to  scab  and  cicatrize  under  the  crust.  If  larger,  carbolated  oxide- 
of-zinc  ointment,  with  or  without  calomel  (3J@§j),  with  suitable  protection  by 
a  bandao-e,  and  rest,  is  all  that  is  needed  as  a  rule.  Simple  avoidance  of  irrita- 
tion  by  means  of  a  bit  of  "protective  or  gutta-percha  tissue  under  an  anti- 
septic dressing  is  often  better  than  ointments.  If  slow  in  healing,  stimulation 
by  the  occasional  light  application  of  nitrate  of  silver  or  a  solution  of  chloral 
(gr.  X  @  ^j)  or  potassio-tartrate  of  iron  (gr.  v  @  5J)  will  be  useful.  Skin-grafting 
is  required  in  large  ulcers,  and  is  now  done  early  in  many  cases  of  large  loss 
of  tissue  which  would  result  in  an  ulcer  at  a  later  period.  For  the  details 
of  its  application  see  the  chapter  on  Plastic  Surgery. 

If  the  granulations  are  too  exuberant  or  are  fungous,  the  application  of  the 
solid  nitrate  of  silver,  a  solution  of  sulphate  of  copper  (gr.  i-x  («;  3J),  or  shaving 
off"  the  exuberant  granulations  with  a  bistoury,  followed  by  compression  by 
Martin's  rubber  bandage  or  strapping  or  skin-grafting,  will  favor  the  healing 
of  such  ulcers.  When  the  fungous  granulations  are  pale  and  edematous,  they 
may  be  due  to  tubercular  disease,  and  in  this  case  a  thorough  curetting  of 
the  surface  should  precede  the  application  of  caustic  or  actual  cautery. 

The  erethistic,  irritable,  or  painful  ulcer  is  a  name  applied  to  ulcers  which 
are  extremely  sensitive.  The  cause  of  this  sensitiveness  is  not  always  clear. 
They  are  found  in  regions  liberally  supplied  with  sensitive  nerve-fibers,  as  the 
anus  or  matrix  of  the  nail,  and  are  then  doubtless  due  to  an  exposure  of  the 
terminal  nerve-branches  in  the  w^ound.  They  are  found  frequently  in  the  lower 
extremities  about  the  ankle  or  over  the  surface  of  carious  bone,  as  the  tibia. 
Fissure  of  the  anus  is  a  good  instance  of  this  kind  of  ulcer,  which  by  inducing 
constipation  and  other  digestive  disturbances  often  seriously  undermines  the 
general  health.  It  is  easily  overlooked  unless  carefully  sought  for  in  the  folds 
of  the  anal  mucous  membrane.  It  is  best  treated  by  forcible  dilatation  of  the 
sphincter  muscle.  Ingrotving  nail  or  ulceration  of  the  matrix  of  the  nail  is 
due  to  irritation  from  a  sharp  corner  of  the  nail,  which  should  be  removed. 
The  local  treatment  consists  of  drying  and  soothing  powders,  such  as  iodo- 
form, or,  better,  the  removal  of  the  sensitive  granulations  with  the  curette 

4 


50  ^iV^   AMERICA X    TEXT- HOOK    OF   SURGERY. 

or  kiiitc  imder  cocaine  anesthesia,  and  protection  of  the  raw  surface  by  daily 
packing  a  very  small  bit  of  absorbent  cotton  under  the  edge  of  the  so-called 
"ingrowing"  nail.  It  is  really  "overgrowing  granulation"  rather  than 
"  intrrowiim'  nail." 

The  calloH>i  nicer  is  sometimes  called  indolent  or  atonic,  and  is  due  to  a 
diminution  to  the  minimum  of  the  reparative  process.  The  thickened  edges  are 
caused  by  the  ineflectual  attempts  of  the  surrounding  skin  to  form  cicatricial 
tissue  and  epidermis.  It  is  found  in  laboring  and  ill-nourished  people,  and  is 
often  due  to  the  presence  of  varicose  veins  (varicose  ulcers)  or  to  eczema  of  the 
skin.  Occasionally  we  find,  as  the  result  of  long-standing  disease  and  neglect 
in  old  people,  a  general  hypertrophy  of  the  affected  leg,  simulating  elejjhantiasis. 
The  treatment  of  such  ulcers  consists  in  rest  in  bed,  elevation  of  the  limb, 
and  the  employment  of  antiseptic  or  emollient  dressings,  and  later  perhaps 
skin-grafting.  These  ulcers  are  likely  to  recur  unless  support  is  given  to  the 
part  b}'  an  elastic  stocking  or  a  bandage  of  flannel  cut  bias,  or  Martin's  rubber 
bandage.  When  circumstances  render  it  imjjossible  for  the  patient  to  rest  in 
bed,  the  ulcer  may  be  treated  by  strapping  with  adhesive  plaster,  and  a  band- 
age made  of  some  elastic  material  to  give  support  to  the  blood-vessels  of 

Fig.  17. 


riiroiiic  rioers  of  the  Legs. 

the  limb.  The  strips  of  adhesive  plaster  should  be  an  inch  wide  and  long 
enough  to  encircle  two-thirds  of  the  limb,  and  should  overlap  each  other  from 
below  upward  like  the  clapboards  of  a  frame  house.  Concentric  incisions  made 
through  the  indurated  tissues  around  an  indolent  ulcer  may  relieve  the  cicatricial 
pressure  on  the  circulation  and  enable  the  edges  of  the  ulcer  to  cicatrize. 

The  thickened  margins,  consisting  of  contracting  cicatricial  tissue,  so  inter- 
fere with  the  access  of  arterial  and  the  egi'ess  of  venous  blood  that  the  foi-mation 
of  healthy  granulations  is  impossible.  As  much  of  the  healing  of  all  ulcers 
results  from  the  reduction  in  size  effected  by  the  contraction  of  their  bases, 
caused  by  the  organization  of  the  deep  layers  of  the  granulation-tissue  into 
young  connective  tissue,  rather  than  by  epidermization,  the  fixation  of  the 
margins  and  base  of  a  chronic  ulcer  to  the  subjacent  parts  must  prevent  healing. 
Upon  this  fact  depends  the  utility  of  incisions  a  little  distance  from  the  margins 
of  the  ulcer.  Blisters  and  the  pressure  of  strapping  owe  much  of  their  efl'ect 
to  the  removal  by  absorption  of  the  constricting  effect  of  the  old  cicatricial 
tissue  upon  the  circulation  through  the  ulcer. 

The  j^hagedenic  ulcer  is  due  to  infection  by  different  forms  of  micro- 
organisms.    When  seen  on  the  genitalia  it  usually  follows  venereal  disease.     In 


ULCERATION   AND    FISTULA.  51 

other  regions  of  the  body  it  ma}^  be  caused  by  constitutional  conditions  combined 
■with  unhealthy  suiToun(lino;s.  Jnteni])enince  and  scurvy  are  predisposing 
causes,  and  wlien  individuals  affected  in  this  -way  are  crowded  together  in 
barracks  or  hospitals  in  time  of  war,  such  types  of  ulceration  are  not  uncommon. 
The  surface  of  the  ulcer  is  devoid  of  granulations,  and  is  covered  with  a  mass 
of  slougliing  tissue.  Its  edges  are  sharply  defined  and  appear  as  if  eaten  out, 
and  it  spreads  with  great  rapidity.  The  treatment  consists  in  curetting  by  a 
sharp  spoon  and  removal  of  the  overhanging  edges  by  the  knife  or  scissors, 
followed  by  a  thorough  disinfection  of  the  part  by  the  application  of  antiseptic 
agents,  such  as  pure  carbolic  acid,  bromine,  sublimate  solution  1  :  500,  and,  if 
these  fail,  in  the  use  of  the  Paquelin  cautery.  Constitutional  treatment  by  means 
of  tonics  and  stimulants  and  favorable  hygienic  surroundings  should  be  employed. 
In  mild  cases  pure  iodoform  or  aristol  or  cliloral  (gr.  x-xx  (a^  gj),  or  the  potassio- 
tartrate  of  iron  (gr.  v@sj),  Avill  often  effect  a  cure. 

Ulcers  depending  upon  specific  origin,  such  as  the  strumous,  scorbutic,  lupoid, 
and  syphilitic  ulcers,  will  be  considered  more  fully  under  their  appropriate  head- 
ings. The  ulcerations  seen  in  malignant  diseases  are  chiefly  carcinomatous. 
One  of  the  most  frequent  forms  is  rodent  ulcer,  which  is  situated  on  the  nose 
and  cheeks,  and  often  resembles  specific  or  tuberculous  ulcerations.  It  is, 
however,  due  to  the  breaking  down  of  a  genuine  epithelial  growth  (Warren). 
Deep-seated  cancers,  when  they  reach  the  surface,  enter  upon  an  ulcerating 
stage,  and  may  affect  large  surfaces  in  this  way.  Sarcomatous  ulcers  are  com- 
paratively rare. 

SECTION   II.— FISTULA   AND  SINUS. 

A  FISTULA  is  an  abnormal  opening  into  a  normal  canal  or  organ — e.  g.  the 
rectum  or  the  duct  of  a  salivary  gland — or  a  communicating  passage  between 
two  adjacent  mucous  cavities — e.  g.  the  bladder  and  vagina,  etc.  Such  a  fistula 
when  it  communicates  with  an  unhealed  wound  or  old  abscess-cavity  is  usually 
called  a  sinus.  The  terms  are  often  used  interchangeably.  There  is  a  great 
variety  of  fistulse,  each  kind  being  named  from  the  organ  with  which  it  commu- 
nicates. Fistulas  may  be  due  to  congenital  deformity,  as  a  branchial  fistula, 
•which  is  formed  by  the  non-union  of  one  of  the  branchial  clefts.  They  may  be 
the  result  of  injury  or  sloughing,  as  the  salivary  or  vesico- vaginal  fistula.  Si- 
nuses which  result  from  the  failure  of  an  abscess  to  heal,  and  which  have  opened 
into  some  canal  or  cavity,  are  usually  called  fistulee,  as  the  urinary  fistula  and 
fistula  in  ano. 

A  SINUS  is  usually  a  canal  opening  upon  the  surface  of  the  skin  or  a  mucous 
membrane  and  terminating  in  the  cavity  of  an  old  abscess.  It  may,  however, 
result  from  the  burrowing  of  pus  beneath  the  skin,  and  will  then  form  a  tor- 
tuous series  of  canals  extending  in  various  directions.  The  failure  of  such  a 
pus-cavity  to  heal  is  usually  due  to  the  presence  of  some  secretion  which  pours 
into  it,  or  to  the  pi'esence  of  a  foreign  body,  as  a  piece  of  dead  bone,  or  to  the 
inability  of  the  walls  of  the  cavity  to  collapse  and  come  in  contact  with  each 
other,  as  in  empyema  or  abscess  in  the  spongy  end  of  a  bone.  Frequently  the 
diseased  condition  of  the  Avails  of  the  sinus  is  an  obstacle  to  repair.  Many 
such  sinuses  are  due  to  the  presence  of  the  bacillus  of  tuberculosis.  In  such 
cases  they  are  lined  with  a  membrane  resembling  that  of  cold  abscesses,  which 
must  always  be  carefully  extirpated  or  cauterized. 

The  treatment  consists,  first,  in  the  removal  of  all  irritating  or  diseased 
substances.  It  is  often  necessary  to  lay  the  fistula  fully  open  and  thoroughly  to 
curette  its  walls  before  healthy  granulations  Avill  s])ring  uj)  and  aid  in  the  heal- 
ing process.     Special  fistulie  will  be  considered  under  their  respective  regions. 


52 


^^V  AMERICAN    TEXT-BOOK    OF  SURGERY 


CHAPTER    VII 


GAXGRENE. 


Gangrene  is  a  term  employed  to  denote  death  of  a  part  of  the  body  in 
mass.  Necrosis  and  mortification  are  terms  used  in  a  simihir  sense,  but  in  sur- 
gery necrosis  is  often  limited  to  death  of  bone :  it  is  applied  also  to  death  of 
internal  organs  where,  owing  to  the  absence  of  bacteria,  putrefaction  does  not 
take  place  and  the  dead  mass  is  absorbed,  new  tissue  growing  in  from  the  sur- 
rounding healthy  parts  to  take  its  place.  Gangrene  results  either  from  a  ces- 
sation of  the  arterial  blood-supply  or  from  an  obstruction  to  the  venous  outflow, 
or  purely  from  a  stasis  of  blood  in  the  capillary  vessels.  It  may  also  take  place 
independently  of  any  disturbance  of  the  circulation  by  the  direct  action  of 
destructive  agents  upon  the  cells  of  the  tissues. 

The  most  frequent  non-traumatic  cause  of  deprivation  of  arterial  blood- 
supplv  is  a  diseased  condition  of  the  arteries,  such  as  is  seen  in  senile  gangrene. 
It  mav  also  be  due  to  arterial  spasm,  such  as  is  produced  by  the  action  of  ergot 
or  disturbance  in  function  of  the  vaso-motor  nerves.  Obstruction  to  the  flow  of 
venous  blood  is  usually  of  a  purely  mechanical  origin,  as  in  strangulated  hernia, 
or  it  may  be  the  result  of  a  venous  thrombosis.  Many  causes  act  directly  upon 
the  tissues  of  the  part,  such  as  pressure,  mechanical  or  chemical  injuries,  inflam- 
matory swelling,  heat  or  cold,  and  bacterial  infection.  The  state  of  the  tissue, 
due  to  an  impaired  nutrition  of  the  body,  is  often  favorable  to  the  development 
of  wano-rene.  This  is  observed  during  the  progress  of  fevers  or  in  individuals 
suffering  from  grave  constitutional  conditions,  such  as  diabetes,  or  in  parts 
deprived  of  their  nerve-supply.  , 

Typical  gangrene  occurs  chiefly  in  two  forms,  the  moist  and  the  dry,  which 
present  striking  contrasts  to  each  other  in  their  physical  appearances. 

Dry  gangrene  (Fig.  18),  or  mummification,  is  a  condition  produced  by  the 
loss  of  water  from  the  tissues.  The  skin  becomes  black  and  wrinkled,  and  is 
often  of  a  leather-like  hardness.  The  amount  of  decomposition  which  occurs 
in  this  form  is  very  slight,  and  the  dead  part  in  typical  cases  causes  but  slight 
disturbance  to  the  adjacent  living  tissues.  In  this  form  of  gangrene  there  is  a 
gradual  diminution  in  the  supply  of  arterial  blood,  while  the  outflow  of  venous 

Fig.  18. 


Dry  Gangrene  (original). 

blood  continues  unobstructed.     In  this  way,  aided  by  evaporation,  water  is 
gradually  removed  from  the  part. 


GANGRENE.  53 

The  most  typical  form  of  this  variety  is  known  as  senile  gangrene,  due 
to  arterial  sclerosis,  the  result  of  an  obliterating  endarteritis  or  of  atheromatous 
changes  in  the  walls  of  the  vessels,  combined  with  feeble  heart-action.  The 
calcareous  condition  of  the  arteries  can  often  be  easily  detected  at  the  wrist. 
The  circulation  in  the  capillaries  becomes  very  feeble,  and  a  slight  bruise  suf- 
fices to  produce  permanent  stasis.  Senile  gangrene  usually  occurs  in  the  lower 
extremities,  involving  the  toes,  where  the  circulation  is  least  vigorous.  The 
tibial  arferies  are  frequently  the  seat  of  an  endarteritis  which  materially  dimin- 
ishes their  lumen,  and  a  serious  lessening  of  the  blood-supply  may  exist  in 
all  the  regions  supplied  by  these  vessels.  The  arterial  blood  may  also  be  cut 
oft'  by  the  presence  of  an  embolus  derived  from  valvular  growths  incidental  to 
cardiac  disease.  In  this  case  the  disturbance  in  the  circulation  may  occur  so 
rapidly  that  mummification  may  not  take  place  and  moist  gangrene  will  result. 
Dry  gangrene  may,  however,  be  produced  by  embolism,  and  a  large  portion  of 
an  upper  or  lower  extremity  may  occasionally  be  involved. 

Symptoms. — The  disease  usually  originates  in  some  slight  injury,  as  the 
bruising  of  a  toe  or  the  tearing  of  a  portion  of  the  nail,  and  is  recognized  by 
the  change  of  color  in  the  part,  the  dark -red  congestion  which  at  first  appears 
gradually  assuming  a  purple  hue.  The  surrounding  tissues  are  deeply  con- 
gested, and  the  boundary-line  between  them  and  the  dead  tissue  is  at  first 
imperfectly  marked.  The  gangrene  slowly  advances  beyond  the  limits  of  the  toe 
in  which  it  originated,  and  the  adjacent  toes  may  also  become  involved.  When 
the  progress  of  the  disease  is  arrested,  the  inflamed  parts  set  up  a  barrier  of 
granulation-tissue  and  the  line  of  demarcation  is  formed.  The  suppura- 
tion which  follows  separates  the  dead  tissue  from  the  living,  and  a  spontaneous 
cure  may  be  eff"ected  in  this  way.  As  the  line  of  demarcation  forms,  the  colors 
of  the  respective  parts  stand  out  in  strong  contrast.  The  inflamed  tissues 
assume  a  brighter  tint,  while  the  purple  hue  of  the  dead  part  changes  to  black. 
An  attempt  on  the  part  of  the  adjacent  tissue  to  form  a  barrier  to  the  advance 
of  the  disease  often  fails,  and  the  gangrene  spreads  and  may  involve  the  whole 
foot,  and  even  all  the  parts  supplied  by  the  tibial  arteries.  In  the  milder  forms 
of  the  disease  the  amount  of  constitutional  disturbance  is  slight,  but  when  a 
large  portion  of  a  foot  or  leg  is  involved  there  is  more  or  less  septic  infection, 
and  a  rise  of  temperature  will  indicate  the  presence  of  fever.  This  type  is 
sometimes  called  uliopathie  gangrene.  The  amount  of  pain  is  not  great  in  this 
variety :  during  the  early  stages  there  may  be  a  stinging  or  smarting  pain,  but 
after  the  formation  of  a  line  of  demarcation  this  disappears.  The  pain  in  dry 
gangrene  due  to  embolism  is,  however,  much  more  severe,  and  generally  is  the 
cause  of  much  intense  sufiering. 

Occasionally  obliteration  of  the  arteries  of  internal  organs  may  take  place 
also,  and  infarctions  Avith  necrosis  may  be  associated  Avith  senile  gangrene. 

Moist  gangrene  (PI.  VI)  is  caused  by  a  sudden  arrest  of  the  arterial  blood- 
supply  or  a  similar  obstruction  to  the  return  of  the  blood  through  the  veins. 
It  is  likely  to  occur  in  deeply-seated  tissues  where  evaporation  cannot  easily 
take  place,  as  in  strangulated  hernia.  Idiopathic  gangrene  may  be  of  the 
moist  type  when  the  obstruction  of  the  circulation  is  rapidly  brought  about  and 
involves  a  large  portion  of  a  limb. 

Severely  contused  or  lacerated  wounds  of  the  soft  parts,  or  fractures  com- 
plicated with  laceration  of  the  large  vessels,  are  a  frequent  cause  of  moist  gan- 
grene, known  in  this  case  as  traumatic  gangrene.  Acute  inflammations 
may  be  attended  with  such  intense  congestion  and  swelling  that  the  circulation 
may  be  arrested  over  a  considerable  area,  and  death  of  the  part  will  then  occur. 
The  same  result  will  ensue  from  burns  and  frost-bites.     In  this  form  of  fran- 


54  ^.V   AMERIVAX    TEXT-BOOK    OF  SURGERY. 

grene — localized  traumatic  gangrene — tlie  tissues  become  soft  iuid  jmlpy, 
the  skin  is  discolored  and  clianges  to  a  deep  purple  or  black  or  is  covered  Avith 
green  and  black  spots.  A  thin  brownish  fluid  filters  through  the  skin,  and 
raises  the  epidermis  in  the  form  of  blisters  or  exudes  from  the  open  surface  of 
wounds.  Decomposition  takes  place  tlirough  the  agency  of  the  saprogenic 
bacteria.  In  most  cases  a  line  of  demarcation  forms  around  the  area  affected 
by  the  destructive  agency. 

There  is.  however,  another  form  of  traumatic  gangrene — spreading 
traumatic  gangrene — in  which  the  disease  extends  with  frightful  raj)idity, 
due  to  an  acute  infectious  process.  These  are  cases  in  which  the  main  artery 
or  vein  has  been  ruptured  and  the  blood-supply  of  a  portion  of  an  extrem- 
ity is  suddenl}'  cut  off,  followed  by  infection.  In  other  cases  acute  inflammation 
of  severe  type,  together  with  the  intense  septic  infection,  produces  the  death 
of  the  part.  The  gangrene  spreads  rapidly,  even  hour  by  hour,  up  the  limb. 
Acute  putrefaction  sets  in  and  spreads  through  the  agency  of  micrococci  or 
bacilli.  The  changes  in  color  are  rapid  and  striking :  a  deep  bronze  hue,  like 
rind  of  bacon,  spreads  rapidly  along  the  line  of  extension  of  the  disease,  and 
is  accompanied  by  streaks  of  green  and  black.  The  part  feels  dense  and 
brawmy.  The  evolution  of  gas  produced  by  the  changes  brought  about  by  the 
putrefactive  bacteria  sometimes  gives  an  emphysematous  crackling  to  the  sub- 
cutaneous tissue — a  condition  which  is  often  observed  somewhat  in  advance  of 
the  gangrenous  changes.  Constitutional  disturbance  is  by  this  time  very 
marked,  and  is  due  to  the  absorption  of  ptomaines,  which  the  process  of  decom- 
position forces  into  the  lymphatic  channels  and  connective-tissue  spaces  or 
beneath  fasciae  or  along  the  course  of  tendon  sheaths.  As  the  parts  through 
which  the  gangrene  spreads  are  beyond  the  point  of  injury,  no  opportunity 
offers  itself  for  the  escape  of  these  chemical  poisons,  and  they  spread  upward 
through  the  circulation.  The  result  is  septicemia  of  a  grave  type,  from 
which  the  patient  succumbs  unless  the  progress  of  the  gangrene  has  been 
arrested  by  amputation.  This  type  of  gangrene  is  sometimes  known  as  ful- 
minating gangrene  or  gangrenous  emphysema. 

Fortunately,  such  grave  results  do  not  always  follow  death  of  a  part  from 
trauma.  The  gangrene  may  be  limited  to  the  part  the  circulation  in  Avhich  has 
been  arrested,  and  a  line  of  demarcation  will  soon  separate  it  from  the  adjacent 
healthy  parts.  This  form  occurs  frequently  in  a  stump  after  amputation  for 
railroad  injury  when  the  limb  has  not  been  removed  at  a  point  sufficiently 
remote  from  the  seat  of  injury.  A  considerable  portion  of  a  limb  may  be 
destroyed  by  injury  without  a  tendency  of  the  gangrene  to  spread.  In.  this 
case  the  numerous  lacerations  permit  an  escape  of  blood  and  serum,  and  the 
conditions  for  the  development  and  spreading  of  the  intense  forms  of  decom- 
position are  less  favorable. 

Smaller  portions  of  dead  tissue,  such  as  the  flap  of  an  amputation-stump  or 
masses  of  connective  tissue  or  skin,  are  usually  called  sloughs.  These  are 
separated  from  the  living  parts  by  the  septic  inflammation  which  ensues  and 
which  results  in  suppuration ;  and,  as  the  wound  cleanses  itself  and  the  sloughs 
are  thrown  off,  healthy  granulations  are  found  covering  its  surface. 

Gangrene  may  residt  occasionally  from  pressure,  but  unless  the  latter  is 
excessive  this  occurs  only  in  parts  where  the  circidation  is  already  feel)le  and  the 
conditions  are  favorable  for  complete  stasis.  Decubitus,  or  bed-sore,  is  pro- 
duced in  this  way  from  long  rest  in  the  recumbent  posture  in  individuals  debili- 
tated by  fevers  or  long-standing  chronic  disease.  When  the  slough  has  separated 
the  ulcer  thus  formed  may  enlarge,  and  sometimes  becomes  quite  formidable  in 
size,  and  may  be  a  complication  more  serious  than  the  original  disease.     The 


H.-VI 


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AMtmcftN  (.rTHOoR«pmc«o 


Schullzc.  pin  •, 

GANGRENE  FOLLOWING  A  SHOT  LACERATION  OF  THE  FEMORAL  ARTERY. 


GANGRENE.  55 

parts  most  frequently  attacked  are  the  integuments  lying  over  the  sacrum  and 
coccyx,  or,  more  rarely,  the  shoulder-blades  and  great  trochanters.  Sloughs 
may  also  be  produced  by  bandages  and  splints  wlien  applied  to  a  iVactured  limb. 
A  tVe(iuent  seat  of  such  a  "splint-sore"  is  the  posterior  aspect  of  the  heel  or 
the  skin  covering  the  tendo  A  chillis. 

This  form  of  local  gangrene  is  much  more  likely  to  occur  if  the  parts  sub- 
jected to  pressure  have  been  deprived  of  their  accustomed  nerve-supply.  Neuro- 
pathic gangrene,  as  it  is  sometimes  called,  is  frequently  observed  after  fractures 
of  the  spine.  Sloughs  Avill  form  "with  great  rapidity  under  the  heels  and  sacrum. 
This  predisposition  to  death  of  the  part  has  been  ascribed  to  a  functional  dis- 
turbance of  the  vaso-motor  nerves  or  to  an  abnormal  action  of  the  so-called 
''trophic  nerves"  which  are  supposed  to  preside  over  the  nutrition  of  a  part. 

A  type  of  gangrene  more  clearly  due  to  abnormal  vaso-motor  action  is  the 
symmetrical  gangrene,  or  Raynaud's  disease.  This  appears  most  fre- 
quently upon  the  tips  of  the  fingers  or  the  toes.  It  may  also  be  found  in  various 
other  parts  of  the  body,  as  the  tip  of  the  nose,  the  cheeks,  the  knee,  and  other 
salient  points  where  the  heat  of  the  body  is  less  than  in  deeper  parts.  It  is 
due  to  a  spasm  of  the  vaso-constrictors  brought  about  by  reflex  action.  It 
is  extremely  rare  in  America.  The  "cold  finger"  often  observed  in  bathers 
is  ascribed  to  a  similar  cause.  In  symmetrical  gangrene  the  parts  affected  are 
at  first  the  seat  of  abnormal  pallor  and  numbness,  then  of  a  purplish  dis- 
coloration, and  a  small  slough  finally  forms  which  is  thrown  off  and  is  followed 
by  healing  of  the  sore  thus  produced.  Several  fingers  are  simultaneously 
affected  on  both  hands. 

A  similar  spasm  of  the  vaso-motor  nerves  is  produced  by  the  prolonged 
use  of  ergot,  and  epidemics  of  gangrene  have  been  observed  in  France  and  else- 
where which  were  due  to  the  presence  of  ergot  of  rye  (tSecale  cornutum)  in  the 
grain  employed  as  food. 

Individuals  affected  with  diabetes  are  frequently  attacked  with  diabetic 
gangrene.  This  is  often  seen  in  elderly  people  subjects  of  the  disease,  and  may 
be  mistaken  for  senile  gangrene.  The  presence  of  sugar  in  the  urine  should 
therefore  be  carefully  sought  for.  Operations  upon  such  persons  are  supposed  to 
be  followed  by  gangrene  or  sloughing  of  the  lips  of  the  wound,  and  it  is  advised 
by  some  authorities  to  abstain  from  surgical  operations  if  they  can  be  avoided. 
A  more  extended  experience  with  aseptic  surgery,  however,  will  probably  not 
bear  out  this  view.  In  one  case  known  to  the  writer  both  legs  were  success- 
fully amputated  for  diabetic  gangrene.  There  was  an  interval  of  one  or  two 
years  between  the  two  operations. 

Noma,  or  cancrum  oris,  is  a  gangrene  of  the  cheek  usually  occurring 
in  children  as  a  complication  of  the  eruptive  fevers — e.  g.  scarlatina.  It  is  the 
result  of  a  gangrenous  stomatitis,  and  is  of  bacterial  origin,  producing  capillary 
thrombosis.  The  disease  may  even  attack  the  bone,  and  in  the  majority  of 
cases  is  fatal.  If  recovery  takes  place  a  large  defect  usually  results  which 
must  be  restored  by  a  plastic  operation. 

Gangrene  from  frost-bite  may  result  partly  from  the  intensity  of  the  cold 
and  partly  from  the  enfeebled  condition  of  the  individual.  The  part  at  first  is 
blanched,  but  subsequently  turns  black.  It  may  assume  the  dry  or  the  moist 
condition.  It  may  be  limited  to  the  toes,  which  are  the  most  frequent  seat  of 
this  form  of  gangrene,  or  the  whole  foot  may  be  involved.  It  is  frequently 
quite  superficial,  and  no  attempt  at  surgical  interference  should  be  made  until 
the  line  of  demarcation  is  clearly  established. 

Treatment. — The  prophylactic  treatment  of  gangrene  consists  in  the 
removal,  as  far  as  possible,  of  the  causes  Avhich  may  favor  the  development  of 


56  AN  AMERICAN    TEXl-BOOK    OF  SURGERY. 

gangrene,  and  in  the  adoption  of"  such  measures  as  uill  promote  the  circula- 
tion of  blood  in  the  part. 

If  inflammation  threatens  to  terminate  in  gangrene,  free  incisions  may 
relieve  the  tension  sufficiently  to  avert  the  impending  danger.  Division  of  the 
constricting  ring  of  a  strangulated  hernia  Avill  remove  the  obstruction  to  the 
circulation  in  the  bowel. 

If,  however,  the  obstruction  cannot  be  removed,  as  in  embolism  or  throm- 
bosis, attention  must  be  given  to  the  establishment  of  the  collateral  circulation 
in  the  limb  by  favoring  as  much  as  possible  the  flow  of  venous  blood  and 
preserving  thewarmth  of  the  part.  Moderate  elevation  of  the  limb  and  gentle 
massage  may  favor  the  return  of  Itlood  through  the  superficial  veins.  Slightly 
flexing  the  joints  will  favor  the  flow  of  blood  through  the  larger  vessels.  An 
equable  temperature  of  the  desired  degree  may  be  maintained  by  enveloping 
the  limb  in  dry  cotton-wool,  which  should  be  loosely  applied. 

Minute  abrasions  or  sores  about  the  nails  in  feeble  individuals  should 
receive  careful  attention,  but  meddlesome  interference  should  be  avoided,  as 
these  are  frequently  the  starting-points  of  senile  gangrene.  If  death  of  the 
part  is  unavoidable,  great  care  should  be  taken  to  prevent  infection  and 
decomposition.  The  gangrenous  part  must  be  disinfected  witli  the  same  care 
as  for  an  operation,  and  then  be  kept  dry  and  odorless.  Antiseptic  dressings 
containing  powders,  as  iodoform,  boric  acid,  or  aristol,  should  be  applied.  If 
the  fluid  products  of  decomposition  are  retained  beneath  the  surface,  they 
should  be  released  by  incisions  into  the  gangrenous  tissues,  or  if  pus  is  bur- 
rowing, openings  should  be  made  into  the  living  tissues  to  evacuate  it. 

It  was  at  one  time  the  almost  universal  custom  to  wait  for  the  line  of 
demarcation  to  form  in  senile  gangrene  before  making  any  attempt  to  remove 
the  dead  mass,  and  as  a  rule  it  is  better  to  adopt  this  plan.  If  the  gangrene 
shows  a  disposition  to  localize  itself,  it  would  be  bad  practice  to  interfere  in 
any  way  Avith  the  processes  that  are  going  on  in  the  enfeebled  living  tissues,  as 
any  disturbance  of  them  might  cause  the  gangrene  to  spread  still  farther.  As 
soon  as  the  gangrene  involves  the  sole  or  the  dorsum  of  the  foot,  the  question 
of  amputation  will  become  one  of  vital  importance.  In  determining  the  point 
at  which  to  amputate  the  pathology  of  the  disease  should  be  kept  in  mind. 
If  we  have  to  deal  with  a  disease  of  the  tibial  arteries,  it  will  be  necessary 
to  decide  at  what  point  in  their  course  the  circulation  is  of  sufficient  volume 
to  maintain  the  life  of  the  stump.  Never  amputate  low  down.  Heidenhain 
recommends  amputation  of  the  thigh  as  close  above  the  condyles  as  possible. 
An  amputation  of  the  leg  below  the  tubercle  of  the  tibia  in  some  cases  may 
be  sufficiently  high,  but  generally  it  is  necessary  to  remove  the  leg  at  or 
above  the  knee.  The  latter  point  is  often  to  be  preferred,  since  the  flaps  will 
then  be  largely  nourished  by  branches  of  the  profunda  femoris,  which  is 
rarely  thrombosed.  A  considerable  number  of  cases  which  in  former  times 
were  allowed  to  die  without  surgical  interference  are  now  undoubtedly  saved 
by  amputation. 

In  gangrene  from  embolism  amputation  should  be  performed  well  above  the 
gangrenous  area  as  soon  as  the  extent  of  the  gangrene  has  been  determined  by 
the  establishment  of  a  line  of  demarcation. 

In  traumatic  gangrene  involving  portions  of  the  integuments  it  is  not 
necessary  to  attempt  removal  of  the  sloughs  until  the  line  of  demarcation 
indicates  clearly  the  extent  of  the  injury.  A  partial  removal  of  the  dead  skin 
may,  however,  favor  drainage  of  the  parts  below. 

When  a  portion  of  a  limb  is  destroyed  by  injury,  the  question  of  an  imme- 
diate amputation  should  first  be  carefully  considered.     If  this  is  not  done  and 


GANGRENE.  57 

gangrene  sets  in,  and  there  are  any  signs  of  its  spreading,  this  should  prompt 
the  surgeon  to  urge  the  necessity  ofainputiition. 

If  the  gangrene  is  localized,  the  general  condition  of  the  patient  "will  enable 
one  to  decide  whether  it  is  best  to  remove  the  dead  portion  of  a  limb  immedi- 
ately or  not.  The  effect  of  the  presence  of  such  a  putrescible  mass  must  be 
weighed  against  the  danger  of  an  operation  in  a  patient  suffering  from  shock 
and  possibly  other  severe  injuries.  The  conditions  of  each  case  will  enable 
one  to  decide  whether  it  is  better  to  remove  the  limb  at  the  line  of  demarcation 
or  to  amputate  through  sound  tissue. 

In  spreading  traumatic  gangrene  it  will  of  course  be  necessary  to  amputate 
instantly  and  tar  away  ;  that  is,  sufficiently  high  to  remove  all  tissues  involved 
in  the  septic  process.  There  is  perhaps  no  atlection  in  the  whole  domain  of 
surgery  which  demands  such  prompt  interference  in  order  to  avert  impending 
death. 

The  constitutional  treatment  consists  in  attention  to  the  condition  of  shock 
and  in  supporting  the  strength  of  the  patient.  Absolute  rest,  careful  nursing, 
and  a  diet  that  will  be  nutritious  without  interfering  with  the  digestive  func- 
tions will  best  meet  these  indications.  Alcoholic  stimulants  are  also  of  great 
value  and  should  be  used  freely,  but  with  due  regard  to  the  patient's  powers 
of  assimilation. 

The  treatment  of  bed-sores  is  largely  prophylactic  by  frequent  change  of 
posture,  and — thanks  to  the  present  system  of  nursing — the  attention  of  the 
physician  or  surgeon  is  now  rarely  called  to  this  affection.  Dry  dressings  are 
to  be  preferred,  as  moisture  favors  the  enlargement  of  ulcers  produced  in  this 
way.  Mechanical  support  to  relieve  pressure  and  strict  attention  to  antisepsis 
will  usually  arrest  the  progress  of  the  disease. 

The  rules  for  the  treatment  of  diabetic  gangrene  vary  but  slightly  from 
those  laid  down  for  senile  gangrene.  The  disease  is  not  necessarily  a  contra- 
indication to  amputation.  In  any  event  a  most  careful  attention  to  the  diet 
will  form  an  important  factor  in  the  prognosis  of  the  case. 

Little  operative  interference  is  necessary  in  symmetrical  gangrene:  the 
main  points  in  the  treatment  of  such  cases  are  attention  to  the  diet  and 
hygienic  surroundings  and  the  administration  of  tonics. 

Hospital  gangrene  is  one  of  the  traumatic  infective  diseases,  and  is 
characterized  by  a  septic  inflammation  of  the  surface  of  a  wound,  causing 
ulceration  and  the  formation  of  sloughs,  and  is  accompanied  by  more  or  less 
constitutional  disturbance.  The  disease  at  the  present  time  has  almost  com- 
pletely disappeared,  oAving  to  the  general  employment  of  aseptic  and  antiseptic 
treatment.  It  formerly  occurred  when  patients  were  crowded  together  in  small 
quarters  with  insufficient  attendance  and  food  and  under  poor  hygienic  condi- 
tions. The  principal  varieties  usually  described  are  the  diphtheritic,  the  ulcer- 
ating, and  the  pulpy  forms.  The  disease  has  been  regarded  by  some  as  iden- 
tical Avith  diphtheria,  but,  as  the  latter  disease  has  continued  its  activity  for 
twenty  years  after  gangrene  has  disappeared,  this  assumption  does  not  appear 
probable.  No  bacteriological  studies  of  value  have  been  made,  but  some 
writers  report  large  numbers  of  streptococci,  and  Koch  produced  in  mice  a 
disease  resembling  hospital  gangrene  in  which  the  streptococcus  was  found. 

The  diphtheritic  form  is  characterized  by  the  occurrence  of  coagulation- 
necrosis  in  the  granulations.  There  is,  moreover,  less  inflammation  in  the  mar- 
gin of  the  wound  in  proportion  to  the  depth  to  which  the  tissues  are  involved. 
The  discharge  is  at  first  diminished,  but  later  becomes  more  watery  in  char- 
acter, the  sloughs  separate,  the  wound  has  a  crater  shape,  and  its  edges  are 
eroded.     In  the   ulcerating   form  there  is  a   progressive  enlargement   of  the 


58  AN  AMERICAN    TEXT-BOOK    OF   SUROERY. 

wound,  cliielly  on  tlic  .surface,  accompanied  by  an  unhealthy  or  grayish  dis- 
coloration of  the  granulations.  The  edges  break  down,  recede  daily,  and 
have  a  gnawed  look,  and  the  wound  may  finally  become  very  large.  This 
type  is  sometimes  called  pliagedcna.  'Die  j)ul|)y  form  is  more  common  in 
epidemics.  The  granulations  swell,  become  oedeiuatous  and  necrotic,  the 
surface  of  the  wound  is  soon  enormously  swollen,  and  a  fetid  discharge  wells 
up  in  large  (}uantities  from  its  depths.  Its  margins  become  swollen,  everted, 
and  are  ex(iuisitely  sensitive.  There  are  great  discoloration  and  swelling  of 
the  surrounding  parts,  with  profound  constitutional  disturbance.  The  wound 
increases  in  size  with  great  rapidity,  and  secondary  hemorrhage  often  occurs. 
Joints  are  laid  open  and  muscles  dissected  out  as  the  disease  spreads,  and  if  the 
disease  is  not  arrested,  the  ])aticiit  finally  succumbs  to  se[)ticemia. 

The  prophylactic  treatment  consists  in  the  application  of  the  rules  of 
aseptic  surgery,  and  when,  as  in  time  of  war,  these  cannot  be  observed  with 
sufficient  care,  in  avoiding  the  accumulation  of  great  numbers  of  patients  in 
confined  ((uarters  and  their  prompt  isolation  if  the  disease  appears. 

Tiie  local  treatment  consists  in  a  thorough  disinfection  of  the  surface  of  the 
wound  and  the  surrounding  infected  tissues.  This  may  be  accomplished  by 
removing  the  diseased  tissue  with  the  curette  or  scissors,  and  by  the  sub- 
sequent application  of  the  cautery,  bromine,  fuming  nitric  acid,  or  acid 
nitrate  of  mercury.  The  operation  will  require  anesthesia,  as  even  the  ordi- 
nary dressing  of  such  a  wound  is  exceedingly  painful.  For  milder  cases  a  weak 
solution  of  nitric  acid  may  }je  used  with  advantage,  or  the  wound  may  be  freely 
dusted  with  iodoform.  Perchloride  of  iron  was  used  with  success  by  the 
French  in  their  last  war.  Whatever  the  agent  employed,  it  must  be  applied  as 
directly  as  possible  to  the  living  tissues.  The  constitutional  treatment  consists 
in  the  free  use  of  stimulants  and  supporting  diet.  An  entire  change  of  the 
patient's  surroundings  may  bring  about  a  prompt  improvement.  Epidemics 
have  been  broken  up  by  moving  the  patients  from  the  wards  of  a  hospital  into 
tents.  All  clothing  and  bedding  and  dressings  should  be  changed  at  the  same 
time.  Amputation  may  be  sometimes  called  for,  and  can  be  successfully  done 
under  strict  antiseptic  precautions.  The  disease  being  distinctly  contagious, 
isolation  and  the  non-use  of  sponges,  towels,  basins,  etc.,  from  patient  to  patient, 
are  evidently  necessary. 


CHAPTER    VIII 
THROMBOSIS  AND  EMBOLISM. 


A  THROMBUS  is  a  clot  of  blood  Avhich  forms  in  the  blood-vessels  during 
life.  An  embolus  is  a  detached  fragment  of  a  thrombus,  a  fragment  of  a 
vegetation  on  one  of  the  valves  of  the  heart,  a  globule  of  fat  or  of  air,  etc., 
which  has  been  transported  to  some  other  part  of  the  arterial  system  and  acts 
as  a  plug. 

Coagulation  of  l)lood  may  take  place  in  one  of  two  ways :  "When  blood  is 
allowed  to  remain  stagnant  in  a  fiask,  the  clot  which  forms  is  nearly  as  large 
as  the  whole  amount  of  blood,  and  is  of  a  deep-red  color,  which  still  remains 
after  the  serum  has  been  pressed  out.  It  contains  chiefly  red  corpuscles  held 
together  by  fibrin.     It  is  such  a  clot  that  is  found  in  the  red  thrombus. 

The  clot  from  blood  beaten  with  a  stick  loses  its  red  color,  and  is  of  a  yel- 


Tl[h'()}riiOSIS    ANJ)    KMliOIJSM. 


59 


Fk;.  19. 


lowisli-wliite  tiiifje,  consisting  of  a  tough  mass  of  fibrin  containing'  but  few 
red  corpuscles.  As  has  been  shoAvn  else^vhere,  this  coaguluni  contains  chiefly 
broken-(h)wn  white  corpuscles  which  have  yielded  up  their  fibrin-j)roducing 
material.      This  is  one  way  in  which  a  w/iifc  thnnnbuH  is  formed. 

Coagulation  appears  to  be  due  to  slowing  of  the  current  and  also  to 
roughness  of  the  inner  wall  of  the  vessel,  to  injury  to  the  wall  of  the  vessel, 
or  to  septic  infection. 

A  thrombus  usually  forms  in  a  vein,  but  it  may  also  form  in  the  distal 
portions  of  the  arterial  system  and  in  the  heart.  After  a  thrombus  has 
formed  it  may  undergo  several  changes.  It  may  become  organized,  young 
tissue  growing  into  it  from  the  vessel-wall  and  forming  cicatricial  tissue. 
As  portions  of  the  clot  are  disintegrated  and  absorbed  spaces  are  h^ft,  and  the 
thrombus  is  then  said  to  be  canalized.  Blood  flows  through  these  channels, 
and  the  circulation  is  in  this  Avay  partly  re-established.  At  other  times 
the  fibrin  and  leucocytes  break  up  and  form  a  slimy  fluid,  which  is  swept 
away  and  the  thrombus  disappears.  When  sep- 
tic infection  takes  j)lacc  the  thrombus  is  said  to 
undergo  a  "  puriform  softening."  A  thrombus 
thus  disorganized  may  break  into  fragments, 
which  become  detached  and  are  swept  into  the 
circulation  as  infective  .emboli.  Such  thrombi 
are  often  found  in  the  cerebral  venous  sinuses  or 
in  the  large  veins  of  the  extremities  in  septic 
inflammations. 

A  thrombus  once  formed  may  grow  by  addi- 
tions of  coagulated  blood,  and,  when  it  has  devel- 
oped so  as  to  project  into  a  large  vessel,  a  por- 
tion of  the  protruding  clot  may  become  detached 
and  give  rise  to  embolism.  Pulmonary  embo- 
lism, a  fatal  complication,  is  produced  in  this 
way,  and  may  follow  phlebitis  or  capital  opera- 
tions, such  as  hysterectomy.  Very  small  emboli 
may  pass  through  the  lungs  and  enter  the  arterial 
system. 

Emboli  are  found  in  the  arteries  and  also 
in  the  veins  of  the  liver.     When  an   embolus  is 


lodged 


in   a 


terminal"    artery^    the    part   sup- 


A  Thrombus  in  a  Vessel.  The  de- 
tached fragment  about  to  be 
carried  away  in  the  direction 
of  the  blood-stream  is  an  em- 
bolus     (Billroth). 


plied  by  this  vessel  is  deprived  of  its  circulation 
and  becomes  anemic,  or  occasionally  a  backward  flow  of  blood  takes  place 
from  the  veins  into  the  emptied  vessels  and  a  congestion  with  extrava- 
sation or  a  "hemorrhagic  infarction"  occurs.  If  the  embolus  is  an 
infected  one,  suppuration  will  take  place  and  a  metastatic  abscess 
forms. 

Emltoli  which  are  detached  from  the  endocardium  are  lodged  in  the 
peripheral  portions  of  the  arterial  system.  Those  found  in  the  brain  are  of 
little  practical  interest,  as  they  produce  conditions  not  amenable  to  surgical 
interference.  Emboli  are  occasionally  arrested  in  the  arteries  of  the  extrem- 
ities, and  produce  that  form  of  gangrene  known  as  embolic  gangrene.  Such 
emboli  are  found  in  the  brachial  arteries  or  one  of  the  arteries  of  the  fore- 
arm ;  but  more  often  in  one  of  the  tibial  arteries.  When  a  large  vessel  is 
thus  plugged  a  thrombus  begins  to  form  upon  the  proximal  side  of  the  em- 

'  Terminal  arteries  are  arteries  without  anastomoses,  and  are  found  in  the  brain,  lung, 
spleen,  and  kidney. 


60  .l.V   AMKRICAX    TEXT-BOOK    OF  SURGERY. 

bolus,  and  often  extends  a  long  distance  toward  the  main  trunk,  tims  increas- 
ing the  extent  of  the  gangrenous  area. 

Thrombi  are  also  occasionally  found  in  the  terminal  portions  of  the 
diseased  arteries  of  aged  or  infirm  individuals,  and  may  give  rise  to 
gangrene. 

Embolism  of  a  mesenteric  artery  may  give  rise  to  gangrene  of  the 
intestine ;  but  if  the  embolus  is  small  enough  to  find  its  way  into  one  of 
the  intestinal  branches,  no  serious  results  may  be  feared,  as  the  anasto- 
mosis is  very  free.  Thrombosis  of  the  mesenteric  veins  occurs  as  the 
result  of  marasmus,  cirrhosis  of  the  liver,  or  thrombophlebitis.  Elliot 
successfully  removed  four  feet  of  intestine  which  had  become  gangrenous 
from   this  cause. 

The  treatment  of  thrombosis  or  embolism  is  mainly  prophylactic.  Care 
should  be  taken  that  the  thrombus  does  not  give  rise  to  emboli.  The  part 
therefore  should  be  kept  at  rest  until  organization  or  absorption  of  the  thrombus 
has  taken  place. 

The  danger  of  embolism  from  thrombosis  usually  ceases  about  three  weeks 
from  the  time  of  the  development  of  the  thrombus,  as  the  clot  by  this  time 
has  become  firmly  adherent  to  the  vessel-wall. 

When  an  artery  of  an  extremity  has  been  plugged  the  limb  should  be 
kept  warm :  no  constricting  dressings  should  be  applied,  and  every  oppor- 
tunity for  the  establishment  of  a  collateral  circulation  should  be  given. 


CHAPTER    IX, 
SEPTICEMIA. 


Septicemia  is  a  disease  due  to  the  absoi-ption  of  the  products  of  putrefac- 
tion into  the  system,  or  to  the  introduction  into  the  blood  and  tissues  of  bacteria 
which  rapidly  multiply  there.  It  is  characterized  by  grave  constitutional 
disturbance,  with  acute  fever,  disorders  of  the  nervous  system,  inflammation 
of  certain  viscera,  and  a  local  infection  of  the  wound.  The  nature  of  the  poison 
which  produces  the  disease  is  not  yet  fuUy  understood.  Experiments  on 
animals  have  .shown  that  there  are  two  varieties  of  this  form  of  blood-poisoning. 
In  certain  cases  .symptoms  supervene  immediately  upon  the  inoculation,  and  the 
animals  die  of  a  chemical  poison,  no  bacteria  being  found  in  the  blood  or  tis- 
sues (sapremia,  toxemia,  or  septic  intoxication).  In  other  cases  the 
symptoms  come  on  le.-s  rapidly.  an<l  <leaTli  is  caused  Ijv  the  presence  of  bacilli 
or  micrococci  in  the  blood  (septic  infection).  Many  observers  have  sought 
for  bacteria  in  the  blood  in  the  .septicemia  of  man,  and  micrococci  have  been 
found  occasionally,  but  not  with  sufficient  regularity  to  identify  them  with  the 
disease.  Since  the  existence  of  ptomaines  as  a  product  of  decomposition  has 
been  understood,  it  is  generally  recognized  that  the  poisons  elaborated  by  bac- 
teria play  a  prominent  part  in  the  production  of  the  disea.se. 

Clinically,  we  find  the  same  two  types  of  the  disease  in  man.  One  is  due 
clearly  to  the  absorption  of  a  chemical  substance  or  ptomaine.  The  .'symptoms 
of  this  variety  cea.se  as  soon  as  further  introduction  of  the  chemical  substance 
is  prevented  by  a  cleansing  of  the  wound.  In  the  other  variety  there  are 
progressive  changes  coming  on  gradually,  as  in  the  bacterial  type  in  animals, 


i^EPTICEMIA. 


61 


and  continuing  fre(|uently  to  a  fatal  termination  in  spite  of  efforts  to  check  them 
by  treatment  of  the  ■wound.  This  variety  suggests  the  action  of  bacteria,  and 
these  organisms  are  found  in  some  cases,  those  most  frequently  observed  being 
the  streptococci. 

The  method  by  which  infection  of  the  system  takes  place  is  through  a  wound 
■which  is  undergoing  putrefactive  changes  owing  to  decomposition  of  the  blood- 
clot  or  wound-iiuids  (sjiprouiia),  or  through  the  diffusion  and  multiplication 
of  the  bacteria  from  an  infected  wound,  even  of  a  trivial  character  (septic 
infection).  Tiiis  is  most  likely  to  occur  before  the  wound  has  become  covered 
by  healthy  granulations.  It  may  also  take  place  through  the  intestinal 
mucous  membrane  (sepsis  intestinalis),  as  in  cases  of  tyrotoxicon-poisoning, 
and  more  rarely  through  the  urogenital  tract. 

Sapremia. — The  toxic  form  of  septicemia  is  frequently  seen  in  obstetrical 
cases  in  which  putrefaction  of  retained  clots  or  placenta  has  taken  place  within 
the  uterus.  The  poison  may  be  absorbed  through  the  mucous  membrane  of 
the  vagina  or  uterus,  or  through  open  wounds  in  these  regions  or  through  the 
uterine  sinuses.  The  disease  is  ushered  in  with  a  sharp  rise  of  temperature, 
the  chill  usually  being  absent.  The  temperature  continues  high,  and  is  accom- 
panied later  with  delirium.  The  skin  is  cold  and  clammy,  and  there  is  more 
or  less  tendency  to  diarrhea.  A  prompt  removal  of  all  decomposing  substances 
from  the  interior  of  the  uterus  will  be  followed  in  a  few  hours  by  a  disappear- 
ance of  all  alarming  symptoms.  Conditions  favorable  for  such  a  type  of 
poisoning  are  rare  in  general  surgery,  although  a  large,  ill-drained  wound,  or 
decomposition  occurring  in  the  contents  of  a  psoas  or  other  abscess,  is  a  not 
uncommon  cause :  these  conditions  also  may  be  found  in  abdominal  Avounds 
■where  extensive  injury  of  the  peritoneum  has  favored  oozing  and  the  accumu- 
lation of  blood-clot  in  the  peritoneal  cavity. 

Fig.  20. 


\ 

2 

3 

A 

5 

6 

7 

8 

9 

10 

II 

12 

13 

107* 

106' 

105' 

|0«' 

103* 

102* 

101° 

100° 

99° 

98° 

97° 

/ 

/ 

A 

/ 

/ 

/ 

/' 

H 

./ 

/ 

V 

/ 

r^^ 

^ 

1 

/ 

Temperature  Chart  of  a  Case  of  Septicemia  (original). 

Symptoms  of  Septic  Infection. — In  true  septicemia  or  septic  infection 
the  development  of  the  disease  is  more  gradual.  The  fever  curve  is  of  the  con- 
tinuous type  as  in  sapremia,  and  as  the  fatal  end  approaches  the  temperature 
will  range  higher.  In  certain  cases  the  temperature  is,  however,  subnormal, 
as  is  seen  occasionally  in  strangulated  hernia  or  in  gunshot  injuries  of  the  abdo- 
men. There  is  great  prostration  with  headache  and  anorexia,  and  a  typhoid 
condition  supervenes  which  renders  the  patient  indifferent  to    surroundings. 


02  A\   AMKRKAy    Tl.XT-llOi )K    OF   SVItdEllY. 

Diarrhea  frequently  <levelops.  and  may  at  times  be  accompanied  with  vomiting, 
but  it  is  usually  not  severe.  There  is  a  tendency  to  the  enlargement  of  the  lym- 
phatic glands  throughout  the  body,  and  more  particularly  of  the  sjdecn.  The 
skin  is  j)ale  and  dusky,  but  an  icteric  tinge  is  not  so  common  as  in  ])yemia.  The 
hue  is  due  to  the  rapid  deterioration  of  the  blood  caused  by  the  presence  of 
the  virus.  A  scarlet  eruption  may  occur  resembling  closely  that  seen  in  scar- 
let fever.  The  skin  in  the  early  stages  is  hot  and  dry,  but  later  is  bathed  in 
perspiration,  and  finally  becomes  cold  and  clammy.  The  sallow  hue  becomes 
more  marked.  The  senses  are  dulled  and  the  countenance  is  listless.  The 
tongue  is  covered  with  a  brownish  fiir.  The  pulse  is  now  weak  and  rapid  ; 
diarrhea  increases,  and  the  urine  is  concentrated  and  scanty.  Delirium  is 
followed  by  coma,  and  the  patient  becomes  moribund. 

The  pathological  changes  observed  in  the  internal  organs  are  slight. 
The  blood  is  thin,  of  a  tarry  color,  shows  no  tendency  to  coagulation,  and 
contains  numbers  of  micro-organisms.  Cloudy  swelling  of  the  liver  or 
kidneys  is  usually  found.  In  the  alimentary  canal  there  is  evidence  of  a 
gastro-intestinal  catarrh.  The  mucous  membrane  is  swollen  and  mottled,  and 
punctiform  hemorrhages  are  found  at  certain  points.  Enlargement  of  the  lym- 
phatic glands  is  noticeable,  particularly  of  the  spleen.  The  wound  occasionally 
is  in  an  extremely  septic  condition ;  at  other  times  there  is  little  evidence  of 
anv  pathological  change.  When  septicemia  follows  the  infliction  of  a  disnect- 
ing  wound  or  other  injury  by  Avhich  material  already  loaded  with  the  bacteria 
of  putrefaction  is  inoculated  into  the  tissues,  there  is  a  diflFused  septic  inflam- 
mation about  the  wound  which  develops  rapidly  and  spreads  along  the  line  of 
lymphatics  leading  from  the  part,  as  shown  by  red  streaks  running  to  the  adja- 
cent chain  of  lymphatic  glands.  In  very  malignant  cases  oedema  of  the  adja- 
cent tissues  involving  a  considerable  area  will  be  observed. 

The  original  focus  from  which  septicemia  is  sometimes  developed  may  be  a 
wound  involved  in  gangrene  or  erysipelas,  or  some  deep-seated  infective  inflam- 
mation around  the  kidney  or  appendix  or  in  the  medulla  of  bone,  or  a  tract 
of  connective  tissue  infiltrated  with  foul  urine. 

The  principal  diagnostic  signs  of  septicemia  are  the  continued  fever, 
the  absence  of  chills,  the  peculiar  condition  of  euphoria  or  apathy,  the  intesti- 
nal catarrh,  and  the  presence  of  an  increased  area  of  dulness  about  the  region 
of  the  spleen.  The  general  appearance  of  the  patient  and  the  condition  of 
the  pulse  will  prove  valuable  guides  in  enabling  the  surgeon  to  distinguish 
between  this  type  and  the  less  malignant  forms  of  surgical  fever  which  occur 
independently  of  suppuration.  The  condition  of  the  wound  and  the  presence  or 
absence  of  pronounced  suppuration  will  also  aid  in  the  diagnosis,  although  it 
should  be  remembered  that  septicemia  may  develop  even  during  the  suppura- 
tive process,  provided  the  conditions  for  putrefaction  exist  in  the  wound. 

The  prognosis  of  the  disease  is  always  grave,  but  its  duration  may  vary 
greatly  according  to  the  intensity  of  the  virus.  In  sapremia  of  a  pure  type 
the  prognosis  is  much  more  favorable,  as  the  fever  will  disappear  as  soon  as  the 
local  mass  of  putrefaction  is  removed ;  but  inasmuch  as  it  is  quite  diflicult  to 
say  in  any  given  case  whether  there  is  not  also  a  true  septic  infection  in  addi- 
tion to  the  toxic  poisoning,  the  opinion  expressed  by  the  .surgeon  must  be  a 
guarded  one.  The  weakness  and  frequency  of  the  pulse,  the  extremes  of  tem- 
perature, and  the  mental  condition  are  important  .symptoms  as  guides  in  estimat- 
ing the  gravity  of  a  given  case.  In  the  acute  type  we  have  to  deal  with  one  of 
the  most  fatal  of  diseases.  When  the  disea.se  takes  a  more  chronic  course,  as  it 
occasionally  does,  we  may  have  rea.son  to  hope  for  a  cure,  although  a  very  large 
proportion  of  these  cases  also  terminate  fatally. 


PYEMIA.  63 

Treatment. — The  prophylactic  treatment  consists  in  the  application  of 
the  rules  ot"  aseptic  and  antiseptic  surgery,  which  have  greatly  diminished  the 
number  of  cases  of  sejjticeniia  at  the  present  time.  ^Vhen  the  disease  makes 
its  appearance  the  attention  of  the  surgeon  should  at  once  be  directed  to  the 
condition  of  the  wound,  and  no  time  should  be  lost  in  carrying  out  a  thorough 
disinfection  of  its  entire  surface.  Stitches  should  be  removed  and  sinuses  care- 
fully exposed.  All  collections  of  blood-clot  or  decomposing  fluids  should  be 
washed  out  with  corrosive  sublimate,  1  :  1000,  and  subse(iuently  the  tissues 
should  be  disinfected  with  strong  solutions  of  carbolic  acid  (1  :  20,  or  pure 
crystals)  or  chloride  of  zinc  (1 :  10).  The  wound  can  then  be  packed  with 
gauze  containing  a  large  amount  of  iodoform  powder,  or  antiseptic  poultices 
can  be  applied  to  favor  a  free  discharge  (carbolic  acid  1  :  1000,  or  corrosive 
sublimate  1  :  20,000).  When  the  wound  has  deep  recesses  or  pockets  which 
cannot  easily  be  reached,  irrigation  with  boiled  water,  boric  acid  (4  per 
cent.),  or  a  saturated  solution  of  acetate  of  aluminum  may  be  employed.  In 
septicemia  following  laparotomy  the  prognosis  is  so  grave  that  little  success 
can  be  expected  from  local  treatment.  An  attempt  to  save  life,  however, 
should  be  made  by  reopening  the  wound  and  by  a  thorough  hot-water 
douching  of  the  peritoneal  cavity,  followed  by  drainage.  In  sapremia  douch- 
ing of  the  wound  is  generally  followed  by  an  immediate,  and  frequently  by  a 
permanent,  improvement..  In  puerperal  fever  from  this  cause  the  antiseptic 
washing  of  the  uterus  is  productive  of  most  satisfiictory  results. 

The  constitutional  treatment  consists  principally  in  the  fearless  use  of  stim- 
ulants. Very  large  quantities  will  be  assimilated  under  these  conditions  without 
producing  alcoholism.  The  use  of  drugs  taken  internally  for  their  antiseptic 
action  has  not  proved  sufficiently  successful  to  encourage  a  further  trial  at  pres- 
ent. The  heart's  action  should  not  be  hampered  by  any  depressing  agents. 
On  the  other  hand,  a  free  use  of  digitalis  and  other  heart  tonics  may  prove  a 
valuable  aid  to  stimulation.  One  of  the  best  is  strychnia  administered  sub- 
cutaneously  in  doses  of  gr.  ^^  ^^  every  two  to  six  hours.  Nutritious  diet 
should  be  administered  in  such  form  as  not  to  impede  digestion  and  to  favor 
rapid  assimilation. 


CHAPTER   X, 

PYEMIA. 


Pyemia  is  an  infective  disease  developed  during  the  process  of  suppuration, 
and  is  due  to  the  absorption  of  pyogenic  organisms  into  the  circulation.  It  is 
characterized  by  the  development  of  multiple  or  metastatic  abscesses  in  differ- 
ent portions  of  the  body,  frequent  chills,  and  an  intermittent  type  of  fever. 
The  name  given  to  it  by  Piorry  is  derived  from  tz'jov,  pus,  and  aJfia,  blood. 
The  old  view  that  pus  formed  in  the  wound  obtained  an  entrance  into  the  cir- 
culation has  long  since  been  abandoned,  but  we  now  know  that  certain  elements 
of  pus  may  find  their  way  into  the  circulation  and  produce  metastatic  abscesses. 

Etiology. — Reliable  investigations  on  the  special  forms  of  bacteria  which 
are  found  in  cases  of  pyemia  have  been  made  only  within  the  last  decade. 
Among  the  most  important  are  those  of  Koch,  who  succeeded  in  producing  the 
disease  in  rabbits.  He  found  in  the  vessels  chain-like  cocci  which  caused  the 
blood-corpuscles  to  adhere  and  form  thrombi.      Ogston  showed  that  the  pyogenic 


(U 


AiV  AMERICAN    TEXT-BOOK    OF  SURdERY. 


cocci  were  jmrtly  anaerobic,  and  grew  more  readily  iu  deep  sinuses  and  pockets, 
and  tlnis  readily  obtained  an  entrance  into  the  circulation.  The  examination 
of  the  blood  of  individuals  ill  with  pyemia  has  shown  that  both  the  staphylo- 
coccus and  the  streptococcus  may  be  the  active  agents  in  the  formation  of 
metastatic  abscesses.  When  the  conditions  become  favoralile  for  an  unusual 
development  of  these  bacteria,  the  barrier  of  granulation-tissue  does  not  prevent 
their  growth  into  the  surrounding  tissues.  From  these  they  obtain  an  entrance  into 
the  system  through  the  blood-vessels  more  often  than  through  the  lymphatics. 
Coming  in  contact  with  the  wall  of  a  vein,  an  infective  inflammation  is  started 
which  terminates  in  a  thrombo-phlebitis.  Rough  places  are  formed  on  the 
intima  which  lead  to  the  formation  of  parietal  thrombi  and  the  subseijuent 
development  of  an  extensive  thrombus,  which  undergoes  a  puriform  softening ; 
or  a  zobglea  mass  of  micrococci  may  accumulate  on  the  inner  surface  of  the 
wall  of  the  vein  and  may  be  swept  oflF  into  the  circulation  as  an  embolus. 
Minute  emboli  may  pass  the  pulmonary  ca])illaries,  and,  entering  the  arterial 
system,  become  lodged  in  the  glomeruli  of  the  kidney  or  other  capillary  dis- 
tricts, or  even  in  the  valves  of  the  heart.  . 

Larger  emboli  detached  from  the  softened  thrombus  may  be  lodged  in  the 
capillaries  of  the  lung.  At  all  these  points  infective  inflammation  and  sup- 
puration may  occur,  and  metastatic  abscesses  are  thus  developed.  As  a 
rare  occurrence  pus  from  an  abscess  may  fin<l  its  way  directly  into  the  circula- 
tion by  the  breaking  of  the  abscess  into  a  vein.  The  bacterial  infection  may 
also  occasionally  take  place  through  the  lymphatic  system.  The  so-called  spon- 
taneous pyemias  occur  by  a  process  of  intravascular  infection.  In  individuals 
in  feeble  health  micrococci  are  sometimes  found  circulating  in  the  blood  tem- 
porarily. If  under  such  conditions  a  slight  internal  bruise  or  wound  is  received 
— as,  for  instance,  in  the  medulla  of  bone  from  a  fall — the  micro-organisms 
gain  an  entrance  from  the  blood-vessels  into  the  injured  part,  and  an  acute 
osteomyelitis  is  developed  which  may  become  the  starting-point  of  a  pyemia. 

Fic;.  21. 


Temperature  Chart  of  a  Case  of  Pyemia  (original). 


Symptoms. — The  first  symptoms  of  the  disease  are  noticed  usually  in  the 
second  week  of  the  healing  process  at  a  period  when  suppuration  has  been 
fully  established.  These  are  ushered  in  with  a  chill  which  may  be  of  a  widely 
varying  degree  of  intensity.  The  occurrence  of  such  a  symptom  should  always 
put  the  surgeon  upon  his  guard,  and  the  wound  should  be  carefully  inspected. 


PYEMIA.  65 

An  increase  in  the  local  inflaniniation  may  or  may  not  be  discovered.  A  sec- 
ond chill  will  probably  occur  on  the  following  day,  and  frequent  repetition  of 
the  chill  is  a  characteristic  feature  of  the  disease.  The  fever  is  of  an  irregular 
intermittent  tyjie,  and  varies  not  only  according  to  the  frecjuency  of  the  chill, 
but  has  an  almost  hourly  variation  of  its  own.  The  undulating  character  of 
the  daily  fever  curve  is  quite  characteristic  of  pyemia,  and  a  fall  to  the  normal 
point  in  acute  cases  is  rarely  observed    (Fig.  21). 

The  development  of  metastatic  abscess  is  indicated  by  a  febrile  exacerbation 
and  by  the  symptoms  of  local  inflammation.  A  sharp  pain  in  the  side,  with 
respiratory  disturbance  and  fever,  accompanies  the  formation  of  an  abscess  in 
the  lung  or  a  septic  eff'usion  into  the  pleura.  The  joints  are  also  a  frequent 
seat  of  inflammation,  and  this  is  accompanied-  wMth  considerable  swx'lling  of  the 
adjacent  soft  parts.  The  next  point  attacked  may  be  the  parotid  gland.  The 
skin  is  always  markedly  discolored,  and  frequently  assumes  a  deep  yellow  hue. 
With  the  development  of  the  icterus  there  is  already  marked  emaciation,  which, 
in  chronic  cases,  is  extreme.  Erythematous  rashes,  which  subsequently  become 
pustular,  are  occasionally  noticed.  The  tongue  is  furred  and  coated,  but  may 
vary  greatly  in  appearance.  The  pulse  is  rapid,  and  as  the  disease  progresses 
becomes  weaker. 

The  mental  condition  of  the  patient  is  usually  not  affected.  There  is, 
however,  in  the  later  stages  great  hyperesthesia,  and  such  patients  are  con- 
stantly complaining  of  pain  in  various  parts  of  the  body,  due  not  only  to 
metastatic  inflammations,  but  to  the  sensitiveness  of  the  nerves.  An  examina- 
tion of  the  heart-sounds  may  reveal  the  presence  of  an  infective  endocarditis. 
Brain  symptoms  are  rarely  present,  although  metastatic  inflammations  may 
occur  in  the  brain,  and  hemiplegia  may  result  from  emboli  due  to  the  endo- 
carditis. The  mind  usually  remains  clear  until  the  development  of  delirium 
and  coma  in  the  latest  stages  of  the  disease. 

The  duration  of  the  disease  will  vary  according  totheacutenessof  the  attack. 
Chronic  pyemia  may  be  prolonged  for  Aveeks  or  even  months.  Usually  in  acute 
cases  a  fotal  termination  will  be  reached  in  the  course  of  a  week  or  ten  days. 

Pathological  Anatomy. — The  wound  is  of  a  gangrenous  color  or  odor, 
or  the  granulations  are  still  present  and  have  a  glazed  and  indolent  appearance. 
Extensive  thrombi  are  found  in  the  adjacent  veins.  In  amputation-stumps 
of  the  loAver  extremitv  the  femoral  vein  mav  be  filled  as  high  as  Poupart's 
ligament  with  a  puriform  mass.  In  the  lungs  metastatic  abscesses  are  found 
chiefly  in  the  lower  lobes  and  near  the  pleural  surface.  Infarctions  are  also 
not  infrequent.  The  pleural  cavity  may  be  the  seat  of  a  serous  effusion.  The 
liver  is  in  a  state  of  cloudy  swelling,  and,  less  frequently  than  in  the  lung,  meta- 
static abscesses  are  found.  Miliary  abscesses  may  be  found  in  the  kidney,  in 
the  valves  of  the  heart,  in  the  intestinal  mucous  membrane,  and,  in  fact,  in 
almost  any  organ  of  the  body.  Metastatic  inflammations  are  also  seen  in  the 
connective  tissue  and  in  the  joints.  The  synovial  membrane  is  at  first  con- 
gested, and  later  suppuration  may  occur.  The  knee  and  shoulder  are  the  joints 
most  frequently  affected.  The  bones  may  also  be  the  seat  of  metastatic  foci. 
Icterus  is  caused  by  the  breaking  down  of  the  red  blood-corpuscles,  and  is  said 
therefore  to  be  hematogenous  {i.  e.  of  blood  origin). 

Diagnosis. — In  the  early  stages  of  traumatic  inflammation  a  chill  may  be 
due  to  the  development  of  some  other  form  of  infective  disease,  as  erysipelas, 
but  repeated  chills  are  characteristic  only  of  pyemia.  The  clearness  of  the 
mind,  the  hyperesthesia,  the  emaciation  and  great  prostration,  are  all  well  marked 
and  significant  in  this  disease.  The  presence  of  metastatic  abscess  and  joint 
inflammations  when  they  finally  occur  leave  no  doubt  as  to  the  diagnosis. 


66  .l.V   AMERICAN    TEXT- BO  OK    OF  SURGERY. 

The  prognosis  is  exceedingly  grave.  It  lias  been  maintained  that  no 
case  of  pyemia  ever  gets  well,  but  many  cases  of  undoubted  recovery  hav^e 
been  rep<>rtt'(l.  particularly  in  the  chronic  forms  of  the  disease. 

Treatment. — The  prophylactic  treatment  consists  in  the  prevention  of 
suppuration.  The  antiseptic  treatment  of  wounds  has  almost  abolished  the 
disease  in  hospitals,  where  it  was  formerly  of  frecjuent  occurrence.  When 
the  first  septic  disturbances  have  developed  in  the  wound  and  adjacent  veins 
an  attempt  should  l)e  made  to  arrest  the  further  progress  of  the  disease  by  a 
thorough  disinfection,  not  only  of  the  wound,  but  of  the  interior  of  the  vein. 
Such  attempts  liave  been  successfully  carried  out  in  thrombosis  of  the  lateral 
sinuses  and  jugular  veins  following  suppuration  in  the  mastoid  cells.  If  the 
interior  of  the  vein  cannot  be  th(ti'oughly  disinfected,  a  ligature  may  be  placed 
upon  it  at  a  point  between  the  puriform  thrombus  and  the  heart.  When  the 
infected  area  is  seated  in  an  extremity  amputation  may  be  performed,  provided 
the  surgeon  can  be  reasonably  certain  that  the  thrombus  does  not  extend  above 
the  point  selected  for  the  operation.  When  it  is  possible  all  metastatic  ab- 
scesses or  suppurating  joints  should  be  laid  open  and  thoroughly  disinfected. 

Drugs  are  of  little  use  in  the  internal  treatment  of  the  disease.  Anti- 
streptococcic serum  has  been  advocated  and  tried,  but  its  usefulness  is  still 
in  doubt.  Antipyretics  depress  the  hearts  action.  Carbonate  of  ammonium 
and  digitalis  are  more  likely  to  be  of  service  during  the  stage  of  prostration. 
Alcohol  should  be  given  freely,  and  in  as  large  quantities  as  the  patient  will 
bear.  Easily-digested  food  should  also  be  administered  unsparingly.  If  the 
patient  is  in  a  hospital,  he  should  be  immediately  isolated  from  all  other 
patients,  and  as  strict  a  quarantine  as  possible  of  those  in  attendance  should 
be  preserved.  Ventilation  should  be  free,  and  the  patient  may  be  placed  in 
a  tent,  or  even  for  a  portion  of  the  time  in  the  open  air,  in  certain  cases. 


CHAPTER   XI, 
ERYSIPELAS. 


Erysipelas  is  an  acute  infective  inflammation  spreading  along  the  upper 
layers  of  the  integuments  of  the  body  and  mucous  membranes  tlirough  the 
lymphatic  system.  It  is  accompanied  by  a  remittent  type  of  fever  and  shows 
a  tendency  to  recur.  The  name  is  probably  derived  from  ioo&oo^,  red,  and 
TrikXa,  skin.  Erysipelas  was  known  to  the  ancients,  but  authentic  accounts 
are  of  comparatively  recent  date.  Severe  epidemics  of  erysipelas  raged  in 
France  in  1750.  in  Great  Britain  in  1800,  and  in  1842-43  both  Europe  and 
America  were  visited  by  an  epidemic  of  a  most  virulent  type.  Since  then 
there  are  no  records  of  epidemics  of  similar  severitv.  Although  much  less 
frequently  met  with  since  the  introduction  of  the  antiseptic  treatment,  it  is  the 
most  common  of  the  traumatic  infective  diseases  seen  at  the  present  time. 

Etiology. — The  organism  Avhich  is  the  cause  of  the  disease  is  the  strepto- 
coccus erysipelath.  This  has  been  abundantly  proved  by  experiments  in  ani- 
mals and  man.  Opinions  vary  as  to  the  identity  of  the  streptococcus  pyogenes 
with  the  streptococcus  of  erysipelas.  The  cocci  grow  in  serpentine  chains ; 
each  measures  from  0.3  to  0.4  micro-millimeters  in  diameter.  These  cocci 
are  said  to  be  somewhat  larger  than  the  streptococcus  pyogenes,  but  smaller 
than  the  staphylococcus.     They  are  found  in  the  capillary  lymphatics  of  the 


ERYSIPELAS.  67 

skin  cliielly,  but  tliov  may  also  be  seen  occasionally  in  the  capillary  blood- 
vessels, 'riiey  are  most  active  near  the  mar<fin  of  the  erysipelatous  blush,  and 
the  lymphatics  are  cnjwded  with  them  at  this  point.  They  are  not  found  in 
any  numbers  in  the  circulation,  but  it  is  probable  that  the  constitutional 
disturbance  is  due  to  their  presence  or  to  the  })resence  of  ptomaines  in  the  blood. 
The  organism  usually  obtains  an  entrance  through  a  wound.  In  idiopathic 
erysipelas,  Avhen  no  wound  is  seen,  it  is  probable  that  small  a})rasions  of  the 
skin  are  the  route  through  which  the  virus  enters  the  body.  Probably  also 
cases  of  internal  infection  occur,  the  organisms  having  been  previously  absorbed 
through  the  respiratory  or  digestive  tract. 

The  contagiousncHS  of  erysipelas  had  been  abundantly  proved  clinically 
before  the  nature  of  the  poison  was  understood.  The  disease  has  been  conveyed 
to  a  large  number  of  children  through  the  medium  of  vaccine  virus  taken  from 
a  child  affected  with  erysipelas.  Instances  of  er^^sipelas  carried  from  a  distance 
to  certain  localities  where  no  such  disease  had  existed  previously,  and  produ- 
cing there  an  epidemic,  abound  in  literature.  The  close  relationship  between 
erysipelas  and  puerperal  fever  has  long  been  recognized,  and  examples  of  the 
transmission  of  the  virus  of  erysipelas  to  puerperal  women  by  the  medical 
attendant,  and  the  consequent  production  of  puerperal  fever,  are  far  too 
numerous.  Both  diseases  are  produced  by  the  streptococcus,  and  experiment 
has  shown  that  this  organism  can  be  cultivated  from  a  puerperal  case  and  can 
then  be  injected  into  rabbits,  producing  erysipelas.  It  seems  probable  that 
the  disease  is  more  prevalent  at  certain  seasons  of  the  year,  particularly  in  the 
early  spring  months. 

Symptoms. — This  disease  is  usually  ushered  in  with  a  chill  which  is 
accompanied  with  vomiting  or  more  or  less  gastric  disturbance.  In  chil- 
dren a  convulsion  not  uncommonly  takes  the  place  of  the  chill.  An 
examination  of  the  wound  at  the  time  shows  no  perceptible  change,  although 
the  nearest  lymphatics  are  apt  to  be  enlarged,  and  it  is  not  until  the 
end  of  twenty-four  hours  or  longer  that  a  blush  is  seen  in  the  skin  at  this 
point.  There  is  an  increased  tension  in  the  part,  accompanied  by  an  itching 
or  burning  sensation.  When  the  local  inflammation  has  developed  the  color 
of  the  skin  is  a  yellowish  red,  and  there  is  considerable  infiltration  of  the 
inflamed  part,  which  has  a  doughy  feel.  The  area  invaded  is  well  defined  and 
its  margins  are  quite  irregular,  presenting  a  zigzag  outline.  During  the  height 
of  the  inflammation  vesicles  form  on  the  surface  and  sometimes  become  quite 
large.  When  resolution  takes  place  there  is  considerable  desquamation.  The 
inflammation  does  not  remain  long  in  one  spot.  It  spreads  widely,  and  may 
involve  large  areas  or  even  the  whole  surface  of  the  body.  In  the  mean  time, 
at  the  end  of  three  or  four  days  the  part  first  attacked  begins  to  improve. 
During  the  heicrht  of  the  inflammation  the  constitutional  disturbance  is  well 
marked.  The  temperature  ranges  from  102°  to  104°  F.  The  pulse  is  rapid 
and  shows  a  tendency  to  become  Aveak.  The  tongue  is  heavily  coated  and  the 
urine  is  charged  with  urates.  With  each  fresh  outbreak  of  the  cutaneous 
inflammation  there  is  an  increased  pyrexia  and  the  fever  curve  presents  a  most 
irregular  outline.  There  are  marked  remissions,  but  usually  no  return  to 
normal  until  the  dermatitis  has  subsided.  The  duration  of  the  disease  is  quite 
uncertain.  In  favorable  cases  it  Avill  last  no  longer  than  a  week  or  ten  days, 
but  frequently  the  attack  may  last  a  month.  Toward  the  close  of  the  disease 
when  the  case  is  terminating  favorably  there  is  usually  a  tendency  to  subnormal 
temperature,  show^ing  the  great  prostration  Avhich  the  disease  has  produced. 
This  depression  of  the  vital  powers  is  a  feature  of  the  affection  which  it  is 
always  important  to  bear  in  mind. 


G8  AN  AMERICAN    TKXT-JiOOK    OF  SURGERY. 

Varieties. — When  the  virus  does  not  confine  itself  to  the  superficial  capil- 
hiry  lymphatics,  l)ut  spreads  to  the  subcutaneous  connective  tissue,  we  have  the 
varietv  known  as  philegmonous  crvsipelas.  Under  these  circumstances  sup- 
puration, -which  is  extremely  rare  in  ordinary  erysipelas,  is  likely  to  occur. 
The  foul,  acrid,  and  thin  pus  infiltrates  large  areas,  and  there  are  sloughs 
of  the  connective  tissue  which  are  discharged  in  masses.  In  some  of  the 
severe  epidemics  of  this  type  the  muscles  were  attacked  and  the  periosteum 
was  destroyed,  giving  rise  to  necrosis.  Gangrene  of  the  skin  may  also 
occasionally  occur  from  deprivation  of  blood  due  to  death  of  the  underlying 
connective  tissue.  The  presence  of  a  jjhlegmonous  inflammation  is  indicated 
by  the  increased  amount  of  local  swelling  and  constitutional  disturbance. 
Fluctuation  or  bogginess  is  soon  felt,  and  if  the  pus  is  not  liberated  by 
incision  it  burrows  freely  in  all  directions. 

Pinlegmonous  cellulitis,  or  inilammation  of  the  subcutaneous  cellular 
tissue,  is  regarded  as  identical  with  phlegmonous  erysipelas  by  many  writers. 
It  is  probable  that  the  streptococcus  rather  than  the  staphylococcus  is  most 
frequently  found  in  this  form  of  inflammation,  but  the  question  must  remain 
open  until  the  identity  or  non-identity  of  the  streptococcus  pyogenes  and  the 
streptococcus  erysipelatis  is  settled.  Clinically,  the  two  types  are  readily  dis- 
tinguished by  the  absence  of  cutaneous  erysipelas  in  phlegmonous  cellulitis. 

There  are  other  forms  of  rapidly-spreading  inflammations  of  the  skin  and 
cellular  tissue,  particularly  those  Avhich  follow  infected  wounds  of  the  fingers  or 
hand,  Avhich  are  regarded  by  some  authors  as  akin  to  erysipelas.  These  at 
times  take  the  form  of  lymphangitis ;  at  other  times  they  occur  as  acute  swell- 
ings of  the  integuments  and  connective  tissue,  extending  with  great  rapidity, 
showing  but  slight  tendency  to  suppuration,  and  frequently  terminating  fotally 
with  symptoms  of  acute  septicemia.  They  are  probably  due  occasionally  to 
infection  Avith  streptococci  or  Avith  saprogenic  bacilli. 

Facial  erysipelas,  which  at  one  time  was  regarded  as  idiopathic  ery- 
sipelas, is  now  supposed  to  be  due  to  infection  through  some  slight  wound  or 
abrasion  on  the  face.  It  usually  begins  with  a  blush  near  the  root  of 
the  nose  or  the  lachrymal  duct  and  spreads  laterally  toward  the  ears.  The 
color  is  a  scarlet  red,  and  the  amount  of  swelling  is  usually  great  and  is  accom- 
panied with  oedema  about  the  eyelids,  obliterating  all  facial  expression  and 
causing  entire  closure  of  the  lids.  Vesicles  and  bullne  also  form  on  the  cheeks. 
The  inflammation  may  extend  to  the  scalp  or  the  neck,  but  the  chin  is  rarely 
involved.  The  glands  at  the  back  of  the  neck  are  enlarged.  In  some  forms 
the  fever  runs  high,  and  there  is  usually  considerable  delirium.  This  may  be 
due  to  reflex  irritation  of  nerves  or  rarely  to  a  suppurative  meningitis,  the 
result  of  a  direct  extension  of  suppuration  in  the  orbit  or  to  the  meninges. 
Ordinarily,  the  delirium  disappears  when  the  fever  subsides.  There  is 
more  or  less  conjunctivitis,  and  some  oedema  in  the  orbital  tissues.  If  sup- 
puration should  occur,  blindness  may  result,  a  complication  which  is  for- 
tunately rare. 

Erysipelas  neonatorum  occurs  usually  in  epidemic  form  in  hospitals. 
It  begins  as  a  slight  inflammation  about  the  umbilicus,  but  as  it  s]ireads  to  the 
genitals  and  thighs  the  constitutional  disturbance  is  great  and  the  prognosis 
grave.  It  may  be  complicated  w'ith  phlebitis  of  the  umbilical  veins  extending 
to  the  liver. 

Erysipelas  may  involve  the  mucous  membranes.  In  severe  epidemics 
of  erA'-sipelatous  angina  the  tonsils  are  greatly  inflamed  and  the  tongue  is  often 
swollen.  Diphtheritic  or  gangrenous  inflammation  of  the  fauces  may  also 
occur.     These  epidemics  are  rarely  seen  at  the  present  time.     Erysipelas  may 


FJi  VSIPELAS.  69 

extend  to  the  "glottis,  and  erysipelatous  pneumonia,  or  imeunionia  migrans,  is 
described  by  some  aiitbors.  The  female  genitals  and  tlie  rectum  may  also  be 
invaded  by  the  disease. 

The  curative  influence  of  erysipelas  is  shown  not  only  in  the  effect  pro- 
duced by  it  on  old  ulcers,  but  even  by  the  Avound  itself,  which,  when  in  the 
granulating  stage,  appears  to  heal  more  rapidly.  Tumors  also  have  sometimes 
disa]>peared  during  an  attack.  Lympho-sarcoma  of  the  neck  has  been  absorbed, 
tiie  cells  having  uiulergone  fatty  degeneration.  Both  lupus  and  epithelial  ulcers 
of  tlie  face  have  been  known  to  break  down,  healthy  granulations  su))sequently 
appearing  which  healed  rapidly.  Fehleisen  took  advantage  of  this  circum- 
stance to  inoculate  certain  ulcers  with  cultures  of  the  streptococci  of  erysipelas, 
and  thus  demonstrated  the  identity  of  the  virus  of  the  disease  (p.  207). 

'^\\Q  prognosis  of  erysipelas  is  usually  favorable,  as  there  is  a  tendency  to 
self-limitation.  The  severity  of  the  disease  cannot,  how^ever,  be  predicted  in 
any  given  case,  but  in  small  granulating  wounds  the  disease  is  usually  lighter 
than  in  large  fresh  wounds.  Danger  frequently  arises  from  complications,  as 
oedema  of  the  glottis  or  secondary  hemorrhage. 

Treatment. — Attempts  to  restrain  the  infective  process  by  antiseptic 
applications  have  thus  for  not  been  very  successful.  The  apparent  success  of 
many  drugs  may  be  due  to  the  spontaneous  arrest  of  the  process  which  so  often 
occurs.  Hot  fomentations,  containing  corrosive  sublimate  of  the  strength  of 
1 :  10,000  or  1 :  15,000,  or  carbolic  acid  may  be  used  ;  but  care  must  be  taken 
to  avoid  increased  local  irritation  or  poisoning  by  absorption  of  the  drugs  when 
a  large  surface  is  covered.  An  ointment  of  carbolic  acid  and  vaseline,  1  to 
100,  may  be  brushed  on  the  face  with  a  soft  brush  or  applied  to  other  surfaces 
and  protected  with  a  thin  layer  of  gutta-percha  tissue  or  oiled  paper.  Zinc 
ointment,  or  an  ointment  of  ichthyol  (25  per  cent.),  is  often  useful.  In 
phlegmonous  erysipelas  free  incisions  are  indicated.  The  slough  should  be 
removed,  and  the  pus-cavities  must  be  disinfected  as  thoroughly  as  possible. 
Pressure  with  plasters  or  bandages  in  situations  where  they  can  be  conveniently 
applied,  has  been  advised  to  arrest  the  spread  of  the  disease. 

The  constitutional  treatment  should  always  be  supporting,  and  any  deplet- 
ing measures  should  be  carefully  avoided.  The  presence  of  delirium  does  not 
necessarily  contraindicate  the  use  of  stitnulants.  Tincture  of  the  chloride  of 
iron  has  been  recommended  in  large  and  frequent  doses  on  account  of  its  action 
upon  the  red  blood-corpuscles,  which  are  found  crenated,  and  when  placed 
under  the  microscope  run  together  readily.  This  method  was  at  one  time 
received  with  great  favor,  but  is  less  used  at  present.  Quinine  has  also  enjoyed 
a  great  popularity.  Antipyretics  as  a  rule  have  little  effect  upon  the  fever, 
and  should  be  avoided,  owing  to  the  depressing  influence  upon  the  heart's 
action  which  many  of  them  exert.  Opium  in  some  form  and  hypnotics  are 
indispensable  to  allay  the  pain  and  procure  sleep.  Food  should  be  carefully 
and  frequently  administered.  When  the  blush  has  disappeared  a  complete 
change  of  bedding  and  clothing,  with  careful  disinfection,  may  serve  to  pro- 
tect the  patient  from  a  relapse  due  to  a  reinfection  of  the  system. 


70  .l.V   AMKIUCAX    TKXT-nOOK    OF   SLlKiEUY. 

CHAPTER   XII. 
TETANUS. 

Tetanus  is  an  infective  disease,  almost  always  originating  from  a  wound. 
The  central  nervous  system  is  the  region  chiefly  affected  by  the  bacterial  poison 
which  is  the  cause  of  the  disease. 

The  bacillus  of  tetanus  (PI.  IT,  Fig.  T))  was  discovered  in  1885  by 
Nicolaier.  It  is  a  siiort  rod  with  an  enlargement  at  one  end.  due  to  sporulation, 
which  gives  it  the  characteristic  drumstick  shape.  Although  it  is  found  in 
the  dust  of  the  street,  it  rarely  finds  an  opportunity  to  grow  in  the  living  ti.ssues, 
owing  to  its  anaerobic  properties ;  hence  the  rarity  of  the  disease.  It  is  found 
principally  in  the  tissue  near  the  wound,  and  is  rarely,  if  ever,  seen  in  the 
internal  organs  or  blood.  Several  ptomaines  have  been  extracted  from  the 
cultures  of  this  bacillus,  such  as  tetanine  and  tetano-toxine,  and  it  is  probable 
that  most  of  the  symptoms  of  irritation  of  the  nervous  system  are  due  to  the 
presence  of  these  substances,  as  but  few  bacilli  are  found  there. 

Punctured  wounds  naturally  offer  the  best  opportunity  for  the  growth  of  the 
anaerobic  bacillus,  and  if  such  wounds  are  inflicted  in  dirty  parts  of  the  body, 
as  the  hands  or  feet,  or  foreign  bodies  covered  with  dust  containing  the  bacilli 
are  lodged  in  the  tissues,  the  conditions  favorable  for  infection  are  obtained. 
The  state  of  the  weather  is  said  to  have  an  influence  upon  the  development  of 
the  disease.  It  has  appeared  in  epidemic  form  with  sudden  changes  in  the 
weather  after  battles.  It  is  also  said  to  be  much  more  common  in  tropical 
climates. 

Tetanus  is  said  to  be  traumatic  or  idiopathic.  It  is  probable,  however, 
that  all  cases  of  tetanus  are  traumatic,  but  tliat  the  wound  is  so  slight  in  many 
cases  as  to  escape  notice.  It  has  been  known  to  follow  such  injuries  as  simple 
fracture,  in  which  case  internal  infection  probably  occurs. 

Acute  tetanus  most  fre((uently  makes  its  appearance  at  the  end  of  the  first 
week  after  the  infliction  of  an  injury,  although  tliis  period  varies  considerably. 

The  first  symptom  complained  of  is  a  stiff  neck,  which  the  patient 
attributes  to  a  slight  cold.  The  muscles  of  the  face  and  jaw  are  next  involved, 
and  the  patient  is  unable  to  open  his  mouth,  this  symptom  giving  rise  to  the 
popular  name  "  lock-jaw."  The  muscles  of  the  fauces  and  the  pharynx  are 
often  in  a  state  of  spasm,  rendering  deglutition  difficult.  The  muscles  of  the 
thorax  and  abdomen  are  next  involved,  and  the  muscles  of  the  back  are  so 
painfully  contracted  that  the  head  is  thrown  l)ack,  the  spine  is  arched,  and  the 
body  assumes  the  position  known  as  opisthotonos.  The  lower  extremities 
may  also  become  rigid ;  the  arms  are,  hoAvcver,  only  partially  affected.  The 
muscular  spasms,  which  are  tonic,  permit  of  little  rest,  and  the  sufferings  of 
the  patient  are  excessive  and  almost  continuous.  The  expression  of  the  face 
is  totally  changed  by  the  contraction  of  the  various  muscles,  which  jn-oduces 
the  characteristic  risus  sardonicus.  The  patient  often  experiences  considerable 
difiiculty  in  passing  urine  or  in  having  a  movement  of  the  bowels.  Any  dis- 
turbing influence,  especially  noise,  instantly  evokes  the  muscular  contractions 
and  adds  to  the  patient's  sufterings.  These  have  been  known  at  times  to  be 
so  severe  as  to  produce  rupture  of  a  muscle  or  fracture  of  a  bone.  Such  a 
condition  permits  of  little  sleep,  and  in  the  acute  cases  the  patient  rarely 
obtains  any  rest  from  the  moment  the  disease  makes  its  appearance.  The 
temperature  is  usually  not  much  elevated,  but  the  skin  is  bathed  in  perspira- 
tion. The  pulse  is  weak  and  rapid,  and  as  the  disease  progresses  the  exhaus- 
tion becomes  marked,  owing  to  loss  of  food  and  sleep.      Sudden  death  often 


TiyrAxcs.  71 

occurs  in  :i  jKiroxysm  of  dysj)iieii.  The  niiiid  is  usually  clear  to  the  last. 
Such  an  attack  will  run  its  course  usually  in  two  or  three  days. 

In  chronic  tetanus  the  disease  makes  its  appearance  at  a  later  date. 
The  muscles  arc  extensively  involved,  but  there  are  ])eri()ds  of  comparative 
relief,  and  as  these  intervals  become  <!;radually  |)rolonged  the  jiatient  has  an 
oj)p()rtunity  to  sleej).  In  the  chronic  form  the  disease  may  last  several  weeks. 
There  is  little  change  to  be  observed  in  the  wound,  although  in  some  cases  there 
are  evidences  of  an  infective  inflammation. 

Trismus  is  a  name  given  to  a  milder  form  of  the  disease  when  the  con- 
tractions an   limited  to  the  group  of  muscles  alxtut  the  neck  and  face. 

Cephalic  tetanus  or  tetanus  hydrophobicus  occurs  after  injuries 
in  the  region  of  distribution  of  the  twelve  cranial  nerves.  It  is  accompanied 
by  paralysis  of  the  facial  nerve,  usually  on  the  side  affected,  and  there  is 
often  spasm  of  the  pharyngeal  muscles,  causing  difficulty  in  swallowing. 
There  is  also  trismus,  and  sometimes  the  muscles  of  the  trunk  are  affected. 
It  may  be  either  acute  or  chronic.  Many  recoveries  from  the  chronic  form 
are  re|)orted. 

Tetanus  neonatorum  or  trismus  nascentium  is  a  general  affection 
of  the  muscles  in  the  newborn  infant,  beginning  with  trisnnis,  and  is  due  to  an 
infection  through  the  navel.  It  occurs  occasionally  in  epidemic  form  in  lying- 
in  hospitals,  and  is  a  fatal  disease.  From  1860  to  1865,  on  the  island  of  St. 
Kilda,  S4  out  of  125  children  died  of  this  disease  within  14  days  after  birth. 
In  18tt2,  following  the  introduction  of  iodoform  dressing  for  the  umbilical 
cord,  not  a  single  death  occurred  from  this  cause. 

Post-mortem  examinations  of  cases  of  tetanus  do  not  usually  show 
any  evident  pathological  changes.  Some  observers  have  found  hyperemia  of 
the  medulla  and  cord,  but  others  have  detected  no  change.  BroAvn-S^quard 
described  an  ascending  neuritis,  and  Lockhart  Clarke  observed  softening  of 
portions  of  the  gray  substance  of  the  cord. 

The  diagnosis  of  tetanus  is  usually  not  difficult  in  the  acute  cases,  but  in 
the  milder  forms  it  may  be  mistaken  for  other  affections,  as  rheumatic  inflamma- 
tion of  the  jaws  or  hysterical  contractions  of  the  masseter  muscles  and  excessive 
muscular  spasm  during  the  dressing  of  a  sensitive  wound.  In  strychnia-pois- 
oning the  muscles  of  the  jaw  are  not  rigid  at  first.  Where  the  dose  is  small 
and  repeated  there  w'ill  be  intervals  of  rest.  There  is  hyperesthesia  of  the 
retina  and  objects  are  colored  green. 

Tetany  is  a  disease  characterized  by  attacks  during  which  tonic  spasms 
of  the  various  groups  of  muscles  occur,  principally  of  the  upper  extremities. 
According  to  Weiss,  these  attacks  are  due  to  an  irritable  condition  of  the  gray 
matter  of  the  medulla  and  spinal  cord.  It  sometimes  foUow's  childbed  and 
fevers  and  some  mental  shocks.  It  has  also  been  frequently  observed  after 
operations  for  the  removal  of  goitre.  The  spasms  are  tonic  and  give  rise  to 
great  rigidity  of  the  muscles.  Between  the  attacks  the  p&tient  appears  well. 
The  majority  of  cases  get  well  without  treatment.  It  occurs  chiefly  in  young 
persons.  Opisthotonos  may  occur,  but  trismus  is  absent.  Pressure  upon  the 
nerve-trunk  leading  to  the  afi"ected  muscles  will  always  bring  on  an  attack. 
It  is  a  rare  disease  in  America. 

Hydrophobia,  which  is  popularly  thought  to  resemble  tetanus,  is  easily 
distinguished  from  it.  The  paroxysm  of  hydrophobia  is  not  a  true  muscular 
spasm,  and  is  limited  to  the  muscles  of  respiration.  The  intervals  of  repose 
in  early  stages  and  the  mania  in  later  stages  are  also  distinctive.  One  who  has 
once  seen  the  two  affections  would  not  be  likely  to  mistake  them  a  second  time. 

The  prognosis  of  acute  tetanus  is  of  the  gravest  character.     The  only 


72  ^l.V   AMKIilCAX    TKXT-IKJOK    OF  SLIldKIiV. 

liopo  in  such  cases  is  that  the  acute  form  may  <rra(hially  assume  a  chronic  type. 
According  to  Yandell's  statistics,  those  ])atients  wlio  live  beyond  the  fifth  day 
are  more  likely  to  recover.  Every  day  beyond  this  period  improves  the 
chances  for  recovery.  Cases  occurring  after  injury  received  in  battle  are 
much  more  fatal. 

The  prophylactic  treatment  consists  in  the  thorough  disinfection  of  all 
suspicious  Avounds.  As  soon  as  symptoms  appear  the  patient  shoulil  be  iso- 
lated and  kept  in  a  darkened  room,  and  extreme  care  should  be  taken  to  disturb 
him  as  little  as  possible.  Any  method  of  treatment  which  involves  motion  should 
therefore  be  avoided.  Of  all  drugs,  chloroform  appears  to  have  the  most  sooth- 
ing effect  uiKin  the  nervous  system,  and  can  be  administered  in  small  (juantities 
by  inhalation  at  frecjuent  intervals.  Chloral  can  also  be  given  Avith  the  same 
end  in  view,  and  it  may  be  combined  with  bromide  of  potassium.  Inhalations 
of  nitrite  of  amyl  often  act  well,  the  relief  persisting  for  some  time  after  each 
inhalation.  Morphine  may  be  injected  subcutaneously.  Calabar  bean  has 
been  used  successfully.  All  of  these  drugs  must  be  given  in  unusually  large 
doses  and  for  a  considerable  time,  as  a  hesitating  policy  entails  great  suffering 
upon  tlie  patient.  Retention  of  urine  must  be  relieved  by  catheterization,  and 
if  the  muscular  spasm  of  the  throat  is  excessive  it  may  be  necessary  to  admin- 
ister nutrient  enemata.  There  are  few  diseases  where  skilled  nursing  is  of  so 
much  importance.  Several  authors  have  recently  published  cases  of  cure  by 
injections  of  the  tetanus  antitoxin  of  Tizzoni  and  Cattani  (see  p.  81). 

Kitasato  has  shown  that  injections  of  iodoform  render  an  animal  immune 
to  tetanus,  and  it  seems  possible  that  this  drug  may  be  of  value  in  the  actual 
treatment  of  the  disease. 


CHAPTER    XIII 

SCURVY. 


Scurvy  is  a  constitutional  disease  ti-aceable  to  the  use  of  improper  diet, 
defective  chiefly  in  suitable  vegetable  food,  and  to  imperfect  hygienic  surround- 
ings. It  is  characterized  by  great  disturbances  of  nutrition  and  a  tendency  to 
hemorrhage  in  the  various  tissues  of  the  body. 

History  teems  Avith  accounts  of  diseases  strongly  resembling  scurvy,  but 
no  reliable  descriptions  of  any  epidemic  are  to  be  found  before  the  fifteenth 
century,  when  the  great  extension  of  navigation  exposed  the  crews  of  vessels 
to  prolonged  privations  such  as  had  not  before  been  experienced.  During  the 
present  century  it  has  been  noticed  chiefly  in  Arctic  voyages  and  in  many 
wars.  The  Allied  armies  suffered  from  this  disease  in  the  Crimea,  and  during 
the  late  Civil  "War  the  troops  on  both  sides  were  affected.  Perhaps  the  most 
striking  epidemic  of  any  occurred  at  Andersonville.  During  the  siege  of 
Paris  in  1871  many  cases  of  scurvy  were  discovered  and  carefully  studied. 
It  is  rarely  seen  at  the  present  time,  and  no  opportunity  has  been  obtained  for 
studying  it  with  the  care  which  modern  methods  of  investigation  offer. 

Scurvy  has  been  supposed  to  be  a  contagious  disease  and  also  one  of 
miasmatic  origin,  but  it  is  now  conclusively  proved  that  imperfect  nutrition 
is  the  most  important  factor  in  the  causation  of  the  disease.  All  are  agreed 
that  a  deficiency  in  the  variety  of  the  diet  is  the  principal  cause  of  scurvy,  but 
opinions  differ  widely  as  to  the  particular  alimentary  substance  the  absence  of 
which  brings  out  the  symptoms  of  the  disease.  Some  have  supposed  that  the 
disorder  Avas  due  to  tlie  lack  of  fresh  vegetables.     Others  have  thought  that 


SCUB  VY.  73 

tlic  excessive  use  of  salt  meats  produced  conditions  favoral)le  for  the  disease. 
Garrod's  theory  that  a  deficiency  of  easily  assimilated  potassium  salts  in  the 
food  is  one  of  the  causes  of  scurvy  has  excited  a  good  deal  of  attention.  The 
most  important  factor,  however,  is  certainly  the  absence  of  variety  in  diet. 
In  certain  instances  the  use  of  impure  water  has  caused  an  outbreak  of  the 
disease,  as  was  the  case  in  Rankes  ex})edition  into  the  interior  of  Australia. 
Unhealthy  surroundinfrs,  as  foul  quarters  in  a  ship ;  a  bad  state  of  the  health, 
such  as  might  result  from  great  fatigue  or  dissipation  ;  and  mental  depression, 
such  as  might  occur  among  convicts, — are  all  predisposing  causes. 

Symptoms. — The  early  stages  of  the  disease  are  marked  by  a  condition 
of  extreme  lassitude.  On  slight  exertion  the  heart's  action  becomes  rapid  and 
the  respiration  is  increased  in  frequency.  The  patient  complains  of  muscular 
pains  in  various  portions  of  the  body  and  is  extremely  sensitive  to  low  tempera- 
tures. He  is  drowsy  and  apathetic  and  has  an  appearance  of  depression. 
There  is  no  febrile  disturbance  and  the  pulse  is  slow  and  feeble.  The  skin  is 
of  a  pale  yellow  hue,  and  is  mottled  here  and  there  with  brownish-colored  spots. 
The  epidermis  is  dry  and  brittle  and  there  is  considerable  desquamation.  The 
cutaneous  follicles  are  unusually  prominent,  giving  the  appearance  of  "  goose- 
flesh."  This  condition  will  last  for  several  weeks  before  the  symptoms  dis- 
tinctly characteristic  of  scurvy  make  their  appearance.  The  gums  then  begin 
to  be  swollen  and  oedematous,  and  the  mucous  membrane  of  the  mouth  assumes 
a  bluish  tinge.  The  alveolar  membrane  is  sensitive  and  bleeds  easily,  and 
the  breath  has  a  characteristic  foul  odor. 

Petechise  and  numerous  small  extravasations  are  seen  beneath  the  surface 
of  the  skin.  They  are  at  first  observed  about  the  roots  of  the  hair,  and  appear 
as  round  bluish-red  spots  the  size  of  a  pin's  head,  which  do  not  disappear  on 
pressure.  Later,  some  of  the  extravasations  Avhich  take  place  are  of  consider- 
able size  and  appear  like  bruises.  Small  vesicles  form  Avhich  later  grow 
to  large  size  and  become  occasionally  the  starting-points  of  ulcerations.  The 
latter  may,  however,  result  from  a  septic  infection  and  breaking  down  of  the 
extravasations  themselves.  The  ulcers  vary  in  size,  are  covered  with  a 
brownish  scab,  and  are  surrounded  by  a  violet  discoloration  of  the  skin.  The 
granulations  are  unhealthy  and  give  vent  to  a  foul-smelling  discharge.  The 
muscles  and  the  connective  tissue  are  also  the  seat  of  hemorrhages,  some  of 
which  break  down  and  discharge  an  ichorous  fluid.  At  other  times  they 
indicate  their  presence  only  by  peculiar  indurations  to  be  felt  in  those  tissues. 
Hemorrhages  may  occur  also  from  the  mucous  and  serous  membranes.  Inflam- 
matory hemorrhagic  efiusions  may  take  place  in  the  periosteum.  Swellings 
occur  at  the  epiphyseal  line,  and  the  epiphyses  may  be  separated  from  the 
shafts  of  the  bones.  The  joints  also  may  be  involved.  Even  the  eyes  may  be 
afl'ected,  and  more  or  less  disturbance  of  vision  result  (hemeralopia).  The 
quantity  of  the  urine  is  decreased,  as  also  the  urea  and  all  the  solid  elements 
of  urine.  Fever  is  present  during  the  height  of  the  disease  only  when  inflam- 
matory complications  prevail. 

The  j)08t-mortem  changes  observed  are  the  hemorrhagic  eff"usions  in  various 
parts  of  the  body  and  such  inflammatory  complications  as  may  have  occurred, 
especially  croupous  pneumonia  and  ulcerative  endocarditis.  Hemorrhagic 
infarctions  are  often  found,  the  result  of  embolism  derived  from  thrombi  which 
form  in  the  right  auricle.  Analyses  of  the  blood  have  not  as  yet  thrown  much 
light  upon  the  hemorrhagic  tendency  so  conspicuous  in  this  disease.  Water 
is  found  in  excess  and  an  increased  number  of  white  corpuscles  is  observed. 
It  is  probable  that  a  diminished  power  of  resistance  exists  in  the  walls  of  the 
capillaries. 


74  AX    AMi:iUl'Ay    TEXT-noOK    OF   ,Sl'R(i KUV. 

Diagnosis. — Scnrvv  may  bo  (listiniruislieJ  from  purpura  by  tlie  cachexia 
ami  the  persistent  pains  and  the  fetid  breatli  accompanyiiif^  the  jieculiar  con- 
dition of  the  gums.  It  may  be  distinguished  in  the  same  way  from  anemia, 
hemophilia,  and  leucocythemia. 

Tlie  prognosis  of  the  disease  will  depend  greatly  upon  the  stage  at  which 
the  ])atient  comes  under  treatment.  Under  favorable  conditions  imj)rovement 
soon  begins  in  most  cases,  but  the  duration  of  the  convalescence  is  usually 
a  prolonged  one.  If  the  use  of  the  limbs  is  regained  after  a  few  days  of 
treatment,  the  prospects  of  ultimate  recovery  are  excellent.  The  recovery  in 
uncomplicated  cases  is  usually  a  complete  one. 

The  pro j)hy lactic  treatment  consists  in  strict  attention  to  the  hygienic 
conditions,  especially  as  to  dryness  and  cleanliness  on  sliips  and  in  laying  in  a 
supply  of  live-stock.  Among  the  antiscorbutics  of  repute  at  the  })resent  time 
may  be  enumerated  eggs,  milk,  potatoes,  beets,  carrots,  cabbages,  onions,  fruits, 
cocoanuts,  pickles,  cranberries,  cider,  lemonade,  and  lime-juice.  The  various 
meat  extracts  are  also  valuable  and  portable  articles  of  food.  Good  drinking- 
water  is  also  of  the  greatest  importance  as  a  prophylactic. 

The  curative  treatment  of  the  disease  is  almost  exclusively  dietetic.  Nitrate 
of  potassium  is  said  to  be  of  especial  value.  It  may  be  used  alone  or  mixed 
with  vinegar  (Wales).  Antiseptic  mouth-washes  and  lotions  for  the  ulcers  are 
also  indicated.  Any  medication  contemplated  should  be  of  a  distinctly  tonic 
character. 


CHAPTER    XIV. 
TUBERCULOSIS. 

The  inoculability  of  tuberculous  material  Avas  regarded  as  a  possibility 
by  Laennec  and  others,  but  Yillemin  in  18(35  was  the  first  to  demonstrate  the 
fact  that  the  disease  could  be  transmitted  by  inoculation  to  animals,  and 
was  therefore  infectious  like  small-pox  or  syphilis.  These  views  were  con- 
firmed in  1877  by  Cohnheim,  Avho  successfully  inoculated  the  anterior 
chamber  of  the  eye  in  animals,  and  was  able  to  observe  through  the  trans- 
parent cornea,  after  a  period  of  incubation,  a  development  of  numerous  miliary 
tubercles  in  the  iris. 

The  search  for  the  bacillus  was  from  this  time  pursued  with  energy,  but 
the  observations  of  Baumgarten  gave  the  only  reliable  results.  His  discoveiy 
of  the  bacillus  was  almost  simultaneous  with  that  of  Koch,  who,  however,  in 
1882  was  the  first  to  establish  fully  the  identity  of  the  organism  and  to  culti- 
vate it  successfully. 

The  length  of  the  bacillus  tuberculosis  is  about  one-half  the  diameter 
of  a  red  blood-corpuscle.  It  is  a  thin  rod,  found  single,  in  pairs,  or  in  clusters. 
In  tubercle  in  the  human  subject  it  is  seen  usually  either  single  or  in  .small 
numbers,  and  at  times  is  quite  difficult  to  demonstrate.  It  is  found,  however, 
in  large  numbers  in  experimental  tuberculosis  in  certain  stages  of  development, 
and  therefore  when  it  is  not  possible  to  discover  bacilli  with  the  microscope  a 
diagnosis  can  be  made  by  inoculation  of  a  suspected  tubercle  into  animals. 

The  miliary  tubercle  consists  of  a  minute  gray  non-vascular  nodule 
about  the  size  of  a  mustard-seed.  Under  the  microscope  it  is  seen  to  contain 
a  mass  of  leucocytes,  near  the  centre  of  which  are  to  be  found  a  number  of 
larger  cells  with  one  or  more  nuclei  known  as  epithelioid  cells  and  one  or  more 


TUBERCULOSIS.  75 

giant-cells.  The  appearance  of  such  a  cluster  of  cells  is  so  characteristic  that 
a  tubercle  can  usually  be  recognized  by  the  presence  of  the  giant-cells  without  a 
demonstration  of  the  bacilli,  although  these  cells  are  also  found  in  other  growths 
besides  tubercle  (PI.  IV,  Fig.  1).  The  structure  of  these  giant-cells  is  peculiar, 
the  nuclei  being  arranged  in  a  somewhat  radiating  manner  around  the  periphery 
of  the  cell,  the  center  of  which  is  made  up  of  a  granular  protoplasm  in  a  more 
or  less  advanced  stage  of  degeneration.  In  studying  experimentally  the 
development  of  a  tubercle  it  has  been  found  that  the  first  change  consists  in 
a  division  of  the  fixed  cells  of  the  part  involved  (by  karyokinesis),  by  means 
of  which  process  the  epithelioid  cells  are  formed.  The  giant-cell  formation  is 
due  to  the  fiict  that  the  epithelioid  cells  do  not  show  a  tendency  in  the  less 
active  forms  of  tuberculosis  to  ])roliferate,  but  the  division  of  the  nuclei  of 
certain  cells  continues,  and  the  unusual  cell-growth  is  thus  produced.  In  acute 
miliary  tuberculosis  the  cell-division  is  more  active  and  giant-cells  are  less 
frequently  found. 

As  the  growth  of  tissue-cells  begins  to  subside,  the  number  of  leucocytes 
which  have  Avandered  in  from  without  begins  to  increase.  The  fine  reticulum 
or  network  of  fibers  which  supports  the  cells  of  the  tubercle  does  not  appear 
to  be  a  new  formation,  but  is  merely  the  remains  of  the  intercellular  substance 
of  the  pre-existing  tissue. 

The  bacilli  are  found  either  in  the  larger  cells  or  between  them  ;  at  times 
but  one  or  two  bacilli  are  found  in  the  giant-cells.  They  are  seen  usually  near 
the  nuclei  at  the  border  of  the  cell.  More  rarely  they  are  found  in  large  num- 
bers in  the  human  subject.  How^  they  are  brought  to  the  part  affected  is  not 
clear :  it  is  thought  by  some  that,  not  possessing  any  movements  of  their 
own,  they  are  transported  by  the  leucocytes,  but  this  view  would  not  accord 
with  that  first  expressed  (Baumgarten) — namely,  that  the  leucocytes  appear  only 
at  a  later  stage  in  the  process  of  development.  The  bacilli  are  rarely  found  in 
the  circulating  blood. 

Sections  of  tubercle  are  well  shown  by  the  double  staining  process,  the 
fibers  of  the  tissue  being  colored  red  by  eosine,  and  the  giant-cells  being  well 
brought  out  by  the  hematoxylin.  In  order  to  show  the  tubercle  bacilli  a 
special  staining  method  is  necessary.  The  staining  fluid  consists  of  the  follow- 
ing ingredients :  Saturated  alcoholic  solution  of  fuchsin,  10  parts ;  5  per  cent, 
aqueous  solution  of  carbolic  acid,  90  parts. 

The  section  should  be  placed  in  a  small  quantity  of  this  fluid  in  a  watch- 
glass,  and  allowed  to  remain  from  one  to  twenty-four  hours  according  to  the 
degree  of  staining  required.  The  section  should  then  be  decolorized  with  a 
5  per  cent,  solution  of  sulphuric  acid  for  a  few  seconds.  If,  when  the  specimen 
has  been  washed  in  alcohol  60  per  cent.,  it  is  found  not  to  be  sufficiently 
decolorized,  it  should  be  replaced  in  the  sulphuric  acid.  It  should  finally 
be  dehydrated  in  absolute  alcohol,  cleared  in  oil  of  cloves,  and  mounted  in 
Canada  balsam. 

Tubercle  shows  a  tendency  at  an  early  period  of  its  existence  to  undergo  a 
caseous  degeneration.  This  tendency  is  fiivored  by  the  absence  of  blood- 
vessels, and  the  pjart  which  first  succumbs  to  this  process  is  the  center  of  the 
tubercle,  the  portion  farthest  removed  from  the  supply  of  nutriment.  The 
change  is  principally  due  to  a  coagulation-necrosis,  presumably  caused  by  the 
action  of  the  bacilli  upon  the  cells.  As  a  result  of  this  change  the  mass  pres- 
ently assumes  the  appearance  of  a  caseous  nodule.  If  the  progress  of  the  dis- 
ease is  arrested  at  this  point,  the  tubercle  becomes  enclosed  in  a  fibrous  layer 
the  result  of  a  reactive  inflammation,  and  is  said  to  be  encapsuled,  and  the  cells, 
having  all  undergone  cheesy  degeneration,  are  finally  absorbed  or  the  caseous 


70  .1-v  AMi:ni<AX   'iiix'r- !',(>( n<  <)isii;(;i:in'. 

product  is  calcified.  If,  however,  the  process  extends,  the  caseons  nodule 
becomes  laro;er,  the  necrosed  material  breaks  up  into  a  granular  d(''bris,  and  a 
fluid  is  produced  which  in  appearance  resembles  true  pus.  These  products  of 
degeneration  frequently  contain  the  bacilli,  and  when  inoculated  into  animals 
may  re])roduce  the  disease. 

This  tuherruIouH  pus  or  puruloid  material  contains  the  broken-down  masses 
of  cells  and  a  certain  numl)er  of  leucocytes  and  fragnu-nts  of  the  coagulation- 
necrosis.  The  contents  of  cold  abscesses  arising  from  tuberculous  processes  are 
usually  of  this  character,  but  occasionally  the  pyogenic  organisms  are  found  in 
this  fluid,  in  which  case  true  suppuration  occurs.  The  tubercular  pus  is  thin 
and  of  a  peculiar  white  or  chalk-like  color:  it  contains  lumps  of  cheesy  matter 
the  product  of  tubercular  softening,  and  fragments  of  sloughs  of  the  connective 
tissiu'.  Crumbs  of  bone  may  occasionally  be  felt  in  it.  If  the  tubercular 
nodule  is  on  the  surface  of  the  skin  or  a  membrane,  such  degenerative  changes 
will  lead  to  ulceration. 

The  local  spreading  of  tubercular  inflannnation  is  caused  by  the  growth  of 
the  bacilli,  Avhich  involve  new  areas  of  tissue.  Adjacent  cavities  or  organs 
mav  thus  be  invaded.  By  the  breaking  down  of  bone-tissue  the  bacilli  may 
gain  an  entrance  into  a  joint,  or  the  peritoneum  may  become  infected  from  a 
tuberculosis  of  the  intestine.  When  the  bacilli  enter  the  blood-vessels  or 
lymphatics,  they  may  be  transported  alone,  or  in  the  interior  of  small 
emboli,  to  a  distant  organ,  and  a  general  miliary  tuberculosis  may  be  thus 
produced. 

Tuberculosis  is  probably  the  most  common  of  all  diseases,  for  it  is  estimated 
that  IS  per  cent,  of  all  cases  of  death  occur  from  this  cause.  According  to 
Baumgarten,  it  arises  more  frequently  by  inheritance  than  in  any  other  way  ; 
but,  although  the  bacillus  may  undoubtedly  ])e  transmitted  from  parent  to  off- 
spring, it  is  probable  that  only  a  predisposition  to  the  disease  is  the  more  fre- 
quent result  of  heredity.  The  disease  easily  arises  then  in  such  predisposed 
persons  when  the  bacillus  gains  an  entrance  to  the  body  through  the  respiratory 
organs,  Avhether  inhaled  with  the  air  as  dust  arising  from  dried  sputa  and  other 
excretions,  or  taken  into  the  alimentary  canal  with  food  and  penetrating  the 
intestinal  mucous  membrane.  It  may  also  be  introduced  through  wounds  of 
the  skin,  chiefly  of  a  trifling  character,  such  as  bruises  or  scratches.  It  is 
undoubtedly  an  infectious  disease,  and  may  be  contracted  by  persons  of  healthy 
ancestry  by  continued  exposure  to  its  germs. 

Tiiherculosis  of  the  skin  includes  a  number  of  diseases  which  until  recently 
have  been  regarded  as  diff'erent  aflcctions.  The  most  frequent  form  is  that 
known  as  lupus.  This  disease  is  now  recognized  as  a  lesion  due  to  the  pres- 
ence of  the  bacillus  of  tuberculosis,  although  it  is  often  extremely  difficult  to 
find  the  organism.  The  tendency  of  the  disease  is  to  remain  local,  but  it  may 
occasionally  lead  to  a  general  tuberculosis.  Lupus  vuJ(/an's  is  most  frequently 
seen  on  tlie  face,  but  other  portions  of  the  body  may  be  the  scat  of  the  affection, 
particularly  the  extremities.  It  is  characterized  by  a  chronic  inflammatory 
process,  forming  brown-red  nodules  with  a  tendency  to  ulceration  and  sul)se- 
quent  cicatrization.  In  this  way  a  considerable  area  gradually  may  be  involved. 
When  the  tendency  to  ulceration  is  excessive  we  have  the  form  known  as  lupus 
exedens,  although  this  name  is  often  given  erroneously  to  ulcerating  forms  of 
cancer  of  the  face. 

In  other  cases  the  amount  of  granulation-tissue  may  be  a  prominent  feature, 
and  then  we  have  the  form  known  as  Jup}(s  hi/pfrfropJu'eus.  When  there  is  a 
tendency  to  the  formation  of  cicatricial  tissue  the  disease  may  produce  exten- 
sive superficial  alterations  in  the  skin,  and  give  rise  to  great  deformity,  the 


TUBEJicrLOSIS.  77 

whole  surface  of  the  face  bring  occasionally  involved.  l*atients  with  lupus 
not  infre(iuently  die  of  pulmonary  tuberculosis. 

The  aft'ection  known  to  surgeons  as  anatomical  tubercle,  and  frequently 
found  on  the  fingers  and  hands  of  assistants  in  the  autopsy  and  dissecting 
rooms,  is  now  recognized  as  tubercular,  and  is  regarded  as  almost  identical  with 
the  variety  known  chietly  as  tuberculosis  verrucosa  cutis  or  verruca  necrogenica. 
It  is  characterized  by  plaques  situated  chiefly  on  the  backs  of  the  hands,  arms, 
and  fingers,  looking  at  first  sight  like  a  cluster  of  inflamed  warts.  There  are 
also  erythematous  patches  and  pustules. 

Scrofuloderma  is  a  name  applied  to  certain  tuberculous  affections  of  the 
skin  which  formerly  were  not  regarded  as  allied  to  lupus.  It  occurs  as  a  more 
or  less  deep-seated,  chronic  inflammatory  process  in  any  part  of  the  skin,  prefer- 
ably on  the  neck,  body,  or  extremities,  and  shows  a  tendency  to  the  formation 
of  granulation-tissue,  which  breaks  down  and  gives  rise  to  sinuses  or  minute 
ulcerations.  It  is  occasionally  associated  with  disease  of  the  lymphatic  glands 
and  bones.  It  is  sometimes  called  scrofulous  gumma,  owing  to  its  resemblance 
to  syphilis. 

Primary  tuberculosis  of  the  panniculus  adiposus  is  observed,  particularly  in 
children,  in  the  form  of  flat  subcutaneous  nodules  which  gradually  soften  and 
break  down  and  discharge.  In  some  cases  they  may  burrow  extensively  with- 
out coming  to  the  surface-  Tubercular  abscesses  of  the  deeper  connective  tissue 
are,  however,  usually  secondary  to  some  affection  of  the  bones  or  joints  or  lym- 
phatic glands.  The  larger  abscesses,  generally  known  as  cold  abscesses, 
originate  most  frequently  from  tuberculous  disease  of  the  bones.  Such 
cavities,  when  opened,  present  a  characteristic  appearance.  The  walls  are 
covered  with  a  membrane  of  a  grayish-yellow  or  grayish-red  color,  which  is 
loosely  attached,  and  can  readily  be  removed  with  the  finger  or  sharp  spoon 
in  large  fragments.  It  consists  of  a  very  soft  and  slimy  material,  which  con- 
tains great  numbers  of  miliary  tubercles  closely  packed  together  and  imbed- 
ded in  masses  of  fibrin.  AVhen  scraped  away  healthy  tissue  is  exposed.  At 
one  spot  the  persistence  of  a  small  islet  of  granulations  indicates  the  opening 
of  a  fistulous  track  which  leads  to  diseased  bone.  Occasionally  no  such  fistula 
can  be  found.  This  is  the  case  in  the  so-called  peri-  or  para-articular  abscess 
when  the  septic  infection  of  the  connective  tissue  is  transmitted  from  a  diseased 
bone  or  joint  through  the  lymphatics.  Such  abscesses,  although  at  first  not 
communicating  with  the  affected  joint,  may  later  establish  an  opening  into  it. 
Fistulse  leading  to  tubercular  abscesses  are  also  lined  Avith  a  tuberculous  mem- 
brane. The  pus  of  these  abscesses  may  contain  a  few  leucocytes,  but  consists 
chiefly  of  the  products  of  caseous  degeneration.  The  presence  of  the  bacilli 
of  tuberculosis,  although  not  easily  determined  with  the  microscope,  is  often 
demonstrated  by  experimental  inoculation  in  guinea-pigs.  In  the  tyj^ical  cold 
abscess  pyogenic  cocci  are  not  usually  found  under  the  microscope,  nor  can 
they  be  obtained  from  cultures  of  this  pus.  The  absence  of  fever  in  cases  where 
these  large  abscesses  are  found  is  thus  explained,  and  the  constitutional  dis- 
turbance which  frequently  follows  the  opening  of  a  cold  abscess  is  undoubtedly 
due  to  a  subsequent  additional  infection  with  the  pyogenic  cocci. 

Adjacent  muscles  are  rarely  infected  by  tubercular  abscess:  it  is  now  well 
understood  that  striped  muscular  fiber  is  not  liable  to  tuberculous  disease. 

Tuberculosis  of  the  mucous  membranes  may  follow  or  accompany  lupus  of 
the  skin.  A  direct  extension  may  take  place  from  the  alae  of  the  nose  or  from 
the  lips  to  the  nostrils,  gums,  or  pharynx. 

Tuberculosis  of  the  tongue  is  a  comparatively  rare  affection,  and  is  liable  to 
be  mistaken  for  cancer  or  syphilis.     It  appears  as  a  chronic  inflammatory  pro- 


78  AN  AMEJIICAX    TEXT-BOOK    OF  srUdKRV. 

cess  Avhicli  produces  an  infiltration  extending  to  the  dee|)er  muscular  tissue. 
On  the  surface  ulceration  may  take  place.  It  may  he  associated  Avith  tuhercu- 
losis  elsewhere,  and  the  presence  of  pulmonary  signs  or  fistula  in  ano  ■would 
serve  as  aids  to  diagnosis.  The  prognosis  will  depend  largely  upon  the  general 
condition  of  the  patient. 

Lupus  of  the  vcluiii,  totis/Ls,  and  pliarjpix  is  often  found  associated  with 
lupus  of  the  skin,  and,  according  to  Lennox  IJrowne,  is  more  likely  to  be  seen 
in  skin  than  in  throat  clinics.  It  appears  in  the  form  of  numerous  suj)er- 
ficial  ulcerations  surrounded  l)y  inflamed  and  thickened  borders,  which  show 
a  tendency  to  become  confluent.  There  is  less  loss  of  substance  than  in 
syphilitic  lesions  of  these  parts,  as  the  ulcer  tends  to  cicatri/-e.  The  adjacent 
mucous  membrane  is  often  found  studded  with  miliary  nodules,  which  run 
together,  break  down,  and  form  new  ulcerations.  The  miliary  tubercles  are 
situated  immediately  beneath  the  epithelial  layer,  and  may  also  involve  the 
intermuscular  and  connective  tissue.  The  giant-cells  are  numerous  and  well 
developed;  the  number  of  bacilli  is,  however,  usually  small.  Many  of  the 
patients  wlio  are  the  subjects  of  these  affections  succumb  to  pulmonary  tuber- 
culosis. 

Tuberculosis  of  the  throat  or  lungs  may  give  rise  to  tubercular  disease  of 
the  intestinal  canal.  As  a  result  of  such  infection  ulcers  may  form  in  the 
neighborhood  of  the  caecum  and  appendix,  and  may  perforate  the  bowel 
and  give  rise  to  a  tubercular  abscess.  Tubercular  inflammation  of  the  large 
intestine  has  been  known  to  give  rise  to  so  much  obstruction  as  to  necessitate 
laparotomy,  which  has  been  successfully  performed.  The  development  of 
tubercular  peritonitis  from  this  source  is  supposed  to  be  much  less  common 
than  from  the  Fallojiian  tubes. 

Most  cases  of  fistula  in  ano  are  tuberculous.  They  are  characterized 
by  the  formation  of  fungous  granulations  and  a  tendency  to  burrow  beneath 
the  skin  and  mucous  membrane.  In  many  of  these  cases  symptoms  of  pul- 
monary disease  are  also  present,  and  the  prognosis  is  then  exceedingly  unfiivor- 
able. 

All  portions  of  the  f/enito-urinari/  tract  appear  to  be  affected  by  tuber- 
culosis. Lupus  is  found  occasionally  on  the  labia  majora.  Cornil  has  found 
the  bacilli  in  ulcerations  of  the  vagina  adjoining  a  vesico-vaginal  fistula.  In 
six  autopsies  of  cases  of  tuberculosis  of  the  uterus  he  found  in  three  a  number 
of  bacilli.  Tubercular  infection  of  the  Fallopian  tubes  often  supervenes  upon 
a  clnonic  catanlial  salpingitis  in  cases  of  tubercular  disease  of  other  portions 
of  the  genital  mucous  membrane.  It  is  possible  that  infection  of  the  female 
o-enital  organs  may  result  from  coitus,  as  the  bacilli  of  tuberculosis  have  been 
found  in  the  semen  of  tuberculous  men  even  in  cases  where  the  genital  organs 
are  not  the  seat  of  tuberculous  disease.  Tuberculous  peritonitis  not  infre- 
quently accompanies  tuberculous  pyosalpinx. 

Tuberculosis  of  the  mamma  is  rare.  Tuberculous  ulcerations  or  sinuses 
may  occasionally  be  seen  about  the  nipple,  and  yield  readily  to  treatment. 
Several  cases  are  reported  by  Cornil  where  miliary  tubercles  containing  giant- 
cells  and  bacilli  were  found  in  the  ducts  of  the  gland.  Tillmans  recommends, 
in  every  case  of  tuberculosis  of  the  mamma,  extirpation  of  the  breast  and  the 
lymphatic  glands. 

Tuberculosis  of  the  7nale  genital  organs  has  usually  an  unfavorable  prog- 
nosis. Tuberculosis  of  the  testicle  occurs  most  frequently  in  early  adult  life. 
Many  cases  of  cure  occur  without  operative  interference,  although  there  is 
danger  that  the  disease  may  propagate  itself  along  the  course  of  the  vas 
deferens  to  the  vesiculae  seminales,  the  prostate,  and  the  bladder  if  the  testicle 


TUBERCULOSIS.  7!) 

is  not  removed.  Tubercles  are  found  in  tlic  uictlii;!,  in  llie  nienibninous  por- 
tion chiellvi  but  the  disease  is  more  fre(iuently  described  as  existing  in  the 
bladder.  It  nuiy  at  times  be  quite  extensive  and  involve  the  kidneys.  It  is 
one  of  the  most  difficult  forms  of  the  affection  to  deal  with,  and  early  diagnosis 
by  detection  of  bacilli  in  the  urine  is  therefore  important. 

The  tubercular  affections  oi'  bones  are  found  most  frec^uently  in  the  vascular 
spongy  tissue  of  the  epiphyseal  ends  of  the  long  bones.  Tuberculosis  of  the 
shaft  of'  the  long  bones  is  comparatively  rare.  The  disease  is  found  in  the 
short  spongy  bones,  as  the  bodies  of  the  vertebraj  and  the  bones  of  the  tarsus 
and  carpus.  It  is  also  seen  occasionally  in  the  fiat  bones,  as  those  of  the  skull 
and  the  pelvis,  the  orbital  portion  of  the  superior  maxilla,  and  the  ribs.  In 
the  epiphysis  the  tuberculous  nodule  is  usually  formed  some  little  distance  from 
the  cartilage.  On  section  of  the  bone  one  sees,  in  the  beginning  of  the  disease, 
a  yelloAvish-'white  or  pure  yellow  well-defined  mass  lying  in  the  spongy  tissue, 
which  even  with  low  powers  can  be  seen  to  be  made  up  of  miliary  tubercles, 
some  of  them  already  in  a  state  of  cheesy  degeneration.  As  this  nodule  grows 
in  size  it  becomes  softened,  and  finally  forms  a  cavit}'^  containing  a  more  or  less 
softened  material  mingled  with  minute  fragments  of  bone ;  or  the  degenerated 
bone  becomes  necrosed  in  a  mass  and  forms  a  sequestrum.  This  is  generally 
of  a  roundish  form  and  frequently  as  large  as  a  walnut,  and  is  surrounded  by 
a  layer  of  granulation-tissue  which  is  also  infected  with  tubercle  bacilli.  More 
rarely  the  tuberculous  nodule  may  break  down  and  form  a  small  abscess.  Such 
pus-cavities  are  most  often  seen  in  the  extremities  of  the  tibige.  Occasionally 
the  nodule  may  remain  for  a  long  time  unaltered,  and  is  then  surrounded  by 
a  dense  capsule.  Sclerosis  or  eburnation  of  the  surrounding  bone  may  occur 
under  these  circumstances.  The  bacilli  reach  the  epiphysis  usually  through 
the  circulation.  They  are  most  frequently  conveyed  there  as  single  organisms 
floating  in  the  blood,  but  they  may  be  transmitted  in  emboli,  possibly  from 
a  tubercular  mass  in  the  bronchial  glands.  If  such  an  embolus  should  plug 
a  terminal  arteriole,  an  infarction  of  the  bony  tissue  may  result,  forming  a 
wedge-shaped  sequestrum  with  its  base  directed  toward  the  joint  and  the  apex 
pointing  toward  the  diaphysis.  These  Avedge-shaped  tubercular  infarctions 
have  been  produced  experimentally  in  animals  by  injecting  tuberculous  pus 
into  the  tibial  artery.  It  is  possible  that  a  growth  of  granulations  may  invade 
the  tubercular  mass,  and  that  complete  absorption  may  take  place ;  and  the 
part  may  be  thus  restored  to  its  normal  condition.  Even  a  tubercular  seques- 
trum may  be  disposed  of  in  this  way  under  favorable  conditions.  Usually, 
however,  the  nodule  softens  and  the  tubercular  pus  breaks  into  the  joint  or 
into  the  adjacent  connective  tissue.  When  the  joint  is  involved,  tubercular 
infection  of  its  surface  will  occur  and  disorganization  will  probably  take  place- 
When  the  pus  discharges  through  the  periosteum,  a  cold  abscess  will  form 
which  may  burroAv  extensively  and  finally  break  externally. 

Tuberculous  osteomyelitis  of  the  shaft  of  the  long  bones  occurs  chiefly  in 
the  phalanges  of  the  hands  and  feet.  The  disease  appears  first  in  the  marrow, 
which  with  the  cortical  bone  is  changed  into  granulation-tissue :  at  the  same 
time  the  periosteum  is  stimulated  into  a  new  bone-formation,  which  in  its  turn 
becomes  involved.  In  consequence  of  these  progressive  changes  the  bone  is 
much  distended  in  the  middle  of  its  shaft,  the  so-called  spina  ventosa.  The 
disease  may  undergo  spontaneous  cure  or  suppuration  may  take  place.  Con- 
siderable deformity  may  be  caused  by  atrophy  of  the  affected  bones  in  early  life. 

Tuberculosis  is  also  frequently  observed  in  the  short  spongy  bones,  par- 
ticularly in  the  bodies  of  the  vertehroe,  giving  rise  to  Pott's  disease,  and  in 
the  bones  of  the  carpus  and  tarsus.      The  changes  produced  in  bone-tissue  by 


80  AN  AMKUICAX    TEXT-BOOK    OF  SURGERY. 

the  bacillus  of  tuberculosis  is  that  known  hitherto  as  caries;  that  is,  an  absorp- 
tion of  the  bony  tissue,  giving  it  a  worm-eaten  appearance.  Necrosis  is  more 
freciuently  the  result  of  acute  inflannnation  produced  l)y  the  ])resence  of  the 
pyogenic  cocci,  but,  as  we  have  seen,  it  may  occasionally  be  due  to  the  action 
of  the  bacilli  of  tuberculosis. 

Tuberculosis  of  the  joints  (known  often  as  white  swelling,  tumor  albus,  hip 
disease,  ankle  disease,  etc.)  usually  results  from  infection  by  the  opening  of  a 
primary  nodule  from  the  bone  into  the  joint.  A  primary  tuberculosis  of  the 
synovial  membrane,  however,  may  also  occur.  As  the  consequence  of  infiltra- 
tion with  miliary  tubercles  we  find  a  thickening  of  the  membrane  with  forma- 
tion of  granulation-tissue  which  may  not  be  accompanied  by  any  collection  of 
fluid  in  the  joint.  At  other  times  there  is  considerable  turbid  or  bloody  fluid, 
or  suppuration  may  take  place  and  the  joint  contain  the  characteristic  thin  and 
pale  tubercular  pus.  AVhen  the  tendency  to  the  formation  of  granulation- 
tissue  is  excessive,  the  condition  known  as  caries  sicca  exists.  Little  or  no 
pus  is  formed,  but  there  is  extensive  loss  of  bone  as  the  result  of  caries. 
Occasionally  circumscribed  tubercular  nodules  form  on  the  synovial  membrane 
and  project  into  the  joints  as  small  pedunculated  tumors,  consisting  of  fibrous 
tissue,  but  containing  a  softened  tuberculous  mass  in  the  interior.  In  the  serous 
form  of  tuberculous  synovitis  numerous  '■'rice  bodies''  or  '■'melon-seed"  bodies 
are  seen  in  some  cases,  either  free  in  the  joint  or  attached  to  the  capsule  by  a 
pedicle.  They  are  composed  of  concentric  layers  of  fibrin,  a  substance  which 
is  so  often  associated  with  the  formation  of  tubercles. 

As  the  disease  progresses  the  articular  cartilage  is  attacked  by  the  granu- 
lation-tissue in  the  joint,  and  ulceration  takes  place,  or  granulation-tissue  may 
form  in  the  epiphyses  and  perforate  the  cartilage  from  beneath.  In  cases  of 
long  standing  the  disease  spreads  from  the  capsule  to  the  surrounding  tissues, 
and  the  connective  tissue,  the  tendons,  and  even  the  muscles,  become  involved 
in  a  gelatinous  degeneration.  This  peculiar  change  is  supposed  by  some  to  be 
a  saturation  of  the  diseased  tissue  with  a  fluid  of  a  mucous  or  synovial  character. 
Under  favorable  conditions  a  more  or  less  complete  restoration  of  the  joint- 
cavity  may  take  place,  but  when  the  disease  is  once  Avell  develo|)t'd  the  best 
that  can  be  hoped  for  is  a  fibrous  or  bony  ankylosis.  If  suppuration  takes 
place,  the  abscess  may  open  externally,  and  fistuhie  communicating  with  the 
joint  may  be  established.  In  long-standing  cases  of  joint-suppuration  amyloid 
changes  are  found  in  the  internal  organs. 

Tuberculosis  of  the  tendon  sheaths  is  usually  secondary  to  bone  or  joint 
disease,  but  it  occurs  occasionally  as  a  primary  affection.  A  thickening  of  the 
tendon  sheaths  takes  place  and  develops  into  a  cylindrical  doughy  swelling, 
Avhich  is  usually  not  painful.  Rice  or  melon-seed  bodies  often  form.  A  por- 
tion of  the  new  tissue  softens  down  and  fistulous  openings  occur.  If  the  sheath 
is  laid  open  by  a  longitudinal  incision,  a  mass  of  gelatinous  tissue  is  found 
which  can  easily  be  stripped  off.      Such  an  operation  may  result  in  cure. 

Tuberculosis  of  the  hpnphatic  glands  is  a  very  common  affection.  Enlarged 
glands  may  be  found  at  the  autopsies  of  children  dying  of  almost  any  disease, 
and  on  examination  prove  to  be  the  seat  of  tubercle.  The  disease  may  occur 
in  the  glands  secondarily  to  the  involvement  of  some  adjacent  organ,  as  in  the 
bronchial  or  mesenteric  glands  from  pulmonary  or  intestinal  tuberculosis.  In 
the  glands  of  the  neck,  which  are  by  far  most  frequently  affected,  the  disease 
often  appears  to  occur  primarily,  but  is  in  reality  usually  secondary  to  a  catarrh 
of  a  mucous  membrane  or  to  a  cutaneous  eczema.  The  bacilli  are  few  in  num- 
ber except  in  the  glands  nearest  to  the  primary  focus,  and  in  many  glands  they 
cannot  be  found.     In  abscesses  of  lymphatic  glands  they  may  be  found  in  the 


TUBERCULOSIS.  81 

tuberculous  membrane  which  lines  their  walls.  In  the  ))r(jnchiiil  glands  the 
bacilli  are  often  seen  in  the  capsule  and  the  periglandular  tissue.  As  a  result 
of  caseous  degeneration  and  infection  with  pus  cocci  abscesses  may  form,  and  a 
spontaneous  cure  may  be  rarely  eifected.  Where  an  extensive  invasion  of  the 
lymphatic  system  takes  place  the  bacilli  eventually  reach  the  circulation,  and 
acute  miliary  tuberculosis  may  result;  but  this  is  brought  about  more  freciuently 
by  the  entrance  of  the  bacilli  into  the  veins  and  their  dispersion  in  emboli  to 
diflferent  parts  of  the  body. 

The  diagnosis  of  tuberculosis  can  usually  be  established  by  the  clinical 
symptoms  and  history  of  the  case,  but  in  doubtful  cases  a  microscopic  examina- 
tion may  reveal  the  presence  of  the  bacilli.  This  can  be  done  by  an  exami- 
nation of  the  sputa  or  urine.  (See  Surgical  Bacteriology.)  If  the  case  is  one 
of  doubtful  lupus,  a  fragment  can  be  punched  out  Avith  the  Mixter  exploring 
canula,  and  sections  can  thus  be  obtained  for  microscopical  study.  In  those 
cases  in  which  the  bacilli  cannot  be  found  recourse  must  be  had  to  experimental 
inoculation.  A  fragment  of  the  suspected  tissue  can  be  implanted  into  the 
subcutaneous  connective  tissue  of  the  groin  of  a  guinea-pig,  and  if  the  speci- 
men is  tuberculous  a  miliary  tuberculosis  will  be  produced  in  from  five  to  six 
weeks. 

The  prognosis  of  the  disease  depends  greatly  upon  its  locality.  In  tuber- 
culosis of  the  skin  and  Superficial  tissues  it  is  more  favorable  than  that  of 
internal  organs.  In  children  the  prognosis  is  generally  more  favorable  than  in 
adults.  Any  tuberculous  nodule  is  always  a  source  of  danger,  and  should  not 
be  allowed  to  remain  if  it  can  be  removed.  There  is  always  the  possibility  of 
recurrence  even  after  operation. 

The  operative  treatment  consists  either  in  complete  removal  of  the  dis- 
eased tissue  by  incisions  carried  through  the  surrounding  healthy  tissue 
or  in  a  thorough  curetting,  followed  by  free  irrigation  with  iodine-water 
or  painting  with  tincture  of  iodine,  packing  with  iodoform,  or  occasionally 
by  the  actual  cautery.  In  laying  open  healthy  tissues  the  possibility  of  an 
infection  of  the  system  with  bacilli  should  not  be  forgotten ;  hence  thorough 
removal  or  no  operation  is  the  rule.  Tuberculous  cavities,  like  cold  abscess 
or  tuberculosis  of  the  joints,  may  be  treated  by  the  injection  of  an  emulsion 
of  iodoform.  A  10  per  cent,  suspension  of  iodoform  in  glycerin  may  be  used 
for  this  purpose,  or  a  10  per  cent,  suspension  of  iodoform  in  Avater  with  20 
per  cent,  glvcerin,  5  per  cent,  gum  arabic,  and  1  per  cent,  carbolic  acid.  The 
cavity  should  be  first  irrigated  with  a  3  per  cent,  solution  of  boric  acid. 
The  emulsion  is  tlien  introduced  with  a  trocar  about  2  mm.  in  diameter. 
The  special  methods  ol  dealing  with  the  local  conditions  Avill  be  considered  in 
their  appropriate  places.  The  general  treatment  of  the  disease  is  of  the 
greatest  importance.  This  consists  chiefly  in  the  selection  of  a  suitable 
nourishing  diet  and  an  appropriate  climate.  When  change  of  residence  can- 
not be  effected  the  patient  should  be  kept  as  much  as  possible  in  the  open 
air.  Among  the  most  valuable  of  internal  remedies  are  cod-liver  oil,  the 
hypophosphites,   and  alcohol. 

Orriiotherapy  (Serumtherapy). 

The  brilliant  results  which  have  followed  the  introduction  of  orrhotherapy 
in  diphtheria,  and  the  large  number  of  attempts  to  apply  similar  principles 
to  other  diseases  of  bacterial  origin,  make  it  necessary  that  all  should  under- 
stand, as  far  as  possible,  the  theories  upon  which  this  form  of  medication  is 
based,  what  its  present  status  is,  and  what  may  be  hoped  from  it  in  the  future. 

6 


82  .l.V    A.Vi:i{r('AX    TEXT-BOOK    OF   SFRf; KHY. 

Tlie  threat  difficulty  wliich  lies  in  the  way  of  further  lulvance  i.s  the  incom- 
pleteness of  our  knowledge  of  the  toxins  and  antitoxins  with  which  we  have 
to  deal.  A  short  sketch  of  the  general  suhject  will  give  the  student  some 
idea  of  the  j)rohlenis  involved. 

The  starting-point  lies  in  the  fact  that  certain  animals  are  found  to  he 
immune  to  the  attacks  of  bacteria  which  are  specially  virulent  to  other  ani- 
mals. Thus  rats,  dogs,  and  the  carnivora  generally  are  not  harmed  by  anthrax 
bacilli,  while  mice,  cattle,  guinea-pigs,  and  rabbits  are  vet}'  susceptible.  Next, 
it  was  observed  that  all  fresh  blood  had  some  bactericidal  pi'operties  which  it 
lost  if  allowed  to  stand  or  was  heated  to  .')0°  C.  (131°  F. ).  The  blood  of 
different  animals  varied  much  in  its  germicidal  powers.  The  potent  part 
was  found  to  lie  in  the  serum,  and  not  in  the  cellular  elements  of  the  blood. 
Still  further  study  showed  that  though  a  given  serum  or  blood  might  have 
but  little  bactericidal  |)Ower,  yet  it  might  be  able  to  modify  the  toxin  in 
virtue  of  which  the  bacteria  exerted  their  disease-producing  power. 

It  was  argued  that  if  the  bloo<l-serum  of  immune  animals  was  capable  of 
protecting  the  immune  aninial.  that  this  protection  could  be  conferred  upon 
susceptible  animals  by  the  introduction  of  the  serum  into  their  circulation. 
But  it  was  found  that  neither  artificial  immunity  nor  cures  could  be  brought 
about  in  this  way  in  any  number  of  cases,  but  that  artificial  immunity  could 
frequently  be  produced  by  the  continued  introduction  of  at  first  very  small 
followed  bv  orraduallv  increasing  doses  of  the  pathogenic  bacteria  or  of  their 
toxic  products. 

The  natural  immunity  is  characterized  for  the  most  part  by  the  presence 
in  the  blood-serum  of  alexins/  which  have  bactericidal  properties,  produce 
coagulation,  and  destroy  blood-corpuscles ;  and  are  unstable  and  destroyed  by 
heat  (o0°-5o°  C. ;  122°-131°  F.)  and  sunlight. 

The  artificial  immunity  is  induced  by  the  development  of  antitoxins,  which 
are  neither  bactericidal  nor  globucidal.  are  more  resistant  to  sunlight,  and  are 
only  destroyed  by  a  temperature  of  70°-s0°  C.  (158°-176°  F.j.  As  to  the 
mode  of  action  of  the  antitoxins  produced,  there  is  still  dispute.  Their  pro- 
duction is  doubtless  due  to  increased  cell-activity  called  into  play  by  the  action 
of  the  bacteria,  or  their  toxins,  upon  the  tissues  of  the  organism  into  which 
they  have  been  introduced.  Whether  these  plasma-cells  and  leucocytes,  which 
are  called  into  being  by  the  toxin,  secrete  a  distinct  antitoxin,  or  a  "' fi'rmi-nt" 
which  is  capable  of  setting  up  cell-activity  when  introduced  into  the  tissues 
of  a  person  or  animal  suffering  from  the  same  bacterial  disease,  is  as  yet  unde- 
cided, though  the  weight  of  authority  inclines  to  the  former  supposition.  The 
practical  working  is  the  same  in  either  case.  It  is  attempted  to  secure  a 
blood-serum  from  an  animal  which  Avill  produce  a  large  amount  of  serum  of 
strong  antitoxic  potency.  Whenever  it  can  be  employed,  horse-serum  pre- 
sents the  most  desired  qualifications,  as  the  blood  can  be  easily  obtained  in 
large  amounts,  and  when  allowe<l  to  stand  a  clear  amber-colored  serum  sepa- 
rates from  the  clot,  and  the  simplicity  of  technique  renders  it  easy  to  secure 
sterility. 

Tetanus. — The  poison  of  tetanus  is  extremely  virulent,  as  shown  by  the 
fact  tliat  a  dose  of  0.00005  c.c.  of  toxin  will  kill  a  jzuinea-pig,  Avcighing  550 
grams,  in  four  days  with  tyj)ical  symptoms.  This  will  serve  to  ex])lain  the 
seriousness  of  even  smnll  wounds  thus  infected,  and  the  small  number  of 
bacilli  usually  present  in  them. 

Immunity  to  the  poison  of  the  tetanus  bacillus  can  be  gradually  induced 

'  An  alexin  acts  by  destroying  the  bacteria;  an  antitoxin,  by  neutralizing  their  toxic 
product. 


Tl  li  KR  CUL  OSIS.  83 

and  antitoxic  properties  develop  in  tlie  blood  during  its  acquisition.  The 
horse  is  the  animal  which  is  used,  and  the  amount  of  antitoxin  developed 
may  be  so  great  that  .2')  c.c.  of  serum  will  neutralize  toxin  sufficient  for 
40.000  fatal  doses.  Though  this  power  is  very  great  when  the  toxins  and 
antitoxic  serum  are  mixed  in  vitro  (in  a  glass  dish),  yet  the  ability  to  check 
the  disease  diminishes  ra])idly  as  time  goes  on.  This  is  possibly  to  be 
explained  by  the  theory  that  the  toxin  combines  with  certain  cells  of  the 
body,  particularly  with  the  neuron,  and  this  union  gradually  becomes  firmer 
and  firmer,  and  the  antitoxin,  therefore,  is  unable  to  neutralize  the  toxin,  as 
it  has  undergone  chemical  change.  To  secure  success  a  large  quantity,  100- 
200  CO..  of  serum  should  be  injected  at  the  earliest  possible  moment.  Its 
intra-cerebral  injection  after  trephining  is  the  latest  method  of  using  it,  but 
this  method  is  too  recent  to  make  any  autiioritative  statement  as  to  its  value. 

The  mortality  in  severe  acute  cases  probably  has  not  been  diminished  by 
the  use  of  antitoxin,  but  it  would  seem  as  though  in  chronic  cases  more 
favorable  results  were  obtained  than  before  its  introduction,  Lambert  having 
collected  61  chronic  cases  treated  with  the  serum,  with  a  mortalit}^  of  16.4 
per  cent.,  instead  of  40  per  cent.,  the  average  mortality  in  chronic  cases 
heretofore. 

This  serum  can  be  obtained  from  the  Boards  of  Health  of  several  States 
and  from  some  manufacturers. 

Anthrax. — Although  the  toxin  of  the  anthrax  bacilli  has  received  a  great 
deal  of  attention,  and  the  induction  of  artificial  immunity  has  been  successful 
to  a  large  degree,  nevertheless  but  little  j)rogress  has  been  made  in  its  orrho- 
therapy,  and  even  uniform  laboratory  results  have  not  been  obtained. 

By  various  methods  of  attenuation,  as,  for  example,  growing  the  anthrax 
cultures  at  unfavorable  temperatures,  protective  vaccines  have  been  produced 
which  have  ffreatlv  diminished  the  mortalitv  in  cattle  from  anthrax.  Thus 
in  twelve  years  in  France  there  were  1,788.677  sheep  and  200.902  cattle  inoc- 
ulated, with  a  mortality,  including  deaths  from  the  inoculations,  of  .94  per 
cent,  for  the  sheep  and  .34  per  cent,  for  the  cattle,  against  a  mortality  of 
about  10  per  cent,  for  sheep  and  5  per  cent,  for  cattle  previous  to  the  intro- 
duction of  protective  inoculations. 

Streptococcus. — Marmorek  has  obtained  a  serum  from  horses  immu- 
nized with  streptococcus  cultures,  which,  though  toxic  if  drawn  during  the 
time  that  the  injections  are  being  practised,  becomes  protective  after  a  period 
of  about  four  weeks.  With  this  serum  some,  though  by  no  means  constantly, 
favorable  reports  have  been  obtained  in  streptococcus  septicemia.  The  ques- 
tion is  an  open  one  whether  the  good  results  did  not  arise  from  the  simple 
stimulative  action  of  the  horse-serum  upon  the  tissue-cells,  especially  as 
equally  favorable  results  have  come  from  the  use  of  this  serum  in  cases 
in  which  there  were  probably  no  streptococci  present. 

The  .still  unsolved  question,  whether  all  the  various  forms  of  streptococci 
with  pyogenic  properties  are  practically  one  and  the  same  or  are  varieties 
having  di.stinct  toxins,  adds  much  to  the  difficulties  in  the  way  of  the  solu- 
tion of  the  problem  of  streptococcic  diseases. 

Staphylococcus. — But  little,  and  for  the  most  part  contradictory,  work 
has  been  done  with  this  organism,  and  the  work  has  not  yet  passed  the  labor- 
atory-stage. The  blood  of  animals  treated  with  the  toxin  is  said  to  be  both 
bactericidal  and  antitoxic,  if  obtained  several  weeks  after  the  treatment.  The 
difficulty  in  the  way  of  the  solution  of  this  problem  seems  to  lie  in  the  absence 
of  any  immunity  conferred  by  this  organism  upon  the  human  subject. 

Bubonic   Plague. — Horses  react  vigorously  to  the  action  of  the  poison, 


84  ^^y  AMERICAN   TEXT-BOOK    OF  SURGERY. 

become  iiukIi  oiiuiciatetl,  and  finally  iiumunc  Tlic'  blood  is  drawn  tlirce 
weeks  after  stojijiin<r  the  injections.  Yersin  has  treated  sonic  cases  with 
favorable  results,  when  the  injections  of  serum  were  Itegun  early  in  the  dis- 
ease. In  the  cases  reported  death  only  occurred  in  patients  when  the  injec- 
tion was  begun  on  the  iifth  day.  The  doses  have  been  from  20  to  |H>  c.c.  of 
the  serum. 

Hydrophobia  or  Rabies. — Orrhotherapy  of  rabies  is  quite  different 
from  tile  method  of  treatment  introduced  by  Pasteur,  lie  treated  patients 
who  had  been  bitten  by  rabid  dogs,  by  injecting  emulsions  made  from  the 
spinal  cords  of  rabbits  which  had  died  of  rabies,  beginning  with  cords  that 
had  been  removed  for  two  weeks,  and  repeating  the  injection  each  day  or 
every  other  day  with  fresher  cords,  the  theory  being  that  by  the  time  the 
period  of  incubation  had  passed  the  ))atient  would  be  rendered  immune. 
There  has  been  marked  success  from  this  method  of  treatment,  although  it 
has  been  subjected  to  much  adverse  criticism.  In  the  attemj)ts  at  orrho- 
therapy, sheep  and  dogs  have  been  immunized  in  the  above  manner,  and 
from  their  serum  a  precipitate  has  been  obtained  which  it  is  hoped  will  neu- 
tralize the  poison  of  rabies  and  at  the  same  time  do  away  with  most  of  the 
objectionable  features  of  the  Pasteur  treatment. 

Snake-venom. — Calmette  maintains  that  the  active  toxin  of  all  snake-, 
lizard-,  and  scorpion-venom  is  identical,  and  that  by  immunizing  a  horse  with 
repeated  doses  of  cobra-poison,  the  strongest  of  the  snake-venoms,  he  is  able 
to  produce  a  serum  of  antivenomous  properties  and  capable  of  neutralizing 
the  poison  of  the  most  venomous  serpents.  The  dose  of  this  serum  is  about 
20  c.c,  and  the  serum  Avill  bear  transportation  to  the  tropics  and  yet  retain 
its  antivenomous  power.  A  number  of  very  favorable  cases  are  reported  in 
which  lives  have  been  saved  by  its  use  (see  p.  127). 

Glanders ;  Mallein. — This  disease  is  common  to  both  animals  and  man. 
The  mallein,  which  is  a  glycerin  extract  of  the  toxins  of  the  bacillus  of  glan- 
ders has  a  twofold  use — diagnostic  and  immunizing.  Injected  into  a  horse 
having  glanders,  a  characteristic  "reaction"  takes  place.  At  the  end  of 
four  to  six  hours  there  is  a  rise  of  temperature  which  reaches  its  maximum 
of  2^^  C.  (3.6°  F.)  in  eight  to  sixteen  hours,  rarely  longer,  and  returns  to 
normal  in  twenty-four  to  thirty-six  hours.  This  result  does  not  take  place 
in  unaffected  horses. 

Immunity  follows  the  injection  of  gradually-increasing  doses,  and  it  is 
asserted  that  cures  have  occurred  both  in  man  and  in  animals  in  chronic 
cases  treated  in  a  similar  manner. 

Tuberculin. — The  treatment  of  tuberculosis  presents  many  difficulties. 
In  the  first  place,  there  seems  to  be  no  such  thing  as  immunity.  One  patient 
may  have  a  tuberculous  process  continue  for  years,  and  another  who  has  a 
healed  tuberculous  lesion  appears  to  be  specially  susceptible  to  reinfection. 
The  only  conditions  in  which  anything  like  immunity  is  obtained  are  those 
in  which  there  is  a  general  dispersion  of  bacilli  through  the  whole  organism, 
as  in  acute  miliary  tuberculosis  or  the  form  seen  in  guinea-pigs. 

If  dead  bacilli  are  injected  into  living  tissues,  they  |)roduce  sterile  abscesses. 
The  first  attempt  to  secure  cure  and  immunity  was  by  the  use  of  tuberculin, 
which  was  a  glycerin  extract  of  the  toxins  of  the  bacilli  of  tuberculosis.  The 
iniection  of  this  material  gave  a  distinct  characteristic  "reaction,"  or  rise  of 
tempei'ature.  Tuberculous  processes  were  seen  to  improve  after  its  use.  and  as 
the  doses  were  increased  the  patient  ceased  to  react  even  to  large  doses  of  the 
tuberculin.  This  was  a  toxin-immunity,  and  not  a  bacterial  immunity,  and 
only  partly  a  toxin-immunity,  as  there  are  other  toxins  than  those  extracted 


BIIA  CJIiriS.  85 

with  ;:;lyct'rin.      'I'lio  iiiiprovc'iiK'Ht  observed  was  doubtless  due  to  the  stimu- 
hiting  action  of  th<;  toxin  upon  the  tissue-cells. 

Its  use  as  a  diagnostic  agent  has  distinct  value.  Koch  and  many  others 
assert  tliat  there  is  no  danger  of  setting  bacilli  free  and  causing  a  spread  of 
the  disease,  as  others  have  maintained  to  be  the  case.  Some  people  and  some 
animals  react  either  when  the  tuberculosis  is  absent  or  when  it  is  of  but  small 
im]>ortance  from  a  diagnostic  point  of  view,  being  absolutely  latent.  Hence, 
in  its  use,  one  has  to  take  this  fact  into  consideration. 

Koch's  new  tuberculin,  or  tuberculin  T.  R.,  as  it  is  called,  is  made  with  an 
attempt  to  overcome  the  faults  of  the  old  glycerin  extract.  It  is  impossible, 
as  stated  above,  to  introduce  bacilli  of  tuberculosis  and  to  have  them  absorbed 
without  abscess-formation.  Hence  the  bacilli  are  mechanically  broken  up  by 
grinding  in  an  agate  mortar,  are  put  in  distilled  water,  and  are  centriiugalized. 
The  upper  portion  of  the  mass  has  the  properties  of  the  old  tuberculin,  while 
the  residue  at  the  bottom  has  different  properties,  and  is  called  Tuberculin 
T.  R.  This  contains  the  constituents  of  the  bacilli  insoluble  in  glycerin,  pro- 
duces no  abscess  or  rise  of  temperature,  and  has  immunizing  power.  This 
immunization  takes  place  in  the  course  of  about  three  weeks  in  guinea-pigs. 
The  period  in  man  is  also  short — from  four  to  six  weeks. 

The  method  of  treatment  is  to  begin  with  a  dose  of  5^75-  of  a  milligram, 
doubling  the  dose  each  day  until  a  dose  of  20  milligrams  has  been  reached. 
The  course  of  treatment,  therefore,  covers  about  four  w  eeks'  time  if  there  are 
no  unpleasant  reactions.  Lupus  and  other  surface-lesions  seem  to  be  most 
easily  affected. 

Enough  time  has  not  yet  elapsed  to  determine  finally  the  exact  curative 
value  of  the  proceeding.  Though  many  favorable  cases  have  been  reported, 
the  results  are  not  as  satisfactory  as  could  be  wished. 

Serum  of  horses  treated  with  tuberculin  has  been  tried,  but  without 
special  success,  and  now  some  are  advocating  the  serum  of  horses  that  have 
been  treated  with  tuberculin  T.  R. 

In  tuberculosis,  as  in  all  cases  in  which  orrhotherapy  is  employed,  it  is 
well  to  begin  the  treatment  in  the  earliest  stage  of  the  disease,  in  order  to 
secure  the  best  results. 


CHAPTER   XV. 
EHACHITIS. 


The  term  rhachitis  is  derived  from  pd-'/e',  the  spine.  The  English  name 
rickets  is.  however,  more  commonly  used.  It  is  a  general  disturbance  of  the 
nutrition  of  the  body  in  infancy  and  childhood,  and  consists  principally  in  an 
insufficient  deposit  of  lime-salts  and  in  absorption  of  already-formed  bone. 

Etiology. — It  is  a  disease  seen  chiefly  among  the  poor  in  large  cities,  less 
frequently  in  the  country.  It  is  much  more  common  and  severe  in  Europe 
than  in  America.  In  America  the  disease  is  neither  very  prevalent  nor  very 
severe,  and  except  in  colored  children  or  in  Italians  and  Portuguese  very 
great  deformity  is  rare  (Bradford).  Bad  hygienic  influences,  such  as  poor  venti- 
lation, damp  dwellings,  and  crowded  rooms,  are  frequent  causes  of  the  disease,  but 
the  most  important  cause  of  all  is  improper  feeding.  The  substitution  of  patent 
foods  for  the  mother's  breast-milk  is  said  to  favor  its  development  In  menag- 
eries, where  animals  live  under  highly  artificial  conditions,  the  disease  is  frequently 


86  A.\  AMKRICAX    TEXT-llOOK    OF  SURGERY. 

observed.  In  congenital  sj'philis  changes  in  the  bones  closely  resembling  those 
of  rickets  are  occasionally  seen.  The  disease  begins  in  the  first  or  second  year 
of  life,  exceptionally  after  the  fifth  or  sixth.  It  is  not  often  seen  in  newborn 
infants, but  rliachitic  changes  are  occasionally  found  in  the  bones  during  fetal  life. 

The  pathological  changes  are  due  to  the  formation  of  incompletely 
calcified  bone.  '*  Osteoid  tissue  "  persists,  therefore,  much  longer  than  usual. 
At  the  epiphyses  there  is  an  absence  of  the  line  of  calcification ;  there  is  a 
great  increase  in  size  of  the  zone  of  cartilage-growth,  and  the  medullary  tissue 
grows  into  the  cartilage  area  in  the  most  irregular  manner.  The  cortical 
portion  of  the  bone  becomes  porous,  and  the  trabeculne  of  the  spongy  bone 
become  thinner  or  disappear  entirely.  After  the  disease  has  run  its  course 
calcification  may  take  place  on  an  increased  scale,  and  sclerosis  of  the  bone 
may  occur.  Rhachitic  bones  are  frequently  so  soft  that  they  can  be  cut  with 
the  knife,  and  as  a  result  of  this  change  great  deformity  often  occurs.  In 
older  children  such  changes  are  seen  in  the  bones  of  the  thorax,  spine,  and 
extremities ;  less  frequently  in  the  skull.  The  ligaments  are  relaxed  and 
movements  of  the  joints  are  often  painful.  The  promontory  of  the  sacrum 
is  depressed,  and  the  pelvis  thus  greatly  narrowed.  Curvatures  of  the  spine, 
as  scoliosis  or  lateral  deviation,  kt/phosis  or  curvature  with  convexity  back- 
ward, and  lordosis  or  curvature  with  convexity  forward,  are  also  observed. 
In  the  skull  the  bones  are  often  unnaturally  thin  and  crackle  under  pressure 
like  parchment.  This  condition  is  known  as  craniotahes.  Dentition  is  often 
delayed,  and  during  convalescence  progresses  with  great  rapidity.  It  is 
always  irregular. 

The  brain  may  be  hypertrophied,  and  sometimes  is  sclerosed ;  hydro- 
cephalus may  also  occur.  The  bronchial  tubes  are  filled  with  mucus,  and 
emphysema  of  the  lungs  is  occasionally  found.  Evidences  of  intestinal  catarrh 
are  seen.     The  spleen  is  often  enlarged. 

Among  the  early  symptoms  is  restlessness  at  night,  Avith  a  tendency  to 
profuse  perspiration  especially  about  the  head ;  the  bowels  are  constipated  and 
the  belly  becomes  distended.  The  urine  is  large  in  amount  and  loaded  with 
phosphates.  In  the  bones  the  earliest  changes  are  seen  at  the  epiphyses,  which 
become  thickened  chiefly  at  the  end  of  the  radius,  and  in  the  ribs,  where  the 
row  of  beaded  enlargements  is  quite  characteristic.  "With  the  softening  of  the 
bones  deformities  of  the  spine  and  extremities  begin.  The  head  is  increased  in 
size,  particularly  the  forehead  and  the  frontal  eminences.  The  distortion  of 
the  ribs  gives  rise  to  the  characteristic  pigeon-breasted  deformity.  Catarrhal 
affections,  as  bronchitis,  and  even  pneumonia,  may  occur  as  complications,  as 
also  laryngismus  stridulus.  Among  important  diagnostic  symptoms  are  delayed 
dentition  and  delayed  closure  of  the  anterior  fontanel.  A  search  for  the 
epiphyseal  enlargements  will  usually  settle  the  diagnosis.  Rickety  children 
are  often  stunted  in  stature. 

The  prognosis  is  usually  favorable.  Deformity  disappears  in  90  per  cent, 
of  the  cases.  A  few  cases  terminate  fatally  from  complications,  such  as 
broncho-pneumonia. 

In  the  treatment  of  rickets  careful  regulation  of  the  diet  is  of  the  utmost 
importance.  Fresh  food  should  be  given  in  preference  to  prepared  foods; 
fresh  milk  properly  diluted  for  infants,  and  meat-juice  or  raw  beef  for  older 
children.  Fresh  air  and  light  in  the  nursery  should  be  obtained  if  possible. 
Salt-water  bathing  is  highly  recommended.  Cod-liver  oil  is  considered  the 
most  valuable  of  drugs.  Phosphorus  is  also  a  favorite  remedy  ;  syrup  of  the 
iodide  of  iron  is  perhaps  to  be  preferred.  Lacto-phosphate  of  lime  is  given  on 
theoretical  grounds  chiefly,  but  is  a  good  tonic  for  children.     Those  modem 


CONTUSIONS  AND    WOUNDS.  87 

inventions,  "sea-.shore  homes"  and  "clay  nurseries,"  are  particularly  adajited 
for  the  treatment  of  this  disease.  The  surgical  operations  for  deformities  of 
bones  are  described  elsewhere. 


CHAPTER    XVI. 

CONTUSIO^'S  AND  WOUNDS. 
SECTION   I.— CONTUSIONS. 


An  injury  produced  by  a  blunt  body  in  which  tissue-elements  are  more  or 
less  rent  asunder,  but  in  Avhich  there  is  no  gross  or  manifest  external  breach 
of  tissue,  constitutes  a  contusion.  In  a  simple  contusion  or  bruise  the  area  of 
damage  is  limited  by  the  area  of  impact  of  the  bruising  body,  but  the  amount 
of  damage  may  be  of  any  grade,  from  the  imperceptible  molecular  division  of 
a  slight  bruise  to  the  pulpification  of  large  masses  of  tissue.  The  element  of 
contusion  is  present  as  a  complication  of  most  wounds,  and  in  many  constitutes 
a  grave  and  most  important  factor.  The  distinction  between  a  contusion  and 
wound  is  therefore  one  of  degree  and  not  of  kind.  A  contusion  should  be 
defined  more  properly  as  a  hidden  wound,  the  firmer  tissues  of  the  skin  being 
able  to  resist  the  rending  effect  of  the  blow,  which  produces  its  greater  effect 
upon  softer  tissues  underneath.  Whether  an  injury  shall  be  defined  as  a  con- 
tusion or  a  wound  depends  also  upon  the  character  of  the  injured  structures  and 
the  nature  of  the  tissues  which  lie  underneath  the  surface.  Thus  a  hard,  bony 
surface,  so  related  to  the  tissues  on  which  a  blow  is  struck  that  they  are  forced 
against  it  by  the  bruising  body,  will  necessarily  aggravate  an  injury,  and  much 
more  readily  cause  an  absolute  destruction  of  all  the  tissues,  including  the  skin, 
and  so  produce  a  wound,  than  if  a  thick  cushion  of  soft  tissue  alone  is  involved. 
The  results  of  blows  over  the  shin  are  examples  of  the  first,  while  those  upon 
the  surface  of  the  abdomen  or  upon  the  fleshy  masses  of  the  nates  or  the  thighs 
are  examples  of  the  second. 

Pathology. — The  pathology  of  a  contusion  is  that  of  a  subcutaneous 
wound.  The  more  delicate  and  easily-torn  tissues  suffer  first  and  most  exten- 
sively ;  ruptured  blood-vessels  give  rise  to  more  or  less  hemorrhage;  injured 
nerve-fibrils  are  the  sources  of  pain ;  functional  disability  follows  according 
to  the  extent  and  character  of  the  tissues  injured;  local  swelling,  both  from 
hemorrhage  and  from  serous  effusion,  quickly  ensues.  When  the  effused  blood 
ahows  itself  as  a  somewhat  diffused  subcutaneous  discoloration,  an  ecchymosis  is 
said  to  be  present ;  when,  however,  it  is  collected  in  a  more  or  less  well-defined 
cavity,  so  as  to  constitute  a  blood-tumor,  it  is  known  as  a  hematoma.  When 
blood-vessels  of  some  size  are  involved  in  a  contusion,  special  conditions  of 
hemorrhage  may  ari.se  ;  thus  they  may  be  either  ruptured  outright  or  their  walls 
so  bruised  that  they  subsequently  slough,  and  so  occasion  a  later  hemorrhage. 
The  hemorrhage  from  the  smaller  vessels  is  usually  soon  controlled  after  moder- 
ate escape  of  blood  by  the  reactive  pressure  of  the  surrounding  engorged  tissues. 
The  force  of  the  blood-current  in  large  veins  and  in  most  arteries  is  likely  to 
be  such  as  to  cause  a  considerable  loss  of  blood,  especially  when  it  escapes  into 
any  of  the  great  cavities  of  the  body  or  when  the  locality  involved  is  one  in 
which  there  is  present  much  loose  connective  tissue.  Contusions  of  nerves 
may  produce  more  or  less  paralysis  of  the  regions  supplied  by  them.  A  pro- 
gressive degeneration  of  a  nerve  may  result  from  the  changes  produced  in  it 


88  A.\    AMI'JilCAX    TKX'l-BOOK    OF   SrUCKHY. 

by  a  violent  contusion.  The  effects  of  contusions  of  muscles  depend  upon  the 
extent  of  the  damage  done ;  local  soreness  and  pain  upon  movement  attend 
less  severe  injuries ;  rapid  recovery  under  rest  and  proper  treatment  is  to  be 
expected  in  such  instances  ;  from  even  quite  extensive  lacerations  ultimate 
rectnerv  with  full  functional  power  often  takes  place.  In  less  favorable  cases, 
however,  atrophy,  contracture,  and  permanent  loss  of  power  may  result.  The 
contusions  of  bone  Avhen  short  of  absolute  fracture  are  usually  rapidly  recov- 
ered from,  but  may  develop  into  acute  or  chronic  inflammatory  conditions  or 
determine  caries  or  necrosis,  or  even  the  development  of  malignant  changes. 

Diagnosis. — The  symptoms  which  indicate  the  occurrence  of  a  contusion 
are  easily  recognized.  The  part  is  tender  and  quickly  becomes  somewhat 
swollen,  with  some  elevation  of  temperature.  In  simple  and  superficial  con- 
tusions discoloration  of  the  skin  soon  declares  itself  as  the  result  of  the 
subcutaneous  hemorrhage.  In  cases  where  deeper  structures  are  especially 
contused  the  appearance  of  the  external  discoloration  may  be  delayed  for  some 
days,  owing  to  tlie  slowness  with  which  the  effused  blood  finds  its  way  to  the 
surface.  Loss  of  function  may  be  present,  dependent  upon  the  character  of 
the  tissues  injured  and  the  extent  of  the  injury  inflicted.  The  amount  of 
pain  in  the  part  may  vary.  At  first  there  is  numbness,  followed  quickly  by 
severe  acute  pain,  which  gradually  subsides  with  the  lapse  of  time.  Shock  is 
almost  always  present  to  some  extent.  Contusions  of  moderate  severity  pro- 
duce a  degree  of  shock  characterized  by  momentary  stunning  ;  others  of  greater 
severity  may  produce  faintness  or  total  loss  of  consciousness  for  a  variable 
period ;  while  in  the  more  severe  cases,  as  in  contusions  of  the  abdomen, 
immediate  death  may  ensue. 

Treatment. — For  the  general  shock  and  the  local  pain  the  treatment 
required  for  such  conditions  accompanying  any  injury  is  indicated.  For 
the  contusion  itself  the  first  thing  to  be  secured  is  rest  to  the  injured  part. 
This  is  especially  important  when  the  contusion  is  severe  and  the  injuries  to 
deeper  structures  are  extensive.  For  securing  rest,  if  voluntary  immobiliza- 
tion is  not  sufficient,  the  use  of  apparatus  of  some  kind  may  be  required. 
Bandages,  slings,  splints,  a  recumbent  position  in  bed,  all  may  have  their  use. 
By  rest  local  irritation  is  diminished,  hemorrhage  and  inflammatory  effusions 
are  restricted,  the  absorption  of  effused  fluids  and  of  necrotic  tissue  is  favored, 
and  the  normal  repair  of  the  injured  tissue  is  fostered.  Of  all  means  for 
treating  these  injuries,  rest  is  the  one  of  primary  and  greatest  importance. 

Next,  hemorrhage  and  serous  effusion  may  require  attention.  Equable, 
elastic,  and  firm  compression  is  to  be  recommended  for  their  control.  Com- 
presses of  cotton  wool  secured  by  proper  bandages  are  especially  serviceable  for 
this  purpose.  A  simple  flannel  bandage  alone  will  often  be  of  great  service. 
When,  for  any  cause,  the  use  of  compresses  and  bandages  is  inconvenient  or 
undesirable,  some  advantage  may  be  obtained  from  the  ap])lication  of  cold,  by 
ice-bags,  evaporating  lotions,  or  affusions  of  cold  water.  In  the  more  severe 
forms  of  contusion  cold  is  to  be  used  with  caution,  since  by  its  continued  use  the 
vitality  of  the  parts  is  depressed,  and  tissues  which  under  more  stimulating 
treatment  might  be  preserved  from  necrosis  and  regain  their  normal  condition 
may  be  precipitated  into  absolute  death.  In  the  slighter  and  more  superficial 
forms  of  contusions  evaporating  lotions  are  frequently  both  convenient  and  effi- 
cient. As  an  example  of  such  a  lotion  a  solution  of  chloride  of  annnonium  and 
alcohol  (gr.  v  (o^  f5j)  is  to  be  recommended.  Tincture  of  camphor,  tincture  of 
arnica,  tincture  of  witch-hazel,  all  favorite  popular  Applications  for  contusions, 
are  of  use,  but  depend  for  their  efficiency  chiefly  upon  the  alcohol  which  they 
contain. 


COXTUSIOXS   AXl)     WOUNDS.  89 

In  eases  in  Avhieli  much  bruising  and  disorganization  of  tissues  are  present 
great  care  must  be  taken  to  avoid  everything  which  may  still  further  depress 
the  vitality  of  the  part.  The  indications  are,  then,  to  support  and  stimulate. 
In  addition  to  the  rest  already  recommended,  a  moderate  amount  of  heat  will 
be  of  use ;  hot-water  bags,  the  hot-water  coil,  masses  of  cotton  wool,  or  flan- 
nel previously  heated,  may  be  found  useful.  In  the  later  history  of  many 
contusions  massage  and  stimulating  liniments  are  of  value.  Thev  promote  the 
activity  of  circulation  in  the  part,  break  up  and  diffuse  among  the  tissues 
blood-clots  and  serous  accumulations,  and  hasten  their  absorption ;  they  pro- 
mote the  nutrition  of  the  injured  tissues,  break  up  adhesions,  and  expedite 
the  return  of  the  normal  functional  activity  of  the  contused  parts.  Blood- 
extravasations  as  a  rule  should  be  left  to  the  natural  processes  of  absorption 
for  their  removal. 

Blood-effusions  Avidely  dispersed  along  connective-tissue  planes,  infiltrating 
tissues  already  lowered  in  their  vitality  by  a  contusion,  present  conditions 
eminently  favorable  for  the  development  of  widespread  and  disastrous  septic 
infection,  for  which  reason  an  attempt  to  evacuate  a  hematoma  by  incision 
under  ordinary  circumstances  is  always  to  be  deprecated.  When,  however, 
continuous  subcutaneous  hemorrhage  is  present,  showing  the  existence  of  a 
wound  of  a  vessel  of  importance,  it  is  imperative  to  make  a  free  incision,  so  as 
fully  to  expose  the  wounded  vessel,  and  to  apply  a  ligature  to  it.  In  such 
cases  the  incisions  through  the  external  parts  should  be  very  free,  and  all 
recesses  into  which  the  effused  blood  has  found  its  way  should  if  possible  be 
opened  up.  All  clots  should  be  turned  out,  and  the  most  perfect  disinfec- 
tion and  drainage  of  the  infiltrated  areas  provided  for.  Circumscribed  blocd- 
tumors  may  sometimes  be  relieved  by  aspiration.  After  the  lapse  of  two  or 
three  weeks  from  the  time  of  the  original  injury  any  persisting  blood-tumcr 
may  be  more  freely  laid  open  and  its  contents  evacuated ;  by  this  time  it  will 
be  surrounded  by  a  layer  of  condensed  connective  tissue  reinforced  by  inflam- 
matory exudation ;  the  surrounding  tissues  will  have  recovered  from  the  state 
of  depression  immediately  following  the  injury  ;  and  as  the  result  of  these  con- 
ditions the  danger  of  septic  infection  will  have  greatly  diminished. 

Severe  inflammatory  reaction  following  contusion  must  be  treated  upon 
general  surgical  principles,  including  rest,  elevation  of  the  parts,  evaporating 
lotions,  together  with  such  constitutional  measures  as  may  be  required  for 
relieving  pain,  reducing  temperature,  and  lessening  the  intensity  of  the  general 
febrile  reaction.  If  suppuration  occurs,  adequate  incisions  must  be  made  for  the 
evacuation  of  the  pus  ;  if  local  gangrene  threatens,  stimulating  applications  are 
first  required,  as  dry  heat  or  stimulating  liniments,  until  the  line  of  demarcation 
of  the  slough  is  distinctly  formed.  Fomentations  should  now  be  used,  composed 
of  compresses  wet  with  some  antiseptic  solution  and  covered  with  rubber  dam 
or  oil  silk,  to  hasten  the  separation  of  the  slough.  If  phlegmonous  inflamma- 
tion advances  into  adjacent  parts,  free  incision  into  the  inflamed  tissues,  with 
abundant  antiseptic  irrigation  and  iodoform  tampons,  should  be  used. 

SECTION   II. — WOUNDS. 

A  "WOUND  is  a  solution  of  continuity  of  any  tissue,  produced  either  directly  or 
indirectly  by  sudden  mechanical  force.  The  occurrence  of  a  solution  of  continu- 
ity in  any  of  the  solid  tissues  of  the  body  may  be  due  to  slowly-acting  causes,  as 
the  gradual  waste  of  atrophy,  or  the  more  active  disintegration  of  ulceration ; 
but  a  breach  of  tissue  thus  affected  would  not  be  a  wound.  There  is  involved 
in  the  idea  of  a  wound  the  action  of  a  force  outside  of  the  tissue  itself,  which 
by  mechanical  violence  has  rent  or  divided  its  substance.     The  term  "  wound," 


90 


.-l.V   AJfKL'fCAX    TKXT-JiOOK    o/'   SI ' l;( ; i:i!  V. 


tlierefore,  is  susceptible  of  a  very  wide  range  of  application.  Contusions, 
sprains,  fractures,  subcutaneous  as  well  as  cutaneous  breaches  of  tissue,  are 
included  in  the  term.  In  all  essential  particulars  they  are  identical  accidents, 
involving  the  same  methods  of  repair  and  subject  to  the  same  principles  of 
treatment,  the  apparent  differences  depending  upon  accidental  differences  of 
structure,  function,  nutrition,  relation  to  other  parts,  extent  of  traumatism  suf- 
fered and  of  exposure  to  intiuences  from  without.  In  the  present  chapter  the 
■wounds  of  bones  will  not  be  considered. 

Classification. — Wounds  may  be  divided  primarily  into  the  two  great 
classes  of  subcutaneous  and  open  wounds.  Subcutaneous  wounds  include  all 
which  are  unaccompanied  by  breach  of  the  skin.  Protected  by  the  unbroken 
skin  from  external  irritation  and  infection,  their  repair  is  usually  rapid  and 
undisturbed  by  untoward  irritations.  The  preceding  paragraphs  devoted  to  the 
consideration  of  contusions  are  descriptive  of  the  greater  number  of  subcuta- 
neous wounds.  Open  wounds,  as  a  class,  include  all  in  which  there  has  been  a 
breach  of  the  skin  or  mucous  membrane. 

Open  wounds  are  subdivided,  according  to  the  manner  in  which  they  are 
produced,  into  incised,  punctured,  contused,  lacerated,  gunshot,  or  poisoned 
wounds,  according  as  the  wounding  agent  has  been  a  sharp  cutting  edge,  a 
penetrating  point,  a  dull  and  bruising  body,  a  tearing  force,  a  projectile 
impelled  by  the  force  of  an  explosive,  or  one  which  carries  with  it  into  the 
wound  a  poison.  Penetrating  wounds  are  those  in  which  the  vulnerating 
body  enters  a  cavity  without  emerging ;  perforating  wounds,  those  in  which 
the  vulnerating  body  both  enters  and  emerges  from  the  cavity. 

All  wounds  are  accompanied  by  death  of  tissue  in  their  track  ;  even  the  path 
of  the  keenest  knife-edge  through  a  tissue  is  lined  by  disorganized  particles 
that  have  been  killed  by  its  impact.  Between  a  slight  and  clean  incised  wound, 
in  which  the  destruction  of  tissue  is  limited  to  the  molecules  traversed  by  the 


Fig.  22. 


Showing  the  Extensive  and  Frightful  Effects  of  a  Severe  Accident  (original i. 

cutting  instrument,  and  an  extensive  lacerated  wound  (Fig.  'I'l),  with  roughly 
torn  and  contused  edges,  or  between  a  slight  bruise  and  a  contusion  producing 
the  death  and  disorganization  of  large  masses  of  tissue,  the  diff'crence  is  one 
of  degree  and  not  of  kind.      The  important  practical  difference  which  has 


COATi)SJOA\S   AND     WOUNDS.  91 

always  been  recognized  in  the  healing  of  these  different  classes  of  wounds 
depends  simply  upon  the  difference  between  tlie  facility  with  which  the  devi- 
talized tissue  is  j)revented  from  becoming  a  source  of  disturbance  to  the  heal- 
ing of  the  wound  in  the  several  instances. 

Wounds  may  be  again  classed  as  aseptic  and  septic.  Asejitic  wounds  include 
all  which  are  preserved  from  contamination  by  poisonous  bacterial  products, 
whether  such  poison  come  in  contact  with  the  wound  directly  or  be  generated  in 
it  by  the  action  of  germs  that  gain  access  to  it.  An  aseptic  condition  in  a  wound 
may  be  obtained  either  by  the  protection  which  the  wound  received  from  the  first 
against  the  access  of  any  septic  agent,  or  by  the  power  of  tissues  to  resist  and 
destroy  septic  agents,  or  by  the  application  to  the  wound  of  substances  which 
destroy  them.  Subcutaneous  wounds,  as  a  rule,  remain  aseptic  in  consequence 
of  the  protecting  covering  which  the  skin  affords;  operative  wounds  inflicted 
under  certain  precautions  may  be  aseptic ;  all  open  wounds  in  which  union  by 
first  intention  is  secured  without  special  and  adequate  aseptic  precautions  are 
examples  of  the  power  of  living  tissues  to  resist  septic  infection.  Septic  wounds 
include  all  those  in  which  any  agent  capable  of  exciting  fermentation  or  putre- 
faction lodges  and  grows.  In  all  cases  they  are  attended  Avith  some  degree  of 
inflammation  and  suppuration  and  with  sloughing  of  dead  tissue. 

Symptoms. — The  symptoms  indicative  of  a  wound  are  local,  dependent 
upon  the  efi'ects  produced  at  the  point  at  which  the  wound  is  inflicted,  and  con- 
stitutionalj  dependent  upon  the  effects  on  the  body  at  large. 

Local  Symptoms.  —  First,  Impairment  of  Fuxctiox.  —  A  certain 
amount  of  disability  is  the  inevitable  result  of  a  division  of  tissue.  Its  extent 
and  nature  will  depend  upon  the  amount  of  injury  and  the  tissue  injured.  The 
duration  of  the  disability  will  depend  upon  the  promptness  of  healing  and  the 
susceptibility  of  the  wounded  tissue  for  perfect  repair. 

Divided  tissues  tend  to  retract  from  each  other,  and  thus  a  greater  or  less 
amount  of  gaping  becomes  a  wound-symptom. 

Pain  is  a  usual  accompaniment  of  a  wound.  It  is  due  to  the  irritation 
sustained  by  the  sensory  nerves.  The  amount  of  pain  is  of  variable  quantity. 
At  the  moment  of  the  infliction  of  a  wound  no  pain  at  all  may  be  experienced, 
owing  to  mental  preoccupation  or  excitement  or  to  the  rapidity  with  which  the 
wound  was  inflicted.  The  temperament  of  the  individual  may  modify  the 
amount  of  pain.  Some  individuals  experience  great  pain  from  causes  which  in 
others  produce  but  little  suffering.  The  sharp  pain  usually  felt  at  the  moment 
of  the  infliction  of  a  wound  soon  gives  way  to  a  dull  aching  or  smarting  pain, 
which  may  last  for  some  hours,  but  will  finally  subside  and  disappear,  provided 
the  Avounded  parts  are  kept  at  rest  and  their  repair  progresses  without  disturb- 
ance. Attempts  at  motion  in  a  wounded  part,  which  tend  to  pull  apart  the 
divided  tissues,  or  the  occurrence  of  a  high  orrade  of  inflammation,  causing 
tension  and  excessive  congestion,  awakens  pain  anew.  "When  large  sensory 
nerve-trunks  have  been  involved  in  wounds,  later  and  continuous  pain  may  be 
due  to  slight  inflammatory  conditions  extending  from  the  wound  upward  along 
these  nerves ;  hence  the  pain  often  complained  of  in  the  stumps  of  amputated 
limbs  during  the  first  few  days  following  operation. 

Hemorrhage. — Some  amount  of  bleeding  is  the  immediate  effect  of  every 
wound.  It  is  always  the  invariable  and  most  manifest  symptom  that  a  Avound 
has  been  inflicted,  but  the  amount  of  the  blood  lost  may  vary  greatly  according 
to  the  constitutional  condition  of  the  wounded  person,  to  the  character  of  the 
tissue  wounded,  and  to  the  size  of  the  blood-vessels  implicated.  In  scorbutic 
conditions  of  the  system,  and  in  those  occasional  instances  where  a  hemor- 
rhagic diathesis  exists,  prolonged  and  even  dangerous  loss  of  blood  may  result 


92  .L^'    AMERICAN    TEXT- HOOK    OF  SLRGEliY. 

from  a  trifling  wound.  Ordinarily,  when  merely  capillai-ics  or  small  arterioles 
or  venules  are  divided,  spontaneous  cessation  of  licinorrhajije  quickl}-  occurs, 
especially  if  the  tissues  wounded  are  retractile,  so  that  the  wounded  vessels 
become  withdrawn  among  and  embraced  by  them.  AVhatevcr  favors  the 
production  and  retention  of  a  clot  about  a  wounded  vessel  favors  the  arrest  of 
hemorrhage;  hence  lacerated  wounds,  where  the  wound-edges  are  ragged  and 
the  openings  of  the  vessels  themselves  irregular,  the  coats  of  the  larger  vessels, 
being  unevenly  divided,  are  not  likely  to  bleed  much,  on  account  of  the  entan- 
glement of  the  blood-fibrin  in  the  irregularities  of  the  wound-surfaces  and  the 
speedy  production  of  blood-clot.  When  large  blood-vessels  are  opened  profuse 
and  speedily  fatal  hemorrliage  may  occur. 

Shock. — The  primary  constitutional  symptom  of  a  wound  is  "shock." 
Shock  is  that  condition  of  general  vital  depression  which  marks  the  immediate 
effect  upon  the  individual  as  a  whole  produced  by  the  local  wound.  It  may 
be  of  any  grade  of  intensity,  from  a  slight,  evanescent,  and  hardly  appreci- 
able disturbance  of  mental  force  to  the  most  profound  general  depression  and 
speedy  death.  Its  manifestations  are  through  the  nervous  system,  and  are 
exhibited  most  markedly  by  depressed  action  of  the  circulatory  organs — vaso- 
motor paralysis.  Shock  is  to  be  distinguished  from  the  effects  of  hemorrhage ; 
and  in  cases  of  surgical  operations  from  the  effects  of  anesthetics,  although  in 
many  instances  it  may  be  aggravated  by  either  or  both.  Martin  and  Hare 
have  recently  proposed  to  use  the  hemoglobinometer  as  a  means  of  distinguish- 
ing hemorrhage,  especially  intra-abdominal,  from  shock.  In  shock  the  hemo- 
globin would  be  unaltered ;  in  hemorrhage  the  hemoglobin  would  be  greatly 
diminished.  The  pathology  of  shock  cannot  be  determined  by  the  ordinary 
methods  of  research.  In  such  cases  death  leaves  no  change  which  can  be 
detected  in  any  of  the  tissues.  The  eff"ects  manifest  themselves  chiefly  through 
the  agency  of  the  nervous  system  in  the  same  way  as  all  the  phenomena  of  life 
which  are  controlled  by  that  system.  Sometimes,  however,  as  seems  to  have 
been  shown  by  Goltz,  a  marked  distention  of  the  intra-abdominal  veins  exists. 
The  phenomena  of  shock  must  be  accepted  as  the  measure  of  the  ability  of  an 
individual  to  resist  hurtful  influences  from  without.  The  same  injury  will 
produce  different  degrees  of  shock  in  different  individuals,  and  diff"erent  degrees 
likewise  in  the  same  individual  at  different  times.  Women,  as  a  class,  are  less 
susceptible  to  shock  than  men.  Persons  who  are  inured  to  suffering,  or  who 
by  long  confinement  to  bed  or  by.  the  influence  of  drugs  have  acquired  a  cer- 
tain torpidity  of  the  nervous  energies,  are  less  susceptible  to  shock  than  indi- 
viduals whose  nervous  forces  are  in  a  high  degree  of  activity.  Temperament 
modifies  the  manifestations  of  shock.  The  phlegmatic  and  lymphatic  tem- 
peraments resist  shock ;  the  sanguine  and  mobile  temperaments  favor  it 
in  the  highest  degree.  Mental  conditions  modify  shock  ;  fear,  despair,  despond- 
ency, disappointment,  depressed  mental  states  of  any  kind,  aggravate  shock  ; 
on  the  contrary,  hope,  joy,  cheerfulness,  glad  expectation,  success,  diminish 
shock.  Age  modifies  shock.  The  young  bear  injuries  well,  and  rally 
quickly  from  shock  Avhen  unaccompanied  with  much  loss  of  blood  ;  in  the 
aged  the  frequent  presence  of  organic  disease  often  renders  shock  more  severe 
and  })rolonged.  In  the  absence  of  organic  derangements  the  dulled  nervous 
susceptibility  of  the  aged  diminishes  their  liability  to  shock. 

Symptoms  of  Shock. — The  symptoms  of  shock  are  those  of  geno-al  depres- 
sion :  the  skin  is  pale  and  cool ;  the  pulse  is  feeble  and  rapid,  the  respiration 
is  shallow  and  irregular;  the  body-temperature  is  lowered;  a  sense  of  faintness 
is  experienced  by  the  individual,  and  in  the  more  severe  forms  total  loss  of 
consciousness  ensues ;  the  functional  activity  of  all  the  organs  of  the  body  is 


CONTUSIONS  AND    WOUNDS.  93 

retarded ;  musc-ular  tone  is  diminished,  with  a  sense  of  general  muscular  pow- 
erlessness ;  the  sphincters  may  fail  to  act,  causing  involuntary  evacuations ; 
nausea  and  vomiting  often  occur.  Every  degree  of  intensity  in  these  symp- 
toms of  depression  which  have  been  enumerated  may  exist  in  diff'erent  cases, 
from  a  transient  feeling  of  weakness  and  momentary  mental  confusion  to  abso- 
lute death.  The  symptoms  of  shock  are  the  immediate  consequence  of  the 
injury  sustained.  The  assumption  of  the  possibility  of  a  condition  of  delayed 
shock  is  not  consistent  with  what  has  been  said  as  to  the  nature  of  shock 
itself.  Whenever  a  condition  of  sudden  and  marked  depression  declares  itself 
some  time  after  the  reception  of  an  injury,  it  is  always  due  to  some  dis- 
tinct cause  other  than  the  original  injury,  and  when  recovery  from  shock  is 
delayed  and  manifests  oscillations  of  improvement  and  retrogression,  distinct 
diseased  conditions,  possibly  directly  resulting  from  the  injury,  are  always  its 
cause.  For  this  reason  the  terms  which  are  found  in  older  text-books,  and 
which  are  still  often  used  in  ordinary  surgical  parlance — namely,  delayed 
shock,  secondary  shock,  and  imperfect  reaction  from  shock — may  be  misleading, 
as  they  tend  to  divert  the  attention  from  real  conditions.  The  conditions 
which  most  frequently  cause  these  symptoms  of  later  depression  are  concealed 
hemorrhage,  septic  infection,  and  fat  embolism.  Pulmonary  oedema  and  renal 
congestion  are  also  possible  conditions  always  to  be  inquired  after  when  a 
sudden  unfavorable  turn  occurs  in  the  condition  of  a  patient  soon  after  an 
injury  has  been  sustained,  especially  when  ether  has  been  used  as  an  anesthetic. 
The  occurrence  of  any  of  these  conditions  may,  of  course,  produce  its  own 
shock,  but  this  shock  arises  de  novo. 

Prognosis  of  Shock. — Very  quick  and  complete  recovery  from  a  state 
of  most  profound  shock  may  occur.  The  chief  elements  upon  which  recovery 
from  shock  depend  are  these:  First,  whether  the  injury  has  to  do  with  a  vital 
part ;  and  second,  whether  it  entails  a  continued  source  of  irritation  and  depres- 
sion. Thus  in  injuries  to  the  head  the  immediate  shock  may  be  overwhelm- 
ing in  consequence  of  the  vital  relations  of  the  injured  part,  or  Avhen  not  at 
once  fatal  may  be  continued  and  masked  by  inflammatory  conditions  arising 
in  the  cerebral  tissues  as  a  consequence  of  the  injury.  So  in  crushing 
injuries  of  the  extremities:  the  immediate  shock  of  the  injury  may  be  pro- 
longed and  intensified  by  the  pain  and  irritation  arising  in  the  mangled  tissues, 
so  that  the  surgeon  is  often  called  upon,  even  in  the  presence  of  much  general 
shock,  to  run  the  risks  of  subjecting  his  patient  to  the  additional  brief  shock 
of  an  amputation,  rather  than  to  leave  him  exposed  to  the  continued  irritation 
of  his  mangled  limb,  with  possible  added  septic  infection,  while  waiting  for  reac- 
tion to  be  established.  In  general  it  may  be  said  that  Avhen  an  injury  is  not 
primarily  fatal  through  shock,  and  continually  renewed  shock  can  be  prevented, 
speedy  recovery  therefrom  may  be  confidently  looked  for  under  proper  treat- 
ment. Severe  shock  is  so  often  complicated  with  the  acute  anemia  caused  by 
loss  of  blood  that  it  is  difficult  to  separate  its  prognosis  and  its  treatment  from 
those  of  the  latter  condition ;  nor  in  practice  is  it  essential  to  do  so. 

Reaction. — The  symptoms  which  indicate  the  passing  away  of  the  effects  of 
shock  are  a  gradual  increase  of  the  strength  and  volume  of  the  pulse,  a  dimi- 
nution in  its  frequency,  a  more  natural  color  and  heat  of  the  skin,  return  of  con- 
sciousness, and  the  manifestation  of  muscular  power,  as  the  shifting  of  his  position 
by  the  patient.  The  appearance  of  such  favorable  symptoms  constitutes  w^hat 
is  termed  a  state  of  reaction.  In  the  most  favorable  cases  reaction  is  gradual 
and  progressive,  though  it  may  occupy  many  hours  or  even  days  in  its  course. 
Returning  color  to  the  face  and  an  increased  power  in  the  heart's  action  are 
unmistakable  signs  of  its  occurrence.     In  certain  cases  fluctations  in  the  reac- 


94  A.y   A.VKIUCAX    TEXT-IIOOK    OF   SintdKRY. 

tioH  occur,  relapse  alternating  with  improvement  for  a  variable  time.  The  real 
significance  of  such  fluctuations  has  already  been  (hvelt  upon.  In  other  cases, 
before  perfect  reaction  ha»s  been  accomplished,  there  supervenes  a  condition 
characterizeil  by  a  rapid  and  weak  heart's  action,  cerebral  excitement  and 
delirium,  muscular  tremor,  and  high  body-temperature.  These  are  the  signs 
of  septic  infection.  Reaction  from  shock  is  commonly  attended  by  some  ele- 
vation of  the  body-temperature,  quickening  of  the  pulse,  thirst,  derangement  of 
the  secretions,  restlessness,  and  headache.  This  fever  attending  reaction  may  be 
so  trifling  and  evanescent  as  to  escape  notice.  Its  grade  of  severity  depends 
chiefly  upon  the  nervous  activity  of  the  patient,  his  previous  constitutional 
condition,  and  the  amount  of  local  irritation  produced  by  the  injury,  ("liil- 
dren  manifest  it  most  readily.  It  makes  its  appearance  usually  within  a  few 
hours  after  the  reception  of  an  injury,  and  may  be  expected  to  decline  on  or 
after  the  second  day.  This  aseptic  fever  is  to  be  distinguished  from  the 
traumatic  or  surgical  fever  which  sometimes  complicates  the  repair  of  injuries, 
which  does  not  develop  until  two  or  three  days  after  an  injury,  and  which  is 
dependent  upon  general  blood-infection  by  absorption  of  septic  matter  from 
the  injured  part. 

Propliylaxh  of  Shock. — In  cases  of  surgical  operations  it  is  possible  for 
the  surgeon  to  diminish  to  some  extent  the  shock  resulting  from  the  wounds 
inflicted.  These  means  include  moral,  physical,  and  medicinal  measures.  The 
patient  should  be  inspired  to  believe  that  success  will  crown  the  surgeon's 
efl"orts.  and  to  place  implicit  reliance  upon  his  skill.  However  plainly  the 
surgeon  should  state  the  possibilities  of  mischance  to  the  friends  of  the  patient, 
nothing  but  hope  and  happy  expectation  should  usually  be  expressed  to  the 
patient  himself.  Among  physical  means  are  included  all  measures  of  a  general 
character  which  tend  to  diminish  nervous  irritability  and  promote  the  general 
resisting  power  of  the  individual.  Confinement  to  the  bed  for  some  days  is  of 
value  as  a  nervous  sedative.  The  regulation  of  all  the  secretions  of  the  body 
80  as  to  secure  as  nearly  a  perfect  condition  of  well-being  as  possible  is  not  to  be 
overlooked.  The  choice  of  the  period  of  the  day  for  operating  when  the  vital 
powers  are  at  their  best  is  likewise  to  be  considered.  As  a  rule,  this  is  during 
the  morning  hours.  All  unnecessary  exposure  of  the  body  occasioning  loss  of' 
body-heat  is  to  be  avoided ;  if  the  operation  is  to  be  long,  artificial  heat  by  hot- 
water  bags  and  bottles  should  be  applied  during  the  operation.  Hemorrhage 
is  to  be  carefully  guarded  against  and  restrained. 

Medicinal  measures  include  the  use  of  narcotics,  as  opiates,  the  bromides, 
and  the  free  administration  of  alcohol.  These  may  be  of  benefit  when  a  state  of 
excessive  nervous  irritability  has  to  be  antagonized.  They  are  of  special  value 
in  preparing  alcoholic  subjects  for  operation.  In  patients  the  subjects  of 
malarial  cachexia  the  free  preliminary  use  of  quinine  should  be  resorted  to. 
The  administration  of  an  anesthetic  should  be  conducted  with  great  care,  lest 
the  depressing  eff"ect  of  excessive  anesthesia  should  be  added  to  that  of  the 
surgical  procedure,  but  at  the  same  time  complete  anesthesia  should  be  secured. 
For  the  same  reason,  while  avoiding  undue  haste,  operations  should  be  done  a? 
quickly  as  possible.  Strychnia  may  be  used  hypodermatically  in  full  medicinal 
dose,  "517  ^^  TmT  ^^  ^  grain,  after  anesthesia  has  been  induced,  at  the  beginning  of 
serious  surgical  procedures,  as  a  prophylactic  against  shock  through  its  stim- 
ulating action  upon  the  cerebro-spinal  centers. 

Treatment  of  Shock. — Shock,  having  once  become  established  in  a  severe 
degree,  requires  prompt  treatment.  If  it  occurs  in  the  course  of  a  surgical 
operation,  the  operation  must  be  brought  to  a  conclusion  as  speedily  as  possible, 
or  may  even  have  to  be  suspended.     The  head  should  be  lowered  and  the  body 


CONTUSIONS   AND     WOUNDS.  95 

placed  ill  tlio  reeuiiibciit  j)()sitioii,  if  it  is  not  already  so.  l{esj)iration  should  be 
kept  free  from  impediment,  and  when  practicable  thestiinulatiiiiT  effect  of  inhala- 
tions of  oxyijen  should  be  resorted  to.  Tloat  should  be  applied  not  only  to  the 
extremities,  but  to  tlie  whole  surface  of  the  body  as  far  as  juacticahle.  Hot- 
water  bottles  and  hot  blankets  should  iiave  been  ])r(»vided  for  this  j)urpose.  In 
cases  of  severe  shock  an  ellicient  and  S})eedy  method  of  api)lyiii<f  heat  is  to  wrap 
the  whole  body  in  bhmkets  wrung  out  of  hot  water.  Diffusive  stimulants 
should  be  instantly  and  freely  administered.  The  most  (juickly  acting  and 
reliable  stimulation  is  obtainable  by  an  intravenous  injection  of  a  hot  (48.3°- 
44.5°  C. :  110°-112°  F.)  normal  saline  solution  (.^  to  ()j).  Such  injection 
is  especially  important  when  the  injury  has  been  accompanied  with  loss  of 
blood.  As  the  right  heart  feels  the  pressure  of  the  injected  fluid,  the  lieart- 
beats  become  lengthened  and  more  forcible,  and  the  blood-pressure  in  the 
peripheral  vessels  rises.  To  ensure  permanence  in  this  cardiac  and  vascular 
reaction  the  amount  of  fluid  thrown  in  should  be  large — from  one  to  two 
quarts;  or,  better,  repeated  injections  of  smaller  quantities — twenty  to  forty 
fluidounces — should  be  made;  renewal  of  the  injection  being  made  as  the 
effects  of  the  previous  one  are  found  to  be  waning.  Ilypodermoclysis — an 
injection  into  the  subcutaneous  cellular  tissue — is  valuable  as  a  substitute  for 
intravenous  injection,  in  cases  of  less  emergency,  or  in  the  absence  of  facil- 
ities for  its  proper  performance.  The  injecting-needle  may  be  thrust  into 
the  loose  tissue  under  each  breast,  where  from  twenty  to  thirty  ounces  of 
fluid  can  be  readily  forced  into  the  connective-tissue  spaces.  (The  technique 
of  transfusion  and  of  hypodermoclysis,  and  the  best  formula  for  the  solution, 
will  be  found  under  Minor  Surgery.)  High  enemata  of  hot  liquids,  a  quart 
or  more,  are  of  great  value,  either  alone  or  as  an  adjuvant  to  the  measures 
named.  An  infusion  of  black  coffee  (f.5iij)  and  whiskey  (f.^),  or  an  emul- 
sion of  turpentine  (f  5ss  of  the  turpentine),  adds  additional  stimulating  power 
to  such  enemata. 

Strychnia,  in  dose  of  -^^  grain,  repeated  every  half-hour  until  four  doses 
have  been  given,  and  afterward  at  intervals  of  four  hours,  is  most  valuable 
in  maintaining  cardiac  energy.  It  should  be  used  in  connection  with  the 
diff'usible  stimulants.  Nitroglycerin,  in  doses  of  -^^  grain,  may  be  given 
with  the  strychnia. 

In  the  lesser  degrees  of  shock  dependence  may  be  placed  on  Avhiske}^ 
half  an  ounce  by  the  mouth  every  half-hour,  or  one  dram  under  the  skin 
every  fifteen  minutes,  till  reaction  has  been  secured.  Recovery  from  shock 
under  proper  treatment,  if  it  occurs  at  all,  is  usually  quite  speedy  ;  delay  in 
recovery  or  alternations  of  improvement  and  relapse,  as  has  already  been 
stated,  are  due  to  the  nature  of  the  injury  itself  or  to  new  complications  in- 
troduced, and  are  not  to  be  attributed  to  or  classed  as  shock. 

Death  from  shock  may  be  immediate  or  gradual.  When  instantaneous  death 
takes  place  the  nerve-centers  must  be  considered  as  having  been  overwhelmed 
beyond  the  power  of  resistance.  In  some  such  cases  the  heart  has  been 
found  contracted  and  empty.  More  commonly  the  fatal  issue  occurs  only  after 
some  minutes  or  hours  of  struggle  against  the  inevitable.  The  fatal  approach 
is  then  more  gradual ;  the  action  of  the  heart  becomes  more  and  more  feeble ; 
the  pulse,  weak  and  thready  and  counted  with  difficulty  on  account  of  its 
rapidity,  becomes  finally  lost ;  the  extremities  become  cool,  the  face  pinched 
and  haggard ;  the  mind,  apathetic,  gradually  sinking  into  unconsciousness ; 
the  temperature  continues  to  fall  until  it  becomes  a  degree  or  more  subnormal ; 
the  respiration  is  feeble  and  shallow,  until  finally,  by  combined  respiratory  and 
cardiac  failure,  death  closes  the  scene. 


•JG  .l.V   AMERICA  y    Ti:XT-Ji(j(JK    OF  .Sf/.'f./J/n'. 

Fat  Emrolijs.m. — Injuries,  especially  those  c»f  bones  and  of  soft  jtarts 
involving  much  adipose  tissue,  when  there  is  much  crushing  of  the  parts, 
through  the  fact  that  many  fat-cells  are  broken  down  and  minute  fat-globules 
set  free,  mingling  with  the  eftused  fluids  and  wound-secretions,  may  exhibit  a 
train  of  symptoms  which  are  due  to  the  entrance  into  the  circulation  of  this 
fluid  fat.  The  condition  is  known  as  fat  embolism.  In  extensive  compound 
and  multiple  fractures  its  most  severe  forms  are  likely  to  be  developed,  causing 
symptoms  complicating  and  succeeding  those  of  shock,  and  often  resulting  in 
death.  These  deaths  have  commonly  been  attributed  to  shock  ;  their  real 
cause  has  only  been  appreciated  within  a  few  years,  and  even  now  is  fre- 
quently overlooked.  Fat  embolism  is  rare  in  children,  because  their  skeletons 
contain  relatively  little  fat.  The  severity  of  the  symptoms  depends  on  the 
quantity  of  fat  which  has  gained  entrance  to  the  circulation,  on  the  rapidity 
with  which  it  has  entered,  and  on  the  proximity  of  its  source  to  the  heart. 
Having  once  gained  access  to  the  general  venous  current,  the  fatty  globules 
are  carried  to  the  right  heart,  and  thence  are  driven  with  the  blood-stream 
into  the  pulmonary  capillaries,  which  they  plug  up  to  a  greater  or  less  degree, 
and  by  their  presence  here  determine  the  first  symptoms  of  fat  embolism. 
When  the  amount  of  fatty  material  which  is  poured  into  the  capillaries  of  the 
lungs  is  not  verv  great  or  when  it  arrives  but  slowlv.  the  disturbance  which 
it  causes  may  be  but  slight ;  gradually  the  oil-molecules  are  forced  through 
and  pass  on  into  the  general  circulation.  They  may  now  again  be  arrested 
in  the  capillaries  of  the  brain  or  spinal  cord,  and  here  excite  the  special 
disturbances  incident  to  lesions  of  these  organs.  More  frequently  they  are 
arrested  and  disposed  of  in  the  liver  and  in  the  kidneys.  The  urine  secreted 
by  kidneys  thus  blocked  up  by  fat  will  present  oil-globules  floating  on  its 
surface. 

The  symptoms  of  fat  embolism  as  a  rule  develop  within  from  thirty-six  to 
seventy-two  hours  after  an  injury,  though  fatal  cases  are  recorded  in  which  the 
symptoms  developed  and  ran  their  entire  course  in  less  than  twelve  hours.  The 
symptoms  indicative  of  the  lesser  degrees  of  fat  embolism  are  restlessness, 
anxiety,  slight  dyspnea,  and  accelerated  breathing,  with  quickening  of  the 
pulse.  In  the  more  severe  degrees  these  conditions  become  aggravated,  general 
prostration  rapidly  increases,  the  countenance  becomes  pallid  and  anxious,  and 
later  cyanosis,  mental  excitement,  delirium,  somnolence,  and  coma  succeed  in 
turn.  The  dyspnea  becomes  intense,  the  respiration  very  rapid,  and  finally 
stertorous.  CEdema  pulmonum  develops  :  hemoptysis  may  occur;  the  pulse  is 
weak,  frequent,  irregular,  and  finally  imperceptible.  The  temperature  at  first 
is  subnormal,  and  may  remain  so,  or  may  rise  later,  according  to  the  develop- 
ment of  secondary  complications.  The  urine  will  display  oil-globules  floating 
on  its  surface. 

Diagnosis  of  Fat  Embolism. — Fat  embolism  is  to  be  distinguished  from 
shock,  the  effects  of  anesthetics,  acute  septicemia,  acute  congestions  of  the 
lungs  and  of  the  kidneys,  and  cerebral  hemorrhage  or  embolism.  It  is  to  be 
distinguished  from  shock  by  the  fact  that  its  symptoms  make  their  appearance 
at  a  time  when  the  symptoms  of  shock  should  have  greatly  subsi<led,  and  in 
many  cases  where  in  the  first  place  the  amount  of  shock  has  never  been  verv 
great.  The  remote  effects  of  ether  are  not  so  easily  to  be  distinguished  from 
the  effects  of  fat  embolism.  The  irritative  effects  upon  the  lungs  and  the  kid- 
neys of  the  prolonged  administration  of  ether  to  persons  predisj)osed  to  pul- 
monary or  renal  congestion  often  declare  themselves  in  severe  congestion,  which 
determines  symptoms  not  unlike  those  of  fiit  embolism.  In  cases,  tnerefore,  in 
which  such  administration  of  ether  has  been  resorted  to  the  diagnosis  mav  be 


COXTUSIOXS   AM)     WOIWDS.  97 

made  obscure.  The  appearance  of  oil-globules  floating  on  tlie  urine  would  be 
sufficient  to  determine  the  presence  of  fat  embolism.  The  symptoms  of  acute 
septicemia  are  later  in  their  development  than  those  of  embolism.  They  are 
acconi])anied  by  marked  elevation  of  temperature.  They  arc  more  gradual 
in  their  onset,  however  active  their  course  may  be,  and  not  infrequently  are 
engrafted  upon  those  of  fat  embolism.  The  sequence  of  the  conditions  of 
shock,  ftit  embolism,  and  acute  septicemia  is  not  infrequent,  and,  when  its  pos- 
sibility is  borne  in  mind  by  the  surgeon,  will  readily  explain  the  course  of 
many  otherwise  anomalous  cases.  Acute  inflammatory  states  of  the  lungs 
arising  from  conditions  entirely  independent  of  fat  embolism  may  develop 
rapidly  after  operations  or  injuries,  and  are  to  be  distinguished  from  the  efi'ects 
of  fat  embolism,  which  may  also  be  present  and  which  may  be  masked  by  them. 
The  symptoms  indicative  of  such  acute  inflammatory  lung  congestion  are  suffi- 
ciently clear  for  diagnostic  purposes  if  attention  is  only  directed  to  them.  The 
danger  is  rather  that  the  symptoms  of  fat  embolism  will  be  confounded  with 
them  than  that  they  should  be  mistaken  for  fat  embolism.  The  not  infrequent 
occurrence  of  acute  renal  congestion,  with  total  arrest  of  the  urinary  secretions, 
after  a  severe  operation,  is  to  be  borne  in  mind  by  the  surgeon  in  making  his 
diagnosis  as  to  the  cause  of  threatening  symptoms  which  complicate  or  super- 
vene upon  the  shock  of  the  original  operation  or  injury.  The  disturbance  of 
cerebral  conditions  likew;ise,  through  embolism  or  cerebral  hemorrhage,  is  to  be 
borne  in  mind  as  a  possible  occurrence. 

Prognosis  of  Fat  Embolism. — AVhen  the  symptoms  indicating  the  presence 
of  fat  embolism  are  severe  the  probabilities  of  recovery  are  very  slight.  In 
its  lesser  degrees  the  disturbances  caused  by  it  are  transient  and  are  speedily 
and  spontaneously  recovered  from.  The  prognosis  depends  upon  tAvo  factors 
especially — the  amount  of  fat  that  has  gained  access  to  the  circulation,  and  the 
ability  of  the  heart  to  force  the  oil-globules  through  the  capillaries  of  the  lungs. 
Should  this  first  danger  have  been  overcome,  possibilities  of  renewed  danger 
from  arrest  of  oil-globules  in  the  capillaries  of  the  brain  or  spinal  cord  in 
vital  regions  still  exist.  In  such  conditions  a  fatal  result  is  not  long  delayed,  a 
few  hours  only  sufficing  to  bring  the  case  to  a  close.  When  the  pulmonary 
trouble  is  the  chief  one,  a  longer  time  may  be  ret^uired  to  determine  the  final 
result,  whether  recovery  or  death.  At  best,  however,  the  struggle  is  a  brief 
one,  and  is  determined  one  way  or  the  other  within  less  than  forty-eight  hours. 
Treatment  of  Fat  Embolism. — The  first  indication  for  treatment  is  to  pre- 
vent, if  possible,  and  at  all  events  to  diminish,  the  entry  of  fatty  matter  into 
the  blood-current.  The  two  conditions  that  foster  this  accident  are  the  churn- 
ing up  of  bruised  and  broken  fatty  tissue  by  movements  of  a  part,  and  the 
tension  resulting  from  the  accumulation  of  wound-secretions  that  have  no  vent. 
Immobilization  of  the  injured  part  and  relief  to  tension  by  provision  for  free 
drainage  are  therefore  of  primary  importance.  The  second  indication  for 
treatment  is  to  sustain  and  stimulate  the  action  of  the  heart.  For  this  purpose 
alcohol,  digitalis,  and  strychnia  in  full  doses  will  be  found  useful. 

REPAIR    OF   WOUNDS. 

The  repair  of  all  breaches  of  tissue  is  accomplished  by  essentially  the  same 
process,  subject  only  to  minor  peculiarities  of  structure.  This  process  has  been 
described  in  a  preceding  section  (Process  of  Repair).  By  reference  to  this 
section  it  will  be  seen  that  the  essential  element  of  repair  consists  in  a  modifi- 
cation of  the  normal  nutritive  processes  at  the  seat  of  injury,  by  which  the 
tissues  to  be  repaired  return  to  their  embryonic  state  and  new  embryonic  tissue 


•98  .l.V    AMKh'K'AX    TEXr- IK )<>K    OF   SCUdl.HY. 

is  i"(>niic(l  between  tliein.  witli  wliicli  tlicv  hlcml.  \\\  the  or^raiii/ation  aiul 
development  of"  the  new  tissue  a  |)erniaiient  ttoiid  of"  uiiioTi  is  foimccl.  In  no 
case  is  union  of  divided  tissue  effected  without  tlie  inteijtosition  of  new  material. 
AVheii  divided  tissues  are  at  once  hrouf^ht  into  jx'rfect  apposition,  and  there 
retained  and  shielded  from  disturbance,  the  amount  of  new  tissue  required 
for  the  accomplishment  of  union  will  be  extremely  small,  and  may  be  with 
difficulty  recognizal)le ;  but  its  existence  in  some  degree  is  nevertheless 
undeniable. 

When  the  process  of  i-ejiair  wliereby  the  union  of  divided  surfaces  is  secured 
proceeds  without  comj)lication  or  interruption,  union  by  first  intention  or  by 
primary  adhesion  is  said  to  have  taken  place.  (See  Cha])ter  TIL)  This  pri- 
mary union  is  the  ideal  to  be  sought  for  whenever  possible.  To  secure  it  it  is 
necessary  that  the  divided  surfaces  be  brought  together  and  kept  in  close 
apposition  ;  that  the  wound  be  protected  and  kept  from  all  further  injury  ;  and 
that  adefjuate  local  nutritive  conditions  be  maintained.  Wliatever  interferes 
■with  any  of  these  conditions  will  introduce  a  complication  in  the  healing  of  a 
■wound.  It  is  not  infrequently  the  case  that  wounds  occur  in  which  from  the 
outset  it  is  apparent  to  a  surgeon  that  in  some  one  or  all  of  these  respects  it 
will  be  impossible  to  secure  the  necessary  conditions,  so  that  no  attempt  to 
secure  union  by  first  intention  can  be  made.  Thus  the  loss  of  tissue  may  be 
so  great  that  apposition  of  the  <livirled  surfjices  is  impracticable,  or  some  motion 
is  unavoidable,  or  there  is  pre-existing  infection,  or  such  relation  of  the  wound  to 
the  bodily  excretions  or  secretions  exists  that  some  contamination  is  inevitable. 
The  presence  of  any  of  these  conditions  will  make  it  obvious  that  a  wound 
should  not  be  closed.  Again,  the  tissues  bordering  the  wound  may  be  so 
bruised  or  reduced  in  their  vitality  by  general  or  local  causes  that  their  power 
of  sustaining  the  necessary  processes  of  repair  is  uncertain,  perhaps  obviously 
hopeless.  In  all  such  cases  the  method  adopted  by  the  surgeon  for  the  treat- 
ment of  the  wound  will  be  quite  different  from  those  in  which  primary  union 
is  expected.  Healing  by  second  intention  is  the  process  which  is  now  the 
resource  of  the  surgeon,  as  it  is  also  in  those  cases  in  which  attempts  at  primary 
union  have  been  made  and  have  failed.  By  its  means  the  ultimate  healing  of 
the  Avound  is  secured. 

The  conditions  which  may  thwart  the  ideal  primary  rej)air  of  the  wound 
•will  have  to  do  with  either  the  apposition,  the  ])rotection.  or  the  nutrition 
of  the  ■wounded  parts.  Under  the  first  of  these  headings  the  surgeon  must 
consider  the  natural  gaping  of  divided  tissues  and  the  necessity  of  supply- 
ing adequate  means  of  retaining  them  in  coaptation.  The  inevitable  aggrava- 
tion of  this  natural  gaping  by  certain  positions  of  the  body  or  of  the  limbs 
and  by  motion  at  joints  suggests  at  once  the  necessity  of  considering  a  favor- 
able posture  for  wounded  parts,  so  that  relaxation  of  the  injured  tissues 
as  complete  as  possible  may  be  secured.  The  accumulation  of  blood  and  of 
wound-secretions  between  the  divided  surfaces  is  a  frequent  cause  of  lack  of 
success  in  attempts  at  securing  primary  union.  Under  conditions  of  typically 
perfect  protection  from  external  infection,  as  in  most  subcutaneous  wounds,  and 
in  some  operation-wounds  made  under  rigid  conditions  of  ase])sis.  such  accumu- 
lations of  blood  and  wound-secretions  may  not  introduce  any  serious  complica- 
tion into  the  healing  of  the  wound.  Later,  these  effusions  become  absorbed, 
or  they  are  diffused  among  the  adjacent  connective  tissue-spaces,  and  the  nat- 
ural processes  of  repair  proceed.  In  yet  other  cases  the  blood-clot,  remaining 
as  an  intervening  mass  between  the  wound-surfaces,  serves  as  a  su])j)ort  and 
scaffolding  for  new  tissue  ■which  is  thrown  out  from  the  surrounding  ])arts,  and 
"which  penetrates  the  mass  of  the  clot  and  coalesces  with  it,  and  finally  replaces 


COXTL'S/OXS   AX/)     WOUNDS.  99 

it  by  fibrous  tissue  that  unites  the  previously  separated  wound- surfaces. 
Union  by  secondary  intention  is  thus  accom])lished  Avithout  suppuration  or 
waste  of  nutritive  material.  As  a  rule,  the  most  assiduous  effort  of  the 
surgeon  must  be  to  prevent  any  accumulation  of  Ijlood  or  \vound-secretions 
in  any  Avound  uhich  he  is  called  upon  to  treat.  Perfect  apposition  may, 
again,  be  prevented  by  the  presence  of  foreign  matter  between  the  wound- 
surfaces.  Shreds  of  clothing,  splinters  of  wood,  sponges,  bits  of  foreign  matter 
of  every  conceivable  character,  at  times  are  found  in  wounds,  and  their  removal 
is  to  be  carefully  secured  by  the  surgeon. 

For  the  protection  of  a  wound  it  is  requisite  that  it  be  guarded  first  from 
motion,  since  by  motion  the  apposition  of  the  wound-surfaces  is  disturbed,  the 
delicate  new  adhesive  material  which  has  already  been  formed  is  ruptured,  and 
the  conditions  of  the  original  injury  are  renewed  in  tissues  already  weakened 
by  that  injury.  The  wound  must  be  protected  also  from  mechanical  violence, 
such  as  rude  handling,  friction,  and  gross  mechanical  injuries  of  every  kind. 
It  must  be  protected  from  chemical  irritants,  and  especially  from  the  products 
of  decomposition  of  retained  secretions  or  of  portions  of  dead  tissue ;  and,  lastly, 
it  must  be  protected  from  infection  from  poisonous  agents,  especially  the  more 
common  infecting  organisms  everywhere  abounding  in  nature. 

The  local  nutritive  conditions  to  which  attention  must  be  paid  have  to  do 
with  the  circulation  and  the  innervation  of  the  parts  to  be  repaired.  A  depend- 
ent position  of  the  injured  part  or  an  impediment  to  the  free  return  circulation 
by  improper  bandaging  may  produce  excessive  and  persistent  congestion 
and  interfere  with  its  repair.  Temperature  is  not  unimportant :  prolonged 
cold  w'ill  impair  nutrition,  and  too  high  a  temperature  may  cause  local  death. 
Too  great  tension  of  wound-flaps  or  tension  from  pent-up  secretions  impairs 
local  nutrition  by  obstructing  the  flow  of  blood  in  the  capillaries,  as  well  as 
by  the  reflex  effects  of  irritated  nerve-fibrils,  and  also  mechanically  prevents 
rest  and  coaptation  of  deeper  parts.  The  details  of  treatment  to  be  applied  in 
every  wound  have  their  rational  basis  in  the  principles  thus  outlined,  which  will 
serve  for  the  safe  guidance  of  the  practitioner. 

Treatment  of  Wounds. — Arrest  of  Hemorrhage. — To  stop  bleeding 
is  the  first  care  of  the  surgeon  in  his  treatment  of  a  Avound.  The  physi- 
ology of  spontaneous  hemostasis  and  the  methods  of  securing  artificial  arrest 
of  hemorrhage  are  given  at  length  under  Injuries  of  the  Blood-vessels. 
The  aim  of  the  surgeon  should  always  be  to  secure  the  arrest  of  bleeding 
by  means  that  shall  cause  the  least  disturbance  in  the  future  repair  of  the 
wound.  Unnecessary  ligatures  are  therefore  always  to  be  avoided.  When 
ligatures  are  unavoidable,  those  made  of  absorbable  material,  as  catgut,  are 
to  be  preferred,  and  the  size  of  the  thread  should  be  as  small  as  is  consistent 
with  the  strength  required  to  occlude  the  vessel.  When  non-absorbable  mate- 
rials are  used  for  ligatures,  as  silk  thread,  if  it  has  been  perfectly  disinfected 
and  primary  union  of  the  wound  can  reasonably  be  expected,  this  too  may  be 
cut  off  and  left  buried  in  the  wound.  The  first  and  most  generally  applicable 
means  for  restraining  hemorrhage  is  that  of  direct  pressure  made  upon  the  bleed- 
ing point.  This  may  be  by  the  finger  or  by  a  tampon,  or  by  an  instrument,  as  a 
pressure-forceps.  These  means  are  often,  in  the  nature  of  the  case,  but  temporary 
expedients.  In  many  instances,  however,  the  temporary  use  of  pressure  will 
be  all  that  will  be  required  for  the  arrest  of  hemorrhage  that  at  first  was  very 
abundant.  When  copious  and  continuous  capillary  oozing  persists,  it  may 
frequently  be  controlled  by  pressure  with  compresses  wrung  out  in  water  as  hot 
as  can  be  born  by  the  hand — 115°  to  120°  F.  The  use  of  heat  as  a  hemostatic 
is  to  be  preferred  to  cold,  as  being  more  favorable  to  local  nutrition  and  subse- 


100  AiV  AMKIUCAX    TEXT-HOOK    OF  SLJlOKliV. 

quent  active  repair.  The  use  of  hemostatic  forceps,  wliicli  when  once  apjdied 
automatically  compress  the  orifices  of  bleedirif^  vessels,  is  a  very  efficient  and 
convenient  means  of  applying  pressure.  Many  vessels,  which  at  first  bleed 
freely,  after  a  few  moments'  compression  in  this  manner  will  no  longer  bleed 
when  the  forceps  are  removed.  If  the  bleeding  does  persist,  torsion  may  be 
applied,  Avhich,  being  effectual  in  many  instances,  will  reduce  the  ultimate  need 
for  ligatures  to  a  minimum.  As  a  rule,  hemostatic  agents  which  produce 
tough  clots  of  blood,  as  the  salts  of  iron,  or  Avhich  are  strong  irritants, 
such  as  turpentine,  or  which  destroy  tissue  outright,  as  the  actual  cauter}',  are 
to  be  carefully  avoided.  The  free  access  of  cold  air  is  an  active  hemostatic 
and  the  least  harmful.  Often  when  continuous  oozing  persists  from  a  wound 
under  a  mass  of  soft  blood-clot,  if  the  wound  is  freely  opened  and  the  accumu- 
lated clot  thoroughly  removed  further  oozing  becomes  definitelv  arrested.  A 
dilute  solution  of  iodine  has  both  hemostatic  and  antiseptic  properties,  and  may 
sometimes  be  used  with  advantage.  Iodoform  added  to  a  compress  applied  upon 
a  bleedino;  surface  has  a  distinct  hemostatic  effect.  From  amono-  all  these 
resources  the  surgeon  will  be  called  in  a  given  case  to  make  use  of  those 
which  shall  be  available,  efficient,  and  least  harmful,  keeping  in  view  always 
the  ideal  of  wound  treatment — subsequent  union  by  primary  intention. 

Complete  immediate  hemostasis  is  not  to  be  sought  for  in  the  treatment  of 
wounds  in  which  easy  apposition  of  the  wound-surfaces  cannot  be  obtained,  and 
in  which  dead  spaces  or  open  defects  remain  which  it  is  possible  for  the  surgeon 
to  fill  in  by  tissue  organized  in  and  supported  by  a  moist  blood-clot.  When  a 
surgeon  is  master  of  a  sufficiently  perfect  antiseptic  technique  to  secure  healing 
under  such  a  blood-clot,  and  the  circumstances  are  favorable,  he  may  make  the 
attempt.  He  will  then  encourage,  or  even  provoke,  sufficient  bleeding  to  fill 
up  all  the  dead  spaces  and  the  wound-defects  with  blood  previous  to  the  appli- 
cation of  a  dressing,  and  will  subsequently  protect  the  clot  from  adhesion  to  or 
disturbance  by  the  external  dressing.    (See  page  29.) 

Cleansing  of  the  Wound. — Great  care  should  be  taken  to  remove  from  a 
wound  not  only  all  foreign  matter  which  may  have  been  deposited  within  it, 
but  also  all  dead  or  dying  tissue,  and,  as  a  rule,  all  blood-clots.  The  means 
required  for  effecting  such  cleansing  must  be  adapted  to  the  nature  of  the 
material  to  be  removed.  The  forceps,  scissors,  curette,  sponge,  irrigating 
stream,  each  may  find  its  use.  By  means  of  these  simply  the  more  gross  and 
perceptible  impurities  may  be  removed.  Of  greater  importance  ofttimes  is  the 
cleansing  of  the  wound  of  those  microscopic  organisms  which  may  induce 
suppuration  and  putrefaction.  (For  the  consideration  of  the  means  required 
for  this  latter  degree  of  cleanliness  or  sterilization  see  Operative  Surgery.) 
Suffice  it  here  to  say  that  in  his  treatment  of  wounds  the  surgeon  should 
never  lose  sight  of  the  natural  resisting  power  of  living  tissue  to  such  organisms, 
and  that  in  his  efforts  at  sterilization  he  should  irritate  and  injure  the  living 
tissue  as  little  as  possible.  Strong  and  irritating  antiseptic  lotions  are  there- 
fore, as  a  rule,  to  be  avoided  as  direct  applications  to  wound-surfaces. 

When,  however,  a  wound  is  already  manifestly  contamiiuited,  it  will  be 
good  practice  to  irrigate  it  thoroughly  for  a  considerable  period  of  time  with  a 
germicidal  lotion  of  sufficient  strength  to  secure  the  destruction  of  whatever 
septic  material  may  have  gained  access  to  it.  A  solution  of  carbolic  acid, 
1 :  40,  or  of  corrosive  sublimate,  1 :  1000,  will  be  found  most  generally  suit- 
able for  such  a  purpose.  When  the  full  sterilization  of  a  wound,  even  by  the 
use  of  antiseptic  irrigations,  is  impracticable,  or  it  is  so  situated  that  it  cannot 
be  kept  free  from  subsequent  renewed  contamination,  as  in  many  wounds 
involving  the  outlets  of  mucous  canals  or  when  the  wound  opens  into  suppurat- 


CONTUSIONS   AND     WOLN^DS.  1<>1 

ing  cavities,  resort  must  be  had  to  taiii])oning  the  wound-cavities  with  materials 
impregnated  with  a  permanent  antiseptic,  as  iodoform  or  boric  or  salicylic 
acid.  In  these  latter  cases,  of  course,  union  by  granulation  is  what  commonly 
occui's,  but  what  is  practically  primary  union  may  sometimes  be  attained  by 
"secondary  sutures." 

Coaptation. — In  the  coaptation  of  wounds  the  aim  of  the  surgeon  must 
be  to  bring  the  severed  parts  as  far  as  possible  into  the  same  relations  with 
each  other  as  existed  before  the  wound  was  inflicted,  and  especially  to 
secure  the  closest  possible  apposition  of  eveiy  portion  of  the  wound-surfaces. 
When  im})ortant  nerves,  muscles,  and  tendons  have  been  divided,  especial  care 
must  be  taken  to  bring  and  secure  together  the  divided  ends ;  all  dead  spaces 
where  secretions  may  gather  are  to  be  prevented ;  and  by  various  means  and 
devices  the  tissues  are  to  be  retained  in  their  restored  relation  until  definite 
reunion  has  been  accomplished.  Under  the  term  "  coaptation  "  all  the  various 
aims  and  methods  referred  to  are  included.  In  the  section  devoted  to  Minor 
Suro-erv  the  means  of  accomplishing  coaptation  ai'e  described  in  detail.  Here, 
however,  it  will  be  proper  to  speak  of  the  general  principles  which  should 
guide  the  surgeon  in  the  choice  of  means  and  methods. 

First,  much  tension  must  be  avoided.  When  tissues  are  put  unduly  upon 
the  stretch  in  an  effort  to  bring  them  together,  the  circulation  of  the  blood 
within  them  is  impeded,  '  nutrition  is  impaired,  the  formation  of  sloughs  is 
invited,  and  suppurative  disturbances  are  promoted.  It  is  far  better  to  be 
content  with  whatever  amount  of  coaptation  can  be  easily  secured,  and  to  seek 
for  the  healing  of  any  surfaces  left  uncovered,  either  by  granulation  and  ulti- 
mate cicatrization  or  by  skin-grafts.  In  the  second  place,  care  must  be 
taken  w^ile  securing  coaptation  to  avoid  such  adjustment  of  sutures  or  other 
retentive  apparatus  as  would  be  likely  to  produce  strangulation  of  any  portion 
of  the  tissue.  Sutures  too  closely  applied  and  too  tightly  drawn  are  a  frequent 
cause  of  necrosis  of  wound-edges :  the  pressure  of  compresses  and  bandages 
may  likewise  be  so  great  as  to  produce  local  tissue-necrosis,  so  that  good  judg- 
meiat  should  always  be  used  in  their  application.  Thirdly,  the  relaxation  of 
tissues  by  position  should  not  be  overlooked  by  the  surgeon.  The  spontaneous 
gaping  or  falling  together  of  wounds  in  varying  attitudes  of  a  wounded  part 
need  but  be  noticed  to  suggest  the  advantage  to  be  derived  from  placing  a  part 
in  that  position  or  attitude  in  which  any  tendency  to  gape  during  the  healing 
process  will  be  reduced  to  a  minimum.  The  general  rule  is,  therefore,  in 
order  to  favor  coaptation  of  a  wound,  to  put  the  part  in  that  position  in  which 
the  greatest  relaxation  of  the  wounded  structures  can  be  secured,  and  in  this 
position  they  should  be  fixed  and  held  until  firm  union  has  been  accomplished. 
As  an  accessory  to  the  use  of  position  for  securing  relaxation  is  the  device  of 
sliding  toward  the  wound  tissues  somewhat  distant  from  it.  By  the  use  of 
sutures  traversing  a  deeper  portion  of  the  wound,  and  made  to  embrace  portions 
of  tissue  on  either  side  at  a  considerable  distance  from  the  wound-edges,  and  then 
secured  after  the  manner  in  which  an  upholsterer  secures  the  two  sides  of  a 
mattress  together,  wounds  which  gape  widely  at  first  may  often  have  their  edges 
so  approximated  that  they  are  easily  brought  together  without  tension. 

The  choice  of  materials  for  ensuring  continued  coaptation  is  worthy  of  con- 
sideration. When  a  wound  is  small  and  there  is  no  tendency  to  gape,  or  when 
that  tendency  has  been  overcome  by  attention  to  position,  the  use  of  a  simple 
compress  held  in  place  by  a  roller  bandage  may  be  all  that  is  required  to 
ensure  undisturbed  healing.  In  general,  however,  additional  means  for  secur- 
ing undisturbed  coaptation  will  be  required.  For  this  purpose  are  used  adhe- 
sive strips  and  sutures. 


102  AX    AMi:iil<AX    TEXT- HOOK    OF   SCliOICRY. 

AdJiesive  strips^  as  direct  applications  to  ^voun(l-ilaj).s  to  secure  tlieir  appo- 
sition, should  rarely  be  used.  Bein«j;  disinfected  uith  difficulty,  they  are 
always  to  be  looked  upon  as  surtjically  unclean.  They  favor  infection  likewise 
by  retaining  wound-discharges  underneath  them  and  in  their  substance ;  they 
cover  up  a  wound  from  the  surgeon's  inspection  ;  they  often  irritate  the  skin 
to  which  they  are  applied ;  and,  finally,  from  their  tendency  to  become  loos- 
ened, they  are  unreliable  in  the  support  which  they  give.  Strips  of  gauze 
fixed  with  collodion  are  more  effective  and  are  perfectly  aseptic.  For  purposes 
of  supidementary  support,  however,  placed  o?/^side  of  the  immediate  wound- 
dressing  to  prevent  tension,  to  produce  compression,  and  to  ensure  fixation  of 
the  dressings,  adhesive  strips  are  invaluable. 

Sutures. — The  most  certain,  e.xact,  and  generally  available  of  the  means 
for  retaining  divided  surfaces  in  coaptation  is  the  suture.  As  "stitches  of 
coaptation,"'  applied  superficially  and  close  to  the  Avound-margins,  they  keep 
the  cutaneous  edges  of  the  wound  together.  As  "stitches  of  approximation," 
having  been  passed  more  deeply  and  at  a  greater  distance  from  the  wound- 
margins,  they  approximate  and  hold  together  the  deeper  surfaces.  As 
"stitches  of  relaxation,"  embracing  tissues  at  some  distance  on  either  side  of 
the  wound,  they  relax  the  adjacent  tissues,  so  that  the  wound-surfaces  may  be 
brought  together  and  tension  be  avoided.     The  materials  available  for  sutures 

or?  ^ 

will  be  discussed  elsewhere.  (See  Operative  Surgery.)  Whatever  form  of 
thread  is  chosen  should  have  been  rendered  aseptic  by  previous  preparation, 
and  should  likewise  be  immersed  anew  in  tlie  antiseptic  solution  at  the  time  it 
is  used. 

Drainage. — As  the  surgeon  proceeds  with  his  efforts  at  securing  coaptation 
of  a  wound  he  must  make  provision  for  the  escape  of  the  secretions  which  are 
the  immediate  result  and  accompaniment  of  every  wound.  When  perfect 
coaptation,  deep  as  well  as  superficial,  has  been  secured,  and  when  by  the 
most  scrupulous  and  exact  observance  of  antiseptic  precautions  the  surgeon  is 
assured  that  his  wound  when  dressed  is  as  free  from  infection  as  a  subcutaneous 
one,  means  of  drainage  may  be  dispensed  with,  and  the  local  absorbents  may 
be  relied  upon  to  remove  whatever  secretions  are  poured  out  in  excess  of  the 
quantity  needed  for  repair.  As  a  rule,  however,  it  will  be  important  for  the 
surgeon  to  provide  means  for  the  free  and  continuous  escape  of  wound-secretions. 
It  will  often  be  sufficient  to  leave  open  the  most  dependent  portion  of  the  wound. 
In  some  cases  enlargement  of  Avounds  by  free  incisions  or  the  making  of  coun- 
ter-openings may  be  practised  for  the  purpose  of  securing  free  escape  of  secre- 
tions. In  many  instances  it  will  be  good  practice  to  introduce  the  sutures  at 
the  operation,  but  not  to  tie  them  until  after  the  cessation  of  the  primary  copious 
bloody  and  serous  oozing  which  occurs  during  the  first  tAvelve  to  twenty-four 
hours  after  the  occurrence  of  a  wound  (secondary  suture).  Septic  infection 
having  been  prevented  by  the  use  of  antiseptic  dressings,  at  the  end  of  this 
period  the  wound-surfaces  may  be  brought  together,  Avith  an  increased  prob- 
ability of  securing  union  by  first  intention  Avithout  the  necessity  of  any  further 
means  of  drainage.  Fre([uently,  hoAvever,  the  surgeon  Avill  be  compelled  to 
resort  to  the  introduction  into  a  Avound  of  some  foreign  material  for  the  purpose 
of  conducting  aAvay  i^s  discharges.  This  substance  may  act  by  capillarity, 
serving  to  keep  the  Avound-surfaces  apart  and  permitting  the  outfiow  of  liquid 
along  the  interstices  among  its  strands,  or  there  may  be  provided  tubes  through 
Avhich  free  flow  of  the  discharge  is  secured.  For  the  escape  of  pus  a  tubular  drain 
is  always  required,  and  whenever  provision  is  to  be  made  for  the  escape  of  much 
secretion,  if  absolute  certainty  of  drainage  is  desired  such  a  tube  must  be  used. 
Rubber  tubing  is  the  most  universally  applicable  means  of  drainage,  being 


<<)\Tf  S/OX.S    AAI>     \\()UM)S.  lO.'i 

Hoxiblo,  uiiirritating,  easy  to  manipulate,  easily  sterilized,  nearly  ahvays 
attainable,  and  eheap.  A  drainage-tube,  of  Avliatever  substance  composed,  is 
a  foreign  body,  and  as  long  as  it  remains  in  a  wound  is  liable  to  produce 
disturbance.  It  should  therefore  be  removed  as  soon  as  the  period  of  profuse 
secretion  which  made  its  original  use  necessary  has  passed  away,  or  as  soon  as 
the  cavity  which  it  was  intende<l  to  drain  has  become  obliterated. 

Dressings. — In  the  treatment  of  a  wound  after  hemorrhage  has  been 
checked,  its  surface  has  been  cleansed  and  purified,  coa[itatiori  has  been 
accomplished,  and  drainage  has  been  provided  for,  a  suitable  dressing  must  be 
applied.  Two  main  objects  are  to  be  accomplished  by  a  dressing :  first,  the 
absorption  of  whatever  secretions  may  come  to  the  surface ;  and  second,  the 
protection  from  infection  and  from  injury  and  motion.  The  materials  which 
may  be  available  for  surgical  dressings  are  fully  treated  of  in  the  section  devoted 
to  Operative  Surgery.  Here,  however,  some  general  considerations  concerning 
dressings  are  in  place.  Septic  infection  is  to  be  guarded  against  by  cover- 
ing the  part  with  soft  and  absorbent  material  that  will  receive  and  keep 
aseptic  the  discharges  that  drain  away  from  a  wound,  and  that  will  prevent 
the  access  of  septic  infection  from  other  sources  to  the  wound.  For  this 
purpose  many  substances  may  be  found  useful :  among  those  more  com- 
monly employed  are  cotton  w^ool,  loosely-woven  cotton  cloth  from  which 
all  oily  matter  has  been,  removed,  jute,  sawdust,  moss,  etc.  While  all  these 
substances  are  more  or  less  hygroscopic,  their  usefulness  as  absorbent  dress- 
ings depends  chiefly  upon  the  multitude  of  minute  spaces  existing  between 
their  meshes  or  fibers,  and  a  certain  degree  of  openness  of  mesh  or  loose- 
ness of  fiber  is  requisite  to  enable  them  continuously  to  absorb  thick  and 
viscid  fluids.  It  is  not  enough  that  these  materials  Avhen  applied  should 
themselves  be  simply  sterile,  for  when  they  are  filled  with  wound-secretions 
they  may  then  be  infected  from  without  and  become  the  medium  of  conveying 
infection  to  the  wound.  It  is  better  that  portions  of  the  dressings  should 
themselves  be  impregnated  with  antiseptic  materials,  which  could  actively 
antagonize  or  inhibit  the  activity  of  any  septic  matter  that  might  gain  access 
to  the  secretions  imbibed  by  them.  The  necessity  of  this  is  realized  if  the 
extreme  difficulty,  almost  impossibility,  of  sterilizing  absolutely  the  skin  of 
the  patient  or  the  fingers  of  the  surgeon  is  recalled.  For  this  reason  the  best 
results  in  securing  the  healing  of  their  wounds  will  be  obtained  by  those 
surgeons,  all  other  things  being  equal,  w^ho  make  use  of  wound-dressings 
containing  proper  proportions  of  corrosive  sublimate,  the  double  cyanide  of 
zinc  and  mercury,  boric  or  salicylic  or  carbolic  acid,  or  similar  antiseptic 
agents.  By  the  use,  further,  of  very  voluminous  dressings  it  is  possible  to 
give  additional  security  against  the  conveyance  of  infection  from  without  to 
a  wound,  and  to  protect  it  more  certainly  from  mechanical  violence  and  from 
motion. 

Changes  of  dressings  are  made  at  long  intervals,  and  thus  the  ideal  rest  is 
secured  to  the  injured  part  while  repair  is  going  on.  As  to  when  such  changes 
are  required,  various  considerations  must  determine  the  action  of  the  surgeon. 
The  body-temperature  of  the  patient,  as  indicated  by  the  thermometer,  should 
be  especially  relied  upon  as  an  index  to  the  character  of  the  processes  going  on 
in  the  wound.  If,  after  an  elevation  of  one  or  two  degrees  above  the  normal 
for  the  first  forty-eight  or  seventy-two  hours  after  a  Avound  has  been  inflicted 
and  dressed,  the  temperature  sinks  to  nearly  the  normal  point,  and  remains 
there  with  but  slight  fluctuation,  the  surgeon  is  assured  that  undisturbed  repair 
is  progressing,  and  that  no  demand  for  interference  is  present  by  reason  of  any- 
thing in  the  wound  itself.     If,  however,  the  temperature    continues   elevated 


104  AX  AMKRICAX    TEXT-HOOK    OF   sriidERY. 

after  the  first  t^vo  or  three  days,  or  if,  after  having  once  fallen,  it  again  rises, 
and  especially  if  a  series  of  morning  remissions  and  evening  exacerbations 
show  themselves,  the  evidences  are  unniistaka])le  that  inflammatory  and  sup- 
purative (listur])ances,  with  retention  of  secretion  and  septic  al)sorption,  are 
going  on,  and  that  a  change  of  dressing  with  thorough  exploration  of  the  wound 
is  required.  When  also  the  external  hiyers  of  the  dressings  become  moist  with 
the  secretions  that  have  been  imbibed  from  within,  it  is  imperative  that  the 
dressings  be  renewed.  This  does  not  apply,  however,  to  the  frequent  staining 
of  the  external  layers  of  a  dressing  by  the  copious  sero-bloody  primary  wound- 
secretion,  which,  when  very  hygroscopic  materials  are  used,  often  occurs  within 
a  short  time  after  the  ap])lication  of  a  dressing.  In  these  cases  the  dressings 
quickly  become  and  remain  dry,  and  do  not  require  to  be  changed.  When 
drainage-tubes  have  been  employed  it  is  desirable  that  they  be  removed,  in 
most  cases,  within  a  week  or  ten  days,  or  often  much  earlier,  for  which  purpose 
the  dressing  must  be  renewed.  When  for  the  purpose  of  controlling  hemorrhage 
tampons  have  been  left  in  sitii,  these  should  be  removed  as  early  as  the  third 
day,  and  thus  they  would  form  another  indication  for  a  change  of  dressing. 
If  the  wound  becomes  the  seat  of  suppuration  or  of  sloughing,  such  fre- 
quency of  dressings  is  required  as  may  be  needful  to  secure  the  adequate 
drainage  and  cleansing  of  the  infected  part.  In  general,  changes  of  dressings 
should  be  made  as  rarely  as  possible,  and  only  for  the  purpose  of  meeting  dis- 
tinct indications.  In  changing  dressings  the  same  strict  antisepsis  should  be 
observed  as  in  the  operation  itself. 

Local  Treatment. — While  proper  attention  is  being  given  to  a  wound 
the  needs  of  the  wounded  part  should  not  be  overlooked.  Nothing  which 
could  interfere  in  any  Avay  with  its  most  perfect  well-being  should  be  con- 
sidered insignificant.  The  natural  warmth  of  the  part,  perfect  freedom  of  the 
circulation,  tlie  control  of  muscular  spasm,  and  the  most  perfect  quiet  and 
comfort  are  all  of  importance  to  be  secured. 

Position. — A  position  that  will  be  comfortable  to  the  patient  should  if  pos- 
sible be  selected.  This  will  always  be  one  in  which  the  muscles  are  relaxed 
and  the  return  circulation  of  the  blood  to  the  heart  is  fiivored.  The  relation 
of  position  to  drainage  should  be  kept  in  mind,  and  in  the  arranging  of  the 
means  for  drainage  whenever  possible  the  drains  should  be  so  placed  as  to  be 
most  efficient  when  the  part  shall  have  been  placed  in  a  position  of  the  greatest 
comfort. 

Compression. — Gentle,  uniform,  and  continuous  pressure  is  of  great  value 
in  promoting  rapid  repair  after  injury.  It  restrains  excessive  local  hyperemia, 
limits  effusion,  and  promotes  absorption  of  effusions  already  present ;  h  antag- 
onizes muscular  spasm  and  contributes  to  rest  of  the  ])art.  A  greater  and 
more  methodical  application  of  pressure  than  is  needful  for  maintaining  simple 
apposition  of  the  separated  parts  is  required  in  order  to  obtain  the  full  power 
of  compression  in  favoring  the  repair  of  a  wound.  Comjn-ession  should  be 
smooth  and  uniform,  gentle  but  firm,  carefully  avoiding  any  constriction.  In 
most  cases  it  may  be  best  effected  by  covering  the  wounded  part  with  layers  of 
cotton  wool  and  applying  compression  with  bandages.  The  wool  by  its  elas- 
ticity tends  to  distribute  evenly  the  compression  exercised  by  the  bandage  and 
to  keep  the  pressure  continuously  uniform. 

Immobilization. — While  the  means  of  compression  just  described  will  in 
many  instances  be  sufficient  to  give  whatever  extraneous  aid  is  required  to  pre- 
vent motion  in  the  wounded  part,  in  many  others  there  will  be  needed  some 
further  assistance  in  securing  the  desired  immol)ility.  For  this  purpose  splints 
of  various  kinds  are  available.     Whenever  any  form  of  plastic  splint  can  be 


COXTUSIONS   AXI>    WOUNDS.  105 

used,  it  should  be  chosen ;  such  splints  accurately  take  the  shape  of  the  part, 
forming  a  firm  mould  that  encases  and  fixes  the  limb  ^ithont  pressing  unduly 
on  anv  one  ])oint.  As  a  result,  such  splints  are  borne  "vvith  comfort,  and  thus 
indirectly  contribute  still  more  to  the  well-doing  of  the  wound.  In  an  emer- 
gency, however,  the  ingenuity  of  the  surgeon  may  be  able  to  bend  to  his  pur- 
pose, for  giving  support  and  fixation  to  a  wounded  part,  a  multitude  of  difter- 
ent  substances. 

Constitutional  Treatment. — The  existence  of  pain  or  general  restless- 
ness riMjuirc's  the  administration  of  opiates  for  their  relief.  The  age  of  the 
patient,  his  previous  constitutional  condition,  the  coexistence  of  disease  or 
tendencies  to  disease,  and  the  hygienic  conditions  in  which  he  is  placed,  each 
must  engage  the  attention  of  the  surgeon  in  order  that  whatever  special  indica- 
tions they  present  may  be  met,  and  every  possible  influence  that  might  inter- 
fere with  re])air  be  guarded  against.  Even  the  mental  state  of  the  wounded 
should  be  regarded.  The  surgeon  who  is  able  to  arouse  hope,  expectation, 
and  faith  in  the  minds  of  his  patients  will  see  their  wounds  heal  more  rapidly 
and  certainly  than  when  opposite  states  of  mind  exist.  As  regards  the  influ- 
ence of  age  upon  the  healing  of  wounds,  although  in  some  cases  aged  persons 
display  unimpaired  ability  to  repair  their  wounds,  yet  as  a  rule  in  the  aged 
healincr  is  much  more  sluggish  and  more  likelv  to  suffer  from  disturbance.  In 
aged  patients  especial  attention  must  be  paid  to  their  nutrition,  to  maintaining 
their  bodily  warmth,  and  to  giving  them  the  stimulating  effects  of  abundant 
sunlight  and  pure  air. 

In  all  cases  whatever  departures  from  a  perfect  standard  of  health  a  patient 
may  present  should  engage  the  attention  of  the  surgeon.  Plethora,  anemia, 
obesity ;  that  peculiar  vulnerability  associated  with  the  scrofulous  diathesis ; 
alcoholism  ;  the  exhaustion  from  overwork,  underfeeding,  or  mental  strain  ; 
the  depression  produced  by  vicious  habits  and  the  habitual  inhalation  of 
vitiated  air, — these  are  some  of  the  conditions  for  the  relief  of  which  the 
surgeon  should  see  that  proper  constitutional  treatment  be  given. 

Closely  allied  to  the  conditions  just  named  are  certain  well-marked  diseased 
states,  such  as  s^^philis,  tuberculosis,  malaria,  diabetes  mellitus,  and  scurvy, 
which  by  the  nutritive  defects  which  they  determine  delay  repair,  often  arrest 
it,  and  subject  wounds  to  the  most  serious  complications.  The  pre-existence 
of  pyemia,  septicemia,  erysipelas,  phlebitis,  or  any  diffuse  inflammation  will 
add  special  dangers  to  any  traumatism.  Diseases  of  the  various  organs  of 
the  body,  and  particularly  cardiac,  pulmonary,  hepatic,  and  renal  diseases, 
modify  the  effects  of  wounds,  both  directly  by  the  constitutional  states  which 
they  create  and  w^hich  are  unfavorable  to  repair  and  diminish  the  resisting 
powers  of  the  tissues  in  general,  and  indirectly  by  the  reaction  of  the  injury 
upon  the  pre-existing  affection,  producing  in  it  temporary  exacerbation  or  per- 
manent and  excessive  aggravation,  with,  not  infrequently,  speedy  death.  Each 
of  the  conditions  named  when  present  will  demand  constitutional  treatment 
in  order  to  neutralize  as  far  as  possible  any  influence  for  evil  which  it  might 
exert  upon  the  healing  of  the  wound. 

The  general  hygiene  of  the  patient  should  be  made  as  favorable  as 
possible.  Food  insufficient  in  quantity  or  bad  in  quality,  extremes  of  tem- 
perature, absence  of  sunlight,  depressing  climatic  conditions,  lack  of  exercise, 
insufficient  and  impure  air, — these  not  only  create  previous  constitutional  con- 
ditions unfavorable  to  repair,  but,  when  continued  after  the  reception  of  a 
wound,  directly  diminish  the  activity  of  its  reparative  processes.  The  diet  of 
the  patient  should  be  regulated  so'^that  his  supply  of  food  should  be  ample, 
palatable,  and  digestible,  due  regard  being  paid  to  personal  taste  and  instincts. 


lUG  .l.V   AMi:iiI('AN    TEXT-BOOK    OF  SURGERY. 

In  connection  with  the  sul)joct  of  aliincut.ition  attention  should  he  paid  to 
the  action  of  the  bowels  and  all  the  excretions  and  secretions  of  the  body. 

An  abundant  supply  of  sunliglit  and  of  pure  air  is  es[)e('ially  iinjwrtant  for 
the  well-doing  of  a  person  who  is  confined  by  a  wound  to  one  place,  and  thus 
is  dependent  upon  what  is  brought  to  him  from  without  for  the  purification 
and  renewal  of  the  air  which  he  must  breathe.  This  is  alike  necessary  for 
isolated  cases  in  their  own  homes  and  for  those  in  the  crowded  wards  of 
a  hospital. 

After-Treatment. — The  least  possible  interference  with  a  wound  while 
the  healing  process  is  going  on  is  a  cardinal  principle  in  surgery.  Too 
early  and  too  frequent  interference  inevital)ly  prevents  the  steady  progress 
of  the  healing  process.  Infrequent  dressing  is  eminently  conducive  to  that 
absolute  I'est  which  is  to  be  kept  in  view  whatever  method  of  treatment 
is  adopted.  When  the  first  dressing  of  the  wound  has  been  conducted  in 
accordance  with  the  principles  that  have  been  described,  the  after-care  from 
the  surgeon  will  be  limited  to  a  watchful  oversight  of  the  means  of  protection 
and  immobilization,  of  drainage,  and  of  apposition  that  have  been  employed, 
so  that  they  may  be  removed,  substituted,  or  reinforced  by  others  as  soon  as  they 
are  no  longer  called  for  or  have  become  inefficient.  The  prevention  of  the  access 
of  septic  organisms,  and  the  removal  as  fast  as  formed  of  materials  that  may 
decompose  or  become  the  lodging-places  of  these  organisms,  constitute  two  great 
indications,  to  fulfil  both  of  Avhich  the  surgeon  must  continually  strive  to  the 
best  of  his  ability  if  he  would  acquit  himself  of  reproach  for  the  results  of  dis- 
turbance that  may  supervene  in  the  progress  of  the  wound.  Inflammatory, 
erysipelatous,  gangrenous,  or  septicemic  complications  attacking  wounds  are  not 
always  to  be  regarded  as  unfortunate  and  unavoidable  accidents,  but  must  some- 
times be  accepted  as  the  results  of  errors  or  failures  in  the  treatment  which  the 
wounds  have  received.  When  in  the  first  dressing  of  a  wound  it  has  been  possible 
to  close  it  after  perfectly  satisfying  the  indications  for  treatment  that  have  been 
detailed,  it  should  not  be  disturbed  until  a  sufficient  time  has  elapsed  for  the 
adhesion  of  the  wounded  parts  to  become  firm.  From  ten  to  fourteen  days 
may  often  be  permitted  to  pass  before  the  dressings  are  removed.  The  indica- 
tions which  might  call  for  earlier  interference,  such  as  the  removal  of  drainage- 
tubes,  have  been  detailed  in  a  preceding  paragraph  ;  but  whenever  the  external 
jH'otective  dressings  remain  dry,  the  wound  is  free  from  pain  and  fetor,  and  there 
is  no  acceleration  of  the  pulse  or  elevation  of  the  temperature,  the  dressings 
may  be  left  undisturbed.  Sutures  may  be  allowed  to  remain  as  long  as  their 
support  seems  to  be  desirable,  provided  they  are  not  causing  irritation  or  sup- 
puration. In  the  latter  case  they  should  be  removed  at  once.  It  is  impossible 
to  fix  arbitrarily  the  periods  for  the  renewal  of  the  dressings :  each  case  must 
be  a  law  unto  itself.  In  the  changing  of  the  dressings  and  in  all  the  manipu- 
lations required  about  the  wound  the  utmost  gentleness  should  be  used. 

INTERCURRENT    COMPLICATIONS. 

The  regular  course  of  the  healing  of  a  wound  may  become  disturbed  by 
inflammation,  entailing  suppuration  and  possibly  gangrene,  and  if  healing  is 
ultimately  secured  it  is  accomplished  only  by  a  prolonged  process  of  granula- 
tion. By  the  absorption  into  the  general  circulation  of  materials  formed  in 
wounds  thus  complicated  the  general  phenomena  of  septicemia  and  of  pyemia 
may  be  produced. 

"^Inflammation. — With  but  few  exceptions  an  inflamed  wound  is  a  septic 
wound,  and  the  cause  of  the  inflammation  is  the  irritation  of  the  products  of 


COXTUSIOXS  AM)     WOrXDS.  107 

(lecomposition  of  retained  secretions.  It  is  accordingly  those  wounds  in  which 
the  retention  of  sccrt'tions  is  most  difficult  to  prevent,  as  of  wounds  of  joints 
and  other  cavities,  wounds  leading  down  to  fractured  }»one,  and  deep  irregular 
punciured  Avounds,  in  which  severe  inflamnuition  is  frecjuently  met  with.  To 
give  free  vent,  therefore,  to  all  wound-secretions  that  may  have  Hbeen  retained  is 
the  first  thing  to  be  attended  to  in  the  treatment  of  such  a  wound.  Tliis  may 
require  nothing  more  than  the  cutting  of  a  stitch,  so  that  the  luitural  gaping 
of  the  wound  nuiy  suffice  for  the  reijuired  vent,  or  it  may  re(|uire  counter-incis- 
ions and  tlie  use  of  drains.  AVhenever  an  inflannnation  shows  a  tendency  to 
spread  into  the  adjacent  parts,  abundant,  thorough,  and  systematic  incisions 
into  the  affected  area  must  be  made,  sufficient  to  provide  for  the  free  escape  of 
all  irritating  secretions.  Wherever  there  is  a  possibility  of  a  foreign  substanee 
having  been  left  in  the  wound,  such  as  a  splinter  of  wood,  a  piece  of  glass,  a 
rusty  nail,  a  bit  of  clothing,  a  detached  piece  of  bone,  etc.,  it  should  be  care- 
fully souirlit  for  and  removed.  If  the  inflammation  has  been  caused  or  asirra- 
vated  by  mechanical  irritation,  by  motion,  or  by  the  premature  use  of  the 
wounded  part,  the  recognition  of  such  a  fact  will  at  once  lead  to  its  correction. 
When  the  causes  of  the  inflammation  have  been  removed,  the  parts  should  be 
placed  in  an  elevated  and  comfortable  position  and  subjected  to  such  additional 
means  for  relieving  the  pain,  heat,  and  swelling  of  the  part,  and  overcoming 
the  vascular  congestion  on  which  these  depend,  as  the  judgment  of  the  surgeon 
may  determine.  In  brief,  however,  it  may  be  said  that  for  the  relief  of 
inflamed  wounds  the  surgeon  will  find  of  especial  value  the  use  of  irrigation 
with  cooling  antiseptic  solutions. 

Gangrene. — The  appearance  of  gangrene  in  a  wound  calls  for  the  imme- 
diate adoption  of  even  more  energetic  and  thorough  antiseptic  methods  of 
treatment  than  have  been  prescribed  in  the  preceding  paragraphs.  All  loose 
gangrenous  tissue  should  be  removed  at  once  Avith  knife  and  scissors,  and  the 
living  tissues  exposed  should  be  freely  and  thoroughly  cauterized  by  an  8  per 
cent,  chloride-of-zinc  solution,  which  should  be  injected  into  every  cavity  and 
recess  of  the  wound.  Free  incisions  and  counter-incisions  should  be  made  into 
the  swollen  and  infiltrated  tissues  leadins;  from  the  firansrenous  focus,  so  as  to 
permit  the  escape  of  secretions  and  debris  and  to  enable  the  disinfecting  liquid 
to  reach  every  infected  part.  The  Avound  should  be  left  uncovered,  and  contin- 
uous irrigation  Avith  an  antiseptic  solution  established.  For  such  irrigating 
liquid  a  1  per  cent,  solution  of  carbolic  acid  or  of  acetate  of  aluminium  or  a 
1  :  15,000  sublimate  solution  may  be  used.  The  antiseptic  irrigation  should 
be  continued  until  permanent  arrest  of  the  gangrenous  process  is  manifest,  all 
necrotic  tissues  have  come  away,  and  a  healthy  granulating  surface  has  formed. 

Erysipelas. — The  appearance  of  erysipelas  is  ahvays  due  to  some  defect 
or  neglect  in  the  antiseptic  precautions.  It  is  ahvays  of  specific  septic  origin, 
and  it  most  especially  calls  for  that  method  of  treatment  adapted  to  septic 
Avounds.     (For  a  full  consideration  of  this  subject  see  Erysipelas.) 

Suppuration. — The  occurrence  of  suppuration  in  a  Avound  makes  it  neces- 
sary that  full  provision  should  at  once  be  made  for  the  easy  and  perfect  escape 
of  the  pus.  This  has  already  been  considered  in  Avhat  has  been  said  in  regard 
to  drainage.  Some  further  thought,  hoAvever,  should  be  given  to  the  manage- 
ment of  a  suppurating  Avound,  Avith  a  vicAV  to  the  restriction  of  the  process  of 
suppuration  and  the  hastening  of  the  healing  of  the  Avound  as  much  as  possible. 
When  the  Avound  is  shalloAv  and  Avidely  open,  and  not  too  extensive,  iodoform 
gauze  may  be  applied  upon  its  Avhole  surface  as  a  dressing,  and  Avill  diminish 
greatly  the  amount  of  pus  secreted  and  stimulate  the  granulating  process.  The 
final  healing  may  then  be  accelerated  by  the  application  of  a  secondary  suture 


1U8  AN   AMEHlCAy    TKXT-JiOOK    OF   SlJiGERY. 

■when  possible  or  the  employment  of  skin-grafts.  When  the  supj)uratinif  cavity 
is  deep  or  tortuous,  or  its  external  ojx'iiing  is  conij)aratively  small,  antiseptic 
irrigations  are  of  value.  Care  should  be  taken  in  the  use  of  all  such  irriga- 
tions not  to  inject  the  fluid  with  so  much  force  as  to  break  up  adhesions  already 
formed.  Care  must  also  be  taken  that  the  possibly  poisonous  antiseptic  be  not 
retained  in  the  wound.  This  is  best  accomplished  by  finally  flushing  the  wound 
with  warm  boiled  water  to  wash  away  the  antiseptic  solution.  Injecting  a  fr^'sh 
solution  of  pero.xide  of  hydrogen  into  a  suppurating  wound  answers  the  same 
purpose,  and  is  an  efficient  means  of  decomposing  any  retained  pus  and  of 
sterilizing  the  Avound-cavity.  Solutions  of  bichloride  of  mercury,  1  :  2000, 
of  carbolic  acid,  2  per  cent.,  or  of  boro-salicylic  acid  in  saturated  solution,  are 
also  efficient.  "When,  notwithstanding  the  use  of  these  means,  the  granulating 
process  remains  sluggish  and  the  wound-cavities  delay  in  contracting  and 
healing,  more  strongly  stimulating  applications  are  indicated.  Naphthalin  in 
powder  freely  sprinkled  over  the  sluggish  surface,  or  tlie  balsams  of  Peru  or  of 
copaiba  freely  instilled,  or  tampons  of  gauze  saturated  with  these  agents,  may 
be  used.  If  these  are  not  efficient,  superficial  cauterizing  agents,  such  as 
carbolic  acid  of  full  strength,  fused  nitrate  of  silver,  or  an  8  per  cent,  solution 
of  chloride  of  zinc  may  be  used.  In  all  these  cases  constant  attention  should 
be  paid  to  keeping  the  deeper  parts  of  the  Avound-cavities  in  apposition  by 
properly-applied  pressure,  and  to  securing  absolute  rest  for  the  injured  parts. 
Especial  care  must  be  taken  that  the  external  dressings  that  are  applied  are 
such  as  Avill  freely  absorb  the  pus  which  is  brought  to  the  surface.  Nothing 
\eill  more  aggravate  the  condition  of  a  suppurating  Avound  than  a  dressing  that 
dams  back  and  causes  retention  of  its  secretions.  Viscid  pus  is  not  absorbed 
to  any  great  degree  by  the  ordinary  cotton  dressings,  and  if  they  are  used  they 
must  be  frequently  removed  and  the  Avound  cleansed.  In  ordinary  pine  saAv- 
dust  of  moderate  coarseness  the  surgeon  Avill  alwaA'S  find  an  easily  obtainable 
substance  Avhich  absorbs  pus  freely.  It  can  be  made  aseptic  by  baking,  and 
then  antiseptic  by  Avetting  Avith  a  sublimate  solution.  This  saAvdust  made  into 
convenient-sized  pads  by  enclosing  in  any  thin  gauzy  stuff",  like  cheese-cloth, 
may  be  used  as  a  dressing,  Avith  a  certainty  that  retention  Avill  not  be  caused  by 
it,  so  that  infrequent  dressing  may  be  the  rule  even  in  such  Avounds. 

When  by  any  of  the  means  described  a  vigorous  granulating  surface  has 
been  obtained  and  the  case  is  not  suitable  for  secondary  suture  or  skin-grafting, 
the  further  treatment  of  the  granulating  surface  must  be  one  of  protection 
Avhile  the  gradual  process  of  cicatrization  by  extension  of  the  cuticle  from 
the  edges  is  going  on.  Bland  or  mildly  stimulating  ointments  spread  on  soft 
antiseptic  dressings  of  some  kind  are  commonly  used  for  this  purpose.  Suit- 
able material  for  such  ointments  are  the  simple  cerate  of  the  Pharmacopeia, 
oxide-of-zinc  ointment  Avith  which  a  little  carbolic  acid  has  been  incorporated 
(f^ss  to  5j),  boric-acid  ointment  15  per  cent.,  iodoform  Avith  a  petroleum  basis, 
such  as  carbolated  cosmoline  (sj  to  .5j),  make  invaluable  a]>plications  to  such 
surfaces,  and  should  be  employed  by  preference  Avhen  the  Avound  is  near  a 
mucous  outlet  or  other  possible  source  of  infection.  An  efficient  protection,  and 
one  even  more  cleanl}'  and  in  harmony  Avitli  ideal  asepsis,  is  to  be  found  in 
strips  of  rubber  gauze  or  in  the  fine  oiled-silk  material  knoAvn  as  "protective." 
These  should  be  sterilized  by  immersion  in  a  carbolic  or  bichloride  lotion  of 
suitable  strength  for  some  time  before  they  are  used,  and  Avhen  applied  upon  a 
granulating  surface  Avhich  has  previously  been  sterilized,  and  then  covered  by 
a  suitable  antiseptic  absorbent  dressing,  the  Avhole  forms  an  ideal  dressing  for 
a  granulating  surface.  AVhenever  the  granulating  surface  is  of  any  size,  resort 
should  be  had  to  skin-grafting  for  the  purpose  of  hastening  its  cicatrization 


COXTCSKjys   AM)     WOUNDS.  109 

whenever  practicable.  Tliis  is  a  most  valuable  means  for  shortening  the  period 
of  cure  in  cases  of  open  wounds,  and  deserves  to  be  frequently  used  by  surgeons. 
(For  the  technique  of  skin-grafting  see  the  chapter  on  Plastic  Surgery.) 

INCISED    WOUNDS. 

By  incised  wounds  are  meant  those  clean-cut  divisions  of  tissue  which 
are  produced  by  the  edges  of  a  sharp  instrument.  They  may  vary  in  size 
from  the  most  trivial  to  formidable  and  deep  incisions  of  many  inches  in 
length — from  a  superficial  scratch  to  wounds  opening  deep  cavities  or  almost 
severing  entire  members  from  the  body.  Their  surfaces  present  in  a  minimum 
degree  an  imperceptible  layer  of  devitalized  tissue  destroyed  by  the  impact 
of  the  cutting  instrument,  tissue,  which  is  quickly  removed  in  the  early 
stages  of  normal  repair  and  produces  no  disturbance  in  the  healing  of  the 
w^ound.  For  this  reason  they  present  conditions  most  favorable  for  speedy 
healing,  and  deserve  from  the  surgeon  careful  attention  to  all  the  details  of 
cleansing,  apposition,  and  rest  which  have  been  described  in  previous  pages, 
so  that  primary  union  may  be  obtained. 

Symptoms. — Pain  resulting  from  an  incised  wound  is  severe  and  sharp 
at  the  moment  of  its  infliction,  subsiding  into  a  smarting  or  burning  which 
persists  for  some  time ; .  hemorrhage  is  free,  and  the  gaping  of  the  tissues  is 
restrained  only  by  the  limits  of  the  contractility  of  the  tissues  divided. 

Treatment. — In  the  arrest  of  hemorrhage,  Avhich  in  general  will  be 
accomplished  with  but  little  diflSculty,  care  must  be  taken  to  avoid  any  means 
or  agents  which  could  later  prove  a  source  of  disturbance  in  the  heal- 
ing process.  The  use  of  all  styptic  agents  should  be  especially  avoided. 
Bleeding  from  all  but  vessels  of  considerable  size  will  be  arrested  by  temporary 
pressure,  by  exposure  to  the  air,  or  by  the  application  of  hot  water  aided  by 
compression.  The  mutual  pressure  of  the  wound-surfaces  against  each  other 
after  they  have  been  brought  into  apposition  serves  to  restrain  any  tendency 
to  further  hemorrhage.  When  large  blood-vessels  are  wounded  ligatures  are 
required ;  w^ounds  involving  such  vessels  are  most  dangerous,  and  may  quickly 
terminate  fatally  from  loss  of  blood,  so  that  the  most  energetic  and  instant 
resort  to  measures  for  the  arrest  of  hemorrhage  is  called  for  in  such  cases. 
When  a  vessel  is  but  partially  divided,  it  is  more  difficult  to  stay  the  bleeding 
from  it  than  if  it  is  cut  through  entirely.  In  such  cases  the  first  thing  to  be 
done  is  to  complete  the  division  of  the  vessel,  ligating  it  later  if  necessary. 

The  drainage  of  incised  Avounds,  when  Avith  proper  care  their  deeper  parts 
can  be  maintained  in  apposition,  is  very  simple.  In  the  more  extensive 
wounds  capillary  drains  or  small  tubular  drains  during  the  first  twenty-four  or 
thirty-six  hours  will  suffice.  In  a  large  proportion  of  cases  where  compression 
and  immobilization  of  the  part  can  be  effected  no  provision  for  drainage  is 
required.  The  apposition  of  the  wounded  surfaces  should  be  attended  to  with 
the  utmost  care  and  minuteness,  so  that,  by  the  use  of  sutures,  compresses, 
bandages,  and  position,  coaptation  of  every  part  should  be  perfect  and  no  spaces 
be  left  for  the  collection  of  secretions.  The  protective  dressings  required  by 
incised  wounds  the  coaptation  of  the  surfaces  of  which  is  possible  are  very 
simple.  Exposure  of  the  line  of  suture  to  the  air,  so  that  the  desiccation  of 
the  slight  amount  of  secretion  that  gathers  there  may  form  a  protective  crust, 
gives  excellent  results  Avhen  the  conditions  of  the  wound  are  such  as  to  make 
it  practicable.  A  light,  dry,  clean  absorbent  dressing  of  some  kind  is  all  that 
is  required  at  any  time.  The  provisions  for  rest  in  the  case  of  incised  wounds 
may  and  should  be  made  absolute  by  splints.     The  removal  and  readjustment  of 


no  AN   AMFJilCAX    TKXT-IK tOK    OF   SriidKHY. 

dressing  should  be  long  deferred.     The  ideal  to  be  aimed  at  is  perfect  healing 
without  local  discomfort  or  constitutional  disturbance  under  a  single  dressing. 

LACERATED    AND    CONTUSKD    WOUNDS. 

A  lacerated  wound  is  one  in  which  the  tissues  have  been  forcibly  torn 
asunder  ;  a  contused  wound,  one  in  which  the  wounding  force  has  been  of  a 
crushing  character.  In  many  instances  both  the  lacerating  and  crushing 
elements  are  mingled.  In  any  case  the  character  and  course  of  both  classes 
of  wounds  arc  similar,  so  that  they  may  properly  be  considered  together.  The 
surface  of  such  wounds  is  irregular,  shreddy,  possibly  presenting  long  flangling 
strips  of  fibrous  and  tendinous  tissue,  with  more  or  less  blood-clot  filling  the 
exposed  cavities,  and  with  a  variable  amount  of  dead  or  partially  disorganized 
tissue  scattered  upon  its  surface.  The  skin-wound  is  irregularly  torn,  less  in 
extent  than  the  wounds  of  the  deeper  structures,  from  which  it  is  more  or  less 
separated,  while  its  borders  present  an  area  of  variable  dimensions  that  is  livid 
and  cold,  ready  to  fall  into  necrosis.  The  great  increase  in  the  use  of  machin- 
ery in  modern  times,  and  of  rapidly-moving  and  heavy  vehicles  operated  by 
steam,  electric,  and  horse-power,  has  vastly  multiplied  the  frequency  of  lace- 
rated and  contused  wounds. 

Such  wounds  produce  greater  shock  than  do  incised  wounds,  but  arc  accom- 
panied by  less  appreciable  pain.  The  pain  is  dull  and  aching  in  character; 
the  hemorrhage  is  generallv  slight,  owing  to  the  surface  irregularity  that  favors 
the  coagulation  of  the  blood  fiowing  over  it,  and  to  the  fact  that  the  larger 
blood-vessels  have  had  their  coats  so  irregularly  torn  that  an  occlusive  clot  is 
at  once  formed  in  the  torn  ends.  The  tissue-interspaces  for  some  distance 
from  the  wound-opening  become  infiltrated  with  diffused  and  clotted  blood, 
and  in  many  instances  foreign  material,  dirt  of  every  conceivable  character, 
is  ground  into  the  Avound-surfiices,  so  as  to  defy  every  effort  to  remove  it 
entirely.  In  cases  of  severe  injury  of  this  kind  the  partial  syncope  resulting 
from  shock  so  diminishes  the  force  «f  the  circulation  as  also  materially  to 
lessen  the  tendency  to  hemorrhage.  Although  for  these  reasons  primary 
hemorrhage  is  generally  slight,  serious  later  hemorrhage  is  not  infrequent, 
either  within  a  few  hours,  when  the  heart's  action  has  regained  its  power  and 
local  reaction  has  set  in  ('Mntermediate  "  or  ''reactionary"  or  "consecutive" 
hemorrhage),  or  at  a  more  distant  period,  when  by  the  separation  of  sloughs  the 
vessels  are  again  opened  ("  secondary  "  hemorrhage).  The  external  apjjcarance 
of  these  wounds  often  gives  no  suggestion  of  the  extent  of  the  damage  which  has 
been  done.  They  should  therefore  always  be  examined  with  great  care,  and  the 
possibilities  of  far-extending  subcutaneous  injury  should  be  kept  in  mind. 

JNIore  or  less  death  of  tissue  is  inevitable  in  the  after-course  of  such  wounds. 
Some  tissue,  often  much,  is  killed  outright  by  the  violence,  while  yet  more  is 
left  in  a  seriously  damaged  state,  prone  to  fail  into  necrosis  from  the  defective 
nutrition  that  for  a  time  exists  in  the  part.  Much  of  the  abundant  and  irreg- 
ularlv  diffused  blood-clot  which  is  present  will  subsef[uently  disintegrate  and 
liquefy.  AVhen,  with  greater  or  less  rapidity  according  to  the  activity  of  the 
nutritive  processes  in'  the  part,  all  necrotic  tissue  has  separated  and  been 
removed,  and  the  blood-clot  has  either  been  absorbed  or  has  broken  down  and 
escaped,  there  remains  behind  a  uniform  granulating  surface,  and  the  further 
course  of  the  wound  is  toward  healing  by  granulation. 

All  the  conditions  presented  by  these  wounds  are  such  as  to  render  them 
specially  liable  to  septic  infection  of  serious  character. 

Treatment. — Although  there  may  be  but  little  hemorrhage  at  the  time  of 


COyTUSIONS   AND     WOUNDS.  Ill 

the  first  dressing  of  a  lacerated  or  contused  wound,  yet  if  vessels  of  any  size 
have  been  torn  it  is  the  part  of  -wisdom  to  a])])ly  ligatures  to  them,  though  they 
may  not  be  bleeding  at  the  time.  The  period  of  reaction  from  shock  is  to  be 
watched  with  especial  care  to  guard  against  possil)le  hemonhage.  Should 
this  hemorrhage  at  any  time  occur,  the  application  of  a  ligature  is  imper- 
ative, even  though  the  bleeding  may  have  ceased  spontaneously  as  the  lieart's 
action  is  Aveakened ;  for  so  soon  as  the  reaction  again  comes  on  and  the  heart 
beats  strongly  once  moi'e,  the  hemorrhage  will  surely  recur.  The  j)rimary 
cleansing  of  the  wound  should  be  conducted  with  great  care  by  rubbing  sweet 
oil  thoroughly  over  the  surface,  including  the  adjacent  skin,  then  cleansing 
by  soa])  and  warm  Avater  well  scrubbed  on,  following  this  by  washing  with 
alcohol,  and  finally  l)y  thorough  scrubbing  with  suldimate  solution,  1 :  1000. 
All  detached  particles  of  bone  and  of  the  soft  parts  should  be  carefully 
removed,  and  tissues  into  Avhich  foreign  matter  has  been  so  ground  that 
the  complete  removal  of  the  dirt  is  impossible  should  be  trimmed  away 
with  scissors  or  knife.  Bruised  portions  of  tissue  that  are  still  attached 
should  be  carefully  cleansed  and  replaced  and  preserved  from  further  traumat- 
ism, since  much  that  appears  to  be  hopelessly  destroyed  may  be  saved  in 
many  cases  by  care  in  fostering  its  nutrition.  Thorough  scrubbing  and 
irrigation  of  a  contused  and  lacerated  wound  with  a  warm  antiseptic  lotion 
until  no  element  of  sepsis  •  is  left  within  it  is  important,  for  all  the  conditions 
of  these  wounds  are  such  as  to  create  and  present  to  a  large  degree  the  material 
favorable  for  the  rank  development  of  septic  organisms.  The  natural  resisting 
power  of  the  tissues,  which  enables  the  surfaces  exposed  in  ordinary  incised 
wounds  to  resist  the  development  of  sepsis  and  to  preserve  the  minute  devital- 
ized fragments  of  tissue  that  are  present  from  undergoing  putrefaction,  is  no 
longer  to  be  relied  on,  for  the  bruised  wound-surfaces  have  to  struggle  to  retain 
their  own  vitality,  and  large  masses  of  devitalized  tissue  and  more  copious 
effusions  of  putrefiable  secretions  have  to  be  disposed  of. 

The  fullest  provision  must  be  made  for  drainage  from  all  the  recesses  of  the 
wound.  Free  counter-incisions  must  be  made  wdierever  necessary  for  this  pur- 
pose. Efforts  at  accomplishing  apposition  of  the  wound-surfaces  must  be  sub- 
ordinated to  the  need  for  drainage  and  the  provision  for  the  unhindered  separa- 
tion of  necrotic  tissue.  In  cases  of  severe  contusion  a  degree  of  uncertainty 
will  always  exist  as  to  the  ability  of  the  injured  tissue  to  retain  its  vitality,  and  a 
certain  amount  of  necrosis  is  to  be  expected  and  provided  for.  This  necrosis  will 
be  reduced  to  a  minimum  in  proportion  as  the  provisions  for  making  and  keep- 
ing the  wound  aseptic  are  thorough  and  successful.  When  adequate  antiseptic 
measures  are  practicable,  greater  efforts  at  securing  coaptation  of  the  wound- 
surfaces  are  proper.  Special  care  should  be  observed  to  avoid  all  tension  of 
the  Avounded  tissues  in  the  endeavor  to  approximate  them.  In  a  large  propor- 
tion of  contused  and  lacerated  wounds  there  will  be  such  an  amount  of  destruc- 
tion of  tissue  that  any  attempt  at  closing  them  to  secure  primary  union  will  be 
manifestly  contraindicated.  In  such  cases  the  efforts  of  the  surgeon  should  be 
chiefly  directed  toward  protecting  the  Avound  from  sources  of  disturbance  dur- 
ing the  time  that  the  separation  of  the  sloughs  and  the  process  of  granulation 
are  going  on.  These  are  the  cases  in  Avhich  local  septic  inflammations,  gan- 
grene, erysipelas,  and  general  septic  infection  are  most  prone  to  occur.  The 
manner  in  Avhich  such  disturbances  are  to  be  met  has  been  fully  discussed  in 
preceding  pages.  While  the  constitutional  symptoms  produced  by  them  Avill 
often  require  special  treatment,  they  Avill  spontaneously  subside  if  adequate 
local  antiseptic  measures  are  employed.  The  latter,  therefore,  should  ahvays 
engage  the  first  and  most  constant  attention  of  the  surgeon. 


112  AN  AMERICAN    TENT- HOOK    OF  SURGERY. 

Brush  Buhx. — By  tliis  term  is  meant  a  peculiar  form  of"  siiperfieial  lace- 
rated and  contused  wound  caused  by  friction  applied  to  the  surface  of  the  body, 
as  when  a  portion  of  skin  is  brouujht  into  contact  with  a  rapidly-nioving  belt 
of  machinery,  or  by  an  involuntary  slide  down  a  steep  incline,  or  by  the  slip- 
ping of  a  rope  through  the  closed  hand.  In  this  injury  the  superficial  tissiies 
are  ground  off  and  an  eschar  of  considerable  depth  results.  They  should  be 
treated  by  antiseptic  fomentations  until  the  eschar  has  separated  and  a  granu- 
lating surface  has  formed,  which  should  then  receive  the  treatment  elsewhere 
described. 

PUNCTURED    WOUNDS. 

Deeply  perforating  wounds  made  by  pointed  substances  will  partake  of  the 
nature  of  either  incised  or  contused  and  lacerated  wounds,  according  to  the 
sharpness  of  the  point  of  the  wounding  instrument.  Punctured  wounds  made 
with  sharp,  clean-pointed  instruments,  as  pins,  needles,  trocars,  dagger  and 
stiletto  points,  partake  of  the  nature  of  limited  incised  wounds,  and  unless  in 
their  course  they  have  wounded  organs  of  im])ortance,  as  large  blood-ves- 
sels or  nerves,  the  Avithdrawal  of  the  instrument  is  followed  by  rapid  and  per- 
fect recovery.  Should  the  puncturing  instrument,  however,  be  contaminated 
with  active  septic  material,  an  acute  septic  inflammation  will  result,  depending 
upon  its  depth  from  the  surface  for  its  importance,  and  demanding  free  incisions 
for  the  relief  of  the  pent-up  secretions.  For  its  further  care  those  measures 
which  have  been  described  as  required  for  inflamed  and  infected  incised  wounds 
will  be  indicated.  Punctured  wounds  which  are  formed  by  the  thrusting  into 
the  tissues  of  irregularly-shaped  and  blunt  substances,  such  as  splinters  of 
wood,  nails,  a  bayonet,  and  the  like,  form  deep  and  narrow  wound-tracks,  the 
walls  of  which  are  contused  and  lacerated,  Avhile  minute  fragments  of  devitalized 
tissues  or  small  fragments  of  infected  material  are  driven  in  and  deposited 
in  the  depths  of  the  wound.  The  dangers  and  difficulties  attending  ordinary 
contused  and  lacerated  wounds  are  aggravated  in  these  cases  by  the  long 
and  narrow  track  which  leads  from  their  bottom  to  the  surface.  Should 
no  septic  material  have  been  introduced  by  the  wounding  body,  such  wounds 
may  yet  be  expected  to  heal  kindly  and  promptly  if  care  is  taken  to  avoid 
their  subsequent  infection  from  Avithout  and  to  keep  the  wounded  part  at  rest 
while  repair  is  taking  place.  In  view  of  the  impossibility  of  ade([uately  disin- 
fecting such  a  wound  by  mere  applications  to  the  surface  at  the  time  of  the  dress- 
ing, as  a  general  rule  it  should  be  freely  laid  open  to  the  bottom  by  additional 
incisions,  and  there  should  be  thorough  disinfection  of  the  wound  and  the  adjacent 
integument.  It  should  then  be  covered  with  an  abundant  antiseptic  dressing, 
which  should  be  supplemented  by  any  posture  or  by  the  application  of  whatever 
apparatus  that  may  be  required  to  keep  the  part  at  rest.  If,  notwithstanding 
this,  inflammation  of  the  deeper  part  of  the  wound  develo))s,  immediate  resort 
should  be  had  to  suitable  free  incisions  to  give  vent  to  pent-up  eflusions  and  for 
subsequent  disinfection  and  drainage.  The  more  deep  and  narrow  the  wound- 
track,  the  more  important  that  free  and  early  incisions  should  be  made.  Still 
more  important,  if  possible,  are  such  early  incisions  when  the  puncture  has 
involved  strong  fasciae,  the  thecfe  of  tendons,  or  joint-cavities.  Delay  in  resort- 
ing to  such  incisions  is  not  only  sure  to  produce  extensive  local  damage,  but 
may  even  prove  dangerous  to  life. 

Not  infrequently  portions  of  puncturing  bodies  are  broken  off  and  left 
imbedded  in  the  tissues.  In  some  cases  such  imbedded  substances  may 
remain  innocuous  for  an  indefinite  period  of  time.  In  yet  other  instances  their 
presence   provokes   irritative   symptoms    of    a   marked   character.       Foreign 


VOXTUSIONS    AM>     WOUNDS.  113 

bodies  in  the  iK'i^liltorhood  of  joints,  or  piercing  nerves,  tendons,  or  blood- 
vessels, are  sure  to  be  followed  by  excessive  pain,  muscular  spasm,  or  hemor- 
rhage. Diligent  effort  should  be  made  to  detect  and  remove  foiipign  bodies 
at  the  bottom  of  punctured  wounds  whenever  there  is  reason  to  suppose 
from  the  nature  of  the  body  or  the  nature  of  the  tissues  wounded  that 
they  will  become  a  source  of  peril  or  discomfort  if  allowed  to  remain, 
or  in  any  case  when  the  conditions  are  favorable  to  making  such  a  search 
without  an  unduly  extended  or  dangerous  dissection.  The  instrument  inflict- 
ing the  wound  should  always  be  inspected  to  determine  whether  an}^  of  it  has 
been  broken  off  and  left  in  the  tissues.  For  the  removal  of  such  bodies  the 
enlargement  of  the  original  wound  may  suffice,  or  possibly  counter-openings 
at  distant  points  may  be  re(iuired,  so  as  to  give  more  ready  access  to  the 
body  sought  for.  Such  counter-openings  may  be  of  additional  value  in  pro- 
viding means  for  thorough  drainage.  In  attempting  the  removal  of  minute 
bodies,  such  as  the  fragment  of  a  needle  or  a  small  bit  of  glass,  the  search  may 
often  be  facilitated  by  raising  a  triangular  flap  in  the  centre  of  the  base  of 
which  is  the  original  point  of  puncture,  the  apex  of  the  flap  lying  in  the  direc- 
tion toward  which  the  body  has  penetrated.  This  flap  should  include  the  skin 
and  superficial  fascia,  and  Avhen  raised  gives  more  easy  access  to  the  deeper 
tissues,  and  permits  a  more  free  and  thorough  search  for  any  small  body  which 
may  be  imbedded  among-  them.  To  make  such  an  operation  bloodless,  Es- 
march's  bandage  is  often  of  the  greatest  use.  The  removal  of  a  puncturing 
body  when  it  projects  from  the  surface,  or  lies  so  near  the  surface  that  it  can 
be  readily  seized,  is  usually  easy,  but  in  some  cases,  by  reason  of  the  irreg- 
ularity of  its  surface  or  its  being  barbed,  as  a  fish-hook  or  arrow-head,  its 
removal  is  difficult.  Whenever  the  location  of  such  an  entangled  body 
permits  it  to  be  easily  pushed  through  to  the  other  side,  such  a  course  should 
be  adopted.  When  this  manoeuvre  is  not  feasible,  whatever  incisions  may  be 
required  to  free  the  body  from  entanglement  and  allow  it  to  be  easily  plucked 
out  should  be  made. 

The  hemorrhage  in  punctured  wounds  is  usually  slight  and  requires  no 
special  attention.  Should  it  be  at  all  free,  the  possibility  of  the  wounding  of 
a  large  vessel  should  suggest  itself,  and  a  careful  review  of  the  anatomical 
relations  of  the  puncture  should  be  made.  Should  the  hemorrhage  not  be 
easily  controlled  by  pressure,  the  wound  should  be  enlarged,  the  bleeding  point 
identified,  and  a  ligature  applied.  A  false  aneurysm  is  the  not  infrequent 
result  of  partial  divisions  of  arteries  in  punctured  wounds.  Punctured  wounds 
impaling  a  vein  and  an  artery  lying  in  contact  with  each  other  are  occasionally 
the  cause  of  arterio-venous  aneurysms.  Such  sequeli^  call  in  many  cases  for 
free  incisions  and  for  exposure  of  the  wounded  vessels  and  ligature  above  and 
below  the  point  of  Avound. 

GUNSHOT    WOUNDS. 

The  term  "  gunshot  wound  "  is  applied  generically  to  injuries  inflicted  by 
missiles,  whatever  their  character,  whose  force  is  derived  from  the  explosive 
power  of  gunpowder.  This  definition,  therefore,  includes  every  grade  of  mis- 
sile, from  the  smallest  bird  shot  to  the  immense  projectile  fired  from  mammoth 
pieces  of  heavy  ordnance,  and  every  grade  of  injury,  from  the  mere  peppering 
of  the  surface  of  the  skin  Avith  grains  of  gunpowder  or  minute  shot  to  the 
laceration  and  comminution  of  extensive  portions  of  the  body. 

The  character  of  the  injury  produced  when  the  missile  has  penetrated  the 
tissues,  which  is  usually  the  case,  is  that  of  a  contused,  lacerated,  punctured 
wound ;  when  the  surface  is  merely  grazed,  it  partakes  of  the  nature  of  the 


114 


l.V   AMERICAN    TEXT-HOOK    OE  SURGERY. 


brush  burn,  as  already  described.  In  occasional  instances  a  large  missile  mov- 
ing with  slight  momentum  fails  to  break  the  skin,  but  produces  extensive 
damage  to  the  subcutaneous  tissue.  The  missiles  which  are  more  frequently 
met  with  in  gunshot  wounds  are  {a)  the  shot  used  in  fowling-pieces,  which  are 
of  various  sizes,  from  that  of  a  buck  shot,  which  weighs  133  grains,  to  that  of 
the  smallest  bird  shot,  one  of  which  weighs  only  ^  of  a  grain ;  {b)  pistol  bul- 
lets, varying  in  size  from  about  ^  of  an  inch  to  |  of  an  inch  in  diameter,  and 
weighing  from  20  grains  to  240  grains.  The  size  of  a  pistol  bullet  is  usually 
designated  according  to  the  decimal  part  of  an  inch  which  makes  its  diameter; 
thus  a  22-caliber  bullet  is  one  whose  diameter  is  22-hundredths  of  an  inch. 
{<•)  The  rifle  bullet,  which  is  the  missile  of  the  modern  arm  of  precision,  long 
and  generally  conoidal,  and  weighing  from  |  to  1^  ounces.  For  military  use 
yet  larger  missiles  have  been  devised  which  hardly  arrive  at  the  dignity  of  can- 
non shot,  and  yet  are  heavier  than  the  rifle  balls  of  the  infantryman,  such  as 
the  projectiles  thrown  by  the  mitrailleuse,  (jatling.  and  llotchkiss  guns. 

The  rifles  which  are  now  in  general  use  as  military  weapons  project  bullets 
of  small  caliber  (.25-.32  caliber;  6.5  to  8  millimeters  in  diameter),  which,  by 
the  use  of  cellulose-powder,  shells  of  cupro-nickled  steel,  and  a  more  abrupt 

rifling,  are  driven  with  greatly  increased  velocity, 
and  made  to  revolve  upon  their  longitudinal  axis 
at  the  rate  of  over  two  thousand  revolutions  during 
the  first  second,  and  to  carry  to  a  much  greater 
distance.  The  destructive  effect  of  the  missile  is 
correspondingly  greater.  It  penetrates  and  de- 
stroys every  tissue  with  which  it  comes  in  contact, 
pulpefies  such  organs  as  the  liver  and  kidneys, 
and  extensively  shatters  bones.  These  explosive 
efti'Cts  are  not  developed  at  short  ranges,  but  are 
especially  marked  at  distances  of  500  to  2500 


Fk;.  2R 


ber  lead  bullet  (powder,  6<j  gr.,  penetration,  3.2  in.) ;  B,  new  .:50-ealiber  Kerman-silver-jarketed  bnllet 
(iKtwder,  37  gT.,  penetration,  5.3  in.  i :  c,  oupro-nickeled-steel-jaokcted  30-caliber  bullet  (powder,  37  gr., 
penetration,  19.5  in.i.    (By  kind  permission  of  the  chief  ordnance  oflScer,  U.  S.  A.) 

yards.  Its  effects  will  be  to  increase  greatly  the  number  of  fatalities  upon  the 
battle-field,  both  on  account  of  the  large  number  of  men  injure»l  by  a  single 
bullet  and  because  of  the  necessary  removal  to  a  far  greater  distance  from  the 
battle-field  of  the  field-hospital,  so  as  to  be  beyond  the  range  of  the  firing. 
Fig.  23  shows  (.a)  the  relative  penetration  in  oak,  across  the  grain,  of  the 
.45-caliber  lead  bullet  and  the  great  deformation  of  the  ball ;  (b).  the  .30-cali- 
ber German-silver-jacketed  bullet  and  its  deformation  :  and  fr).  the  .30-caliber 
cupro-nickled-steel-jacketed  bullet,  which  still  retained  its  original  form. 

The  repair  of  gunshot  wounds  is  often  disturbed  by  foreign  matter  carried 
into  the  wound  by  the  projectile,  such  as  portions  of  clothing,  gun-wadding, 
buttons,  pieces  of  coin,  splinters  of  wood,  etc.  The  mere  explosion  of  powder 
from  a  gun  fired  at  short  range  may  produce  a  serious  injury  which  combines 
the  characters  of  a  burn  with  those  of  contusion  and  laceration. 

Gun.shot  wounds  derive  especial  significance  from — 1.  The  special  tissue  or 
organ  injured;  2.  The  conditions  under  which  the  wound  was  inflicted;  3. 
The  presence  or  absence  of  septic  infection. 


CONTUSIOXS   AND     WO CNDS.  115 

Injuries  to  Special  Tissues. —  The  Skin. — The  efteets  of  grazing  tlie 
skin  and  of  contusion  without  penetration  have  already  been  referred  to. 
When  a  penetrating  wound  has  been  inflicted,  the  wound  of  entrance  is  gener- 
ally small  and  less  in  diameter  than  that  of  the  missile  itself,  owing  to  the 
elasticity  of  the  skin,  which  has  been  stretched  by  the  ball  before  being  pene- 
trated by  it.  It  is  also  apt  to  be  dirty,  both  from  the  powder  if  the  wound 
was  at  short  range,  and  from  wiping  the  dirt  from  the  ball  as  it  enters.  Such 
a  wound  will  appear  insignificant  to  one  unfamiliar  with  its  real  gravity. 
Should  other  foreign  matter  be  carried  in  with  the  ball,  the  wound  of  entrance 
will  be  correspondingly  increased  in  size.  Should  the  ball  pass  clear  through 
the  body  or  limb,  the  wound  of  exit  will  be  larger  and  more  ragged  than  that 
of  entrance,  the  diflerence  being  determined  by  the  lessened  momentum  of  the 
ball  and  the  want  of  support  to  the  tissues  at  the  point  of  exit,  as  a  nail 
driven  through  a  board  splinters  largely  the  under  side  or  point  of  exit. 
Conical  bullets,  having  greater  penetrating  power  than  round,  produce  in  the 
skin-wounds  Avhich  they  make  much  less  diflerence  in  size  than  formerly 
resulted  from  tlie  use  of  round  bullets.  By  subsequent  sloughing  of  the  con- 
tused marcfins  of  the  wound  of  entrance  it  often  becomes  after  a  few  days  of 
greater  magnitude  than  that  of  exit. 

Fascice. — Especial  interest  attending  wounds  of  fasciae  arises  from  the  fact 
that  their  interlacing  fibers  are  often  to  a  considerable  degree  split  and 
crowded  aside  by  the  ball  as  it  passes  through  them,  so  that  the  orifice  that 
they  present  is  much  less  free  than  is  found  in  the  softer  tissues  on  either  side, 
and  tends  to  interfere  materially  with  the  drainage  of  the  deeper  parts  of  the 
wound.  Dense  fasciae  again  frequently  present  sufficient  resistance  to  a  ball, 
especially  if  it  is  a  round  one,  to  deflect  it  from  its  original  course. 

Muscles  when  involved  are  subjected  to  widespread  damage  through  con- 
tusion and  laceration  of  their  substance  and  extensive  infiltrations  of  blood. 

Tendons,  by  reason  of  the  resisting  nature  of  their  structure  and  their 
roundness  and  mobility,  are  more  frequently  either  pushed  out  of  the  way  or 
deflect  the  bullet. 

Blood-vessels,  especially  arteries,  whose  walls  are  more  resistent  and  elastic 
than  those  of  veins,  are  not  infrequently  pushed  aside.  Even  in  such  cases, 
however,  such  contusion  of  their  structure  is  often  inflicted  as  to  determine 
subsequent  sloughing  and  secondary  hemorrhage.  Both  partial  and  complete 
division  of  large  blood-vessels  is  a  frequent  concomitant  of  gunshot  wounds, 
and  is  also  the  most  frequent  cause  of  immediate  death  by  reason  of  the  hemor- 
rhage following.  Traumatic  aneurysm  and  arterio-venous  aneurysm  may  result 
in  certain  cases,  as  has  already  been  noted  in  ordinary  punctured  wounds. 

Nerves. — Large  nerve-trunks  when  wounded  present  no  special  symptoms 
that  call  for  extended  notice  here.  The  functional  disability  resulting  from 
such  wounds  will  depend  upon  the  special  function  of  the  particular  nerve,  and 
may  be  more  or  less  complex  and  important.  Severe  pain  may  result  primarily 
from  inflammatory  processes  in  the  injured  nerve,  or  later  from  its  being 
involved  in  a  contracting  cicatrix  or  by  development  upon  its  end  of  a  neuroma. 
Trophic  changes  of  every  degree  are  among  the  ultimate  results  of  nerve-injuries. 
(See  Injuries  of  Nerves.) 

Bones. — A  ball  striking  upon  a  bone  usually  inflicts  much  damage  upon 
it,  splitting  and  comminuting  it,  often  producing  fissures  that  extend  into 
neighboring  joints.  The  bullet  may  become  lodged  in  the  bone,  remaining  as 
a  source  of  irritation,  and  often  of  suppurative  inflammation,  until  removed. 

The  Great  Cavities  of  the  Body. — Balls  penetrating  the  cranial  cavity  will 
produce  symptoms  according  to  the  region  of  the  brain  injured  ;  though  always 


IIG  AN   AMEItlVAy    TEXT-JiOOK    OF  SVUGEUY. 

serious,  the  wounds  they  inflict  are  not  necessarily  fatal.  Penetrating  wounds 
of  the  thorax  may  involve  the  lun<^s,  the  heart,  or  the  <.'reat  vessels,  and,  if  not 
immediately  fatal,  present  S[)ecial  diiliculties  in  the  inflammatory  complications 
or  in  the  resulting  extensive  pleural  or  pericardial  eftusions.  Penetrating 
wounds  of  the  abdominal  cavity,  in  addition  to  the  dangers  from  hemorrhage 
and  from  ordinary  inflammatory  complications,  have  the  special  dangers  inci- 
dent to  possible  wounds  of  the  stomach,  intestines,  bladder,  and  the  various 
other  alxlominal  viscera.     (See  Wounds  of  the  Abdomen  and  its  A'iscera.) 

The  Conditions  under  which  the  Wound  is  Inflicted. — Gunshot 
wounds  differ  especially  from  the  ordinary  operative  wounds  inflicted  by  a  sur- 
geon in  the  special  conditions  incident  to  warfare  which  make  it  difficult,  often 
impossible,  to  give  to  the  patients  the  full  degree  of  care  which  they  require, 
and  Avhich  often  expose  them  to  further  injury  that  greatly  aggravates  the 
original  severity  of  the  wounds.  In  dealing  with  these  conditions  is  found 
the  special  field  of  military  surgery.  In  civil  life,  however,  it  often  happens 
that  gunshot  wounds  are  sustained  under  conditions  that  resemble  those  of 
military  campaigning,  as  in  the  case  of  accidental  wounds  occurring  among 
hunting-parties  in  regions  remote  from  help.  The  frequent  absence  of  skilled 
help  and  of  the  materials  for  the  proper  dressings  for  such  wounds  adds 
greatly  to  the  dangers  which  attend  them.  The  necessary  transportation 
of  wounded  men  for  long  distances,  often  with  the  most  crude  resources  for 
their  comfort,  is  another  fruitful  source  of  evil,  and  has  many  times  demanded 
the  sacrifice  of  a  limb  or  has  occasioned  the  loss  of  a  life  which  under  more 
favorable  circumstances  could  have  been  saved.  In  the  accidental  gunshot 
wounds  of  civil  life  also  it  is  by  no  means  the  rule  that  adequate  Surgical  skill 
and  proper  dressing  materials  are  at  once  attainable. 

The  Presence  or  Absence  of  Septic  Infection. — This  is  a  factor  of  the 
highest  importance  in  determining  the  favorable  or  unfavorable  course  of  a 
gunshot  wound.  If  such  a  wound  is  preserved  from  septic  infection,  the  wound 
of  entrance  is  quickly  closed  and  its  remaining  track,  however  long  it  may  be, 
or  however  much  lined  by  contused  necrotic  tissue,  or  whatever  organ  it  may 
have  traversed  or  bones  it  may  have  shivered,  is  reduced  to  the  condition  of  a 
subcutaneous  injury,  and  is  tliereby  saved  from  a  thousand  dangers  that  might 
otherwise  complicate  its  healing.  Fortunately,  experience  has  shown  that  in 
many  instances  a  penetrating  bullet  does  not  carry  w^ith  it  septic  material,  and 
that  if  a- wound  Avhich  has  been  thus  made  is  preserved  from  subsequent  infec- 
tion, an  aseptic  course  of  healing  will  take  place.  The  question  of  the  removal 
of  the  bullet  itself  in  such  cases  becomes  a  secondary  matter,  depending  entirely 
upon  the  importance  of  the  later  symptoms  of  disturbance  wliich  its  presence  in 
the  tissues  might  occasion.  On  the  other  hand,  the  introduction  of  sepsis  into 
a  gunshot  wound  is  sure  to  determine  inflammatory  and  suppurative  symptoms 
of  the  most  pronounced  type,  and  to  call  for  the  most  energetic  and  thor- 
ough interference  on  the  part  of  the  surgeon.  Secondary  hemorrhages  are 
to  be  feared ;  necrotic  debris  and  the  pent-up  products  of  septic  inflamma- 
tion will  require  to  be  evacuated;  increased  dangers  to  life  and  limb  will  be  in- 
curred ;  and  in  the  most  favorable  event  a  prolonged  convalescence  w  ill  result. 

Diagnosis. — The  circumstances  attending  the  infliction  of  a  gunshot 
wound  will  usually  be  sufficiently  clear  to  settle  the  fact  that  a  given 
wound  is  due  to  the  penetration  of  the  tissues  by  a  projectile  driven  by  the 
explosive  force  of  gunpowder ;  but  the  surgeon  in  investigating  the  case  may 
find  it  important  to  determine  the  course  which  the  missile  has  taken,  the 
organs  injured,  and  the  final  resting-place  of  the  missile,  provided  it  has  not 
already  escaped  by  an  aperture  of  exit.     The  external  marks  of  injury  may 


coy^TcsiONS  Axn   woryns.  iii 

give  no  clue  Avhatever  to  the  character  and  extent  of  the  deeper  injuries 
which  have  been  received.  In  forming  any  conclusion  as  to  the  extent  and 
nature  of  the  wound  which  has  been  received,  a  careful  investigation,  there- 
fore, must  be  made  into  all  the  symptoms  attending  the  injury,  such  as  shock, 
hemorrhage,  functional  disturbance,  local  pain,  and  tenderness,  as  well  as  an 
inspection  of  the  external  signs  of  wounding.  All  such  investigations  should 
be  made  with  the  most  scrupulous  care  to  avoid  touching  the  wound  itself  unless 
under  the  most  rigid  antiseptic  precautions.  When  it  is  possible  to  ascertain 
the  direction  from  which  the  missile  came  and  the  position  of  the  body  or  limb 
at  the  time  the  wound  was  received,  valuable  information  as  to  the  course 
which  the  missile  has  taken  through  the  tissues  may  sometimes  be  gained 
by  putting  the  parts  again  into  the  same  position.  The  possible  deflection 
of  the  bullet  by  bone  or  fasciae  is  not  to  be  forgotten,  and  must  be  given  due 
weiiT'ht  in  explaining  otherwise  confusing  symptoms.  The  slight  differences 
which  have  already  been  remarked  upon  as  existing  between  the  orifices  of 
entrance  and  exit  should  be  borne  in  mind  in  determining  the  point  of  primary 
penetration  when  two  apertures  exist.  The  amount  of  pain  attending  the 
reception  of  a  gunshot  wound  varies  much,  and  is  of  little  value  as  a  diagnostic 
symptom.  In  the  excitement  of  the  moment  many  wounds  are  received  with 
no  consciousness  of  the  fact  on  the  part  of  the  injured  person,  who  discovers  it 
later  only  through  the  hemorrhage  or  the  functional  disability  which  results.  In 
other  cases  a  sharp  stinging  pain  or  a  dull,  numb  sensation  indicates  to  the 
person  that  he  has  been  wounded.  Sometimes  the  shock  of  even  slight  wounds 
is  very  great. 

Probing  a  Wound. — When  the  circumstances  of  the  case  or  the  symptoms 
which  are  present  make  it  important  that  the  deeper  recesses  of  the  wound 
should  be  searched,  this  is  to  be  accomplished  by  the  insertion  of  the  finger  of 
the  surgeon  if  possible,  or  by  the  use  of  suitable  probes,  and  all  the  steps 
of  the  process  of  search  should  be  conducted  with  most  careful  regard  to  the 
requirements  of  rigid  antisepsis.  Such  probings  are  not  to  be  done  as  a  mat- 
ter of  routine,  but  only  when  some  distinct  indication  is  present.  Free  enlarge- 
ment of  the  external  wound  should  be  made  without  hesitation  whenever  it  will 
facilitate  the  prosecution  of  the  search,  and  as  far  as  possible  reliance  should  be 
placed  upon  the  finger  of  the  surgeon  for  gaining  the  desired  information  to  the 
exclusion  of  metallic  or  other  probes.  When  it  is  necessary  to  pursue  the 
investigation  into  depths  which  are  beyond  the  reach  of  the  finger,  a  metallic 
probe  of  suitable  length  and  having  a  bulbous  tip  of  considerable  size  may  be 
used.  Such  a  probe  having  the  tip  made  of  porcelain  biscuit,  and  known  as 
Nekton's  probe,  has  the  special  value  that  when  the  tip  comes  in  contact  with 
the  bullet  at  the  bottom  of  the  wound  it  retains  the  mark  of  the  lead  upon  it, 
and  thus  gives  an  absolute  demonstration  that  it  has  been  in  contact  with  the 
bullet  or  a  fragment  of  it.  Before  using  it  its  freedom  from  any  similar  prior 
stain  must  be  ascertained.  The  stem  of  an  ordinary  clay  pipe  has  been  used 
extemporaneously  for  the  same  purpose.  The  "telephonic  probe"  of  Girdner 
is  an  ingenious  application  of  the  telephone  which  may  occasionally  assist 
in  identrfying  the  location  of  a  bullet  in  the  tissues.  This  device  may  be 
extemporized  whenever  an  ordinary  telephone  receiver  is  accessible :  one  of 
the  wires  of  the  telephone  having  been  attached  to  the  probe,  the  other  is 
made  fast  to  a  metallic  plate,  which  is  placed  upon  any  portion  of  the  surface  of 
the  body  previously  moistened.  The  probe  is  now  inserted  into  the  wound 
for  the  purpose  of  the  search,  while  the  telephone  receiver  is  held  to  the  ear 
of  an  assistant ;  whenever  the  probe  comes  in  contact  with  the  bullet  a  distinct 
elick  is  heard  in  the  telephone — a  click  which  is  not  elicited  except  by  contact 


118  AX  AMKRICAX    TEXT-BOOK    OF  sriiGERY. 

•with  metal.  Other  methods  for  utilizing  the  electric  current  for  detecting  and 
locating  a  bullet  imbedded  in  the  tissues  have  been  devised  ;  some  of  these 
are  ingenious  and  successful  as  experiments,  but  none  are  susceptible  of  being 
utilized  in  general  practice. 

Probing  should  be  done  with  gentleness  antl  care.  It  cannot  be  too 
strongly  impressed  on  the  mind  of  the  surgeon  that  all  ])robing  should  be 
abstained  from  until  such  time  as  the  final,  thorough  examination  and  dre.ssincr 
of  the  wound  can  be  done,  when  once  for  all  tiie  probe  may  be  resorte<l  to  in 
accordance  with  the  restricted  indications  for  its  use  liereafter  mentioned. 

Treatment. — Shock  is  to  be  combated  in  accordance  with  general  princi- 
ples. Persistent  hemorrhage  of  sufficient  extent  to  refjuire  special  interference 
for  its  arrest  indicates  a  wound  of  a  vessel  of  considerable  size.  In  such  cases 
the  rule  is  imperative  to  enlarge  the  wound  sufficiently  to  expose  freelv  the 
bleeding  vessel  and  to  ligate  it  upon  both  the  proximal  and  distal  sides. 
Should  the  vessel  not  have  already  been  completely  severed  by  the  ball,  it 
should  be  divided  between  the  ligatures  after  their  application.  Hemorrhage 
occurring  secondarily  during  the  after-histon,'  of  the  wound  demands  the  same 
treatment,  and  often  involves  an  extensive  dissection  in  the  necrotic  tissue. 
When,  by  reason  of  its  anatomical  position  or  the  difficulty  of  finding  it  in  the 
sloughing  tissues,  it  is  not  practicable  to  expose  the  wounded  vessel  in  this  wav, 
ligation  of  the  main  artery  of  supply  in  its  continuity  must  be  resorted  to.  but 
only  after  a  determined  effort  has  been  made  to  ligate  it  in  the  wound  itself 

From  the  standpoint  of  treatment  gunshot  wounds  are  divisible  into  two 
classes — first,  those  which  are  capable  of  primary  occlusion  of  the  external 
wound  and  of  conversion  into  practically  subcutaneous  wounds  ;  and  secondly, 
those  which  must  be  treated  as  open  wounds  throughout.  A  large  proportion 
of  gunshot  wounds  are  capable  of  being  kept  within  the  first  of  these  two 
classes. 

First  class. — The  first  efibrt  of  the  surgeon,  therefore,  should  always  be 
scrupulously  to  protect  the  wound  from  contamination  from  without,  Tiie  one 
exception  to  this  rule  is  found  when  necessity  for  interference  for  the  arrest  of 
hemorrhage  is  so  great  that  its  urgency  may  compel  the  disregard  of  every  other 
precaution.  The  external  wound  may  be  of  such  extent  as  to  be  manifestly 
incapable  of  being  sealed  up  by  primary  occlusion,  but  such  a  condition  gives  no 
warrant  for  the  neglect  of  every  possible  effort  at  antisepsis  from  the  beginning. 
The  mere  lodgment  of  a  bullet  in  the  tissues  is  not  of  itself  an  indication  for 
the  introduction  of  an  exploring  finger  or  probe,  nor  is  it  justifiable  to  disturb 
the  wound  by  the  new  traumatism  of  an  exploration  until  distinct  evidence  has 
appeared  that  the  missile  is  seriously  interfering  with  the  repair  of  the  wound  by 
its  presence,  or  unless  there  is  good  reason  to  believe  that  there  has  been  car- 
ried into  the  wound  with  the  bullet  septic  material,  such  as  fragments  of  cloth- 
ing. That  exploration  of  a  gunsliot  wound  which  is  called  for  by  reason  of 
such  manifest  extensive  laceration  and  destruction  of  tissue  that  the  questions 
of  excision  and  amputation  require  to  be  decided,  is  of  an  entirely  different 
character  from  that  which  has  as  its  end  the  quest  for  a  bullet  and  its  removal. 
Such  explorations  are  made  on  general  surgical  principles,  and  become  a  part 
of  the  more  formal  and  extensive  operative  procedures  to  which  they  lead. 
It  is  not  infrequent,  in  cases  where  the  foreign  body  has  been  allowed  to 
remain  undisturbed  in  its  new  position  among  the  tissues,  and  satisfactory  and 
rapid  healing  of  the  original  wound  has  been  secured,  that  the  body  subse- 
quently becomes  a  source  of  irritation,  so  that  its  extraction  is  necessitated. 
A  late  operation  of  this  kind,  when  it  can  be  surrounded  by  every  precaution, 
and  is  done  among  tissues  which  are  no  longer  infiltrated  and  from  which  all 


CONTUSIOXS    AND     WO  ('XI)S.  119 

bloody  oxtravusatioii  lias  loiiji;  bt-en  absorbed,  is  attended  with  much  less  dan- 
ger than  a  primary  o[)eration  would  have  been. 

A  gunshot  wound  from  the  time  that  it  is  received  until  adequate  antiseptic 
cleansing  and  dressings  can  l)e  applied  should  be  left  exposed  to  the  air  without 
any  covering  whatever,  inasmuch  as  the  air  is  less  likely  to  be  septic  than  any 
ordinary  (h'cssing  which  coidd  be  applied.  By  such  exposure  desiccation  of 
the  secretions  about  the  wound-aperture  is  favored  and  a  protective  crust  is 
formed.  As  early  as  possible  after  the  infliction  of  the  wound  the  external 
aperture  and  the  surrounding  area  of  skin  for  a  number  of  inches  should  be 
thoroughly  cleansed  with  soap  and  water  and  sterilized  by  the  free  application 
of  a  solution  of  corrosive  sublimate,  1  :  1000,  or  of  carbolic  acid,  1  :  80.  It 
should  then  be  covered  with  an  abundant  dressing  of  absorbent  antiseptic 
material.  Almost  anywhere  ordinary  linen  or  other  similar  dressings  can  be 
used  after  being  made  aseptic  by  heating  in  an  oven  to  a  point  just  short 
of  burning.  The  wound-opening  itself  should  by  preference  be  covered  by 
a  bit  of  oiled  silk  or  rubber  protective  previously  sterilized,  but  this  is  not 
absolutely  essential ;  the  j)art  should  now  be  immol)ilized,  if  it  is  a  limb  that 
has  been  injured,  by  an  adequate  splint,  which  should  extend  sufficiently  far 
above  and  below  the  wound  to  keep  at  rest  all  the  muscular  tissue  of  the  part 
from  origin  to  insertion.  The  wound  should  not  be  disturbed  until  definite 
healing  has  been  accomplished,  unless  symptoms  of  septic  infection  should 
declare  themselves,  especially  by  a  rise  of  temperature,  thus  converting  the 
wound  into  one  of  the  second  class,  next  to  be  considered. 

Tlie  second  class  of  cases,  which  must  be  treated  as  open  wounds,  include 
those  in  which  the  extent  of  the  wound  is  too  great  to  give  any  hope  from  the 
first  of  securing  its  primary  occlusion  ;  those  in  which  these  attempts  have  been 
made,  but  have  failed ;  and  those  in  which  such  attempts  have  been  deferred  or 
omitted  until  the  wound  has  become  manifestly  septic  by  reason  of  its  exposure, 
its  having  been  subjected  to  uncleanly  and  premature  explorations,  or  the 
application  to  it  of  contaminated  dressings.  Even  in  this  second  class  of  cases 
all  explorations  and  other  operative  measures  should  be  deferred,  if  possible, 
until  they  can  be  done  with  the  necessary  disinfection,  and  can  be  accompanied 
by  adequate  protective  dressing.  Treatment  should  be  conducted  with  scrupu- 
lous attention  to  the  thorough  disinfection  of  every  accessible  recess  of  the 
wound  and  to  perfect  freedom  of  drainage.  The  appearance  of  high  fever, 
inflammatory  swelling,  progressive  infiltration,  gangrene,  and  other  evidence 
of  progressive  septic  contamination  calls  for  the  energetic  and  thorough 
application  of  all  the  resources  for  the  control  of  sepsis  which  are  within  the 
command  of  the  surgeon. 

The  primary  examination  and  cleansing  of  the  w^ound  should  be  conducted 
with  the  view  of  making  it  aseptic  if  possible.  Frequent  partial  cleansings 
should  be  avoided ;  repeated  probings,  cuttings,  irrigations,  and  squeezing  for 
the  purpose  of  evacuating  the  wound-secretions  and  debris,  which  keep  up  a 
continued  irritation  of  the  wound,  should  be  replaced  by  one  thorough  primary 
examination  and  cleansing.  This  should  be  conducted  under  an  anesthetic, 
with  deliberation  and  minute  attention  to  the  ultimate  object  in  view — the 
destruction  and  prevention  of  sepsis.  The  external  wound  should  be  freely 
enlarged  when  necessary,  so  as  to  permit  the  introduction  of  a  cleansed  and 
disinfected  finger  for  purposes  of  exploration.  Bullets,  splinters  of  bone 
entirely  detached,  pieces  of  clothing,  and  other  foreign  bodies  which  are  found 
during  the  examination  should  be  carefully  extracted.  A  bullet,  after  having 
in  the  early  part  of  its  course  inflicted  injuries  which  require  to  be  treated  by 
the  open  method,  not  infrequently  continues  its  course  in  such  a  manner  that 


120  AN  AMKinCAX    TEXr-llOOK    OF  SURGERY. 

the  second  part  of  its  track  may  lu'al  primaiily  lu'liiml  ir,  nnd  the  bullet  remain 
shut  otVlVoiii  the  first  part  of  the  woiiihI.  and  there,  becoming  encysted,  remain 
permanently  without  inducing  further  misehief. 

The  treatment  of  such  a  deep  wound-track  should  be  conducted  on  the 
same  principles  as  those  which  control  the  more  superficial  wounds ;  it  should 
not  be  i)robed  nor  irrigated,  nor  in  any  manner  interfered  with,  unh'ss  evidences 
of  inilaiiiniatory  disturbances  of  its  walls  appear ;  no  search  should  be  made 
along  it  for  the  bullet ;  much  less  should  the  presence  of  the  bullet  at  its  bottom 
be  considered  an  indication  for  an  attempt  at  its  removal,  unless  easily  accessible 
from  the  opposite  side,  when  it  should  be  removed  antiseptically.  The  dis- 
infection and  drainage  of  the  superficial  portion  of  the  wound  should  be 
conducted  with  all  care  and  thoroughness.  Should  deeper  disturbances 
manifest  themselves,  the  exploration,  cleansing,  and  drainage  of  that  portion 
of  the  wound  would  then  be  required.  Enlargement  of  the  aperture  of  com- 
munication with  the  superficial  wound,  and  free  counter-incisions  to  the  extent 
required  for  its  easy  and  perfect  drainage  and  for  the  removal  of  any  foreign 
and  irritating  bodies  along  its  track,  will  be  necessary. 

A  certain  proportion  of  these  injuries  will  require  primary  resections  of  joints, 
partial  or  complete,  and  amputations,  as  a  part  of  the  care  required  in  the  pri- 
mary dressing.  The  necessity  for  these  more  important  operative  procedures 
will  have  become  revealed  in  the  course  of  the  explorations  which  have  been 
made.  The  judgment  and  experience  of  the  surgeon  as  to  his  ability  to  ward 
off  the  dangers  which  threaten  badly  shattered  joints  and  bones  and  exten- 
sively-mangled soft  tissues,  and  to  conduct  the  wound  to  a  satisfactory  healing 
so  as  to  preserve  a  useful  limb,  must  influence  the  decision  in  many  cases  as  to 
whether  a  conservative  method  of  treatment  or  the  opposite  should  be  adopted. 
In  yet  other  cases,  when,  in  addition  to  extensive  injury  to  a  bone  or  penetra- 
tion of  a  joint,  the  main  vessels  or  nerves  of  the  limb  are  injured,  or  when 
extensive  loss  of  the  soft  tissues  has  taken  place,  or  when  a  part  of  the  limb 
has  been  carried  away,  no  alternative  is  left  to  the  surgeon  but  amputation. 

When  the  necessity  of  amputation  is  unquestionable,  it  should  be  done  as 
soon  after  the  shock  from  the  primary  wound  has  passed  away  as  is  practicable, 
provided  this  is  before  septic  infection,  inflammatory  infiltration,  and  secondary 
traumatic  fever  have  developed.  This  is  the  period  characterized  by  old  authors 
as  the  primary  'period ;  which,  in  pre-antiseptic  days,  extended  over  the  first 
thirty-six  to  forty-eight  hours.  This  is  followed  by  a  period  extending 
over  a  variable  time,  during  which  there  is  progressive  local  inflammatory 
infiltration  and  general  fever.  This  period  is  termed  the  iiifi^niicdittn/  period- 
During  this  period  no  operative  interference  is  to  be  attempted  other  than  that 
required  for  the  removal  of  necrotic  tissues  or  for  affording  adequate  drainage, 
unless  spreading  gangrene  of  the  wound  develop,  when  distant  amputation 
through  tissues  yet  sound  should  be  done  as  quickly  as  possible.  When  the 
primary  inflammatory  infiltration  has  become  limited  and  begins  to  subside, 
and  free  suppuration  from  the  wound-surfaces  has  become  established,  another 
period  is  said  to  have  been  reached,  known  as  the  seeondart/  period.  When 
the  secondary  period  has  been  reached,  amputation  through  tissues  yet  sound 
should  be  done  without  further  delay. 

The  prolongation  of  the  primary  stage  by  antiseptic  treatment — continuous 
antiseptic  irrigation  being  the  method  which  in  general  is  best  adapted  to 
these  cases — makes  it  possible  for  the  surgeon  to  delay  amputation  until  such 
time  as,  in  his  judgment,  the  patient  will  be  in  the  most  favorable  condition  to 
bear  the  operation.  In  some  cases  it  will  happily  have  served  to  demonstrate 
the  possibility  of  recovery  without  amputation,  for  in  not  a  few  instances  the 


CONTUSIONS    AND     WOUNDS.  121 

possibility  of  saving  a  limb  will  depend  entirely  upon  the  success  of  the  efforts 
to  prevent  the  wound  from  being  invaded  by  septic  infection.  As  soon  as  it  is 
evident  that  these  eftbrts  have  not  been  successful,  amputation  should  be  pro- 
ceeded with,  before  the  full  local  and  constitutional  symptoms  of  sepsis  have 
developed. 

Point  of  Amputation. — The  choice  of  the  point  at  which  the  amputa- 
tion shall  be  made  may  be  greatly  influenced  by  the  facilities  at  the  command 
of  the  surgeon  for  keeping  the  wound  aseptic.  If  these  be  adequate  for  the 
purpose,  the  section  may  be  made  at  whatever  point  may  lie  desirable  to  give 
the  patient  the  most  useful  stump,  even  though  bruised  and  lacerated  parts  be 
included  in  the  flaps.  These  are  preserved  from  inflammatory  disturbance,  their 
full  vitality  is  regained,  and  they  participate  in  the  formation  of  the  stump 
without  disaster  from  sloughing.  When,  for  any  reason,  the  wound  cannot 
receive  adequate  antiseptic  treatment,  amputation,  if  possible,  should  be  made 
at  a  point  sufficiently  far  above  the  injury  to  exclude  all  bruised  and  lacerated 
tissues  from  the  flaps.  A  blind  groping  for  a  bullet  at  the  bottom  of  a  deep 
sinus  should  never  be  attempted.  The  enlargement  of  the  external  aperture 
and  the  dilatation  of  the  deeper  track,  as  required  for  the  purposes  of  the 
cleansing  and  drainage  of  the  wound  or  the  counter-incisions  made  when  the 
length  of  the  track  and  the  location  of  the  ball  demand  it,  should  be  ample 
enough  to  permit  the  sufficient  exposure  and  ready  seizure  of  the  bullet  if  it  is 
to  be  removed  at  all.  For  the  purpose  of  facilitating  the  removal  of  a  bullet 
when  exposed  many  styles  of  forceps  have  been  devised ;  it  is  not  necessary 
that  mention  of  any  special  one  should  be  made.  Any  pair  of  forceps  with 
slender  and  firm  jaws,  with  slightly  projecting  teeth  or  with  roughened  points 
to  increase  the  security  of  the  grasp  upon  the  bullet,  will  answer.  The  bullet 
will  commonly  be  found  to  be  somewhat  battered  and  misshapen  and  entangled 
in  interlacino:  strands  of  fibrous  tissue  that  hold  it  closely,  so  that  some  little 
difficulty  is  often  experienced  in  freeing  the  bullet  so  that  it  can  be  removed 
after  it  has  once  been  exposed.  If  the  bullet  is  firmly  impacted  in  bone,  it 
must  be  first  loosened  by  the  chisel  or  elevator,  and  then  removed. 

Gunpowder  grains  imbedded  in  the  skin  may  be  picked  out  by  a  sharp- 
pointed  bistoury  and  a  fine  curette,  or  be  left  to  spontaneous  discharge  by 
suppuration.  In  an\^  event,  a  permanent  tattooing  will  remain  as  a  mark  of 
the  wound. 

Arroiv-tvounds. — The  wound  made  by  an  arrow  is  a  punctured  incised 
wound.  Such  wounds  demand  special  mention  only  in  connection  with  the 
question  of  the  treatment  of  the  arrow  when  any  portion  of  it  is  lodged  in  the 
wound.  The  barbed  head  of  the  arrow,  by  becoming  entangled  in  the  tissues 
which  close  over  it  after  it  has  penetrated  them,  forms  a  condition  that  is  espe- 
cially difficult  to  overcome  if  the  arrow  has  penetrated  to  any  depth.  The 
general  principles  of  surgery  which  are  applicable  to  the  search  for  and  removal 
of  all  foreign  bodies  imbedded  in  the  tissues  are  equally  applicable  to  imbedded 
arrow-heads.  If  the  shaft  of  the  arrow  is  still  attached  to  the  head,  it  affords 
a  valuable  guide  along  which  the  dissection  of  the  surgeon  may  be  made  for 
adequate  exposure  and  disentanglement  of  the  arrow-head.  It  should  never  be 
pulled  upon  for  the  purpose  of  removing  the  arrow,  for  the  effort  will  certainly 
be  futile,  and  if  the  shaft  becomes  separated  from  the  head  its  further  service  as 
a  guide  is  lost.  If,  however,  the  arrow  has  so  far  penetrated  the  tissues  as  to 
make  it  feasible  to  push  it  clear  through  and  out  on  the  other  side,  that  treat- 
ment should  be  adopted ;  and  in  that  case  the  shaft  should  be  used  to  push  out 
the  head,  the  exit  of  which  through  the  skin  should  be  helped  by  the  proper 
use  of  the  knife.     The  head  and  the  ribbon  which  attaches  it  to  the  shaft  being 


122  AX   AMKliJCAN    TEXT-BOOK    OF   SLUGERY. 

then  removed,  the  shaft  itself  can  be  withdrawn.  Arrow-heads  (h>  not 
become  encysted  like  bullets.  The  experience  of  military  surgeons  is 
uniform  that  an  arrow-head  lodged  in  the  soft  tissues  invariably  produces 
serious  results.  Hence  the  rule  is  without  exception  that  an  arrow-head 
left  behind  and  lodged  in  the  tissues  must  be  removed  as  soon  as  j)o.ssible, 
even  \i  this  removal  should  recjuire  the  severest  and  most  dangerous  ope- 
ration (Bill). 

Injuries  t)'otn  Electric  Currents. — Lii/Iit)iiti(/-!<tro/cc. — The  passage  through 
the  body  of  electric  currents  of  high  voltage,  an  accident  of  frequent  occur- 
rence since  the  introduction  into  common  use  of  such  currents  for  illu- 
minating and  mechanical  purposes,  is  ])roductive  of  ])rofound  inhibition, 
immediate  unconsciousness,  and  often  of  instant  death.  An  alternating 
current  is  more  damaging  than  a  continuous  current  of  the  same  strength  ; 
legal  electrocutions  have  shown  tiiat  no  human  being  can  survive  the  passaf^e 
through  his  body  of  an  alternating  current  of  more  than  loOO  volts  for  a 
period  of  tAventy  seconds  (MacDonaldj.  A  momentary  exposure  to  a  high 
degree  of  electrical  force  may  be  less  disastrous  than  a  longer  exposure  to  a 
current  of  less  intensity.  Intense  general  muscular  rigidity  is  instantly 
induced  by  the  current  and  persists  during  its  continuance;  but  relaxation 
occurs  as  soon  as  the  current  is  broken.  No  recognizable  changes  in  the 
tissues  or  organs  of  the  body  have  been  discovered  in  electrocuted  subjects, 
excepting  slight  local  burns  of  the  skin  at  the  points  of  application  of  the 
electrodes  and  minute  petechial  spots  on  several  organs  (A''an  Giesen).  The 
coagulability  of  the  blood  is  lessened  or  abolished.  In  cases  of  lightning- 
stroke  violent  disruptive  effects  have  sometimes  -been  noted,  even  to  the 
extent  of  the  fracture  of  bones  and  the  laceration  or  avulsion  of  entire 
limbs. 

Asphyxia,  from  paralysis  ot  the  respiratory  muscles,  is  an  imminent 
danger  in  cases  in  which  instant  death  by  inhibition  is  escaped.  Efforts  at 
artificial  respiration  have  resulted  eventually  in  recovery  even  after  apparent 
death.  In  D'Arsonval's  case  there  was  apparent  death  in  half  an  hour,  but 
recovery  followed  artificial  respiration. 

In  non-fatal  cases  the  phenomena  induced  are  those  of  pronounced  shock, 
unconsciousness  lasting  from  a  few  hours  to  days,  muscular  pareses,  areas  of 
superficial  anesthesia,  and  transitory  impairment  of  some  of  the  special 
senses,  especially  of  sight  and  hearing.  Gradual  recovery  from  these  eff"ects 
is  the  rule,  after  variable  periods. 

Treatment. — If  a  man  is  caught  in  electric  wires,  shut  off"  the  current  if 
possible.  If  this  cannot  be  done  and  if  rubber  gloves  can  be  obtained,  let 
some  one  put  on  the  gloves  and  lift  the  wires  away.  If  the  clothing  is  dry, 
it  is  safe  to  pull  the  victim  from  the  wires  by  catching  his  coat-tails.  If  a 
dry  cloth  is  pushed  under  the  body,  it  can  be  safely  moved.  In  all  cases 
artificial  res])iration  with  tongue-traction  should  be  tried  and  persisted  in 
until  its  futility  has  been  demonstrated  or  natural  breathing  is  resumed.  At 
the  same  time  apply  cold  douches  to  the  head,  give  hot  enemata,  wrap  the 
patient  in  warm  blankets,  put  a  mustard-plaster  over  the  heart,  but  do  not 
give  alcoholic  stimulants.  In  some  cases  venesection  has  proved  useful.  The 
later  treatment  of  paralytic  and  sensory  disturbances,  and  that  of  the  local 
burns,  if  any  exist,  is  conducted  as  in  cases  of  similar  disturltances  due  to 
other  causes.  Electric  burns  are  apt  to  slough  extensively  and  are  very  slow 
to  heal.  Iodoform  and  corrosive  sublimate  irritate  them  very  much.  They 
should  be  dressed  with  gauze  wet  with  hot,  normal  salt  solution.  When  the 
slough  separates  they  may  be  dressed  with  dry,  sterile  gauze. 


CO  XT  us  IONS   AND     WOUNDS.  12.3 


POISONED    WOUNDS. 

Certain  wounds  remain  to  be  considered  which  are  associated  with  the 
inocuhition  of  special  hurtful  substances.  They  have  long  been  classed 
together  as  poisoned  wounds,  although  in  some  the  poison  injected  is  of 
a  chemical  character,  while  in  others  it  is  microbic.  A  distinction,  however, 
should  be  made  between  Avounds  that  are  subjected  to  microbic  and  those 
subjected  to  chemical  influences.  The  former  constitute  the  general  class 
of  infected  wounds,  in  which  are  to  be  grouped  not  only  all  those  heretofore 
described  as  subject  to  the  usual  septic  infection,  but  also  those  which  are 
infected  by  special  microbes,  as  rabies,  glanders,  anthrax,  actinomycosis,  etc. 
Chemical  poisons  difter  from  microbic  poisons  in  that  they  are  incapable  of 
self-reproduction,  and  that  their  deleterious  effects  are  proportionate  to  the 
amount  of  the  poison  at  first  introduced  into  the  body.  In  this  class  are  to  be 
grouped  the  bites  and  stings  of  insects  and  of  reptiles.  It  is  not  be  overlooked 
that  in  ordinary  infected  wounds  the  local  and  general  symptoms  which  are 
produced  are  due  largely  to  the  action  of  the  chemical  poisons  or  ptomaines 
which  are  generated  by  the  micro-organisms  that  infest  the  wound,  and  not  to 
the  presence  of  the  micro-organisms  themselves.  Such  Avounds  are  there- 
fore of  a  double  nature.  In  all  cases  where  there  is  a  tendency  to  spreading 
gangrene  this  mixed  character  of  the  poison  is  especially  marked.  The  acrid 
ptomaine  by  its  chemical  effect  upon  the  tissues  with  Avhich  it  comes  in  contact 
produces  their  death  and  converts  them  into  a  fertile  soil  for  the  rapid  multipli- 
cation of  the  invading  micro-organisms,  Avhich,  again,  as  they  multiply,  produce 
a  rencAved  supply  of  the  ptomaine,  that  attacks  a  fresh  layer  of  tissue :  and 
thus  the  vicious  circle  is  completed  and  the  progressively  destructive  proc- 
ess is  maintained.  There  are,  therefore,  three  great  classes  of  poisoned 
wounds : 

First,  that  of  mixed  or  bio-chemical  infection,  Avhich  includes  all  the 
ordinary  septic  Avounds  that  have  been  treated  of  in  the  preceding  pages,  and 
likewise  those  special  Avounds  Avhich  are  at  times  accompanied  AA'ith  marked 
tendencies  to  spreading  inflammation  and  gangrene,  such  as  those  received  in 
the  dissecting-room,  during  post-mortem  examinations,  by  butchers  and  fish- 
dealers  from  tainted  meat  and  fish,  and  those  resulting  in  that  rapidly-extend- 
ing gangrenous  process  knoAvn  as   "malignant  oedema." 

Second,   ciiemical    poisons    alone — the    bites   of   insects   and   reptiles. 

Third,  microbic  infection  alone — rabies,  glanders,  etc.  This  latter  class 
difi"ers  so  Avidely  and  materially  in  every  respect  from  the  first  two  as  to  deserve 
an  entirely  separate  consideration.  We  shall  accordingly  group  the  first  tAA'o 
under  the  one  head  of  Poisoned  Wounds  j)ropey\  while  the  latter  class  w^e  shall 
treat  under  the  designation  Surgical  Diseases  due  to  Microhic  Infection.  A 
number  of  these  are  usually  derived  from  animals. 

POISONED    AVOUNDS    PROPER. 

Dissection  Wounds. — The  term  "dissection  wounds  "is  applied  to  septic 
wounds  of  special  virulence  contracted  in  the  dissection  of  dead  bodies,  both  in 
the  dissecting-room  and  especially  in  post-mortem  examinations.  It  is  applica- 
ble also  to  a  similar  class  of  injuries  sustained  by  surgeons  in  operating  on  the 
living ;  similar  wounds  occur  also  in  butchers,  fish-dealers,  cooks,  and  othei 
persons  whose  vocations  may  demand  their  handling  putrefying  animal  material. 
Only  a  very  small  proportion  of  the  pricks  inflicted  upon  themselves  by  medi- 
cal students  and  surgeons  in  dissecting  the  bodies  of  the  dead  or  in  operating 


124  AX  AMERICAN    TEXT-liOOK    OF  SURGERY. 

upon  the  living  are  followed  by  any  serious  consequences.  For  the  develoj)- 
ment  of  the  more  grave  results  it  is  necessary  that  there  shall  be  some  special 
virulence  in  the  tissues  or  fluids  by  which  the  wound  is  inoculated,  or  that  the 
individual  who  receives  the  wound  should  be  in  a  condition  of  general  consti- 
tutional depression,  so  that  the  natural  resisting  power  of  liis  tissues  is  greatly 
diminished.  The  worst  cases  occur  when  both  these  conditions  happen  to  be 
combined.  Exi)erience  has  shown  that  the  tissues  of  the  recently  dead  are  more 
frequently  capable  of  communicating  serious  infection  than  those  in  which  the 
process  of  decomposition  is  well  advanced.  The  dissection  of  bodies  in  which 
death  has  been  caused  by  virulent  infective  processes,  as  puerperal  fever,  ery- 
sipelas, or  pyemia,  is  especially  dangerous.  Occasionally  the  wetting  of  the 
hands,  on  which  there  is  no  perceptible  scratch  or  breach  of  surface,  by  the 
acrid  fluids  of  a  body  dead  of  virulent  infective  disease  may  be  attended  with 
all  the  results  for  which  the  presence  of  a  prick  or  scratch  or  abraded  surface 
of  some  kind  is  usually  necessary. 

Symptoms. — The  symptoms  presented  by  a  dissection  wound  may  be 
those  of  any  grade  of  septic  infection,  from  that  of  slight  local  inflammation 
and  suppuration  to  that  of  rapid,  pi-ogressive  gangrenous  inflammation,  with 
extreme  general  prostration  from  septic  absorption,  the  development  of  pyemic 
foci  in  other  parts  of  the  body,  and  death.  A  not  uncommon  form  is  that  in 
which  the  inflammation  extends  especially  along  the  lymphatics,  which  appear 
as  red  lines,  and  produces  marked  swelling  of  the  axillary  glands. 

Treatment. — The  treatment  of  these  Avounds  differs  in  no  Avay  from  that 
which  has  been  laid  down  for  a  septic  wound  in  general.  When  an  indivi<lual 
is  conscious  of  the  reception  of  the  wound  at  the  time,  energetic  local  antiseptic 
treatment  should  be  immediately  instituted  ;  thorough  scrubbing  and  cleansing 
of  the  Avound  and  the  surrounding  integument  over  a  wide  area  should  be  made; 
the  wound  itself,  if  a  puncture,  should  be  enlarged  sufficiently  to  permit  of  the 
certain  introduction  to  its  deepest  point  of  the  antiseptic  to  be  used.  The 
wound  should  then  be  thoroughly  swabbed  out  with  some  such  strong  antiseptic 
agent  as  pure  carbolic  acid,  solution  of  corrosive  sublimate,  1 :  oOO,  or  solution 
of  chloride  of  zinc,  8  per  cent.  ;  the  part  should  be  covered  with  an  abundant 
dressing  of  absorbent  material,  Avhich  should  be  kept  wet  Avith  a  solution  of 
corrosive  sublimate,  1  :  2000,  for  three  or  four  days ;  that  is  to  say,  until  suffi- 
cient time  has  elapsed  to  demonstrate  Avhether  or  not  the  disinfection  of  the 
wound  has  been  successful.  When  this  has  been  assured,  any  simple  emollient 
protective  dressing  may  be  substituted  until  complete  healing  of  the  Avound  has 
taken  place.  AVlien,  through  the  neglect  or  inefficiency  of  primary  antiseptic 
care,  advancing  phlegmonous  inflammation  or  lymphatic  irritation  and  glandu- 
lar enlargement  begin  to  develop,  the  surgeon  should  not  wait  until  suppuration 
and  sloughing  of  tissue  have  taken  place  before  incising  the  inflamed  and  mfil- 
trated  regions,  but  should  at  once  make  sufficiently  free  incisions  to  open  up 
thoroughly  every  infected  district  and  to  permit  the  free  exit  of  the  inflamma- 
tory secretions  Avitli  Avhich  the  tissues  are  infiltrated.  The  early  resort  to  free 
incisions  of  this  character  Avill  prevent  much  destruction  of  tissue  and  serious 
impairment  of  function,  will  relieve  pain,  and  greatly  abbreviate  the  course  of 
the  attack.  Abundant  antiseptic  irrigations  should  be  practised  upon  all  the 
tissue-spaces  opened  up  by  these  incisions;  the  incisions  themselves  should  be 
kept  open  by  tents  of  iodoform  gauze  until  all  tendency  to  spreadmg  inflam- 
mation has  subsided  and  a  healthy  granulating  process  has  developed.  Mean- 
Avhile,  the  Avhole  limb  should  be  kept  enveloped  in  Avet  bichloride  dressings. 
Abscesses,  Avhenever  and  Avherever  formed,  should  be  opened  as  soon  as  possible 
and  treated  after  the  iieneral  manner  already  described.     The  constitutional 


CONTUSIONS  AND    WOUNDS.  125 

treatment  required  will  be  conducted  on  general  principles,  and  will  include 
stimulants  in  large  doses,  opiates,  and  tonics. 

Malignant  (Edema,  known  also  as  Gangrenous  Emphysema  and  G-an- 
(jreiie  Foudroi/antc,  is  a  rapidly-spreading  gangrenous  inflammation  in  which  the 
affected  tissues  become  distended  with  the  gaseous  products  of  decomposition,  due 
to  infection  by  a  special  micro-organism.  (PI.  Ill,  Fig.  1).  This  micro-organism 
was  identified  by  Koch  in  1882,  and  is  a  rod-like  bacillus,  resembling  in  form 
and  size  that  of  anthrax,  but  somewhat  smaller,  with  rounded  ends.  The  bacilli 
are  joined  together  in  threads  after  a  peculiar  fashion.  Unlike  the  anthrax 
bacillus,  they  have  the  property  of  spontaneous  motion  and  of  spore-formation 
in  the  living  body;  they  grow  only  in  the  absence  of  oxygen;  they  only 
rarely  enter  the  animal  body  with  any  activity ;  they  abound  in  garden  soil, 
and  may  be  met  with  in  any  kind  of  soil  or  dust.  The  gangrenous  and  putre- 
factive phenomena  Avhich  are  marked  features  of  the  disease  in  question  are  said 
not  to  be  primarily  produced  by  the  bacillus,  but  to  be  due  to  the  admixture  with 
it  of  the  ordinary  putrefactive  forms.  According  to  Park  (Mutter  Lectures  on 
Surgical  Pathologg,  1890  and  1891),  when  a  pure  culture  of  these  specific 
bacilli  is  injected  there  results  an  extensive  hemorrhagic  oedema  of  the  sub- 
cutaneous cellular  tissue,  without  any  appearance  of  putrefactive  action  and 
quite  free  from  gas-formation ;  but  when  an  impure  culture  is  injected  or  when 
garden  earth  is  used  for  inoculation,  the  distinctive  oedema  of  the  previous 
instance  becomes  a  mixture  of  emphysemic  oedema  and  gangrene.  These  organ- 
isms must  be  planted  subcutaneously  in  the  areolar  tissues  in  order  to  produce 
the  typical  results.  Inoculations  upon  abrasions  or  open  wounds  are  harmless, 
owing  to  the  free  access  of  the  inhibiting  oxygen  of  the  atmosphere. 

Symptoms. — The  local  symptoms  of  the  disease  are  those  of  a  rapidly- 
extending  gangrene  surrounded  by  an  extensive  ever-spreading  area  of  swollen, 
livid  tissue,  infiltrated  by  foul-smelling,  acrid  secretion  and  the  gaseous  prod- 
ucts of  decomposition.  The  oedematous  tissues  emit  a  fine  crepitus  when 
pressed  by  the  finger ;  the  overlying  cuticle  is  raised  into  blebs  filled  with  red- 
dish offensive  serum ;  the  sloughing  tissues  are  bathed  in  a  thin  putrid  fluid. 
The  general  state  of  the  patient  is  one  of  great  prostration  and  profound 
septicemia,  accompanied  by  apathy  and  sometimes  by  delirium.  Death  super- 
venes usually  Avithin  from  one  to  two  days  ;  after  death  putrefaction  goes  on 
with  great  rapidity.  Examination  of  the  viscera  shows  them  to  be  congested 
and  oedematous  and  the  subject  of  multiple  hemorrhagic  infarcts. 

The  diagnosis  of  malignant  oedema  is  simple.  The  clinical  picture  which 
it  presents  is  clear  and  not  likely  to  be  mistaken  for  anything  else.  The  first 
symptom  is  hemorrhagic  oedema  of  the  subcutaneous  cellular  tissue,  to  which 
is  added  infection  with  ordinary  putrefactive  organisms  ;  a  rapidly-spreading 
gangrene  results,  with  the  addition  of  an  emphysemic  element  to  the  previously 
existing  oedema  from  the  gases  of  putrefaction.  This  mixture  of  emphysemic 
oedema  and  gangrene  is  the  pathognomonic  clinical  feature  of  the  disease. 
Microscopic  examination  of  the  oedema  fluid  will  show  numerous  bacilli  of  the 
disease.  The  prognosis  is  always  grave ;  with  rare  exceptions  the  disease 
marches  rapidly  to  a  fatal  termination. 

Treatment. — The  treatment  must  be  heroic  and  radical  from  the  moment 
of  the  recognition  of  the  disease.  If  a  limb  is  attacked,  immediate  amputa- 
tion should  be  done  at  a  point  well  above  the  line  to  which  the  disease  has 
extended.  When  amputation  is  not  feasible,  a  radical  excision  of  the  affected 
tissues  should  be  done,  with  the  most  thorough,  continuous,  subsequent  antiseptic 
treatment.  The  general  strength  should  be  sustained  by  vigorous  stimulation 
and  by  other  tonic  and  supporting  treatment. 


12G  J.V    AMI'JUCAX    TKXT-JiOOK    OF  SURGEUY. 


BITES   AND    STINGS    OF    INSECTS    AND    REPTILES. 

These  are  minute  punctured  wounds  into  which  has  been  injected  some 
poisonous  secretion  from  distinct  poison-glands  or  from  modified  salivary  glands 
of  the  animal  inflicting  the  bite. 

Insect-bites  and  Stings. — In  tlie  case  of  insects  tlie  poison  inoculated  is 
acid  in  its  nature  :  the  results  (»f  its  injection  present  everv  dcfrree  of  variation  in 
severity,  from  that  of  the  simple  local  irritation  produced'by  the  minor  and  more 
common  insects,  such  as  the  flea,  the  mosquito,  bedbug,  various  forms  of  mites, 
etc.,  to  the  greater  local  reaction  and  considerable  constitutional  disturbance 
following  the  stings  of  the  more  aggressive  and  venomous  hymenoptera, 
such  as  bees,  wasps,  hornets,  and  yellow-jackets,  and  the  still  more  virulent 
and  dangerous  centipedes,  spiders,  tarantula?,  and  scorpions.  As  a  rule, 
the  stings  of  even  the  most  venomous  of  insects  are  unattended  with  dan- 
ger to  life,  but  where  many  have  been  inflicted  or  when  the  person  is 
weak  and  feeble  severe  constitutional  disturbance,  marked  by  chills,  fever, 
and  great  prostration,  and  even  ultimate  death,  may  result,  the  severity  of  the 
symptoms  depending  upon  the  amount  of  the  poison  which  has  been  absorbed 
into  the  general  circulation.  The  wounds  inflicted  even  by  spiders  and  scor- 
pions of  the  largest  size  rarely  prove  fatal. 

Treatment. — Alkaline  local  applications  should  be  used,  such  as  dilute 
aqua  aiiiinuniie  or  solution  of  bicarbonate  of  sodium.  Ordinary  loam  mixed 
with  water  to  form  a  mud  poultice  is  useful  as  an  extemporaneous  application. 
Local  inflammatory  disturbances  must  be  treated  upon  general  principles ; 
constitutional  symptoms  must  also  be  combated  according  to  the  special  indica- 
tions of  the  particular  case. 

Serpent-bites. — In  the  United  States  naturalists  have  discovered  twenty- 
seven  species  of  poisonous  serpents  and  one  poisonous  lizard ;  eighteen 
species  of  these  are  true  rattlesnakes :  the  remaining  are  divided  between 
varieties  of  the  moccasin  or  copperhead  and  of  the  viper.  The  poisonous 
lizard  is  the  Texan  reptile  known  as  the  "  Gila  monster."  In  all  these 
serpents  the  poison  fluid  is  seci'eted  in  a  gland  which  lies  against  the  side 
of  the  skull  below  and  behind  the  eye,  from  which  a  duct  leads  to  the  base 
of  a  hollow  tooth  or  fang,  one  on  each  side  of  the  upper  jaw ;  Avhich  fsing, 
except  in  the  case  of  the  vipers,  is  movable  and  susceptible  of  erection  and 
depression.  When  not  in  use,  the  fang  hugs  the  upper  jaw  and  is  ensheathed  in 
a  fold  of  mucous  membrane.  In  the  vipers  the  fiing  is  permanently  erect.  In  the 
act  of  biting  the  contents  of  the  poison-sac  are  forcibly  ejected  through  the  hol- 
low fang.  In  India  venomous  snakes  abound,  of  which  the  chief  are  the  hooded 
cobra,  the  viper,  and  the  bungarus.  In  Europe  the  most  dreaded  serpent  is  the 
common  viper,  while  Africa,  South  America,  and  Australia  and  the  islands  of 
the  Pacific  are  not  wanting  in  many  varieties  of  venomous  serpents.  The 
physical  appearances  of  all  serpent-venom  are  nearly  alike :  it  is  a  viistcid  fluid, 
varying  in  color  from  a  pale  amber  to  a  deep  yellow,  and  containing  in  solution 
certain  albuminoid  principles  which  are  the  toxic  elements,  the  nature  of  which 
has  not  yet  been  made  out.  According  to  the  researches  of  Mitchell  and 
Reichert,  venom  induces  rapid  necrotic  changes  in  living  tissues  with  which  it 
is  brought  in  contact.  It  renders  the  blood  incoagulable,  disintegrates  the  red 
blood-corpuscles,  and  produces  such  a  change  in  the  capillary  blood-vessels  that 
their  walls  are  unable  to  resist  the  normal  blood-pressure,  and  wide  and  rapid 
blood-extravasation  results.  Profound  depression  of  the  respiratoiy  nerve- 
centers  is  the  most  common  cause  of  death  from  serpent-venom,  although 
cardiac  paralysis,   hemorrhages    into   the  medulla,    and    general    disorganiza- 


COXTUSIONS   A  XI)     WOCXDS.  127 

tion  of  the  rod  l)lood-coi'pu.scles  niiiy  likewise  each  be  a  sufficient  cause  of 
death. 

Symptoms. — Much  siinihirity  characterizes  the  effects  wliicli  follow  bites 
of  all  Viirieties  of  ])()isonous  serpents.  The  amount  of  the  venom  injected  and 
the  rapidity  with  which  it  enters  the  circulation  govern  the  intensity  and  the 
rai)idity  of  the  symptoms  ])roduced.  The  local  symptoms  are  pain — at  first 
slight,  but  later  becoming  more  severe — with  rapid  tumefaction  and  ecchymotic 
discoloration  in  the  vicinity  of  the  wound.  Symptoms  of  cardiac  and  respira- 
tory depression  soon  manifest  themselves  by  feeble  and  fluttering  pulse,  faint- 
ness,  cold  perspirations,  mental  distress,  nausea  and  vomiting,  and  labored 
respiration.  In  the  more  intense  cases  of  poisoning  death  may  result  in  a 
short  time  by  the  paralyzing  effect  of  the  venom  upon  the  heart,  but  more 
frequently  the  struggle  extends  over  a  number  of  hours.  When  life  is  pro- 
longed over  forty-eight  hours,  the  special  symptoms  of  venom-poisoning  give 
place  to  those  which  are  due  to  the  disintegrating  effect  of  the  venom  upon 
the  blood  and  the  tissues ;  that  is  to  say,  a  sapremia  of  intense  form  remains, 
which  may  prove  fatal  by  exhaustion  or  may  be  slowly  recovered  from.  When 
death  takes  place  from  the  primary  effects  of  the  venom,  it  is  ushered  in  by 
delirium  and  coma,  with  intensification  of  all  the  primary  symptoms. 

The  post-mortem  appearances  are  those  which  would  follow  the  blood-changes 
and  the  visceral  disturbances  that  have  been  described.  In  the  neighborhood 
of  the  bite  the  tissues  are  infiltrated  with  hemorrhages  and  with  the  results  of 
rapidly-extending  gangrene,  the  right  heart  is  engorged,  the  general  blood-mass 
is  fluid,  and  all  the  internal  organs,  especially  the  brain,  spinal  cord,  and  kid- 
neys, are  congested  and  present  multiple  ecchymoses. 

Treatment. — When  a  bite  by  a  venomous  serpent  has  been  received, 
instantaneous  and  energetic  efforts  must  be  made  to  prevent  the  entrance  of  the 
venom  into  the  general  circulation.  When  the  bite  has  been  upon  any  portion 
of  a  limb,  a  ligature  should  at  once  be  thrown  around  the  limb  above  the 
wound,  and  by  twisting  be  drawn  so  tightly  as  absolutely  to  check  the  circu- 
lation of  blood  in  the  part.  This  ligature  should  be  a  broad  one,  so  as  to 
diminish  later  pressure-effects ;  then  free  excision  of  the  wounded  part  should 
be  done.  When  the  bite  is  upon  a  part  of  the  body  other  than  a  limb,  imme- 
diate excision  should  be  practised,  and,  when  this  is  impracticable,  vigorous 
suction  of  the  wound  should  be  made,  which  can  be  done  without  fear  if  no 
cracks  or  abrasions  of  the  lips  or  mouth  are  present,  for  the  poison  is  harmless 
when  taken  into  the  mouth.  Should  a  hot  iron  be  accessible,  its  vigorous  and 
free  application  within  the  wound  might  safely  replace  excision  or  suction.  When 
none  of  these  procedures  are  practicable  or  have  been  only  imperfectly  applied, 
there  remains  the  device  of  permitting  the  poison  to  be  admitted  into  the  gene- 
ral circulation  in  instalments  by  slackening  the  ligature  a  little  at  intervals, 
and  then  tightening  it  again,  while  constitutional  treatment  is  being  resorted 
to  for  the  purpose  of  antidoting  the  poison  thus  slowly  admitted  into  the 
circulation.  Permanganate  of  potassium,  in  1  per  cent,  aqueous  solution,  freely 
injected  by  means  of  a  hypodermatic  syringe  into  a  serpent's  bite,  or  calcium 
hypochlorite,  in  an  8  per  cent,  solution,  freshly  prepared  and  diluted  at 
time  of  use  with  nine  volumes  of  water,  injected  into  the  tissues  in  the  region 
of  the  bite,  and  also  at  intervals  in  other  parts  of  the  body,  in  doses  of  from 
20  to  30  C.C.,  are  reported  to  have  acted  as  effectual  antidotes  to  serpent- 
venom.  The  hypodermatic  injection  of  an  antitoxic  serum,  derived  from  an 
animal  rendered  immune  to  snake-poison  by  repeated  injections  of  venom  in 
doses  of  graduated  strength,  it  has  been  asserted,  will  act  as  an  antidote  to 
the  effects  of  a  bite  of  a  venomous  snake,  even  if  the  injection  is  delayed  as 


128  AN    AMERICAN    TKXT-J'.OOK    OF  SURGERY. 

lonfj  as  an  hour  after  the  bite.  The  close  varies  according  to  the  species  of 
the  snake,  the  age  of  the  person  bitten,  and  tlie  time  of  administration. 
Twenty  c.cm.  is  the  average  dose  for  an  adult.  Together  with  these  pro- 
cedures, the  patient  should  be  rubbed,  given  coffee  or  tea,  and  warmly  cov- 
ered so  as  ti)  induce  perspiration. 

Strychnia,  in  doses  of  yW  grain  of  the  nitrate.  rej)eated  every  two  hours 
until  the  symptoms  produced  by  the  venom  have  been  <tvercome.  has  ap- 
peared to  produce  recovery  in  many  reported  cases.  The  strychnia  injec- 
tions are  to  be  begun  only  after  the  symptoms  of  snake-poisoning  have 
become  pronounced. 

In  the  absence  of  the  agents  named,  or  in  the  case  of  bites  from  mod- 
erately venomous  snakes,  the  free  use  of  alcoholic  stimulants  should  be 
resorted  to.  The  state  of  the  pulse  is  to  be  taken  as  the  guide  to  indicate 
when  the  proper  amount  of  stimulation  has  been  reached,  it  being  remem- 
bered that  alcohol  does  not  act  as  an  antidote  to  the  poison,  but  simply  sus- 
tains the  vascular  and  nervous  systems  while  the  poison  is  being  eliminated 
through  the  natural  emunctories.  The  toxic  sequelae  in  cases  that  survive 
are  to  be  treated  upon  general  principles. 

SUEGICAL  DISEASES  DUE  TO   MICEOBIC  INFECTION. 

As  the  result  of  bacteriological  investigation,  the  number  of  surgical 
affections  Avhich  have  been  demonstrated  to  be  due  to  infection  by  a  specific 
microbe  has  become  quite  considerable.  The  processes  of  suppuration  and 
the  general  septic  disturbances  of  infected  wounds  have  already  received  full 
attention  as  respects  their  bacteriological  relation.  To  these  must  be  added  a 
series  of  distinct  surgical  diseases  in  the  causation  of  each  of  which  a  specific 
micro-organism  has  been  demonstrated  to  be  the  active  agent.  This  list 
includes  the  following  diseases :  Anthrax,  Rahies,  Glanders.  Actinomycosis, 
Erysipelas.  Tetanus.  Gonorrhea.  Tuberculosis,  and  Leprosy.  Of  these  the  last 
five  are  described  elsewhere.  The  first  four  it  seems  proper  to  consider  along 
with  "  Poisoned  Wounds."     They  are  usually  derived  from  animals. 

Rabies  is  generally  admitted  to  belong  to  this  class,  and  is  accordingly 
included  in  the  present  study,  although  a  satisfacton,-  demonstration  of  its 
specific  micro-organism  has  not  yet  been  made. 

There  is  much  evidence  to  show  that  syphilis  also  should  be  included  in 
this  list,  but  the  complete  and  indisputable  evidences  of  its  microbic  origin 
are  still  wanting. 

ANTHRAX, 

Malignant  Pustule,  Wool-sorter  s  Disease,  Charhon.  or  Mihhraml. — A  disease 
caused  by  infection  with  a  peculiar  rod-like  bacillus,  and  characterized  by 
an  acute  inflammatory  primary  local  lesion,  with  subsequent  general  infection 
of  the  fluids  and  tissues  of  the  body,  with  tendency  to  rapidly  fatal  ending. 
The  bacillus  of  anthrax  is  the  largest  of  the  pathogenic  organisms,  and  was 
the  first  to  be  detected,  having  been  identified  as  early  as  18-49  by  Pollender 
in  the  blood  of  cattle  suffering  from  the  disease.  The  organism  is  a  straight 
rod.  from  o  to  10  micro-millimeters  in  length  and  1  to  1.25  micro-millimeters 
in  breadth  ;  it  is  devoid  of  motion,  and  in  the  bodies  of  living  animals  multiplies 
exclusively  by  segmentation.  Under  certain  conditions  in  dead  nutrient  media 
spore-production  also  occurs.  The  disease,  according  to  Pasteur,  is  spread  among 
animals  by  germinating  spores,  which,  having  become  attached  to  plants  and 
grass,  are  taken  in  with  the  food  and  develop  the  primary  lesion  in  the  mouth 


CONTUSIONS   AND     WOUNDS.  129 

or  in  the  walls  of  the  intestines.     The  tenacity  of  life  of  these  spores  is  very 
great. 

Among  animals  the  herbivora  are  especially  susceptible  to  the  disease,  less 
so  the  oninivora,  and  least  so  the  carnivora.     The  disease  occurs  in  all  latitudes 
and  in  any  portion  of  the  world.     It  is  most  widely  spread  in   Russia  and 
Siberia,  and  is  particularly  coiiinioii  in  Ilunrrary  and  in  certain  parts  of  France 
and  Germany.     The  disease  in  man  is  always  acquired  from  affected  animals 
or  from  the  products  of  such  animals.     Any  part  or  tissue  of  an  animal  dead 
from  anthrax  is  capable  of  communicating  the  disease.     In  its  dried  state  the 
bacillus   is  able  to  preserve  its  virulence  for  many  years,  and  through  any 
substance  to  which  it  may  become  attached  the  disease  may  be  communicated ; 
even  the  feet  and  probosces  of  flies  which  have  alighted  upon  the  diseased  animal 
or  upon  the  infected  product  may  carry  the  disease,  and  earth-worms  carry  it 
from  the  buried  animals  to  the  grass  above.     Persons  who  work  in  industrial 
establishments  where  the  products  of  diseased  animals  may  be  among  the 
objects  of  their  labor,  as  hides,  horse-hair,  and  wool,  are  peculiarly  subject 
to  the  disease ;  hence  one  of  the  names  by  which  it  has  been  known,  Wool- 
sorter's  disease.  i      i      i      -n  •  u 
Infection  may  occur  equally  from  inoculation  with  the  bacillus  or  with 
spores.     When  the  skin  is  the  site  of  the  primary  lesion,  some  minute  scratch, 
abrasion,  or  insect-bite  may  suffice  for  the  inoculation;   the  unbroken  skin 
aff'ords  ample  protection  from  the  virus,  but  the  spores  when  inhaled  or  swal- 
lowed may  reach  the  circulation  through  a  healthy  mucous  surface. 

Symptoms  and  Course.— The  attention  of  the  surgeon  is  required  only 
in  those  cases  in  which  the  primary  lesion  is  external ;  cases  in  which  the 
bacillus  enters  the  organism  through  the  gastro-intestinal  canal  or  the  respi- 
ratory passages  fall  under  the  domain  of  internal  pathology,  and  for  their 
description  the  student  is  referred  to  text-books  on  general  medicine. 

The  character  of  the  primary  lesion  when  external  infection  has  taken 
place  depends  upon  the  anatomical  structure  of  the  part  aff"ected.  If  it  is  dense 
and  vascular,  a  circumscribed  carbuncular  inflammation  develops— anthrax 
carbuncle,  malignant  pustule;  if  the  infection  is  in  the  midst  of  loose 
connective  tissue  with  comparativelv  scanty  blood-supply,  a  diff"used  inflam- 
matory infiltration  manifests  itself— anthrax  oedema.  In  either  case  after 
infection  a  variable  period  of  incubation  intervenes  before  the  manifestation  of 
special  symptoms.  This  period  may  be  from  a  few  hours  to  three  days ;  m  rare 
instances  a  longer  period,  even  of  ten  to  fourteen  days,  has  occurred. 

Anthrax  Carbuncle.— A  slight  burning  and  itching  at  the  point  of 
infection,  with  the  rapid  development  of  a  papule  surmounted  by  a  small 
vesicle,  which,  bursting,  discloses  a  central  eschar,  are  the  first  manifestations 
of  the  disease.  The  inflammatory  infiltration  at  the  base  and  circumference  of 
this  primary  papule  rapidly  increases,  with  development  of  a  ring  of  secondary 
vesicles  around  the  margin  of  the  primary  eschar,  and  with  gradual  extension 
of  the  tissue-necrosis.  In  rare  instances  the  progress  of  the  disease  becomes 
spontaneously  limited  at  this  point;  a  gradual  subsidence  of  the  swelling  takes 
place  ;  the  slouc^h  becomes  detached  by  suppurative  inflammation,  and  the  ulcer 
heals  by  granufation.  More  commonly,  the  oedema  and  infiltration  continue  to 
spread,  the  eschar  extends,  phlebitis  and  lymphangitis  develop,  and  symptoms 
of  general  intoxication  follow,  terminating  speedily  in  death. 

Anthrax  CEdema  manifests  itself  by  the  appearance  at  the  point  ot 
infection  of  a  livid  diff"use  oedema  which  rapidly  spreads  in  all  directions ;  the 
swelling  may  become  enormous  in  its  extent  and  size,  and  at  diff'erent  points 
local  gangrene  of  the  skin  and  subcutaneous  tissue  may  occur,  preceded  by  the 

9 


i;JO  ^i.v  j.]//;A'/r.i.v   rKxr-iiooK  of  surgery. 

formation  of  blehs  upon  tin-  surface,  filltMl  wiili  Itloodv  scrum.  In  rare  instanee8 
spontaneous  recoverv  from  this  variety  of  antliiax  takes  ])lace. 

The  local  pain  is  slight,  and,  sis  long  as  the  diseased  process  is  limited, 
there  is  but  little  general  elevation  of  temperature,  the  patient  often  continuing 
to  bo  about  and  manifesting  simply  slight  chills  and  mild  fever,  (ieneral 
infection  is  shown  by  well-marked  rigors,  high  fever,  with  great  weakness, 
delirium,  feel)le  ])ulse,  sweating,  diarrhea,  and  acute  pains  in  many  jiortions  of 
the  body.  Cough,  rapid  respiration,  and  cyanosis  indicate  pulmonary  disturb- 
ance.     Collapse,  often  sudden  in  its  development,  closes  the  scene. 

Pathology. — The  tissue-changes  wiiich  are  discernible  in  cases  of  anthrax 
are  de])endent  upon  the  multiplication  and  diffusion  of  the  bacilli  in  the  capil- 
laries and  lymphatics.  The  local  changes  of  cedema  aiul  necrosis  are  due  to 
the  blocking  uj)  of  the  caj)illaries  by  the  bacilli  and  to  their  irritating  eflect 
upon  the  capillary  walls,  Avliich  produces  such  abundant  intlammatory  exuda- 
tion into  the  paravascular  and  connective-tissue  spaces  that  acute  ischemia 
results.  When  general  infection  has  taken  place,  the  capillaries  in  every  part 
of  the  body  teem  with  bacilli,  which  accumulate  in  largest  numbers  at  points 
where  the  blood-current  is  slowest.  In  the  most  vascular  organs,  like  the 
spleen,  liver,  and  kidneys,  the  bacilli  especially  abound.  They  form  thrombi 
in  the  capillaries  and  lymphatics,  from  which  multiple  and  more  or  less  exten- 
sive extravasations  into  all  the  tissues  result,  and  transudations  into  the  various 
serous  cavities  are  produced. 

Diagnosis. — The  typical  anthrax  carbuncle  is  not  likely  to  be  confounded 
with  any  other  aftection.  The  early  superficial  depressed  eschar,  the  tough 
slough  closely  attached  to  the  surrounding  tissues,  the  lack  of  sensitiveness  of 
the  swelling,  the  widely-extending  infiltration,  the  absence  of  suppuration,  and 
the  general  symptoms  Avhich  attend  its  later  course  form  a  picture  distinct  from 
that  which  characterizes  simple  inflammatory  carbuncle  with  its  prominent  cen- 
ter, its  multiple  soft,  suppurating,  sloughing  foci,  its  local  pain,  and  indolent 
inflammatory  course.  The  nmltiple  small  carbuncles  of  glanders  have  little  in 
common  with  the  carbuncle  of  anthrax.  Anthrax  oedema  at  its  outset  may  be 
confounded  with  acute  })hlegmonous  inflammation  or  with  malignant  oedema. 
Phlegmonous  inflammation  is  characterized  by  its  tendency  to  suppuration, 
which  at  once  distinguishes  it  from  anthrax.  In  malignant  oedema  the  necrosis 
is  attended  with  rapid  disintegration  and  liquefiiction  of  the  dead  tissue,  in 
marked  contrast  with  the  tough  and  adherent  sloughs  of  anthrax. 

In  all  cases  of  suspected  anthrax  microscojjic  examimition  of  the  fluids  of 
the  aff'ected  part  should  be  made.  The  anthrax  l)acillus  can  be  readily  stained 
and  identified  under  the  microscope.  ]Microscopic  findings  may  be  made  still 
more  positive  by  inoculation  experiments. 

Prognosis. — External  anthrax  which  is  allowed  to  take  its  own  course,  or 
in  which  the  treatment  is  too  long  delayed,  is  very  grave,  but  when  an  early 
diagnosis  is  made  and  energetic,  rational  treatment  is  at  once  instituted,  the 
prognosis  is  usually  favorable.  When  general  infection  of  the  system  has 
occurred,  the  result  is  uniformly  fatal.  The  prognosis  of  the  oedcmatous  vari- 
ety is  more  grave  than  that  of  the  carbuncular,  in  consequence  of  the  greater 
liability  to  general  infection  which  attends  the  former.  In  either  case  the  fatal 
termination  is  due,  probably,  as  indicated  by  the  most  recent  researches  of 
bacteriologists  (Bollinger),  to  toxic  ptomaines  formed  in  the  body  by  the 
bacilli  as  the  products  of  their  growth. 

Treatment. — All  treatment  must  be  conducted  ujion  antiseptic  lines,  and 
should  be  energetic,  and  instituted  at  the  earliest  possible  moment.  Excision 
of  the  infected  area  should,  if  possible,  be  done,  the  incisions  being  carried 


CONTUSIONS    AN  J)     UOlNnS.  131 

wido  of  till'  (lisoiisc,  tliroiigli  healthy  tissue  if  ])ossible;  special  care  must  be 
taken  to  ))revent  infection  of  the  oj)enitivc  wound  from  the  diseased  mass  that 
is  excised.  To  ^uard  against  the  results  of  possible  infection,  the  exposed  sur- 
face remain int;  after  the  excision  should  be  thoroughly  mopped  over  with  a 
strong  solution  of  carbolic  acid,  1  :  10,  or  oven  with  the  pure  acid,  or  of  cldo- 
ride  of  zinc,  1  :  8,  or  the  actual  cautery  may  be  applied.  The  innnediate  appli- 
cation of  the  actual  cautery  at  the  seat  of  inoculation,  whenever  such  an  inocu- 
lation is  recognized  as  having  taken  place,  will  destroy  the  virus  and  prevent 
subse(iuent  evil.  When  excision  of  the  entire  infected  area  is  impracticable, 
multiple  deep  crucial  incisions  should  be  made  into  it,  accompanied  by  injec- 
tions of  carbolic  acid,  1  :  10,  by  means  of  a  hypodermatic  syringe,  systemati- 
cally administered  so  as  to  diffuse  the  carbolic  solution  throughout  the  entire 
extent  of  the  base  of  the  affected  tissue  and  through  the  surrounding  healthy 
tissue.  The  punctures  should  be  made  just  outside  the  borders  of  infiltration, 
the  needle  passed  to  the  center  of  the  infected  area,  and  the  solution  slowly 
expelled  as  the  needle  is  withdrawn.  The  carbolic  solution  should  be  mopped 
freely  into  the  cuts,  and  injections  should  also  be  made  into  the  substance  of 
the  diseased  mass,  so  as  to  thoroughly  saturate  it  with  the  antiseptic,  while  at 
the  same  time  an  ice-bag  should  be  kept  applied  upon  its  surface,  and  the 
whole  part  sliould  be  enveloped  in  compresses  saturated  with  sublimate  solution, 
1:1000.  The  carbolic  injections  maybe  repeated  every  six  hours  until  the 
disease  is  manifestly  under  control  or  until  symptoms  of  carbolic-acid  poisoning 
are  developed.  The  treatment  of  the  subsequent  slough  is  to  be  conducted  on 
general  antiseptic  principles. 

The  constitutional  symptoms  of  prostration  and  threatening  collapse  are  to 
be  met  by  stimulant,  tonic,  and  supporting  measures. 

HYDROPHOBIA   (rABIES,    LYSSA). 

Hydrophobia  in  man  is  an  infectious  disease  resulting  from  the  inoculation 
of  a  specific  virus  from  an  animal  suffering  from  rabies.  After  a  variable 
period  of  incubation  following  the  primary  inoculation,  the  disease  declares 
itself  by  certain  spasmodic  muscular  phenomena,  followed  by  great  general 
prostration  and  ultimate  rapidly-ascending  paralysis,  significant  of  lesions  of 
the  spinal  cord,  in  which  organ,  especially  the  medulla  oblongata,  the  effects 
of  the  virus  are  chiefly  centered. 

Etiology. — Hydrophobia  in  man  is  always  the  result  of  inoculations  with 
the  virus  of  a  rabid  animal,  most  frequently  the  dog  (90  per  cent.),  less  fre- 
quently cats,  wolves,  and  foxes.  Not  all  persons  bitten  by  rabid  animals 
develop  hydrophobia.  It  is  often  impossible  to  secure  reliable  statistics  on 
this  point.  In  many  cases,  certainly,  bites  are  inflicted  by  dogs  supposed  to  be 
rabid,  but  that  are  in  fact  not  so  ;  in  other  cases  bites  have  been  inflicted  bv  dogs 
really  rabid  in  which  the  infecting  saliva  was  wiped  off  by  the  clothing  through 
Avhich  the  teeth  passed,  and  the  wounds  Avere  thus  preserved  from  infection. 
In  yet  other  cases  wounds  that  were  really  infected  have  been  subjected  to 
adequate  immediate  cauterization,  and  thus  the  later  development  of  the  disease 
prevented.  There  is,  however,  sufiicient  experience  to  warrant  the  general 
statement  that  about  12  to  14  per  cent,  of  those  who  are  bitten  develop  the  dis- 
ease (Roux),  and  of  these  all  die.  As  regards  immunity,  no  relation  is  trace- 
able either  to  age  or  sex. 

While  the  ordinary  medium  of  infection  is  the  saliva  of  a  rabid  animal,  the 
disease  can  also  be  produced  by  inoculation  with  other  fluids  and  tissues  of 
such  an  animal.  All  the  conditions  relating  to  the  propagation,  development,  and 


132  AN  AMERICAN    TEXT-BOOK    OF  SURGERY. 

course  of  the  disease  indicate  that  it  is  due  to  a  specific  micro-organism,  which, 
by  its  multiplication  within  the  body,  finally  causes  the  ultimate  overwhelming 
symptoms  of  the  disease.  This  micro-organism,  however,  has  not  as  yet  been 
satisfactorily  demonstrated. 

Pathology. — No  well-defined,  gross  pathological  changes  attend  hydro- 
phobia. Microscopic  examination  of  the  medulla  oblongata  and  the  spinal 
cord  shows  irritative  lesions,  marked  by  an  infiltration  of  the  perivascular 
sheaths  with  leucocytes,  which  at  points  may  be  accumulated  in  considerable 
number.  Hyperemia  and  moderate  oedema  of  the  brain  and  spinal  cord  and 
their  membranes  as  a  rule  are  present.  The  pharynx,  fauces,  and  neigliboring 
lymphatic  glands  are  usually  congested,  as  is  also  the  mucous  membrane  of 
the  stomach  and  intestinal  canal ;  the  lungs  and  kidneys  present  general  dif- 
fused, congestive  conditions,  the  whole  condition  indicating  the  presence  in  the 
circulating  fluid  of  an  intense  irritant.  The  heart,  spleen  and  liver  are,  as  a 
rule,  normal. 

Symptoms. — ^tage  of  Incubation. — A  period  varying  greatly  in  length 
intervenes  between  the  time  of  inoculation  and  the  appearance  of  any  constitu- 
tional disturbance.  The  average  period  of  incubation  is  about  six  weeks ;  it 
is  seldom  less  than  fourteen  days,  and  may  be  protracted  to  some  months. 
There  is  credible  evidence  that  in  extremely  rare  cases  this  period  has  been 
prolonged  to  between  one  and  two  years.  During  this  time  the  persons  bitten 
feel  well  and  present  no  symptoms  whatever  of  the  dormant  disease ;  the  local 
■wound  heals  kindly.  In  the  young  the  period  of  incubation  averages  less  than 
in  the  old. 

Premonitory  Stage. — The  outbreak  of  general  symptoms  is  usually  pre- 
ceded by  a  brief  period,  generally  not  more  than  twenty-four  hours,  rarely 
extended  to  two  or  three  days,  during  Avhieh  ill-defined  premonitoiy  symptoms 
manifest  themselves ;  some  uneasiness  or  pain  is  felt  in  the  region  of  the  wound, 
the  cicatrix  of  which  may  become  congested  and  tender  ;  in  other  cases  all  such 
local  symptoms  are  absent.  Symptoms  of  constitutional  disturbance  declare 
themselves  with  headache,  loss  of  appetite,  sleeplessness,  and  much  mental 
depression  and  irritability,  with  tendency  to  aimless  Avandering  about,  accom- 
panied by  great  anxiety  and  apprehension,  especially  if  the  patient  recalls  the 
fact  that  he  has  been  bitten.  A  general  hyperesthesia  soon  shows  itself,  as 
evinced  by  sensitiveness  to  currents  of  air  and  to  light.  The  stage  of  the  full 
development  of  the  disease  is  now  ushered  in  by  noticeable  spasms  of  the  mus- 
cles of  deglutition,  causing  a  sense  of  tightness  and  choking  about  the  pharynx, 
producing  difficulty  in  speaking  and  in  swallowing,  and  hence  dread  of  fluids, 
although  there  is  intense  thirst.  Examination  of  the  pharynx  will  show  that 
its  mucous  membrane  is  congested  and  that  there  is  an  abundant  secretion  of 
viscid  saliva,  which,  since  it  cannot  be  swallowed,  causes  frequent  hawking  and 
spitting  to  get  rid  of  it.  Occasionally  the  precursory  symptoms  are  absent, 
and  the  first  manifestations  of  the  disease  are  spasmodic  contractions  of  the 
pharynx  occurring  while  attempting  to  drink  or  precipitated  by  some  mental 
agitation  ;  at  other  times  some  oppression  of  breathing  is  first  noticed,  culmi- 
nating in  marked  suffocative  attacks  from  spasmodic  contractions  of  the  upper 
respiratory  muscles,  combined  usually  with  the  already  described  pharyngeal 
symptoms. 

Stage  of  Excitement. — The  disease  has  now  fully  declared  itself.  The 
spasms  of  the  muscles  of  deglutition  and  respiration  are  more  marked  and 
more  easily  excited ;  swallowing  becomes  impossible;  the  mere  suggestion  of 
it  suffices  to  bring  on  spasm.  Currents  of  air,  an  unexpected  touch,  the 
slightest  source  of  agitation,  will  suffice  to  provoke  the  convulsion.     The 


CONTUSIONS  AND    WOUNDS.  133 

embarrassment  of  the  breathing  caused  by  the  spasms  of  the  respiratory  mus- 
cles is  often  great,  producing  a  sensation  of  impending  suffocation ;  trequently 
the  entire  muscuhir  system  will  share  in  the  convulsive  attacks  Ihese  suc- 
cessive muscular  spasms  are  separated  by  periods  of  complete  relaxation,  there 
bein'T  no  tonic  spasms,  as  in  tetanus.  •     i     i        v. 

The  mental  faculties  remain  for  the  most  part  unimpaired,  though  excite- 
ment  anxiety,  and  terror  occupy  the  mind.     Intervals   during  which  hallu- 
cinations develop  are  common.     The  duration  of  the  convulsive  paroxysms  is 
variable  •   they  rarely  continue  longer  than  from  one-half  to  three-quarters  ot 
an  hour,' and"  usually  for  a  much  shorter  period.     During  the  paroxysms  the 
excitability  and  restlessness  of  the  patient,  combined  with  dyspnea  and  with 
hallucinations,  may  produce  a  condition  similar  to  mama.     In  the  intervals 
between  the  attacks  the  mind  appears  clear:  these  intervals  are  likewise  ot 
variable  lencrth,  very  brief  at  times,  at  others  prolonged  for  several  hours.     In 
rare  instances  the   convulsive  paroxysms  are  completely  absent,  the  patient 
complaining  merely  of  great  anxiety  and  difficulty  in  breathing.     In  excep- 
tional cases  the  patient  is  able  to  swallow  food  during  the  entire  course  of  the 
disease,  although  the  act  is  accompanied  by  pain.     As  a  rule,  the  taking  ot 
solid  food  is  impossible,  but  in  exceptional  cases  such  food  is  swallowed  without 
difficulty.     The  pulse  at  the  beginning  of  the  attack  is  normal  in  character, 
but,  as  the  disease  progresses,  grows  gradually  weaker  and  quicker,  until  as 
death  approaches  it  is  no  longer  perceptible.     The  body-temperature  is  some- 
what increased,  ranging  from  100°  to  103°  F.,  seldom  rising  as  high  as  lOo 
The  urine  is  scanty,  free  from  albumen,  and  frequently  contains  an  appreciable 

amount  of  sugar.  ,  .         .  ^    ^       u         • 

This  sta^re  of  excitement  may  prevail  from  thirty-six  to  seventy-two  hours , 
during  its  c^'ourse  death  may  occur  amid  the  convulsions  from  exhaustion  or 
from  asphyxia;  more  frequently  there  is  a  gradual  transition  to  a  state  ot 
comparative  tranquillity— the  last  stage  of  the  disease,  the  stage  of  paralysis. 
There  is  then  a  gradual  remission  of  the  severe  symptoms ;  the  reflex  nervous 
excitability  diminishes,  resulting  in  freer  respiration  and  the  recovery  ot 
the  ability  to  swallow,  while  the  general  debility  and  prostration  rapidly 
increase.  The  convulsions  become  feebler  and  cease  entirely.  It  lite  is 
sufficiently  prolonged,  a  condition  of  rapidly-ascending  paralysis  supervenes, 
and  symptoms  of  respiratory  and  cardiac  failure  develop,  terminating  in 
death.  The  duration  of  the  final  stage  of  hydrophobia  is  brief,  being,  as  a 
rule,  between  two  and  eighteen  hours. 

Diagnosis.— Hydrophobia  is  to  be  distinguished  from  tetanus,  trom  the 
effects  of  mental  agitation  and  fear  simulating  hydrophobia  (hydrophobia 
imaginaria,  lyssophobia),  and  from  certain  forms  of  hysteria  and  epilepsy  m 
which  symptoms  affecting  the  organs  of  deglutition  are  manifested  analogous  to 
those  observed  in  genuine  rabies.  The  positive  history  of  a  bite  from  a  prob- 
ably rabid  animal,  the  prolonged  period  of  incubation  m  hydrophobia,  the  tact 
that  in  this  disease  the  spasms  affect  the  muscles  of  deglutition,  and  not  those  ot 
mastication,  as  in  tetanus,  and  are  not  tonic  in  their  character,  and  that  the  respi- 
ratory embarrassment  is  due  to  spasm  of  the  laryngeal  muscles,  and  not  to  those 
of  the  chest,  will  suffice  to  distinguish  between  these  affections  if  any  doubt 
should  otherwise  exist.  The  pseudo-hydrophobic  symptoms  which  are  sometimes 
manifested  in  the  course  of  other  affections  of  the  nervous  system  are  distin- 
guished, as  a  rule,  by  the  absence  of  the  general  reflex  excitability  which  is  a 
marked  feature  of  genuine  hydrophobia.  The  development  of  symptoms  closely 
simulating  genuine  hydrophobia,  through  the  effects  of  fear  and  anxiety,  in 
persons  of  hTghly  excitable  and  imaginative  temperament  who  have  been  bitten 


134  AN  AMERICAN    TEXT-JiOOK    OF  SUUaEliV. 

by  animals  which  Avere  not  rabid,  is  avcII  authenticated.  Such  cases  may  even 
proceed  to  a  fatal  termination,  although,  as  a  rule,  under  appropriate  treatment 
recovery  takes  ])lace ;  which  fact  is  sufficient  to  demonstrate  that  the  case  was 
not  one  of  true  hydrophobia.  Upon  the  result  of  an  examination  of  all  the 
circumstances  that  surround  the  case  must  depend  the  conclusion  as  to  the  real 
character  of  such  an  attack. 

Prognosis. — The  i)rognosis  is  absolutely  hopeless  in  genuine  hydrophobia 
when  once  the  symptoms  of  the  disease  have  declared  themselves. 

Treatment. — Palliative  treatment  is  all  that  any  case  admits  of,  but  the 
utmost  importance  attaches  to  prophylaxis.  The  patient  should  be  kept  in  a 
dark  and  quiet  room,  and  as  absolutely  free  from  every  sourc(i  of  agitation  as 
possible.  Morphia  should  be  administered  hypodermatically  in  amounts  suf- 
ficient to  relieve  pain.  The  severity  of  the  spasmodic  paroxysms  should  be 
mitigated  by  inhalations  of  chloroform.  Thirst  should  be  relieved  as  far  as 
possible  by  rectal  cnemata. 

Prophylaxis. — Every  wound  inflicted  by  a  possibly  rabid  animal  should  be 
subjected  as  soon  as  possible  either  to  free  excision  or  to  thorough  cauteriza- 
tion. In  any  interval  that  must  elapse  until  this  can  be  done  constriction 
should  be  applied  upon  the  proximal  side  of  the  wound  if  possible.  If  the 
part  bitten  is  one  in  which  the  knife  can  be  used  freely,  excision  is  preferable, 
the  cuts  being  made  wide  of  the  bitten  part,  the  resultant  wound  being 
thoroughly  disinfected  and  sutured  or  treated  openly  as  its  special  conditions 
may  require.  If  cauterization  is  more  feasible,  it  should  be  done  with  the 
actual  cautery  if  possible,  which  should  be  applied  deeply  and  thoroughly. 
Of  chemical  caustics,  caustic  potash  or  fuming  nitric  acid  is  to  be  preferred. 

Prophylactic  inoculations  with  emulsions  of  the  dried  spinal  cords  of  rab- 
bits infected  Avith  hydrophobia,  after  the  method  of  Pasteur,  have  certainly 
been  proved  to  be  of  value  in  establishing  absolute  immunity  against  the 
strongest  hydrophobic  infection  if  the  series  of  inoculations  is  conq»leted  a 
sufficient  time  before  the  actual  development  of  constitutional  symptoms.  The 
earlier  the  inoculations  are  begun  after  the  infection  has  been  received,  the 
greater  the  certainty  of  the  immunity  conferred  by  them.  The  practical  appli- 
cation of  the  method  depends  upon  the  discovery  that  the  virulence  of  such 
infected  spinal  cords  may  be  reduced  progressively  from  the  highest  degree  to 
nothing,  according  to  the  length  of  time  during  which  the  cord  is  preserved 
in  a  dry  and  pure  atmosphere,  fourteen  days'  drying  being  sufficient  to  destroy 
all  virulence.  Injections  are  made,  beginning  with  emulsions  of  the  weakest 
virulence  and  passing  gradually  to  the  strongest.  The  duration  of  treatment 
varies  slightly  according  to  the  severity  of  the  bites.  In  bites  about  the  head 
the  incubation  period  is  often  very  short ;  in  such  cases,  therefore,  promptness 
of  action  is  especially  necessary,  and  in  order  to  save  time  the  number  of 
injections  made  during  the  earlier  days  of  the  treatment  is  increased. 

Institutions  for  carrying  on  this  method  of  treatment  have  been  established 
in  various  parts  of  the  world.  About  15  per  cent,  of  persons  bitten  by  sup- 
posedly rabid  animals  develop  hydrophobia,  and  the  mortality  is  lUO  j)er  cent. 
As  the  result  of  these  inoculations  the  mortality  among  persons  who  were 
believed  to  have  been  bitten  by  rabi<l  animals  and  avIio  were  submitted  to 
the  treatment  was  reported  in  1890  to  have  been  but  .U2  per  cent.  In  18U4 
there  was  reported  from  the  same  institute  a  mortality  of  but  .50  per  cent.  ; 
in  St.  Petersburg  in  1893  a  mortality  of  .84  per  cent. ;  in  Turin  in  1894  the 
mortality  for  ten  years  was  .95  per  cent.  In  view,  therefore,  of  these  results, 
and  in  view  of  the  great  danger  of  the  possible  development  of  hydrophobic 
symptoms  in  a  person  bitten  by  an  animal  snITering  from  rabies,  and  the  utter 


rONTUSTONS    A  XI)     W'orXDS.  1^,5 

hopelessness  of  any  otlier  treatment  if  tlic  disease  develops,  it  would  be  the 
part  of  wisdom  in  all  oases  of  bites  from  ])r('sumably  rabid  animals  to  subject 
the  patients  to  the  Pasteur  treatment  if  possible. 

GLANDERS   (fAHCY  ;    EQUINIA). 

Glanders  is  a  contagious,  eruptive,  ulcerative  disease,  primarily  of  horses 
and  their  congeners,  asses  and  nniles,  caused  by  their  infection  with  a,  specific 
micro-organism,  the  haclllus  mallei  (p.  9).  It  is  capal)le  of  being  transmitted 
to  men,  as  well  as  to  many  of  the  lower  animals,  by  inoculation.  The  special 
manifestations  and  course  of  the  disease  vary  much,  being  dependent  upon  the 
location  and  cliaracter  of  the  tissues  first  inoculated  and  the  amount  and  viru- 
lence of  the  inoculating  material. 

The  bacillus  of  glanders  is  a  small  rod,  somewhat  shorter  and  broader  than 
the  tubercle  bacillus ;  it  is  either  straight  or  slightly  curved,  rounded  at  its 
ends,  and  is  usually  found  in  pairs,  the  two  lying  parallel  with  each  other  and 
held  together  by  a  delicate  pellicle.  The  existence  of  spores  is  in  doubt. 
The  bacilli  may  be  killed  by  exposure  for  ten  minutes  to  a  temperature 
of  131°  F,  (55°  C).  Carbolic  acid  in  5  per  cent,  solution  destroys  them 
in  five  minutes,  and  corrosive  sublimate  in  1  :  5000  solution  in  two  minutes. 
Their  tenacity  of  life,  under  ordinary  circumstances  is  great,  so  that  v^irus 
that  has  been  in  the  dried  condition  for  many  months  may  be  eifective. 

Etiology. — Infection  occurs  usually  through  some  abrasion  or  wound ;  the 
possibility,  however,  of  infection  through  an  unbroken  skin  by  rubbing  the 
virus  into  the  hair-follicles  has  been  demonstrated.  Inoculation  through  an 
unbroken  surface  along  the  mucous  lining  of  the  nasal  and  respiratory  pas- 
sages, or  the  conjunctiva,  is  not  rare  through  the  lodgment  thereon  of  par- 
ticles of  infected  muco-pus  deposited  there  by  the  snortings  of  infected  animals. 
As  a  rule,  diseased  horses  are  the  source  of  infection  in  the  human  subject;  in 
rare  instances  the  disease  has  been  transmitted  from  man  to  man.  But  a  small 
proportion  of  the  persons  who  are  exposed  to  infection  develop  the  disease. 

Pathological  Anatomy. — The  histological  changes  determined  by  the 
presence  of  the  bacillus  in  the  tissues  consist  of  a  low  grade  of  inflammation, 
resulting  in  the  formation  of  nodules  of  embryonal  or  granulation-tissue, 
which  speedily  break  down  into  pus,  forming  more  or  less  extensive  abscesses, 
which,  when  they  open  upon  free  surfaces,  degenerate  into  ill-conditioned 
phagedenic  ulcers  with  undermined  edges,  surrounded  by  extensive  areas  of 
inflammation.  Dissemination  of  this  series  of  diseased  processes  may  take 
place  throughout  all  the  organs  and  regions  of  the  body  by  continuous  exten- 
sion, by  transmission  along  lymphatic  channels,  and  by  emboli  carried  in  the 
blood-stream.  The  lesions  of  glanders  appear  first  in  the  skin  and  the  subcu- 
taneous cellular  tissue,  and  upon  the  mucous  membrane  of  the  nares  and  respi- 
ratory passages.  Post-mortem  examinations  show  similar  lesions  in  the  lungs, 
many  of  the  muscles,  the  larger  joints,  and  the  great  viscera.  The  cartilages 
and  bones  are  likewise  involved,  sometimes  primarily,  but  more  frequently 
secondarily  through  contiguity.  The  lesions  of  ordinary  pyemia  are  super- 
added to  the  specific  lesions  of  glanders  as  soon  as  the  suppurative  processes 
become  at  all  general. 

Symptoms. — The  symptoms  that  follow  infection  with  glanders  maybe 
rapid  in  their  course,  manifesting  a  high  grade  of  malignancy,  and  terminating 
in  death  within  tw^o  or  three  weeks,  or  they  may  be  slower  in  their  develop- 
ment and  progress,  extending  over  a  period  of  many  months  ;  hence  the  classi- 
fication which  has  been  made  into  Acute  and  Ohronic  Glanders.     When  the 


136  AX  AMKIiirAX  TEXT-BOOK  OF  Si'RGKIiV. 

lesions  are  well  marked  ami  ahnmlant  in  the  skin,  the  special  term  Farcy  has 
been  aj)jtlii'<l,  more  )»articularly  to  the  disease  amont:  horses. 

After  infection  a  stage  of  incubation  of  varvinfr  len<rth  elapses,  usually  of  but 
a  few  (lays,  but  possibly  prolonged  to  two  or  three  weeks.  "S'aguc  symptoms  of 
general  malaise  usher  in  the  special  symptoms  of  the  disease ;  an  inflammatory 
nodule  appeai-s  at  the  point  of  inoculation,  attended  with  pain  and  an  extend 
ing  zone  of  inflammatory  congestion,  involving  especially  the  lymphatic  trunks  ; 
fever  develops ;  the  primary  nodule  suppurates  and  breaks  down  into  an  ill- 
conditioned  phagedenic  ulcer.  If  the  primary  lesion  is  in  the  mucous  mem- 
brane of  the  nose,  the  progressive  ulceration  soon  destroys  the  soft  parts  and 
attacks  the  bones,  the  neighboring  tissues  of  the  face,  pharynx,  and  palate 
become  involved,  and  the  whole  of  the  face  and  neck  becomes  swollen  and 
inflamed.  In  the  further  course  of  the  disease,  without  regard  to  the  seat  of 
the  priman-  lesion,  multiple  nodules  develop  on  diff'erent  parts  of  the  skin ; 
these  quickly  suppurate  and  degenerate  into  off"ensive  ulcers,  or  larger  swellings 
and  abscesses  are  formed  which  become  converted  into  extensive  and  deeply- 
burrowing  ulcers.  These  diffused  skin  lesions  may  appear  within  one  or  two 
days  from  the  onset  of  the  attack,  or  their  appearance  may  be  delayed  some 
weeks.  In  the  second  or  third  week  of  the  attack  an  outbreak  occurs  upon 
the  mucous  surfaces,  primarily  that  of  the  nose  if  it  has  not  been  the  seat 
of  tlie  original  lesion.  Other  mucous  surfaces — of  the  eye,  mouth,  fauces, 
respiratoi-y  and  gastro-intestinal  tracts — rapidly  take  on  the  same  conditions. 
If  the  infection  has  been  an  internal  one.  the  gastro-intestinal  disturbance,  the 
fever,  and  the  general  prostration  may  cause  the  case  to  simulate  for  a  time 
tvphoid  fever.  The  due  development  of  external  manifestations  suflSces  in 
time  to  correct  the  eiTor.  In  cases  running  an  acute  course  febrile  exacerba- 
tions become  marked.  The  emaciation  and  prostration  increase,  all  the  symp- 
toms of  profound  septic  infection  develop,  with  delirium,  terminating  in  stupor 
and  final  death  in  collapse.  In  some  cases  the  fatal  result  is  accelerated  by  the 
disturbances  consequent  upon  bronchial  and  pulmonary  conditions. 

In  those  cases  which  pursue  a  chronic  course  the  development  of  the 
lesions  is  more  gradual  and  less  generalized.  The  constitutional  symptoms 
depend  upon  the  number,  size,  and  situation  of  the  local  lesions,  and  upon  the 
amount  of  general  septic  infection  which  is  present.  Often,  cases  after  pursu- 
ing a  chronic  course  for  a  time  take  on  an  acute  character  and  rapidly  hasten 
to  a  fatal  termination ;  in  other  cases  death  occurs  from  exhaustion  and 
septicemia  or  from  pulmonary  and  bronchial  complications.  Many  chronic 
cases,  however,  ultimately  display  a  gradual  amelioration  of  all  the  symptoms ; 
cicatrization  of  the  ulcers  and  healing  of  the  abscesses  .«lowly  take  place, 
and  eventual  recovery  is  secured,  more  or  less  perfect,  but  the  patient  is  always 
seriously  crippled.  The  average  duration  of  the  chronic  form  is  about  four 
months. 

Diagnosis. — The  acute  form  in  its  earlier  stages  is  liable  to  be  confounded 
with  acute  suppurative  lesions,  and  even,  in  some  of  its  manifestations,  with 
rheumatism  and  typhoid  fever.  Its  later  manifestations  may  be  referred  to 
pyemia,  which  usually  complicates  it.  but  when  the  local  phenomena  are  once 
fully  developed  the  diagnosis  is  free  from  uncertainty:  the  knowledge  that  a 
patient  has  had  to  do  with  horses  will  aid  in  forming  a  diagnosis.  The  chronic 
form  is  more  likely  to  be  confounded  with  syphilis  or  tuberculosis.  Where 
doubt  exists  search  should  be  made  for  the  specific  micro-organisms  in  the 
nodules  or  the  discharges :  their  detection  will  render  the  diagnosis  positive. 
Inoculation  experiments  on  animals  may  also  be  resorted  to. 

Prognosis. — The  acute  form  of  glanders  is  always  fatal.     When  it  man- 


CONTUSIONS  AND    WOUNDS. 


13' 


ifests  a  tendency  to  run  a  chronic  course  the  prognosis  is  relatively  favorable, 
for  about  one-half  such  cases  ultimately  recover.  As  long  as  the  lesions  remain 
limited  to  regions  accessible  to  direct  surgical  treatment  hope  may  be  enter- 
tained of  securing  a  cure. 

Treatment. — Prophylaxis  is  of  the  utmost  importance.  This  consists 
simply  in  the  immediate  destruction  of  all  animals  affected  or  suspected  ;  the 
burning  of  all  substances  soiled  with  the  infecting  discharges ;  and  the  utmost 
carefulness  on  the  part  of  all  persons  having  to  do  with  infected  animals  to 
guard  against  the  possibility  of  inoculation. 

When  a  point  of  inoculation  has  occurred,  immediate  thorough  disinfection 
and  cauterization  should  be  done.  If  nodules  and  abscesses  develop,  they 
should  be  at  once  thoroughly  laid  open,  curetted,  and  disinfected.  Chloride 
of  zinc  in  solution,  1  :  8,  is  to  be  recommended  for  such  disinfection.  All  sur- 
faces that  have  been  affected  should  be  subjected  to  continuous  antiseptic 
applications.  The  general  treatment  must  consist  of  tonics,  nutrients,  and 
stimulants  freely  administered. 


Fig.  24. 


ACTINOMYCOSIS. 

Actinomycosis  is  an  infectious  disease  due  to  the  presence  in  the  tissues  of 
a  peculiar  fungus,  termed  actinomyces  (ray  fungus),  and  characterized  by  the 
development  of  tumor-like  masses  at  the  points  of  infection,  which  readily 
undergo  softening  and  suppuration,  with  continuous  extension  of  the  original 
process  into  adjacent  tissue   (Fig.    24). 

Etiology. — The  source  from  which  the  infecting  fungus  is  derived  has  not 
been  determined.  The  disease  has  as  yet  been  found  only  among  herbivor- 
ous and  omnivorous  animals,  including  man.  The  medium  of  infection  is 
probably  some  article  of  food.  The  recognition  of  the  disease  as  a  specific 
one  is  of  recent  origin.  Bollinger  first,  in  1877,  described  the  relation  of 
the  fungus  to  certain  swellings  of  the  lower  jaw  in  cattle.  Its  recognition  in 
man  is  due  to  the  labors  of  Israel  and  Pon- 
fick,  especially  the  latter,  the  results  of  whose 
researches  were  published  in  1882.  Since  at- 
tention was  called  to  it  many  cases,  not  a  few 
of  which  have  occurred  in  the  United  States, 
have  been  identified  by  different  observers. 
The  disease  has  heretofore  been  confounded 
with  sarcoma,  since  the  granulation-tissue 
which  composes  the  greater  mass  of  the  tumors 
has  the  microscopical  structure  of  the  round- 
cell  sarcoma.  Section  through  the  tumor,  how- 
ever, will  show  many  soft,  sulphur-yellow  col- 
ored spots  in  strong  contrast  with  the  general 
reddish  tissue  of  the  growth.  If  the  tumor  has 
already  fallen  into  suppuration,  the  pus  will  be 
found  to  contain  numbers  of  sulphur-yellow 
miliary  bodies ;  these  are  frequently  united 
together  in  clusters,  and  have  a  soft  consist- 
ence and  an  unctuous  feel.  By  pressure  these 
clusters  are  easily  separated  into  smaller  gran- 
ules. These  little  granules,  when  viewed  under  the  microscope,  are  found  to 
consist  of  intertwined  mycelia,  the  single  threads  of  which  have  bulbous  ter- 
mini.    In   many  cases  a  single  filament  will  terminate  in  a  mass  of  bulba 


Actinomyces  (Coplin  and  Bevan). 


138  ^i.V  AMERICAN  TEXT-BOOK  OF  SUIiOEEY. 

branchiiicr  in  various  directions.  A  frequent,  and  appirently  tlie  lii^rliest.  type 
of  develojjnu'iit  is  when  the  *rranule  is  eonipose<I  of  a  niultitu(h'  of  fihmients 
radiatinir  from  a  coninion  center,  tlieir  bulbous  termini  presentiii;:  upon  the 
periphery.  'J'hat  this  ray  fungus  is  the  specific  cause  of  the  disease  has  heen 
establislied  by  cidtivation  and  inoculation  experiments. 

Pathological  Anatomy. — The  primary  effect  of  the  lodgment  of  the 
fungus  in  the  tissues  is  to  excite  a  low  grade  of  chronic  inflammation,  resulting 
in  the  accumulation  of  a  mass  of  granulation-tissue,  in  the  midst  of  which  the 
fungus  is  iuibedded.  By  tlie  continued  formation  and  accumulation  of  such 
masses  swellings  of  considerable  size  result.  The  disease  may  remain  stationary 
in  this  stage  for  an  indefinite  time,  though,  as  a  rule,  degenerative  processes 
begin  early,  the  breaking  down  of  the  tumor  resulting  from  a  process  of  sup- 
purative inflammation.  The  fungus  is  probably  not  itself  pyogenic :  the  sup- 
puration that  occurs  is  due  to  secondary  infection  with  pus-microbes. 

Symptoms. — In  cattle  the  disease  occurs  most  frequently  in  the  lower  jaw, 
hence  the  name  "  lumpy  jaw  "  by  which  it  has  been  characterized:  in  man, 
likewise,  the  lower  jaw  is  most  frequently  aifected,  and  in  a  very*  large  propor- 
tion of  cases  the  disease  has  its  site  in  some  tissue  adjacent  to  the  mouth  (of 
73  cases  reported  by  Moosbruegger,  in  41  the  jaws,  mouth,  throat,  tongue,  or 
oesophagus  were  involved;  in  14.  the  respiratory  tract;  in  11,  the  intestines; 
in  the  remaining  7  the  point  of  infection  was  not  ascertained).  Wherever  the 
disease  is,  the  symptoms  are  those  of  an  ill-defined,  slowly-increasing  swelling. 
The  lymphatics  are  not  involved,  and  there  are  no  glandular  enlargements 
until  secondary  infection  has  occurred ;  suppuration  sets  in  early  when  the 
growth  is  in  regions  most  likely  to  be  infected  with  pus-microbes.  A 
chronic  abscess  is  now  inaugurated,  and  the  local  and  constitutional  symp- 
toms which  follow  are  due  to  the  activity  of  the  secondary  infective  pro- 
cess and  the  extent  of  the  septic  infection  which  results.  Diff'usion  of  the 
actinomyces,  with  the  development  of  the  disease  in  distant  organs  and  parts 
of  the  body,  may  occur  when  the  fungus  or  its  spores  have  obtained  entrance 
into  the  general  circulation  through  an  opening  in  a  vein-wall  which  may  have 
occurred  during  the  process  of  ulceration  :  such  general  dissemination  is  of  rare 
occurrence.  In  general,  the  disease  remains  localized,  and  extends  steadily 
from  the  original  point  of  infection  into  adjacent  tissues,  invading  every  tissue 
•with  which  it  comes  in  contact,  irrespective  of  its  anatomical  structure.  Before 
suppuration  takes  place  the  swelling  is  quite  firm  on  pressure  and  free  from  pain 
and  tenderness ;  the  condition  of  suppurative  inflammation,  once  established, 
favors  the  growth  and  extension  of  the  specific  disease  l)y  setting  free  and  dif- 
fusing the  actinomyces.  The  pus  discharging  from  actinomycotic  abscesses 
always  contains  the  actinomyces,  which  can  usually  be  detected  by  the  naked 
eye  as  minute  yelloAvish  granules. 

Diagnosis. — The  presence  of  the  specific  fungus  in  the  granulation-tissue 
or  mingled  with  the  pus  is  the  one  diagnostic  feature  of  actinomycosis.  It  has 
been  most  frecjuently  confounded  with  sarcoma  ;  in  some  of  its  manifestations 
it  may  be  mistaken  for  syphiloma  or  tuberculosis;  sarcoma  does  not  su]i]iurate 
and  break  down  as  early  as  the  actinomycotic  granuloma.  Tuberculosis  is 
attended  with  glandular  infection,  actinomycosis,  previous  to  secondary  infec- 
tion, not  at  all ;  in  suspected  syphiloma  adequate  specific  treatment  will  suffice 
to  establish  its  presence  or  absence  within  a  few  Aveeks.  In  any  case,  resort  to 
the  microscope  should  be  made  as  early  as  possible,  and  the  detection  of  the 
fungus  will  positively  establish  the  diagnosis. 

Prognosis. — The  clinical  course  of  actinomycosis  is  that  of  a  malignant 
tumor.     Without  radical  surgical  treatment  it  tends  to  indefinite  extension,  and 


SYPHILIS.  139 

ultimate  deatli  by  exhaustion,  sepsis,  or  pyemia.  When  the  disease  is  early 
recognized  and  the  afteeted  part  is  susceptible  of  thoroiiifb  extii  pjition,  a  ciii-e 
may  be  obtained. 

Treatment. — Absolute  extirpation  of  all  infected  tissue  should  be  done 
whenever  practicable,  the  incisions  bcini;  ciirried  through  sound  tissue  at 
some  distance  from  the  visibly  infected  ])art.  If  this  is  impracticable,  the  sup- 
purating cavities  and  sinuses  sliould  be  laid  o])en  freely  and  the  surrounding 
infecteil  tissue  should  be  excised  as  far  as  j)Ossible ;  thorough  curetting  of  the 
remaining  diseased  tissue  should  be  done,  followed  by  numerous  injections  of 
a  strong  carbolic  solution  (1:20)  into  the  substance  of  the  tumor  that  may 
still  remain.  Into  any  sinuses  that  have  not  been  fully  laid  open  tampons 
saturated  with  solution  of  chloride  of  zinc  (1 : 8)  should  be  packed,  and  the 
whole  diseased  surface  that  has  been  exposed  should  be  dressed  with  similar 
tampons.  The  wound  should  be  kept  open  and  the  curetting  and  cauteriza- 
tion repeated  as  often  as  any  suspicious  points  show  themselves.  Recently- 
published  experiences  of  veterinarians  indicate  that  iodide  of  potassium  given 
internally  in  full  doses,  pushed  to  the  point  of  iodism,  has  a  specific  curative 
effect  upon  actinomycosis  in  a  large  proportion  of  cases  in  cattle.  It  should 
therefore  be  given  a  trial  in  cases  in  human  beings. 


CHAPTER    XVII. 

SYPHILIS. 


Syphilis^  is  an  infectious,  contagious,  and  inoculable  disease,  transmissible 
also  by  heredity.  It  first  manifests  itself  by  an  indurated  or  infecting  chancre, 
followed  by  general  lymphatic  enlargement,  afterward  by  eruptions  of  the  skin, 
usually  symmetrical  and  at  first  superficial,  and  by  allied  conditions  of  the  mucous 
membranes,  later  by  chronic  inflammation  and  infiltration  of  the  cellulo-vascu- 
lar  tissue  and  bones  and  periosteum,  and  finally  by  special  productions  in  the 
form  of  small  swellings,  which  may  invade  any  tissue  or  organ  of  the  body, 
but  chiefly  involve  the  connective  tissue,  and  are  known  as  gummata. 

During  all  the  acute  symptoms,  and  for  a  period  extending  over  several 
years,  the  patient  has  acquired  an  immunity  against  fresh  infection.  The  dis- 
ease is  probably  caused  by  the  entrance  of  a  specific  microbe  into  the  system, 
and  although  the  final  and  conclusive  evidence,  consisting  of  the  isolation,  cul- 
ture, propagation,  and  re-inoculation  of  the  micro-organism,  is  still  lacking, 
the  clinical  facts  alone  are  sufficient,  in  the  light  of  our  present  knowledge  of 
the  microbic  diseases,  to  place  syphilis  in  that  class.  Considered  in  this  man- 
ner, as  has  been  done  by  Finger,  the  various  symptoms  and  stages  of  syphilis 
are  to  be  explained  as  follows : 

The  general  symptoms  in  the  primary  stage  of  syphilis — the  languor,  fever, 
malaise,  pain,  etc. — are  due  to  intoxication  by  the  ptomaines  produced  by  the 
virus,  as  these  symptoms  are  too  ephemeral  and  changing  to  be  ascribed  to 
localizations  of  the  virus.  In  the  secondary  stage  the  vai'ious  eruptions  on  the 
skin  and  mucous  membranes  are  caused  by  local  deposits  of  the  virus.  Their 
virulence  proves  this ;  but  a  great  many  of  the  so-called  secondary  symptoms 

'  The  histology  and  patholog}'  of  syphilis  will  doubtless  before  long  have  to  be  rewritten 
from  the  bacteriological  standpoint.  At  present  the  observations  of  Cornil  are  the  most  accu- 
rate and  reliable  in  our  possession,  and  have  been  closely  followed  in  this  work.  (See  Comi] 
On  Syphilis,  American  edition.) 


140  ^l.V   AMKRK'AX    TEXT- HOOK    OF  SL'RUERY. 

are  of  intoxicative  character,  bein;^  due  to  tispue-prodncts  passing  into  the  cir- 
culation, and  causing  a  general,  often  severe,  nutritive  derangement.  After  the 
second  stage  comes  a  long  stage  of  latency — for  many  a  period  of  cure ;  for 
others,  only  an  interval  between  the  second  and  third  stages.  That  the  virus 
still  exists  in  the  body  is  shown  in  many  cases  by  its  hereditary  transmis- 
sion. The  general  health  is  not  perfect.  The  immunity  again.st  fresh  infection 
is  the  chief  characteristic  of  the  above  latent  jjeriod.  "We  do  not  know  how 
long  it  lasts,  but  its  duration  is  certainly  limited,  in  some  cases  at  least,  as  the 
undoubted  cases  of  re-infection  show.  The  immunity,  as  mentioned,  began 
even  in  the  primary  period.  It  is  an  immunity  only  against  fresh  virus.  The 
first  virus  which  caused  the  infection  may  still  cause  relapses. 

The  immunity  in  the  primary  stage  is  due  to  tissue-products  of  the  virus  in 
the  circulation,  the  infected  foci  being  still  strictly  localized.  In  support  of 
this  there  is  the  undeniable  fact  that,  under  certain  conditions,  persons  may 
acquire  immunity  against  syphilis  without  passing  through  its  stages.  Heredi- 
tary syphilis  teaches  us  this.  The  specific  products  of  syphilis  have  been  taken 
into  account  in  explaining  the  following  two  kinds  of  immunity  from  syphilis: 
1.  Colles's  immunity  ;  2.  Profeta's  immunity.  By  Colles's  immunity  is  meant 
that  which  is  shown  by  those  healthy  mothers  who,  owing  to  syphilis  in  the 
father,  have  borne  syphilitic  children,  but  have  themselves  apparently  escaped 
infection.  This  immunity  has  been  proved  in  thousands  of  cases,  and  there  is 
no  longer  any  doubt  that  it  may  exist.  Caspary  and  Neumann  even  inoculated 
without  result,  and  Finger  has  done  so  three  times.  The  immunity  in  such 
cases  is  due  to  the  tissue-products  of  the  syphilitic  vinis  which  have  passed 
from  the  foetus,  by  diffusion,  into  the  maternal  circulation,  causing  immunity 
from  syphilis  without  the  symptoms  of  syphilis.  It  is  true  exceptions  are  pub- 
lished, but  they  are  few  and  uncertain.  Profeta's  immunity  {''la  hide  Pro- 
feta,"  Fournier)  is  the  immunity  of  the  children  of  syphilitic  parents,  either 
or  both  being  syphilitic.  The  children  in  many  such  cases  are  bom  healthy 
and  remain  healthy,  but  some  of  them  are  proof  against  the  contagion  of 
syphilis  just  as  if  they  had  had  the  disease.  This  immunity  also  is  due  to 
tissue-products  of  the  vims  passing  into  the  foetal  blood,  and  not  to  the 
entrance  of  the  virus  itself. 

In  fact,  all  immunity  from  syphilis  (and  the  same  holds  with  all  other  infec- 
tious diseases)  is  due  to  the  "tissue-products"  of  its  organized  virus  passing 
into  the  circulation  :  for  (1)  this  immunity  occurs  even  in  the  primary  period ; 
(2)  it  outlasts  the  period  of  activity,  and  even  that  of  the  presence  of  the  virus 
in  the  body ;  (3)  it  can  be  transferred  independently  of  the  virus  itself.  How 
this  immunity  is  to  be  explained  essentially  is,  however,  still  an  open  question. 
Tertiary  symptoms  are  not  due  to  the  syphilitic  virus  per  se,  but  to  its  tissue- 
products.  "  A  moderate  amount  of  tissue-products  of  the  virus  (or  only  slight 
virulence  or  greater  resistance  of  the  body)  causes  simple  immunity ;  an 
increased  amount  or  greater  virulence  of  morbid  products  of  the  virus  causes 
tertiary  syphilis.  It  has  frequently  been  asserted  that  there  is  no  relation 
between  the  various  stages  of  syphilis,  as  there  is  none  between  the  character 
of  the  syphilis  of  the  person  who  supplies  the  poison  and  that  of  the  one  who 
receives  the  infection.  Certain  cases,  however,  will  be  grave  or  "malignant 
from  the  earliest  period,  and  the  dosage  of  virus  or  a  feeble  power  of  resist- 
ance in  normal  cells  may  well  be  factors  in  determining  this  gravity.  The  defi- 
nition given  above  includes  all  the  periods  of  the  disease,  which  are  as  follows  : 
First.  Period  of  primary  incubation,  or  that  intervening  between  the 
exposure  to  contagion  and  the  ajipearanee  of  the  chancre,  on  an  average  about 
three  weeks. 


SYPHILIS.  1^1 

Second.   Period  of  primary  symptoms  (chancre  and  adenitis). 
Third.   Period  of  secondary  incubation,  or  that  between  the  appear- 
ance of  the  ohinuTc  and  tiie  deveh)i.m(Mit  of  secondary  symptoms,  on  an  aver- 

ao;e  about  six  weeks. 

Fourth.  Period  of  secondary  symptoms  (syphdides  of  the  .skin  and 
mucous  membranes,  mucous  patches,  roseola,  papules,  pustules,  etc.).  ihis 
period  mav  last  from  one  to  three  years. 

Fifth  ■  Intermediate  period,  during  which  there  may  be  no  symptoms, 
or  irre-nilar,  sli.-ht,  and  le.ss-symmetrical  and  le.ss-generalized  maniiestations. 
The  palient  is  protected  as  regards  fresh  contagion,  but  if  he  begets  chile  ren 
they  are  likely  to  suffer.  This  period  is  very  variable,  lasting  from  two  to  four 
years  and  ending  in  complete  recovery  or  in 

Sixth  Period  of  tertiary  symptoms  (tuberculo-ulcerous  syphilides, 
periostitis,  osteitis,  gummata,  etc.).     The  duration  of  this  period  is  unlimited. 

This  separation  of  syphilis  into  periods  is,  to  a  certain  extent,  artificial,  but 
it  correspomls,  however,  to  the  course  of  most  cases,  and  is  desirable  for  pur- 
poses  of  dogmatic  description.  ^^^■     -^ 

In  consi°lering  the  methods  of  transmission  of  syphilis  it  must  never 
be  forc-otten  that  it  is  not  necessarily  a  venereal  disease.  AN  hile  it  most  tre- 
Quentfv  has  its  origin  in  sexual  connection,  yet  it  quite  often  occurs  from  the 
contact  of  the  buccal  mucous  membrane  of  a  nursing  chi  d  with  the  nipple  of  its 
nurse,  or  vice  versd,  or  by  the  common  use  of  the  same  drmkmg-glasses  etc  or 
midwives  and  physicians  may  be  infected  in  practising  the  vaginal  touch,  it  is 
the  secretion  from  a  chancre  or  mucous  patch  which  most  frequently  determines 
the  disease  :  the  result  is  always  an  infecting  chancre.  The  theory  of  the  trans- 
mission of  syphilis  from  all  the  lesions  of  venereal  disease— z.  e.  the  doctrine 
of  the  identity  of  gonorrhea  and  chancres— prevailed  without  opposition  dur- 
inc.  several  centuries.     At  the  present  time  it  is  entirely  abandoned. 

°  When  a  person  is  exposed  to  impure  connection,  the  lesions  do  not  imme- 
diately intervene;  there  occurs  a  period  of  from  two  to  four  weeks,  an  aver- 
acre  of  twenty-one  to  twenty-five  days,  before  any  symptoms  appear,  and  some- 
times a  longer  time  elapses— six  weeks  or  two  months.  .  o  ■  i  .a 
This  penod  of  incubation,  which  precedes  the  appearance  of  the  indurated 
chancre,  is  known  as  the  period  of  primary  incubation.  AMienever  an 
inoculation,  whether  intentional  (as  in  some  unjustifiable  experiments  which  ha^  e 
been  made)  or  accidental,  with  the  secretion  or  pus  of  a  secondary  lesion  or  with 
the  blood,  is  successful,  it  produces  a  chancre,  preceded  by  this  long  period  of 
incubation,  and  the  symptoms  of  syphilis  are  then  developed  m  their  regular 
evolution  and  successively  appear.  Mucous  patches  and  moist  papules  not 
only  have  the  power  of  causing  a  chancre  and  syphilis  by  contact,  but  aie 
probably  the  most  frequent  source  of  its  transmission.  Syphilis  transmitted 
by  a  syphilitic  nursing  infant  suffering  with  mucous  patches  of  the  lips  is  seen 
as  a  chTncre  upon  the^nipple  of  the  nurse,  provided  the  latter  is  not  its  mother 
and  has  never  had  syphilis.  Again,  syphilitic  papules  of  the  nipples  of  a  syph- 
ilitic  nurse  occasion'a  chancre  upon  the  lip  of  a  healthy  infant. 

Secondary  lesions  of  syphilis  may  extend  over  a  long  time.  Syphilis  may 
thus  be  communicated  by  a  syphilitic  person  for  several  yeai;s  after  the  begin- 
nincr  of  the  disease.  In  marrying  during  this  period  there  is  danger  of  com- 
municating the  disease  to  the  wife  and  of  1^^^°^/^?^/^^^^^^^;}^,^^;^:^^^ 

There  has  been,  as  far  as  we  know,  not  one  trustworthy  c^e  of  the  tiansmis- 
sion  of  syphilis  by  means  of  inoculation  of  any  of  the  normal  -cretions,  ev^n 
^^here  the  most  careful  and  persistent  attempts  have  been  made  T  theie 
are  no  authenticated  cases  of  syphilitic  contagion  by  the  spermatic  tiuid  oi  of 


142  AN  AM/:/i'/('AX    Th'.V'/- /iOOh'    ()/■'  SCUd i:iiV. 

iiiociihitioii  \)\  this  liiiuid.  Tlic  tears  and  Siiliva  ohtaiiiccl  from  sy])liiliti(;  per- 
sons liave  boon  inoculatcil  upon  liealthy  persons  witliout  ])roducing  tlio  disease. 
As  the  blood  itself"  is  iin(loul)tedly  eontaj^ious  and  inoculable,  while  the  fluids 
of  the  various  secretions  do  not  possess  these  ))roperties,  it  is  very  probable  that 
the  passage  of  the  serum  of  the  blood  through  the  glandular  membranes  and 
cells  arrests  the  contagious  particles  and  renders  the  secreted  fluids  liannless. 
Whatever  may  be  the  lesion  or  fluid  or  organism  determining  the  transmission 
of  syphilis,  it  appears  that  except  in  cases  of  hereditary  syphilis  the  result  is 
always  the  same,  an  infecting  chancre,  preceded  by  a  period  of  incubation. 

SECTION   I.— PRIMARY  SYPHILIS. 

The  Chancre. — AVe  are  not  in  possession  of  absolutely  conclusive  evi- 
dence as  to  whether  or  not  the  virus  of  syphilis  remains  localized  during  the 
period  of  primary  incubation,  but  it  is  probable  that  when  inserted  under  the 
skin  it  remains  there  a  certain  length  of  time  Avithout  any  other  action  than 
gradually  to  pre]>are  the  cells  which  are  in  immediate  relation  with  it  for  the 
hyperplasia  which  soon  constitutes  the  chancre. 

The  chancre  ahvays  appears  at  the  point  of  inoculation.  If  Ave  suppose 
that  the  syphilitic  poison  is  from  the  first  carried  everywhere  in  the  economy, 
it  is  difficult  to  understand  why  there  is  not,  during  one  or  two  months,  any 
other  lesion  elsewhere  than  at  the  point  of  entrance.  The  primary  lesion  is 
invariably  met  Avith  at  the  point  inoculated,  never  elscAvhere ;  and  secondarily, 
a  neighboring  gland  is  SAVollen  after  the  appearance  of  the  chancre,  then  sev- 
eral glands ;  such  glands,  as  we  know  from  our  study  of  other  diseases,  arrest 
for  some  time  the  diffusion  or  generalization  of  morbid  products  and  tumors. 

This  conception  of  the  localization  of  the  virus  at  the  beginning  of  the  con- 
tamination is  very  important  in  a  practical  point  of  view.  It  Avould  indicate 
that  the  destruction  of  the  chancre  at  the  moment  of  its  appearance  Avould  pre- 
vent syphilis.  While  there  is  great  difference  of  opinion  among  syphilogra- 
phers  upon  this  point,  the  weight  of  authority  is  against  the  probability  of  the 
abortion  of  syphilis  by  excising  or  otherAvise  destroying  the  chancre.  Most 
authorities  are  agreed,  how'ever,  that  cauterization  or  excision  of  an  abraded 
or  absorbing  surface  soon  after  exposure,  and  before  the  development  of  the 
chancre,  is  strongly  indicated,  and  has  probably  in  several  cases  prevented 
constitutional  infection. 

The  infecting  chancre  has  a  period  of  incubation  varying  from  ten  days  to 
six  weeks,  the  average  being  about  three  Aveeks. 

It  is  an  excellent  general  rule  for  prognosis  in  cases  of  suspicious  ulcers 
upon  the  genitals  to  assume  that  if  an  interval  of  ten  days  or  more  has  elapsed 
between  the  last  exposure  to  contagion  and  the  development  of  the  sore,  the 
latter  is  probably  the  initial  lesion  of  syphilis. 

It  begins  sometimes  by  a  superficial  papule,  Avhich  generally  extends  in 
circumference  and  depth  ;  sometimes  by  an  excoriation  or  a  superficial  fissure, 
often  very  slight.  As  it  spreads  upon  the  skin  there  are  seen  accom])anying 
redness  and  desquamation  of  the  epidermis :  upon  the  mucous  membranes  a 
superficial  abrasion  or  an  ulceration  covered  by  a  grayish  or  yelloAvish  false 
membrane  ;  there  is  also  observed  an  induration,  sometimes  giving  the  sensation 
of  a  hard  nodule,  fibrous  or  cartilaginous ;  at  other  times,  that  of  a  thin  plate 
like  parchment  or  paper.  There  may  be  no  absolute  loss  of  epidermis  over  the 
surface  of  a  chancre,  but  merely  a  gradual  thinning  of  the  e])idermic  layers 
from  the  margins  of  the  sore  tOAvard  its  center.  Ulceration,  Avhen  it  exists,  is 
a  simple  cup-shaped  depression ;  its  surface  is  smooth  and  the  margins  are  not 


.SYPHILIS.  143 

iibnipt.  At  the  center  of  the  ehanere  there  is  fouii<l  a  false  membrane, 
beneath   ■which   is  a   ra\v   vascidar   htyer,  bleedinji;  readily. 

Section  of  a  chancre  shows,  in  addition  to  the  usual  lesions  of  cutaneous 
inflannnation,  a  special  and  characteristic  chancre — a  sclerosis  or  thickening 
of  the  coats  of  the  venules  and  arterioles,  aflecting  chiefly  the  tunica  adven- 
titia.  This  thickening  of  the  arterioles  and  venules  is  very  important.  In  con- 
nection with  the  preservation  of  the  firm  trabecule  of  the  derm  and  of  most 
of  the  fasciculi  of  the  connective  tissue  and  of  the  elastic  tissue,  it  gives  to  the 
infecting  chancre  its  most  essential  clinical  character — the  induration. 

The  induration  may  be  either  superficial  or  deep,  (Icpcnding  ujjon  the 
arrangement  of  the  vessels,  which  form  on  the  skin  two  horizontal  networks — 
one  beneath  the  papilh«,  the  other  deeper  at  the  base  of  the  derm.  When  the 
former  is  affected  we  have  a  superficial  induration.  If  the  sclerosis  has  involved 
at  the  same  time  both  sets  of  vessels,  the  intermediate  branches  being  ef[ually 
affected,  we  have  a  more  extensive  nodule,  varying  in  thickness  according  to 
the  region  of  the  skin  involved. 

In  the  first  case  the  induration  is  foliaceous  or  parchment-like ;  in  the  sec- 
ond it  is  woody  and  gives  the  sensation  of  cartilage.  Almost  always  the  sclero- 
sis is  continued  along  the  coats  of  the  vessels  farther  than  the  induration  itself. 
These  lesions  do  not  develop  very  rapidly ;  which  fact,  taken  in  connection 
with  the  changes  of  the  tissues  involved,  explains  the  long  duration  of  a  chan- 
cre and  the  persistence  of  the  indurated  nodule. 

The  induration  of  a  chancre  usually  occurs  at  the  end  of  the  first  week, 
dating  from  its  appearance  ;  it  may  not  show  itself  until  much  later.  The  indu- 
ration is  progressively  developed  from  the  surface — that  is,  from  the  papillary 
network — to  the  deep  cutaneous  and  subcutaneous  layers. 

The  variations  in  thickness  of  the  affected  part  give  rise  to  different 
degrees  of  induration.  Laminated  induration  is  thinner  and  less  distinct 
than  the  parchment  variety,  and  gives  to  the  fingers  the  sensation  of  a  piece 
of  paper.  Parchment  induration  is  that  which  gives  to  the  fingers  applied 
to  the  circumference  of  the  chancre  the  sensation  of  a  piece  of  parchment 
forming;  the  base  of  the  erosion.  Nodular  induration  is  that  in  which  the 
base  of  the  chancre  is  hard  and  thick,  feeling  between  the  fingers  like  a 
nodule  of  cartilage  or  wood ;  it  is  the  most  characteristic.  Annular  indura- 
tion is  that  in  which  only  the  margins  of  the  chancre  are  indurated  and  form 
a  hard  ring,  the  tissue  in  the  center  retaining  its  normal  elasticity. 

The  most  readily  recognized  and  the  most  characteristic  chancre  has  the 
shape  of  a  cup-like  depression  seated  upon  the  indurated  and  elevated  skin. 

The  histological  relations  of  the  connective  tissue  and  vessels  beneath  the 
chancre  will  explain  the  anatomical  reasons  for  these  several  forms  of  inchira- 
tion.  The  laminated  or  parchment  induration  corresponds  to  a  sclerosis  limited 
to  the  papilhie  of  the  derm  and  to  the  vascular  network  of  the  papillae ;  deeper 
or  nodular  induration  corresponds  to  a  sclerosis  of  the  cutaneous  and  sub- 
cutaneous connective  tissue  and  of  the  vascular  network  of  these  parts,  which 
latter  is  much  larger  than  the  superficial  network,  and  is  therefore  slower  in 
forming  and  in  disappearing  than  a  similar  lesion  of  small  vessels. 

Traces  of  induration  have  been  observed  four  or  five  years  after  the  begin- 
ning- of  the  chancre.  Ricord  has  found  remains  of  the  induration  ten  and 
fifteen  years  subsequent  to  the  primary  lesion. 

The  induration  and  its  extent  are  best  appreciated  by  seizing  the  chancre 
at  its  margin  between  the  thumb  and  finger,  drawing  it  upward,  so  that  it  may 
move  upon  the  subcutaneous  tissue,  and  then  using  slight  pressure  in  a  direc- 
tion parallel  to  the  surface  of  the  chancre. 


144  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

The  degree  of  induration  varies  very  nmeli  according;  to  the  seat  or  region  of 
the  primary  lesion.  When  occurring  upon  the  glans  penis,  upon  the  mucous  mem- 
brane of  tlie  jirepuce,  or  in  the  fossa  ghindis,  the  chancre  is  generally  very  dis- 
tinctly indurated;  upon  the  skin  of  the  ])enis  and  the  general  integuments  the 
induration  is  not  so  marked  or  extensive.  In  women  the  induration  of  the  chancre 
is  greater  upon  the  labia  majora  than  upon  the  labia  minora  and  fourchette. 

The  induration  of  an  infecting  chancre  is  not  only  variable,  but.  in  rare 
cases,  it  may  be  absent.  Therefore  it  is  not  positive  and  constant,  and  Cornil 
believes  that  induration  is  a  symptom  less  important  in  infecting  chancre  than 
the  characters  of  the  erosion  and  the  condition  of  the  surface  of  the  chancre, 
especially  if,  in  addition  to  these,  we  take  cognizance  of  the  several  indurated, 
movable,  painless,  and  hypertrophied  lymphatic  glands,  which  never  supjnirate 
unless  the  chancre  has  been  irritated  by  caustic  or  other  applications  followed 
by  infection  with  pyogenic  microbes. 

The  induration  generally  does  not  remain  at  its  height  longer  than  three  or 
four  weeks,  and  the  chancre  heals  entirely  in  five  or  six  weeks ;  but  the  indu- 
rated nodule,  if  it  were  primarily  large  and  cartilaginous,  may  persist  and  be 
still  recognizable  for  years. 

According  to  Fournier,  three  times  in  four  the  indurated  chancre  is  single. 
Multiple  infecting  chancres  all  begin  at  the  same  time,  for  the  primary  lesion 
of  syphilis  is  not,  as  a  rule,  auto-inoculable,  and  therefore  it  has  no  tendency  to 
be  reproduced  alongside  of  the  primary  sore,  as  is  the  case  with  chancroid. 

The  appearance  of  infecting  chancre  is  varied.  Between  an  erosion  or 
slight  abrasion  situated  upon  a  parchment-like  base  that  may  be  readily  over- 
looked, and  an  ulceration  with  a  nodular  cartilaginous  base  of  considerable 
size,  even  an  inch  in  diameter,  there  are  found  several  intermediate  degrees. 

The  most  frequent  seat  of  chancres  is  the  genital  region ;  they  are  very 
seldom  met  with  upon  other  parts  of  the  body  ;  this  is  especially  true  Avith  men, 
less  so  in  the  case  of  women. 

The  usual  seat  of  chancres  of  the  genital  organs  with  men  is  the  glans 
penis,  the  internal  surface  of  the  prepuce,  and  especially  the  fossa  glandis  and 
frenum.  Three-fourths  of  all  chancres  are  found  in  these  localities.  At  times 
they  are  found  upon  the  skin  of  the  penis,  at  the  meatus  urinarius,  upon  the 
scrotum,  in  the  urethra,  or  upon  the  groin. 

In  women  the  labia  majora  are  the  most  common  seat  of  genital  chancres; 
then  follow  the  fourchette,  the  labia  minora,  the  clitoris,  the  skin  of  the  pubes 
or  groin,  the  neck  of  the  uterus,  etc. 

It  is  doubtful  if  an  infecting  chancre  has  in  a  single  instance  been  found 
upon  the  vagina,  and  yet  this  canal  is  certainly  the  part  most  exposed  to  con- 
tagion. This  immunity  may  possibly  be  due  to  the  structure  of  the  vaginal 
mucous  membrane,  which  is  covered  with  thick  layers  of  pavement  epithelial 
cells,  and  to  the  absence  of  glandular  orifices  over  its  entire  surfiice  :  the  vaginal 
mucous  membrane  possessing  papilhie  and  prominent  villi,  but  no  glands. 

Extra-genital  chancres,  particularly  those  of  the  anus,  are  very  much 
more  common  in  women  than  in  men,  yet  all  chancres  of  the  anus  in  women  do 
not  indicate  unnatural  sexual  relations :  the  anal  orifice  is  so  situated  that  in 
dorsal  decubitis  the  fluids  from  the  vulva  flow  over  and  often  contaminate  it. 

Anal  chancres  are  usually  situated  at  the  margin  of  the  anus,  at  the  bot- 
tom of  one  of  the  radiating  folds  of  skin  produced  by  the  contraction  of  the 
external  sphincter.  The  ulceration  is  apt  to  follow  the  lines  of  these  folds, 
and  thus  to  assume  an  elongated  or  linear  character.  They  are  hard,  and  do 
not  give  rise  to  the  painful  symptoms  of  fissures  of  the  anus.  They  have 
been  observed  as  high  as  the  upper  margin  of  the  internal  sphincter. 


SYPHILIS.  145 

The  seats  of  extra-genital  chancres  are  the  anus,  mouth,  lips,  tongue, 
uvula,  palatine  arches,  tonsils,  cheek,  nipple,  etc.  A  cephalic  chancre  is  almost 
always  infecting.      Chancroid  is  scarcely  ever  seen  upon  the  lips  or  fiice. 

The  diagnosis  of  chancre  is  a  matter  of  such  great  practical  import- 
ance that  it  may  be  well,  even  at  the  risk  of  repetition,  to  enter  into  it  some- 
what fully : ' 

1.  In  dealing  with  lesions  apparently  non-venereal  in  their  origin  and 
character  we  should  consider  carefully  the  following  points : 

(a)  The  anatomical  situation  and  the  course  of  the  lesion.  Among  those 
particularly  to  be  viewed  with  suspicion  may  be  mentioned  herpetiform  erosions 
of  the  lips,  papules  on  the  tip  of  the  tongue,  squamous  or  "scabby"  ulcera- 
tions of  the  skin,  scratches  which  obstinately  refuse  to  heal,  chronic  inflamma- 
tions at  the  tip  of  the  fingers  resembling  felons,  etc. 

(b)  Indolence,  absence  of  suppurative  tendericies,  and  persistence  in  spite 
of  treatment  are  negative  signs  which  should  lead  us  to  believe  that  any 
cutaneous  or  mucous  lesion  is  not  of  a  simple  nature. 

(c)  If  the  morbid  products  are  slight,  rather  serous  than  purulent,  tend  to 
form  into  crusts  or  to  assume  a  pseudo-membranous  form  upon  an  eroded  sur- 
face, syphilis  should  be  suspected. 

(d)  The  consistence  of  the  base  upon  which  the  lesion  is  situated  is  one  of 
the  most  important  diagnostic  points,  and  should  always  be  carefully  investi- 
gated. If,  upon  palpation,  instead  of  the  usual  inflammatory  swelling  and 
thickening,  shading  off  into  the  surrounding  tissue,  we  meet  with  a  cartilaginous, 
elastic,  sharply-circumscribed  resistance,  we  may  immediately  suspect  very 
strongly  that  we  are  dealing  with  a  syphilitic  lesion,  although  even  this  symp- 
tom cannot  be  considered  as  infallible. 

(e)  If  the  hjmpliatics  of  the  groin  become  slightly  swollen  and  painful  and 
progress  no  farther,  or  if  these  symptoms  occurring  in  a  single  gland  subside 
spontaneously,  it  is  probable  that  they  are  due  to  a  sympathetic  adenitis,  such 
as  follows  many  irritations  of  the  skin  or  mucous  membrane.  If,  on  the  con- 
trary, they  steadily  augment  in  size  and  hardness,  are  almost  painless,  and 
constitute  a  chain  of  little  tumors  including  several  or  all  the  inguinal  glands,  it 
may  be  considered  strong  presumptive  evidence  of  specific  disease,  though  even 
yet  not  conclusive. 

In  addition  to  these  points  the  history  of  the  case  must  carefully  be  inquired 
into — the  probabilities  of  infection,  in  regard  to  w  hich  we  should  not  be  misled 
by  the  beliefs  cf  the  patient — and  the  period  of  incubation,  which,  when  it  can 
be  clearly  established,  is  of  great  value. 

Confrontation — i.  e.  examination  of  the  person  from  Avhom  the  disease  has 
probably  been  contracted — will  often,  not  invariably,  decide  the  matter,  but,  in 
this  country  at  least,  is  rarely  obtainable. 

Difiiculties  of  diagnosis  are  greatest  during  the  first  week  or  ten  days,  and 
steadily  diminish  with  the  age  of  the  lesion,  which,  if  syphilitic,  is  almost  cer- 
tain to  assume  in  time  a  definite  character.  The  chief  points  among  those 
mentioned  are  the  period  of  incubation,  the  presence  or  absence  of  induration, 
and  the  condition  of  the  nearest  lymphatic  glands.  If,  however,  all  of  these 
seem  to  point  to  syphilis,  the  experienced  observer  will  still  refrain  from  giving 
a  positive  opinion^  no  symptom  or  group  of  symptoms  being  absolutely  conclu- 
sive as  to  the  specific  character  of  any  primary  lesion ;  certainty  only  being 
attained  by  the  development  of  some  of  those  general  or  constitutional 
phenomena  which  in  from  six  to  eight  weeks  follow  the  infecting  chancre. 

1  In  doing  so  we  shall  follow  closely  the  paper  of  Ch.  Mauriac,  which  is  the  best  r^sum^ 
of  this  subject  with  which  we  are  acquainted. 
10 


146  AX  AMi:nicAX  Ti:xT-ii(jok'  or  scrgery. 

2.  The  region  occupied  by  a  chancre  may  cause  errors  or  difficulties  in 
diagnosis. 

(rt)  In  the  cephalic  region  chancres  of  the  //'///•//  acalp^  of  the  supi-aoriutal 
prominences,  and  of  the  chin  and  cheeks  are  the  most  deceptive.  They  always 
assume  an  ecthyniatous  form,  and  are  so  concealetl  by  the  hair  that  it  is 
impossible  to  judge  of  the  character  of  their  surface.  In  all  such  cases 
the  hair  must  be  carefully  shaved,  and  if  we  then  find  that  we  are  dealing  Avith 
an  ulceration  lacking  the  ordinary  characteristics  of  ecthyma,  and  glazed,  flat, 
or  even  elevated,  our  suspicious  should  be  aroused,  and  after  eight  or  ten  days 
will  usually  be  confirmed,  if  the  sore  is  syphilitic,  by  the  development  of 
induration  and  of  neighboring  lymphatic  enlargement. 

Razor-cuts  on  the  chin,  cheeks,  or  lips  which,  after  having  healed,  reopen 
and  become  covei'ed  with  a  crust,  should  on  a  p)riori  grounds  be  suspected. 
This  is  equally  true  of  pseudo-furuncles,  acneiform  pustules,  cracks  around  the 
circumference  of  the  nostrils,  etc.,  which  persist  without  giving  rise  to  pain, 
and  become  bloody,  encrusted,  and  surrounded  by  an  area  of  subinflammatory, 
oedematous  swelling.  We  should  then  carefully  examine  the  preauricular, 
parotidean,  and  submaxillary  lymphatic  glands. 

A  stiie  which  behaves  in  an  unaccustomed  manner  or  is  accompanied  by 
hyperplasia  of  the  lid,  or  a  conjunctivitis  which  becomes  localized  and  causes 
an  isolated  swelling,  should  be  attentively  watched. 

In  the  neighborhood  of  the  mouth  errors  of  diagnosis  should  be  less  frequent 
than  in  other  portions  of  the  cephalic  region,  because  it  has  been  shown  so 
often  that  the  lips,  tongue,  and  fauces  are  frequently  brought  into  contact 
with  syphilitic  discharges  and  constitute  one  of  the  principal  channels  of 
infection.  Here,  however,  as  elsewhere,  the  chancre  assumes  at  the  very 
outset  the  appearance  of  ordinary  lesions.  Thus,  upon  the  lips  the  chap,  crack, 
or  fissure  often  found  in  the  median  line,  the  little  aphthous  erosions,  herpetic 
ulcerations,  and  cigar  or  cigarette  burns,  simulate  very  closely  the  characters 
of  the  initial  lesion,  and,  as  the  latter  will  almost  invariably  be  attributed  by 
patients  to  some  such  ordinary  cause,  ma}''  give  rise  to  serious  error. 

At  the  end  of  the  first  week,  however,  the  specific  characters  of  labial 
chancre  are  usually  so  distinct  as  to  render  diagnosis  easy. 

In  several  instances  these  chancres  have  been  mistaken  for  epithelioma,  and 
have  been  excised.     The  diagnostic  differences  may  be  indicated  as  follows : 

Labial  Chancre.  Epithelioma. 

No  marked  difference  between  the  sexes.  Twenty  times  more  common  in  males  than 

in  females. 
The  ulcer  may  involve  either  lip.  Almost  invariably  situated  upon  the  lower 

lip. 
Occurs  at  any  a^i^e.  Rarely  occurs  before  middle  life. 

Patient  often  strong  and  robust.  Patient  usually  in  impaired  health. 

Is  insensitive.  Often  sharp,  burnin<r,  lancinatinfr  pains. 

Regular  in  outline,  smooth  surface,  elevated.     Irre^rular    in    outline,    ragged,    tilled    with 

fungous  granulations,  bleeding  easily. 
Indurated  and  sharply  circumscribed  base.       Induration  less  cartilaginous,  unequal,  not 

clearly  circumscribed,  and  more  extensive. 
Evolution   of  sore  usually   occupies   a  few     Sore  may  lie  months  in  developing  after  its 

weeks  at  the  most.  first  appearance. 

Glandular   involvement   follows  closely   on     Glands  are  not  implicated  for  three  or  four 

appearance  of  sore.  months,  often  not  until  later. 

No  marked  odor  from  secretion  of  sore.  Odor  often  extremely  offensive. 

History  of  exposure  to  syphilitic  inoculation     Frequently  no  such  history. 

often  obtainable. 
Heals  rapidly  or  disappears  under  mercurial     Not    affected    or    rendered   worse    by   such 
treatment.  treatment. 


SYPHILIS.  147 

While  tliore  is  a  possiliility  of  error  in  diagnosis  between  a  chancre  and  an 
epithelioniatous  ulcer  when  a  niaerosco])ical  examination  alone  is  made,  there  is, 
on  the  contrary,  no  such  ap})reliension  when  a  microscopical  examination  of  the 
lesions  is  instituted.  The  histological  structure  and  arrangement  are  so  very 
distinct  and  unlike  in  these  lesions  that  a  mistake  cannot  well  occur.  In  the 
e})itlielioma  we  have  the  ingrowing  of  the  interpapilhuy  layers  of  epithelial  cells, 
the  branching  or  budding  outgrowths  from  the  sebaceous  glands  which  consti- 
tute the  very  characteristic  ej)itheliomatous  pegs,  and  the  formation  of  the 
cell-nests  or  pearls  upon  these  pegs,  which  are  all  so  strikingly  different,  when 
contrasted  with  the  histological  structure  of  a  chancre,  that  no  doubt  as  to 
diagnosis  remains. 

Upon  the  sides  of  the  tongue  ulcerations,  produced  by  the  continual  contact 
of  that  organ  with  rough  and  carious  teeth,  have  been  mistaken  for  chancres. 
This  error  should  ])e  guarded  against,  but  is  not  so  serious  in  its  results  as  the 
failure  to  recognize  the  specific  lesion  when  it  is  situated  at  the  point  of  the 
tongue,  the  possibility  of  its  communication  to  innocent  people  being,  in  such 
cases,  an  element  of  unusual  importance.^  In  the  first  five  or  six  days  it  is 
impossible  to  diagnosticate  it,  but  if  the  original  little  inflamed  papule  enlarges 
and  extends,  becoming  elevated  above  the  surrounding  parts ;  if  its  epithelial 
covering  drops  off  and  its  surface  becomes  diphtheritic ;  if  superficial  cauteri- 
zation with  crayons  of  nitrate  of  silver,  which  so  rapidly  cure  the  common  small 
painful  papule  of  the  tongue,  have  no  effect  upon  it, — there  is  a  strong  presump- 
tion that  it  is  chancre.  This  will  be  confirmed  later  by  the  appearance  of 
submaxillary  glandular  enlargement  and  induration  of  the  sore. 

Of  all  the  chancres  of  the  cephalic  region,  however,  that  of  the  tonsils  or 
of  the  isthmus  of  the  fauces  presents  the  greatest  diagnostic  difficulties,  on 
account  of  the  effacement  of  its  characteristics  by  the  surrounding  inflam- 
mation. If  in  a  case  of  prolonged  sore  throat  there  be  an  appearance  resembling 
a  single  mucous  patch,  and  there  be  no  history  of  antecedent  syphilitic  poison- 
ing, it  becomes  probable  that  the  trouble  is  chancrous ;  and  this  probability 
is  greatly  increased  if  any  induration  can  be  felt  by  palpation  with  one  finger 
in  the  pharynx  and  another  external  to  its  walls  ;  if  enlargement  of  the  glands 
above  the  angle  of  the  jaw  occurs ;  or,  of  course,  if  the  patient  confesses  to 
having  been  peculiarly  exposed  to  contamination. 

The  sore  is  much  more  common  in  this  region  in  females  than  in  males, 
Mackenzie  noting  the  fact  that  out  of  7  cases  of  primary  syphilis  of  the  ton- 
sils Avhich  he  had  met  with,  6  were  women. 

(6)  Superior-  and  Inferior  Extremities. — Chancres  of  the  hands  are  often 
seated  at  the  margin  of  the  nail  and  closely  resemble  simple  whitlows.  They 
may  be  diagnosed  by  their  long  duration,  their  abrupt  limitation,  the  hardness 
of  the  tissues  around  and  beneath  them,  and  the  consecutive  engorgement  of 
the  epitrochlear  ganglion.  Upon  the  dorsal  face  of  the  phalanges  the  initial 
lesion  at  first  simulates  an  inflamed  papule  or  boil,  but  is  less  painful,  dis- 
charges no  "core,"  and  is  elevated,  not  excavated. 

The  anterior  face  of  the  forearm  in  both  sexes,  the  anterior  surface  of  the 
thigh  in  men  and  the  posterior  surface  in  women,  are  the  parts  most  exposed  to 
contagion. 

The  chancre  of  vaccino-syphilis  occurs  after  the  evolution  of  the  vaccine 
sore.  It  can  only  be  confounded  with  the  ulcerations  described  by  Blot  under 
the  name  of  "vaccinal  phagedenism,"  which  are  rounded  with  abrupt  borders 
and  indurated  bases,  and  are  often  accompanied  with  engorgement  of  the  axil- 

^  The  same  remark  applies  to  mucous  patches  of  the  tongue  and  lips  with  even  more  force, 
&o  they  are  so  much  more  frequent  than  primary  sores. 


148 


AN  AMERICAN   TEXT-BOOK   OF  SURGERY, 


lary  lymphatic  glands.  The  diagnosis  from  appearances  is  difficult,  but  may 
be  made  by  noticing  the  fact  that  these  sores  run  an  acute  course,  and  are  read- 
ily cured  by  poultices  or  emollient  applications,  which,  of  course,  have  no  effect 
on  chancre. 

((■)  Upon  the  trunk  the  mammary  and  hypogastric  regions  are  those  most 
frequently  involved.  In  the  former  locality  the  initial  lesion  is  most  likely  to 
be  mistaken  for  eczematous  excoriations,  fissures,  and  small  furuncular  or  papil- 
lary tumors.  The  diagnosis  rests  upon  the  presence  of  the  characteristic  indu- 
ration, elevation,  etc.,  and  upon  the  polyganglionic  axillary  enlargement.  In 
cases  where  syphilis  has  been  transmitted  during  suckling  confrontation  is 
almost  invariably  possible  and  furnishes  the  most  satisfactory  guide. 

Chancres  of  the  hypogastrium  are  generally  large  and  ulcerating,  and  are 
most  liable  to  be  mistaken  for  chancroids. 

{d)   G-enital  Organs. — The  diagnosis  of  sores  situated  in  this  locality  is 
chiefly  between  chancre,  chancroid,  and  herpetic  ulceration, 
table  given  below  expresses  the  main  points  of  diff'erence. 


The  diagnostic 


Chancre. 
Origin : 
Due  to  contagion  from  a  chan- 
cre, a  syphilitic  lesion,  or 
blood  or  pus  from  a  person 
having  syphilis. 


Incubation : 
Not  less  than  ten  days  ;  often 
thi  ee  weeks  ;    very  rarely 
six  to  eight  weeks. 

Situation  : 
Most  frequent  upon  the  geni- 
tals.     Often  seen   on   the 
hands,  nipples,  lips,  etc. 


Commencement : 
Begins  as  an  erosion,  papule, 
tubercle,    or   ulcer.      May 
remain  without  ulceration 
through  its  entire  course. 

Kumber: 
Single  or  simultaneously  mul- 
tiple; occasionally,  but  rare- 
ly, successively  multiple. 

Shape : 
Round,   oval,   or    symmetri- 
cally irregular. 


Chancroid. 

Usually  due  to  contact  with 
pus  from  a  similar  sore, 
or  to  accidental  inoculation 
of  the  secretion  of  a  chan- 
croid upon  a  person  already 
affected  with  syphilis  ;  of- 
ten to  the  irritation  of  pus 
from  other  sources. 

None. 


Almost  always  upon  the 
glans  penis  or  prepuce; 
rare  upon  other  portions 
of  the  genitals ;  scarcely 
ever  seen  elsewhere. 

Begins  as  a  pustule  or  ulcer. 


Herpetic  Ulceration. 

Mechanical  irritation  ;  fric- 
tion, as  in  sexual  inter- 
course ;  chemical  irritation, 
as  of  acrid  discharges  ;  un- 
cleanliness.  Occasionally 
follows  cold  or  fever ;  may 
be  a  neurosis. 


None. 


Glans  penis  and  inner  layer 
of  prepuce. 


Begins  as  a  group  of  vesi- 
cles, which  may  coalesce 
or  may  ulcerate  singly. 


Often  multiple,  frequently  by     Multiple;   apt  to  be  conflu- 
auto-inoculation.  ent. 


Round,  oval,  or  unsymmetri- 
cally  irregular,  with  bor- 
der described  by  segments 
of  large  circles. 

Hollow,  excavated,  or 
"punched  out." 


Depth : 
Usually     superficial  —  cup- 
shaped    or    saucer-shaped 
— or  may  be  elevated. 

Surface  : 
Smooth,  shining,  red,  glazed ;  Rough,  uneven,  "  worm-cat- 
diphtheritic  membrane  or  en,"  warty,  whitish-gray- 
Bcab.  ish,  pultaceous. 


Irregular ;  edges  serrated  or 
described  by  segments  of 
small  circles. 


Superficial. 


Same  as  local  ulcer,  but  more 
superficial. 


SYPHILIS. 


149 


Secretion  : 
Scanty,  serous,  auto-inocula- 
blo  witli  <;reat  diflioulty, 
produc-inj;  either  a  chan- 
croidal sore  or,  in  rare 
cases,  a  second  sore  like 
the  first. 

Induraiion  : 
Almost  always  present ;  firm, 
cartilaiiiiious,  or  parch- 
ment-like -,  circumscribed, 
terminating^  abruptly; 
movable  upon  subjacent 
parts  ;  skin  not  adherent ; 
usually  persistent :  disap- 
pears under  specific  treat- 
ment. 

Sensibiliii/ : 

Very  little  or  no  pain. 
Course : 

Usually  regularly  progressive 
toward  health,  the  sore 
often  healing  spontaneous- 
ly. Phagedena  uncommon. 
Second  attack  also  very 
rare. 


Histology : 
A   new   cell-growth.      Very 
little  destruction  of  tissue. 

Bubo : 
Constant,  painless,  multiple. 


Abundant,  purulent ;  readily 
auto-inoculated 


Only  exceptionally  present ; 
may  be  caused  by  caustics 
or  other  irritants,  or  by 
simple  inflammation  ;  bog- 
gy, inelastic,  shades  ott" 
into  surrounding  parts,  to 
which  it  is  adherent ;  dis- 
appears soon  after  cicatri- 
zation. 

Painful. 

Irregular  ;  may  cicatrize  rap- 
idly or  may  extend,  taking 
on  phagedenic  action.  No 
protection  against  a  second 
attack. 


An  ulceration,  with  more  or 
less  loss  of  substance. 


In   one-third  of   the  cases  5 
painful,  inflammatory,  sin- 


Moderate  secretion  •,  auto-in- 
oculated with  difficulty. 


Same  as  local  ulcer. 


More  serious,  locally,  on  ac- 
count of  loss  of  tissue  5 
occasional  refusal  to  heal, 
and  possibility  of  jjhage- 
dena.  Ve^y  rarely  is  fol- 
lowed by  syphilis. 

Local  treatment  curative. 


Painful. 

May  spread,  in  exceptional 
cases,  by  the  appearance 
of  successive  crops  of 
vesicles.  Usually  heals 
promptly  under  mild  local 
treatment.  Likely  to  recur, 
especially  in  uncleanly 
patients  with  long  fore- 
skins. 

Originally  an  elevation  of 
the  epidermis  in  spots  by 
an  effusion  of  serum. 

Rare.  When  it  does  occur, 
painful,  single,  inflamma- 
tory. 

Always  good  if  the  diagnosis 
be  absolute.  Should  be 
guarded  when  there  is  the 
least  doubt  as  to  the  her- 
petic character  of  the 
affection. 


Local  treatment  curative. 


Prognosis : 
Good  locally ;  constitutional 
syphilis  will  follow  in  the 
great  majority  of  cases, 
but  in  a  few  may  not  ap- 
pear or  may  be  prevented 
by  treatment. 

Treatment : 
Excision   when   seen   early ; 
other   local    treatment  of 
minor  importance. 

Chancres  of  the  meatus  are  more  often  syphilitic  than  simple  in  their  cha- 
racter. In  the  former  case  they  are  attended  with  little  or  no  ulceration,  are 
confined  to  one  lip  of  the  meatus,  are  accompanied  by  the  usual  induration  and 
glandular  involvement,  and  are  often,  indeed  usually,  not  discovered  by  the 
patient,  who  imagines  he  has  a  gonorrhea.  Chancroid  of  the  meatus  is  irreg- 
ular in  shape,  ulcerated,  involves  both  lips,  is  painful,  and  does  not  have  the 
characteristic  induration. 

The  diagnosis  between  infecting  urethral  chancre  and  gonorrhea  may  be 
tabulated  as  follows : 


150 


.4.V   AMERICAN    TEXT-BOOK    OF  SURGERY. 


Urethral  Chancre. 

Symptom?  ayipear  after  a  period  of  incuba- 
tion rarely  less  than  ten  days,  often  two 
or  three  weeks. 

Confined  to  meatus  or  its  immediate  neigh- 
borhood. 

Ardor  urinae  felt  only  at  lips ;  no  chordee. 

Discharge  moderate,  never  purulent,  often 
bloody. 

Induration  perceptible  to  touch,  usually  in- 
volving only  one  lip  of  meatus. 

Invariable  enlargement  of  chain  of  inguinal 
lymphatics,  which  are  painless  and  freely 
movable,  and  almost  never  suppurate. 

Sore  can  almost  always  be  seen  as  a  loss  of 
continuity  of  mucous  membrane. 

Constitutional  symptoms  follow  after  from 
six  to  eight  weeks. 

Use  of  syringe  painful  at  meatus. 


Urethritis. 

Symptoms  follow  suspicious   intercourse  in 

from  twenty-four  hours  to  a  week,  rarely 

at  a  longer  interval. 
Begins  at  meatus,  but  extends  some  distance 

backward. 
Ardor  urinae  felt  along  the  urethra ;  chordee 

often  present. 
Discharge  more  profuse,  decidedly  purulent, 

not  so  often  or  so  largely   stained  with 

blood. 
No  induration. 

If  lymphatics  are  involved  at  all,  only  one 
is  affected,  which  often  goes  on  to  sup- 
puration. 

No  loss  of  continuity  perceptible. 

No  constitutional  symptoms. 

Use  of  syringe  not  usually  painful. 


The  small  hard  tumors  which  occa.sionally  appear  or  may  be  felt  aloncj  the 
under  surface  of  the  penis  during  an  attack  of  gonorrhea,  and  which  are  due 
to  inflammation  and  enlargement  of  the  follicles,  should  not  be  confused  with 
chancre.  They  usually  feel  like  grains  of  sand  or  small  peas  directly  beneath 
the  skin,  are  situated  behind  the  fossa  navicularis,  have  no  characteristic 
induration,  and  subside  spontaneously  or  go  on  to  suppuration. 

When  phimosis  exists  the  diagnosis  between  subpreputial  chancres  and 
chancroidal,  herpetic,  or  balanitic  ulcerations  is  often  one  of  great  difiBculty. 
It  should  be  founded  on  the  followins:  considerations : 


Subpreputial  Chancre. 

The  incubation  is  that  of  chancres,  ten  to 
twenty-one  days  or  more. 

If  the  site  of  the  original  trouble  can  be  felt 
or  can  be  described  by  the  patient,  it  will 
be  found  to  be  single. 

Inflammatorv  phenomena  comparatively 
slight. 

Swelling  hard,  dry,  indurated  character- 
istically. 

The  discharge  from  the  preputial  orifice  is 
moderate,  thin,  serous  or  bloody,  not 
readily  inoculable. 

The  margins  of  the  preputial  orifice  are  not 
markedly  inflamed  or  ulcerated. 

At  some  point  the  induration  can  probably 
be  isolated  from  the  surrounding  tissues 
and  raised  and  felt  between  the  thumb 
and  finger. 

Syphilitic  buboes  are  invariably  present. 


Subpreputial  Ulceration  fnon-syph- 
iliticj. 

The  interval  between  the  exposure  and  the 
subsequent  ulceration,  swelling,  etc.  is 
much  shorter. 

Several  points  of  ulceration,  abrasion,  or 
pustulation  will  usually  be  found  or  de- 
scribed. 

Inflammatory  phenomena — heat,  pain,  red- 
ness, swelling — very  marked. 

Swelling  oedematous.  sero-purulent,  like  that 
of  phlegmonous  erysipelas. 

Discharge  profuse,  purulent,  usually  very 
irritating,  and  apt  to  be  inoculable,  both 
accidentally  and  experimentally. 

Almost  invariably  ulcerated. 

This  is  usually  not  possible,  no  distinct 
dividing  line  existing. 

Buboes,  if  present  at  all,  are  of  an  inflam- 
matory character. 


The  diagnosis  between  a  new  indurated  chancre  and  an  ulceration  occupy- 
ing the  site  of  an  old  chancre,  the  induration  of  which  has  never  entirely  dis- 
appeared— '•  relapsing  chancre  " — is  extremely  difficult,  and,  unless  a  clear 
history  of  the  case  can  be  obtained,  is  impossible.  The  latter  cases  are  often 
reported  as  instances  of  a  second  syphilitic  infection.     The  opinion  must  be 


SYPHILIS.  l-^^l 

ba^ed  upon  the  presence  or  absence  of  a  syphilitic  history  and  the  circumstances 
of  the  exposure,  inculnition.  etc.  The  possible  effect  of  local  irritation  on  an 
old  indurated  iiui.ss  should  always  be  taken  into  account.  ,       ,     «•     ■ 

The  prognosis  of  syphilitic  chancre,  considered  as  a  local  attection, 
depends  chietiv  upon  the  seat  of  the  lesion.  A  chancre  of  the  conjunctiva 
nrfv  crive  rise  to  a  ?rave  ophthalmia;  a  chancre  of  the  tongue  or  of  the  fauces 
maV  'cause  <rreat  debilltv  through  interference  with  mastication,  deglutition, 
and  dicre^tio^n.  As  regards  the  genital  organs,  however,  the  prognosis  is 
almost  uniformlv  favorable.  Phagedenic  or  gangrenous  processes  are  rare; 
ulceration  even'is  usuallv  very  slight,  or,  if  seemingly  extensive,  is  apt  to  be 
at  the  expense  of  the  neoplasm,  and  not  of  the  normal  tissues. 

The  relation  between  the  constitutional  disease  of  which  the  chancre  is  the 
precursor  and  the  sore  itself  is  a  question  of  great  interest.  It  mav  be  at  once 
acknowledged,  however,  that  our  information  upon  this  pomt  is  deficient.  We 
are  able  n'either  to  predict  the  form  of  local  lesion  from  the  character  of  the 
source  of  infection,  nor,  on  the  other  hand,  can  we,  with  any  accuracy,  fore- 
cast the  constitutional  condition  Avhich  will  result  from  any  given  sore,  ihe 
varieties  of  the  chancre  in  form,  extent,  etc.  depend  more  upon  local  causes  or 
upon  the  idiosyncrasies  of  the  patient  than  upon  any  special  source  or  pecu- 
liarity of  the  Virus.  Every  svphilographer  of  experience  has  seen  the  most 
widelV-differincr  forms  of  initial  lesion  derived  from  the  same  individual,  and 
a  similar  diversity  exists  in  the  fonus  of  constitutional  disease  arising  Irom 
a  -iven  focus  of  mfection.  The  amount  of  glandular  implication  is  also  an 
ennrelv  unreliable  Lniide  and  presents  all  sorts  of  variable  phenomena. 

The  Treatment  of  Chancre.— Every  surgeon  whose  work  has  brought 
him  in  contact  with  large  numbers  of  cases  of  venereal  sores  must  recognize 
the  fact  that  between  the  typical  soft,  suppurating  local  sore  and  the  distinctly 
indurated  chancre  there  are  large  numbers  of  doubtful  ulcers  which  partake  of 
the  characteristics  of  both  :  local  sores  with  deceptive  mflammatoiy  hardening, 
an.l  true  chancres  with  equally  deceptive  inflammatory  softening,  suppuration, 
and  even  loss  of  substance.  Nearly  every  specialist  who  has  written  upon 
the  subject  has  recognized  and  been  influenced  by  this  well-known  fact 

Fournier,  perhaps  the  most  eminent  living  syphilographer,  has  recorded 
a   case  which   bears  most   strongly  upon   the   question   under   consideration: 
A  female  child,  six  years  old,  was  said  to  have  been  mfec  ed  with  syphdis 
durinc.  an  attempt  at  rape.      She  had  marked  vulvitis   and  upon    he  labia 
three  "crayish.  shallow,  indolent,  indurated  ulcers  covered  witb  a  diphtheritic- 
looking  membrane  and  raised  a  little  above  the  general  surface      In  both 
groins  there  were  enlarged,  multiple  lymphatic  glands.     He  positively   liag- 
Sosticated  chancre,  but,  conforming  to  his  custom  m  medico-legal  cases,  declined 
to  testify  for  a  few  days.     During  this  time,  under  a  simple  dressing,  the 
symptoms  disappeared,  and  the  patient,  who  was  carefully  observed  for  seyera 
months,  never  showed  any  subsequent  signs  of  infection.     Fournier  be  le^es 
that   the   case  demonstrates   that   small   inflammatory  lesions  may  so   closely 
resemble  chancres  as  to  deceive  the  most  experienced  surgeon,  and  adds    hat 
in  medico-legal  cases  the  diagnosis  should  not  be  made  upon  the  local  le.ions 
alone,  but  should  depend  upon  the  development  of  constitutional  symptoms 

The  surcreon  who  is  daily  called  upon  to  give  an  opinion  m  cases  which 
involve  the  whole  future  of  ihe  individual,  his  relations  to  the  other  sex  his 
determination  toward  celibacy  or  matrimony  his  matrimonial  relations  if  he 
should  be  already  married,  the  question  of  the  influence  of  paternity  the 
institution  of  a  course  of  treatment  extending  over  years,  the  diagnosis  of  any 
obscure  visceral  troubles  which  he  may  develop  later  in  lite,  the  profoundly 


152  AN  AMERICAN    TEXT-HOOK    OF  SURGERY. 

depressinfj  mental  effect  wbicli  a  knowledge  of  sypliilltic  infection  usually  has 
upon  intelligent  j)eoj)le, — the  surgeon  who  renienihers  these  facts  and  recalls 
the  views  above  cited  as  to  the  possiliility  of  error  sliould  surely  hesitate  about 
beginning  a  course  of  treatment  which  will  jiossibly  obscure  or  render  alto- 
gether impossible  the  diagnosis.  While  there  is  no  positive  advantage  in  delay 
as  regards  the  subsequent  course  of  the  case,  yet,  on  the  other  hand,  the  gain 
from  the  immediate  treatment  during  the  primary  sore  is  not  sufficient  to 
counterbalance  the  doubt  and  uncertainty  which  that  treatment  often  throws 
about  the  future  life  of  the  patient.  Certainly  the  cases  are  comparatively 
rare  in  which  a  careful  surgeon  would  be  willing  to  make  an  absolute  diagno- 
sis of  syphilis  during  the  existence  of  the  primary  sore  alone.  A  few  neces- 
sary exceptions  to  this  rule  may  be  included  under  the  following  heads: 

1.  Where  confrontation  is  possible  and  the  sore  is  distinctly  a  typical  one. 
2.  Where  with  a  typical  sore  its  continued  existence  would  destroy  or  imperil 
the  conjugal  relations  of  two  people  or  possibly  the  happiness  of  an  entire 
family.  8.  Sores  with  characteristic  induration,  but  "with  marked  tendency  to 
spread  and  involve  important  regions.  4.  Sores  in  such  conspicuous  positions, 
as  upon  the  lips  or  the  nose,  that  their  continuance  would  involve  a  general 
knowledge  of  the  patient's  condition. 

With  these  exceptions  it  is  the  part  of  wisdom  to  wait  until  tlie  development 
of  glandular  enlargement  at  some  point  removed  from  the  initial  lesion,  and 
not,  therefore,  by  any  possibility  a  result  of  simple  adenitis,  demonstrates  the 
constitutional  character  of  the  trouble.  It  is  to  be  hoped — and,  indeed,  may 
be  confidently  expected — that  the  progress  of  bacterial  investigation  will  in 
the  near  future  enable  us  to  make  a  very  early  and  positive  diagnosis,  but  we 
cannot  do  so  as  yet.  It  is  not  necessary,  however,  to  wait  for  the  syphilo- 
dermata.  Treatment  may  be  safely  begun  when,  after  a  suspicious  sore  upon 
the  genitals,  consecutive  enlargement  of  the  epitrochlear  or  post-cervical  lym- 
phatic glands  takes  place. 

The  argument  above  used  against  the  mercurial  treatment  of  chancre 
applies  with  equal  force  to  the  local  abortive  measures  which  have  from  time 
to  time  been  recommended.  These  include  excision  ;  cauterization  ;  antiseptic 
measures ;  and  various  local  applications  of  mercurial  preparations  by  means 
of  ointments,  hypodermatic  injections,  or  otherwise.  Taking  them  in  the  order 
mentioned,  their  relative  advantages  and  disadvantages  seem  to  be  as  follows : 

As  to  excision,  it  appears  unquestionable  that  it  can  be  of  service  in 
but  a  very  small  proportion  of  venereal  sores  as  they  usually  come  under  the 
notice  of  the  practitioner.  The  opinions  of  syphilographers,  however,  vary 
greatly  in  regard  to  the  value  of  this  form  of  treatment,  and  in  the  light  of  the 
opposing  views  a  safe  general  rule  for  practice  is  to  assume  that  a  sore  seen 
within  a  few  days  after  its  appearance,  and  as  yet  unaccompanied  by  any 
enlargement  of  the  inguinal  glands,  is  still  a  localized  lesion.  If  favorably 
situated — /.  e.  upon  the  skin  of  the  prepuce  or  of  the  genitals — it  may  be 
removed,  the  surgeon  picking  up  the  sore  and  surrounding  tissue  with  a  pair 
of  toothed  forceps,  and  removing  it  by  a  single  sweep  of  the  knife  or  by  means 
of  scissors  curved  on  the  flat,  afterward  dressing  the  wound  with  iodoform  or 
boracic  powder.  By  this  plan  of  treatment  we  give  our  patients  whatever 
small  chance  there  may  be  of  avoiding  constitutional  disease,  while  at  the  same 
time  we  expose  them  to  the  minimum  degree  of  local  pain  and  disturbance. 

When  the  patient  refuses  this  treatment,  or  when  the  sore  is  so  situated 
that  its  removal  would  cause  considerable  pain,  hemorrhage,  or  deformity, 
destructive  cauterization  with  fuming  nitric  acid  may  be  employed.  In  all 
cases  (and  these  comprise  the  majority  which  come  for  treatment)  in  which 


SYPHILIS.  153 

a  week  or  more  lias  elapsed  since  the  development  of  the  sore,  and  in 
■which  involvement  of  the  dorsal  lymphatics  of  the  penis  and  the  in^^uinal 
lymphatic  glands  is  ohservahle,  cauterization  as  a  routine  method  of  treatment 
should  be  rejected,  on  account  of  its  undoubted  uselessness  at  that  stage  in 
preventing  constitutional  disease ;  the  pain  which  it  causes  ;  the  inflammatory 
action  which  follows  it,  and  which  often  produces  enough  oedema  and  swelling 
to  cause  i)liiniosis,  and  thus  convert  an  open  sore  into  a  hidden  one  ;  the  sub- 
sequent effusion  of  lymph,  which  sinndates  true  induration  and  confuses  the 
diagnosis ;  and,  fiiudly,  the  greater  liability  to  the  production  of  suppurative 
action  in  the  ordinarily  indolent  bubo  of  syphilis. 

The  so-called  antiseptic  treatment  of  the  initial  lesion  of  syphilis  is  a  mis- 
nomer, so  far  as  the  essential  character  of  the  sore  is  concerned,  uidess  it  be 
meant  to  include  only  the  thorough  destructive  cauterization  of  all  portions  of 
the  infected  tissue.  -  Applied  simply  to  superficial  dressings  jjlaced  over  the 
chancre,  it  can  refer  only  to  the  prevention  of  the  development  of  pyogenic 
organisms  upon  the  surface  of  the  sore.  As  the  tendency  of  infecting  chancres 
to  suppuration  is  generally  unimportant,  we  can  hardly  expect  advantages  from 
the  employment  of  aseptic  or  antiseptic  methods  which  are  at  all  commensurate 
with  those  obtained  by  the  same  methods  in  ordinary  surgical  conditions. 

The  local  treatment  by  hypodermatic  injection  of  mercurials  beneath  the 
base  of  the  initial  lesion  and  into  the  mass  of  indurated  lymphatic  glands  rests 
upon  the  view  that  mercury  acts  as  an  antidote  when  brought  directly  into  con- 
tact with  the  syphilitic  germs,  and  that  this  influence  would  probably  be  espe- 
cially active  if  the  drug  were  brought  to  bear  directly  upon  the  local  lesions 
which  are  the  foci  of  infection  during  primary  syphilis.  If  we  believe  that  the 
virus  remains  localized  for  a  time  after  inoculation,  and  is  not  disseminated 
through  the  general  system,  and  that  mercury  acts  by  its  germicidal  influence, 
this  treatment  is  not  unphilosophical,  but  seems  inferior  to  the  more  thorough 
plan  of  excising  both  the  chancre  and  the  enlarged  lymphatics  of  the  groin. 
The  latter  procedure  would  be  less  likely  to  result  in  local  troubles,  such  as 
abscess  or  cellulitis,  and  would  certainly  be  more  effective.  The  rules  as  to 
the  treatment  of  chancre  may  accordingly  be  expressed  as  follows : 

1.  While  it  is  unquestionably  desirable  to  begin  mercurial  treatment  at  the 
earliest  proper  moment,  and  while  that  treatment  undoubtedly  either  suppresses 
or  renders  milder  the  subsequent  secondary  manifestations,  and  while  there  is 
every  reason  to  believe  that  in  this  way  the  liability  to  later  or  tertiary  lesions 
is  somewhat  lessened,  nevertheless  the  sum-total  of  these  advantages  does  not 
warrant  the  employment  of  mercury  one  moment  before  the  diagnosis  of  con- 
stitutional disease  is  absolutely  assured. 

2.  While  in  many  cases  that  diagnosis  can  be  made  with  a  high  degree  of 
probability  from  the  appearance  of  the  primary  sore  alone,  yet  it  cannot  be 
said  that  all  possibility  of  error  is  excluded  until  some  general  symptom,  such 
as  the  enlargement  of  distant  lymphatic  glands,  has  shown  itself. 

3.  The  administration  of  mercury  during  the  existence  of  the  primary  sore, 
unaccompanied  by  general  symptoms,  for  the  purpose  of  suppressing  or  "abort- 
ing" syphilis,  is  not,  therefore,  justifiable,  unless  by  confrontation  the  diagnosis 
can  be  confirmed,  or  unless  there  are  urgent  and  unquestionable  reasons  for 
securing  rapid  cicatrization  of  the  chancre. 

4.  It  is  proper  to  employ  cauterization  or  excision,  according  to  the  site  of 
the  chancre,  in  cases  in  which  it  is  seen  very  soon  after  its  appearance,  and 
especially  when  \l  is  known  to  have  followed  intercourse  with  a  syphilitic  per- 
son. The  chances  of  preventing  constitutional  infection  in  this  way,  while 
slight,  may  yet  be  considered  sufficient  in  such  cases  to  counterbalance  the  dis- 


164  A.y   AMERICAN    TEXT-BOOK    OF  SC'liGEJiY. 

advanta<::es  of  the  method,  such  as  pain,  swelling,  the  production  of  phimosis 
or  of  suj>puniting  bubo,  and  the  obscuring  of  tlie  diagnosis  by  the  resulting 
inflammatory  exudation. 

5.  Aseptic  or  antiseptic  measures,  while  harmless,  cannot  be  considered 
especially  indicated  in  the  local  treatment  of  chancre,  and  in  all  probability 
can  have  no  true  abortive  influence. 

6.  The  local  use  of  mercurials,  hypodermatically  or  by  inunction,  is  perhaps 
worth  a  trial,  but  it  is  probably  inferior  to  the  more  radical  methods  based 
essentially  upon  the  same  principles — namely,  excision  and  cauterization. 

Chancroid. — The  form  of  sore  known  as  soft  sore,  soft  chancre,  simple 
chancre,  uon-infccting  chancre,  and  chancroid  is  variously  ascribed  to  the 
inoculation  of  a  specific  virus  (the  chancroidal),  to  infection  with  pus-microbes, 
and  to  a  mixed  (syphilitic  and  purulent)  infection.  There  is  some  reason  to 
think  that  there  is  a  specific  virus  for  chancroid.  Xo  final  conclusion  can  yet 
be  stated,  though  bacteriology  will  doubtless  definitely  settle  the  matter  at  no 
distant  period.  In  the  mean  time  Ave  may  be  content  to  consider  chancroid 
as  a  sore  which  has  a  very  diff"erent  appearance  and  runs  a  very  different 
course  from  an  infecting  chancre. 

In  the  case  of  a  chancroid  there  are  observed  from  the  first  certain  phe- 
nomena. Tlie  first  day  we  see  a  small  red  point,  which  on  the  second  day 
becomes  a  papule,  and  is  converted  into  a  pustule  by  the  end  of  the  second  or 
third  day,  especially  in  a  region  where  the  skin  is  delicate.  The  pustule  soon 
breaks,  and  beneath  the  lowest  epidermic  layers  we  find  a  deep  suppurating 
ulcer,  which  rapidly  extends  in  circumference  and  depth,  becoming  at  the  end 
of  the  first  week  deep  and  crater-like  with  perpendicular  or  undermined  edges  ; 
its  surface  is  granulating,  irregular,  and  infiltrated  Avith  pus,  which  is  abundant 
and  gives  it  a  gravish  color.  The  serum  upon  the  surface  of  an  indurated 
chancre,  on  the  contrary,  is  small  in  amount  and  transparent. 

In  the  chancroid  there  is  no  sclerosis  of  the  vascular  walls  ;  we  meet  with 
the  phenomena  of  inflammation,  but  there  is  no  induration  or  thickening  of 
the  Avail  and  no  narroAving  of  the  caliber  of  the  vessels.  The  fibrous  trabeculje 
of  the  derm  of  the  region  involved  are  not  preserved  intact.  The  fibrils  sepa- 
rated by  the  lyraph-cells  are  themselves  destroyed  by  the  softening  of  the  tissue 
and  by  the  suppuration.  These  changes  upon  the  surface  of  a  chancroid  result 
in  the  fibrous  tissue  losing  its  firmness  and  elasticity  ;  its  fibrous  trabecuhe  have 
a  tendency  to  disappear.  The  lymph-cells,  which  collect  in  great  numbers  in 
the  granulations  and  neighboring  connective  tissue,  are  large,  turgid,  and 
become  free  by  softening  the  fibrils  between  Avhich  they  are  placed.  The 
absence  of  specific  induration  comparable  to  that  of  the  indurated  chancre, 
and  also  a  tendency  to  a  progressive  destructive  involvement  of  neighboring 
tissues,  result  from  this  anatomical  arrangement  of  elements.  From  this  it 
will  be  seen  that  betAveen  chancre  and  chancroid  there  is  a  marked  histolog- 
ical diff"erence,  one  being  essentially  a  prominent  papule  or  ncAv  groAvth,  the 
other  an  ulcer.  A  chancroid  is  apt  to  be  painful  and  itching ;  the  pus,  Avhich 
is  secreted  in  large  amount,  is  inoculable  upon  the  patient.  avIio  frefpiently  inoc- 
ulates himself  inadvertently  or  from  uncleanliness,  so  that  it  is  often  multiple. 

Phagedena. — Either  a  chancroid  or  a  chancre,  but  oftener  the  former, 
may  be  accompanied  by  such  intense  local  infection  and  tissue-necrosis  that 
it  spreads  Avith  great  rapidity  both  on  the  surface  and  toAvard  the  deeper 
structures.  It  may  thus  produce  one  of  the  most  destructive  and  most 
obstinate  forms  of  ulceration.  It  is  not  knoAvn  certainly  Avhether  this  indi- 
cates essentially  a  lessened  poAver  of  resistance  or  a  new  microbic  infection. 
Probably  both  conditions  coexist  in  the  majority  of  cases. 


CHANCROID.  156 

When  tlio  lynipliatic  fjlands  are  affected  tlier(?  may  oecur  a  true  sii])piirating 
bubo,  especially  if  the  patient  be  broken  down  in  health  or  if  he  has  been 
nef!;ligent  of  treatment.  In  this  case  an  inguinal  gland  is  swollen,  fixed,  and 
becomes  very  large  ;  the  skin  reddens  u])on  its  surface,  and  we  soon  feel  a  super- 
ficial fluctuation,  due  to  pus  formed  in  tlie  cellulo-adipose  tissue  surrounding  the 
gland.  When  this  abscess  is  opened  the  gland  in  some  cases  suppurates,  and 
there  is  formed  an  irregular  cavity  which  secretes  sanious  pus ;  the  skin  consti- 
tuting its  borders  is  red,  inflamed,  and  separated  from  the  tissue  beneath. 
These  glandular  abscesses,  like  the  chancroid,  sometimes  become  phagedenic. 

Chancroid  is  variable  in  its  duration,  which  is  sometimes  (juite  short,  last- 
ing three,  four,  or  five  weeks ;  at  other  times  it  continues  several  months,  and 
sometimes,  if  it  is  phagedenic,  one  or  more  years. 

The  Treatment  of  Chancroid. — While  it  has  been  for  many  years  the 
custom  to  cauterize  freely  all  soft  or  suppurating  venereal  ulcers — i.  e.  all 
sores  diagnosticated  as  chancroid,  Avhether  situated  in  the  genital  regions  or 
elsewhere — the  introduction  into  surgery  of  the  principles  of  antisepsis,  and 
with  them  of  such  drugs  as  iodoform,  has  greatly  modified  this  routine  treat- 
ment. It  is  safe  to  say  that  chancroids  are  neither  so  frequent  nor  so  severe 
as  they  were  years  ago,  and  that  by  the  application  of  antiseptic  methods  to 
their  treatment  a  great  advance  has  been  made  in  the  ease  and  certainty  with 
which  they  can  be  cured. 

In  a  large  majority  of  cases  daily  irrigation  with  sublimate  solution  of 
1 :  500  or  1  :  1000,  folloAved  by  free  dusting  with  iodoform  or  by  the  applica- 
tion of  an  ointment  consisting  of  one  and  one-half  drams  of  iodoform  to  one 
ounce  of  carbolated  cosmoline,  will  be  followed  by  speedy  cicatrization.  If 
these  fail,  the  continuous  application  by  means  of  pledgets  of  cotton  or  lint  of  a 
lotion  containing  sublimate,  boric  acid,  and  peroxide  of  hj^drogen  will  often  cure. 
If,  in  spite  of  this,  the  sore  deepens  and  extends,  destructive  cauterization  with 
fuming  nitric  acid  or  the  acid  nitrate  of  mercury  is  at  once  the  safest  and 
speediest  method  of  cure. 

The  objections  to  the  cauterization  of  chancroids  are  as  follows,  and  are 
similar  to  those  mentioned  in  relation  to  chancres :  First.  The  pain  to  which  it 
gives  rise.  Second.  The  inflammatory  action  which  follows,  and  which  often  in 
the  case  of  the  male  produces  enough  oedema  and  swelling  to  cause  phimosis,  and 
thus  to  conceal  the  sore  and  prevent  the  proper  application  of  remedies.  Third. 
The  subsequent  eff"usion  of  lymph,  which  is  apt  to  cause  an  induration  closely 
resembling  that  of  the  true  chancre,  and  thus  greatly  to  obscure  the  diagnosis. 

The  general  rule  may  be  followed  of  meeting  indications — that  is.  of  using 
sedative  lotions,  lead-water,  or  lead-water  and  laudanum,  or  sulphate  of 
zinc  and  opium — in  the  acutely  inflamed,  painful  sores ;  and  of  using  stimulat- 
ing washes — sulphate  of  copper,  strong  zinc  solutions,  nitrate  of  silver,  etc. — 
upon  indolent,  pale,  and  flabby  ulcers.  Special  indications  having  been  met, 
iodoform  will  generally  complete  the  cure. 

SYPHILITIC    BUBOES. 

Almost  at  the  same  time  that  the  chancre  becomes  indurated  the  lymphatic 
glands,  connected  with  it  by  means  of  the  lymphatic  vessels,  undergo  hyper- 
trophy. The  glands  nearest  to  an  infeccmg  chancre  become  enlarged  and  hard ; 
they  roll  readily  beneath  the  skin  ;  they  are  painless  and  do  not  suppurate.  These 
clinical  characters  are  unvarying.  They  are  found  in  the  groin  when  the  chancre 
is  upon  the  external  genitals ;  in  the  submaxillary  glands  when  the  chancre  is 
upon  the  lips ;  in  the  axilla  when  the  chancre  is  upon  the  nipple  or  hand. 


156  AN  AMERICAN  TEXT-BOOK  OF  SURGERY. 

The  glands  of  tlie  groin,  *in  connection  with  a  cliancre  upon  the  genital 
organs,  are  successively  involved,  the  gland  first  affected  being  the  most  interior 
of  the  group  upon  the  diseased  side.  When  the  chancre  is  situated  at  one  side 
of  the  frenum,  it  is  not  uncommon  to  find  the  buboes  in  both  "roins,  a  cer- 
tain  amount  ol  decussation  occurring  between  the  lymphatics  of  the  former 
region.  The  inguinal  glands  are  all  hypertrophied,  but  are  distinct  one  from 
another,  the  skin  remaining  healthy. 

About  a  month  and  a  half  after  this  enlarrrement  of  the  glands  near- 
est  to  the  chancre  all  the  lymphatic  glands  of  the  body  are  successively 
invaded,  at  least  all  those  which  are  visible.  They  appear  a  little  inflamed 
before  or  at  the  same  time  with  the  eruption  of  the  cutaneous  syphilides.  Prob- 
ably all  the  glands  of  the  economy  are  aifected,  and  cases  of  enlargement  of 
the  glands  in  front  of  the  sacral,  lumbar,  and  dorsal  vertebrae  have  been 
reported.  The  subcutaneous  glands  affected  by  syphilis  are  the  cervical, 
maxillary,  occipital,  etc.  Among  the  most  important  glands  for  diagnostic 
purposes  are  the  post-cervical,  which  do  not  enlarge  from  local  causes  so  fre- 
quently as  the  anterior  chains  of  cervical  lymphatics  (glandulae  concatenatse), 
and  which  are  therefore  almost  pathognomonic  when  they  undergo  painless  mul- 
tiple enlargement  at  about  the  period  for  the  appearance  of  the  early  secondaries. 

In  syphilitic  lymphatic  glands  the  follicles  of  the  delicate  reticulated  tissue 
are  hypertrophied,  and  occasion  small  lobulated  projections  upon  their  surface 
when  the  capsule  is  removed.  These  glands  remain  more  or  less  enlarged, 
not  only  during  the  active  period  of  the  secondary  lesions,  but  frequently  after 
the  syphilides  have  disappeared. 

The  following  tables  Avill  serve  to  contrast  the  buboes  and  lymphangitis 
characteristic  of  the  two  chief  forms  of  venereal  sores : 

Syphilitic  Bubo.  Inflammatory  Bubo. 

Always    accompanies  or   follows    infecting  Occurs   in  only  one-third   of  the   cases  of 

chancre.  chancroid  ;  occasionally,  but  more  rarely, 

in  herpetic  or  balanitic  ulceration  or  in 
gonorrhea;  may  follow  an  infected  wound 
of  the  lower  extremity. 

Several  glands  involved,  making  a  group  or  One  gland  implicated,  rarely  bilateral, 
chain   of  small,  movable   glands  in    one 
groin  or  often  in  both. 

Appears  soon  after  chancre.  No  definite  time  of  appearance. 

Slight  enlargement.  Great  enlargement. 

Cartilaginous  induration.  Inflammatory  hardness. 

No  inflammatory  symptoms.  Always  present. 

Glands  freely  movable.  Gland  fixed  (periadenitis). 

Skin  normal,  not  adherent.  Skin  red,  adherent. 

Painless.  Painful. 

Indolent,  slow.  Runs  an  acute  course. 

Terminates  by  resolution,  rarely  by  suppura-  Usually  suppurates,  rarely  undergoes  resolu- 
tion, tion. 

No  marked  tendency  to  phagedena.  Phagedena  not  very  uncommon. 

No  local  treatment  effective.  Local  treatment  required. 

Mercurial  treatment  hastens  resolution.  Mercury  has  no  influence  upon  the  condition. 

Syphilitic  Lymphangitis.  Inflammatory  Lymphangitis. 

Lymphatic   vessels   feel  hard,  like  the  vas  Same,  but  less  hardness. 

deferens ;  size  of  a  knitting-needle. 

Painless  to  touch.  Painful. 

No  pain  on  erection.  Erection  gives  rise  to  pain. 

Skin  normal.  Skin  red  over  inflamed  vessel. 

Terminates  by  resolution.  Resolution  or  suppuration. 

Local  treatment  unnecessary  and  ineffective.  Local  treatment  of  great  use. 


SYPHILIS.  157 


SECTION    II.  :    GENERAL    SYPHILIS. 


At  about  the  time  of  the  general  lymphatic  enlargement — and  coincident 
with  or  preceding  the  earliest  eruption — we  have  a  characteristic  group  of 
symptoms — viz. :  1.  Fever,  varying  fnmi  100°  F.  to  101°  F.,  coming  on  toward 
evening  and  associated  with  moderate  anorexia  and  malaise.  2.  MuHcidar  <uid 
artieidar  j>(tiii)<,  chietiy  aft'ecting  the  muscles  and  joints  of  the  chest,  back,  and 
upper  extremities,  but  sometimes  very  general  and  c^uite  severe.  3.  Alopecia, 
not  confined  to  the  scalp,  but  involving  the  hairs  of  the  whole  body,  distin- 
guished from  ordinary  baldness  by  that  fact,  by  the  concomitant  symptoms  of 
syphilis,  and  by  the  irregtdar,  moth-eaten  character  of  tlie  bald  spots. 

Constitutional  syphilis  may  be  diagnosticated  when  an  indurated  genital 
chancre  is  followed  by  a  painless,  hard  swelling  of  the  inguinal  glands  and  of 
others  like  the  post-cervical,  which  are  remote  from  the  spot  of  local  irritation. 
The  change  of  the  lymphatic  gland  is  so  characteristic  that  from  it  alone  the 
diagnosis  of  syphilis  is  possible  Avhen  the  cervical,  maxillary,  supratrochlear, 
and  other  lymphatic  glands  are  invaded,  as  well  as  those  in  the  inguinal  region, 
and  still  more  easily  when  the  fever,  pains,  and  alopecia  are  present. 

SECONDARY    SYPHILIS. 

The  eruptions  of  the  skin  and  mucous  membranes  soon  make 
their  appearance,  and  constitute  the  first  manifestations  of  the  secondary  stage. 

These  syphilides  usually  appear  about  six  weeks  after  the  beginning  of 
the  infecting  chancre,  sometimes  sooner  ;  at  other  times  later,  even  two  or  two 
and  a  half  months  from  the  date  of  the  chancre.  They  are  seldom  as  late  as 
three  or  four  months,  yet  in  rare  cases  they  have  occurred  after  five  months 
have  elapsed.  Mercurial  treatment,  when  given  during  the  existence  of  the 
chancre,  has  been  accused  of  causing  this  retardation,  and  doubtless  does  so ; 
but  it  must  not  be  forgotten  that  the  evolution  of  the  disease  is  very  variable. 

Cutaneous  and  mucous  syphilides  are  more  superficial  when  they  are  more 
recent,  and  grow  deeper  as  they  grow  older.  Thus  the  syphilides  of  the  first 
period  of  secondary  lesions  affect  only  the  papillary  surfate  and  epidermic  lay- 
ers. These  are  erythemata,  or  superficial  spots,  as  roseola ;  or  limited,  slight, 
and  temporary  inflammations  of  the  papillary  and  epidermic  layers,  as  papules. 
The  older  syphilides,  on  the  contrary,  belonging  to  the  later  secondary  period, 
appear  as  pustules  or  tubercles,^  which  affect  the  deep  cutaneous  and  subcuta- 
neous layers  in  connection  with  the  papillary  network  and  epidermis ;  they  are 
destructive  and  are  followed  by  cicatrices. 

A  classification  of  syphilides  similar  to  that  adopted  by  Cornil  and  based  on 
their  pathological  histology  is  both  useful  and  practical.     It  is  as  follows : 

1st.   Erythematous  syphilides — erythema;  macules;  roseola. 

2d.  Papular  syphilides — conical,  lichen-like  syphilide ;  large  papules. 
— Patches  of  papulo-lenticular  syphilide ;  papulo-squamous. 

3d.   Pustular  syphilides — acneiform;  impetiginous;  ecthymatous;  rupial. 

4th.  Vesicular  syphilides  are  very  rarely  encountered.  Most  so-called 
vesicles  met  with  in  syphilis  are  in  reality  pustules,  and  result  from  the  puru- 
lent softening  of  the  apices  of  papules. 

5th.  Gummatous  and  tubercular  syphilides. 

In  this  classification  there  is  indicated  the  gradual  passage  of  the  superficial 
lesions  of  the  early  period  of  secondary  symptoms  into  the  deeper  and  later 

'  The  word  "  tubercle  "  is  often  used  to  designate  one  of  the  eruptions  of  syphilis.  It  refers 
simply  to  its  visible  characteristics,  and  does  not  mean  that  there  is  any  infection  with  the  bacilli 
of  tuberculosis. 


158  ^I^V  AMimiCAN  TEXT-BOOK  OF  SURGERY. 

lesions  of  tlio  second  period,  and  finally  into  the  rupia,  tubercles,  and  gum- 
mata  of  the  third  period. 

Syj)liilides  of  the  first  period  are  almost  always  iioh/iitorjiliouH  ;  that  is,  the 
eruptions  j)resent  at  the  same  time  the  dift'erent  varieties  of  roseola,  papules, 
and  small  pustules  or  squamous  papules.  In  ordinary  eczema  or  imjietigo  we 
have  the  same  elementary  lesion  of  the  skin  at  all  j)oints,  and  the  same  appear- 
ance of  all  the  regions  affected ;  but,  on  the  contrary,  there  are  found  in  syph- 
ilis varied  elementary  lesions,  spots  of  erythema  alongside  of  papules  and 
vesico-})ustules,  and  other  lesions  modified  according  to  their  location.  In 
other  cases  there  will  be  seen  a  papular  syphilide  in  a  somewhat  chronic  state  ; 
the  papules  when  upon  the  skin  of  the  limbs  appear  dry,  their  ej>idermis  desqua- 
mating. In  those  regions  where  the  skin  is  in  folds,  as  upon  a  dependent 
mammary  gland,  the  papule,  instead  of  being  dry,  is  moist ;  upon  the  palm  of 
the  hand,  where  the  epidermis  is  corneous  and  thick,  the  epidermic  layers 
over  the  papule  form  hard  scales,  which  have  incorrectly  been  compared  with 
psoriasis.  This  polymorphous  condition  and  the  blending  together  of  the 
elementary  lesions  are  among  the  best  diagnostic  characteristics  of  syphilides. 
Syphilides  of  the  late  secondary  period  frequently  involve  all  the  layers  of  the 
derm  and  epiderm,  and  are  given  compound  names,  as  papulo-vesicular,  papulo- 
pustular,  tuberculo-pustular,  etc. — names  which  define  themselves. 

The  syphilides  have  a  coIoj-  Avhich  is  said  to  resemble  that  of  copper  or  of 
ham  ;  this  is  owing  particularly  to  extravasations  of  red  blood-coi-puscles.  and 
is  marked  in  the  eruptions  of  the  first  period.  The  copper  color  is  not  seen  in 
lesions  of  the  mucous  membranes.  Another  distinctive  characteristic  of  syph- 
ilides, except  diffused  erythematous  roseola,  is  that  they  all  have  a  regularly 
round  shape,  whether  isolated  or  in  groups.  They  form  small  circles,  figures-of-H, 
etc.  Finally,  the  lymphatic  glands  are  often  affected  in  the  region  invaded  by 
the  eruptions,  and  the  action  of  mercury  upon  these  eruptions  is  to  cause  their 
rapid  disappearance. 

The  earliest  cutaneous  symptom  in  syphilis  is  almost  equally  apt  to  be  an 
erythema  or  a  roseola,  the  former  a  diffused  mottling  of  the  surface,  affecting 
chiefly  the  trunk  and  abdomen  and  without  appreciable  elevation  ;  the  latter, 
somewhat  darker  in  color  and  apt  to  show  a  tendency  to  become  papular. 
Roseola  may  indeed  be  considered  as  an  eruption  intermediate  between  the 
erythematous  and  papular  syphilides.  The  diagnosis  is  usually  easy,  and  can 
readily  be  made  from  simple  roseola,  the  roseola  caused  by  copaiba,  by  expo- 
sure to  the  atmosphere,  by  measles,  by  bites  of  insects,  etc.,  if  the  patient  be 
examined  Avith  care,  if  enlarged  lymphatic  glands  and  mucous  patches  are 
looked  for,  and,  finally,  if  the  special  color  of  the  papules  and  the  history  of 
the  case  be  remembered. 

The  papular  syphilides  may  be  small  or  large,  and  may  be  associated 
with  such  an  accumulation  of  epidermic  scales  as  to  receive  the  name  of  the 
papulo-squamous  syphilides.  The  first  variety  (small  papules)  has  received  the 
name  of  lichen-like  or  miliary  syphilide.  The  color  of  the  papule  is  very  clia- 
racteristic.  The  elevation  of  the  skin  is  due  to  a  thickening  of  the  papilhv  and 
epidermic  layers ;  but  at  the  summit  of  the  papule  and  over  all  the  surface 
forming  it  the  most  superficial  layers  of  the  corneous  epidermis  have  desqua- 
mated, while  those  at  the  margin  of  the  papule  are  continuous  with  the  normal 
skin  of  the  periphery.  The  papules  remain  a  varying  length  of  time ;  they 
usually  disappear  in  three  or  four  Aveeks  when  mercurial  treatment  has  been 
employed :  at  other  times  they  continue  for  two  and  three  months.  They  are 
modified  according  to  their  location.  The  mucous  patches  corresponding  to 
this  variety  may  be  small  and  acuminated.     Upon  the  scalp  the  eruption  appears 


SYPHILIS.  I'/J 

as  small  pustules  or  papules  covered  with  a  yellowish  or  brown  scab  ;  upon  the 
palmar  surface  of  the  hands  the  papules  are  covered  with  hard  epidermic  scales 
or  they  are  depressed  and  surrounded  by  a  corneous  epidermis. 

The  s,i'ond  variety  of  papular  syphi'lides  is  characterized  by  large  papules, 
havin«r  a  diameter  of  from  half  an  inch  to  an  inch,  or  even  larger.  In  its 
beginning  a  pimple  is  noticed  with  regular  edges  and  pink  surface,  which  soon 
ass'umes  tlie  characteristic  color,  and  upon  which  the  most  superficial  layers  of 
the  epidermis  are  desquamating ;  at  the  periphery  of  the  papule  the  des.iuama- 
tion  is  arrested,  and  here  is  seen  a  thickened  epidermic  border.  Ihe  surface 
of  the  papule  is  smooth  and  circular.  "i      i        i  •        i 

In  the  papular  eruptions  generalized  over  the  entire  body  the  skin  where 
thev  are  situated  often  becomes  so  thick  as  to  warrant  the  term  papulo-tuber- 
culous ;  thev  unite  and  form  large  bands ;  for  example,  upon  the  forehead- 
corona  wnem— or  surround  the  mouth  and  ah«  of  the  nose;  they  also  form 
circles  upon  the  shoulders,  neck,  and  trunk,  and  extend  over  the  surface  of  the 
limbs.  Often,  durins:  the  period  of  acme,  they  are  covered  with  thick  scales, 
which  may  be  removed  in  irretrular  fragments  by  scratching ;  this  form  is  termed 
papulosquamous.  Their  color  is  always  very  distinct,  intense,  deep  copper-red. 
The  essential  histological  changes  which  enter  into  the  formation  of  a 
syphilitic  papule  are  a  hvpertrophy  of  the  papillre  of  the  skin,  an  increase  m  the 
number  of  epithelial  laVers  which  form  the  epidermis,  and  a  proliferation  ot 
the  cells  of  the  rete  inucosum.  The  blood-vessels  are  congested,  and  there 
occurs  an  extravasation  of  the  blood-elements  into  the  tissue  of  the  derm 
which  crives  the  characteristic  coloration  to  the  lesion.  Desquamation  of  the 
superficial  layers  of  the  skin  is  one  of  the  features  of  the  papule.  The  changes 
are  not  limited  to  the  papillae  and  superficial  corium,  but  m  some  varieties 
extend  to  the  subcutaneous  adipose  tissue.  There  is  no  vascular  sclerosis 
comparable  to  that  met  with  in  the  chancre.  These  changes  are  modified  by 
situation,  duration,  etc.  vrc     i        rpx. 

The  diagnosis  of  a  large  papular  svphilide  is  never  very  ditiicuit.  Ihe 
special  color  and  the  arrangement  of  the  papules,  the  involvement  of  the  palms 
of  the  hands  and  soles  of  the  feet,  also  of  the  palmar  surface  of  the  fangers 
and  plantar  surface  of  the  toes,  the  enlargement  of  the  lymphatic  glands,  the 
frequent  existence  of  mucous  patches,  are  all  characteristic.  The  papular 
svphilide  is  indeed  the  most  distinctive  of  all,  and  the  most  common  after  rose- 
ola. It  is  seldom  that  a  svphilide  with  large  papules  continues  less  than  two 
months,  and  frequently  it'  remains  three,  four,  or  five  months,  especially  it 
mercurial  treatment  has  not  been  employed  at  all  or  too  timidly.  There  is  no 
form  of  medical  treatment  in  which  the  curative  power  of  a  remedy  is  so  evi- 
dent and  so  admirable  as  in  the  use  of  mercury  in  cutaneous  syphihdes,  and 
particularly  in  the  severe  forms  of  papulo-squamous  eruption. 

Mucous  Patches.— A  transformation  of  a  syphilitic  papule  into  a  mucous 
patch  takes  place  whenever  it  is  under  the  continuous  influence  of  warmth, 
moisture,  and  friction,  as  on  a  mucous  membrane  at  a  muco-cutaneous  junction 
or  in  the  creases  or  folds  of  skin.  Under  these  circumstances  the  overlying 
epidermis  or  epithelium  is  macerated  and  disappears:  the  papule,  originally 
small,  rapidly  extends  in  superficial  area;  it  becomes  grayish  or  opalescent  in 
appearance  i"f  seated  on  a  mucous  surface ;  red,  smooth,  and  polished  if  on  the 
skin.     In  either  case  it  is  moist  and  has  a  free  secretion,  often  oflensive.  and 

always  highly  contagious.  ^        •      i  i        ^  ^i    • 

The  most  common  seats  of  mucous  patches  are,  first,  m  the  order  ot  their 
frequency,  the  genital  oraans  and  region  of  the  anus.  Their  location  varies 
according  to  the  sex.     With  women  mucous  patches  of  the  labia  and  ot  the 


IGO  AN  AMERICAN  TEXT-BOOK  OF  SURGERY. 

vulva  arc  almost  constant ;  with  men,  on  the  contrary,  they  are  not  very 
freciuently  met  with  on  the  prepuce  or  glans,  the  most  common  seats  being 
the  scrotum  and  anus.  With  women  the  anus  is  also  frequently  the  seat  of 
mucous  ])atches. 

The  /ifstologieal  structure  of  nmcous  patches  consists  in  a  thickening  of 
the  epidermic  layers  and  an  increase  in  the  size  of  the  papillae  of  the  skin  by 
a  development  of  the  elements  entering  into  their  structure.  This  increase  in 
size  of  the  papilhx;  causes  a  corresponding  increase  in  the  lengtli  of  the  inter- 
papillary  prolongations  of  cells  of  the  rete  mucosum.  The  blood-vessels  of  the 
papilljie  are  distended  with  l)lood.  The  tissue  of  the  derm  is  found  jirolifer- 
ating. 

Diagnosis  of  Mucous  Patches. — It  is  almost  impossible  to  mistake 
a  mucous  patch  after  a  number  have  been  seen.  They  are  formed  upon  a 
papule — that  is,  an  inflammatory  swelling  of  the  corium  and  papillae  ;  their 
surface  is  oozing,  and  the  epidermis  or  epithelium  Avhich  covers  them  is  satu- 
rated or  desquamated.  Thus,  u])on  the  labia  majora  and  minora  there  are  seen 
whitish  patches  or  small  points  which  resemble  moist  or  pulpy  paper,  and 
consist  of  epidermic  cells  or  changed  superficial  epithelium ;  upon  a  mucous 
membrane,  as  on  the  lips  or  palate,  the  epithelium  is  whitish,  opaline,  resem- 
bling a  surface  which  has  been  touched  with  nitrate  of  silver.  The  mucous 
patch,  if  eroded,  has  a  surface  Avhich  is  red  and  smooth  after  the  superficial 
epithelium  has  desquamated ;  the  shape  of  the  patch  is  always  circular  or 
regularly  oval,  and  the  derm  is  thickened  upon  its  surface.  The  patches  of 
the  vulva  and  k.bia  majora,  likewise  of  the  anus  and  of  the  scrotum  and  scroto- 
femoral  folds,  even  when  in  process  of  healing  are  very  distinct ;  as  the  epider- 
mis forms,  the  derm  remains  a  little  papular  and  the  surface  dull  red. 

The  syphilitic  papules,  covered  with  thick  superficial  layers  of  corneous 
epidermis — that  is,  with  scales — are  termed  papuio-squamous  syphilides. 
They  are  generally  very  obstinate,  since  the  layers  of  the  epidermis  repose 
upon  the  thickened  and  chronically  inflamed  derm.  These  squamous  papules, 
covered  with  or  deprived  of  their  epidermic  layers,  when  situated  upon 
the  palms  of  the  hands  and  soles  of  the  feet,  are  called  palmar  or  plantar 
sypliilides.  The  papules  are  modified  simply  on  account  of  their  seat  and 
the  structure  of  the  skin  of  the  hands  and  feet.  Here  the  corneous  epidermis 
attains  considerable  thickness  and  resistance ;  it  forms  a  layer  which  at  times 
measures  a  millimeter  in  thickness  and  is  dense  and  hard  like  parchment. 
Thus  it  offers  more  or  less  resistance  to  the  development  of  the  papules, 
especially  at  their  beginning.  Later,  however,  the  epidermis  covering  the 
papule  is  raised,  cracked,  and  partly  or  completely  eliminated,  or  it  forms  hard 
and  irregular  stratifications. 

With  syphilitic  papules,  and  at  the  same  time  with  secondary  syphilides, 
there  occurs  a  lesion  allied  to  the  lesions  of  the  epidermis — viz.  the  changes 
of  the  nails. 

Syphilitic  Onychia  is  a  disease  of  the  nails,  the  peculiarities  of  which 
result  from  the  anatomical  structure  of  the  matrix  of  the  nail  and  of  the  peri- 
and  subungual  papillo-epidermic  tissue.  There  are  described  two  varieties — 
the  dry  and  the  moist. 

The  drt/  variety  of  onychia  generally  accompanies  the  papular  and  papulo- 
squamous eruptions  situated  upon  the  fingers  and  toes,  the  ends  of  which  are 
attacked  by  papules,  which  pass  around  their  extremities  or  may  be  seated  at 
the  roots  and  edges  of  the  nails  or  under  them.  Sometimes  the  nail  is  cracked 
and  readily  broken  ;  it  is  dry  and  separated  from  the  skin.  Sometimes,  when  the 
papules  exist  at  the  ungual  matrix,  there  is  a  swelling  of  the  skin  at  this  region, 


1SYPHILIS.  161 

and  the  formation  of  the  epidermic  hiyers  of  the  nail  is  very  much  interfered 
with.  At  times  there  is  an  irregular  thickening  of  the  nail  by  hard  scabs, 
which  are  stratified  and  occasion  a  dense,  irregular  elevation. 

The  moist  variety  of  onycliia  occurs  with  vesiculo-pustular  or  pustular 
syphilides.      Sometimes  true  whitlow  is  met  with. 

These  conditions  often  terminate  in  tlie  destruction  of  the  nail,  and  neces- 
sitate rest,  antiseptic  fomentations,  and  afterward  some  simple  dressing'. 

Pustular  Syphilides. — The  pustular  syphilide  is  found  in  the  form  of 
acne,  of  impetigo,  or  of  ecthyma.  Syj)hilitic  acne  is  always  early  and  super- 
ficial. Impetigo  and  ecthyma  may  also  occur  in  the  first  stages  and  without 
any  element  of  gravity,  but  in  other  cases,  where  they  appear  very  early,  may 
be  of  graver  import :  during  the  later  eruptions  they  assume  a  still  more  serious 
aspect,  and  tend  to  rapid  extension  both  in  depth  and  superficial  area,  resulting 
in  pustulo-crustaceous  ulcers,  of  long  duration  and  of  extent  corresponding  to 
the  amount  of  suppuration  and  the  tendency  to  confluence  of  the  lesions,  which 
are  often  accompanied  by  symptoms  of  general  cachexia,  and  in  exceptional 
cases  even  terminate  in  death. 

SyphiUtie  acne  is  as  much  a  papule  as  a  pustule  in  its  structure  and 
evolution.  It  forms  a  small  conical  projection,  upon  the  top  of  which  appears 
a  very  slight  epidermic  elevation,  caused  by  a  small  quantity  of  serous  effusion, 
which  rapidly  becomes  purulent.  The  pustule  is  of  short  duration,  and  is  soon 
replaced  by  a  little  crust,  and  then  by  scales,  leaving  only  a  stain,  Avithout 
cicatrix.  This  eruption  appears  in  successive  crops  upon  the  face,  the  shoulders, 
the  trunk,  and  thighs,  in  which  latter  situation  the  pustules  are  often  confluent. 
There  are  generally  at  least  as  many  papules  or  papulo-squamous  spots  as  well- 
formed  pustules,  the  papular  elevation  remaining  after  all  traces  of  the  pustule 
have  disappeared  from  its  summit.  It  is  an  eruption  of  the  early  stages,  and 
behaves  like  the  papular  syphilide.  It  is  distinguished  from  acne  vulgaris  by 
its  distribution — for  it  especially  affects  the  belly  and  thighs,  while  acne  vulgaris 
is  found  on  the  face  and  shoulders — by  its  copper  color  and  its  greater  dryness, 
and  by  the  absence  of  white  permanent  cicatrices. 

Syphilitic  impetigo  appears  in  the  form  of  little  pustules  covered  by  crusts 
and  resembling  isolated  pimples,  or  as  patches  formed  by  the  union  of  many 
pustules.  The  pustulo-crustaceous  form  is  commonly  found  upon  the  scalp  at 
the  same  time  that  a  syphilitic  roseola  or  mucous  patches  have  invaded  the 
general  integumental  surface. 

The  impetigo  may  be  the  predominant  eruption,  the  scalp,  face,  and  fore- 
head being  the  points  of  election.  The  reason  for  the  transformation  of  a 
papular  syphilide  into  the  pustulo-crustaceous  form  upon  the  face  and  scalp  is 
found  in  the  abundance  of  sebaceous  glands  with  which  those  parts  are  supplied. 
These  glands,  when  involved  in  the  inflammatory  action,  produce  a  papule; 
upon  the  cutaneous  surface  their  secretion  is  modified,  and  consists  then  of  a 
sebaceous  liquid  more  or  less  intermingled  with  blood-corpuscles.  As  a  result 
there  is  seen  either  a  w^ell-formed  pustule,  a  sebaceous  concretion,  or  a  crust 
upon  the  surface  of  the  papule. 

Usually  the  pustules  are  seated  upon  a  reddish,  copper-colored  patch  or 
papule.     When  the  eruption  is  confluent  it  covers  large  surfaces  with  scabs. 

Syphilitic  ecthyma  may  be  superficial  or  deep.  The  former  variety  occurs 
usually  on  the  lower  limbs,  and  appears  as  a  large  pustule  with  a  thick  dark 
crust.     It  leaves  behind  it  ecchymotic  stains. 

Deep  ecthyma  at  first  appears  as  a  collection  of  pus  under  a  large  elevation 
of  superficial  epidermis,  as  occurs  in  the  variety  already  described.     The  pus- 
tule is  regularly  circular ;  the  contents  inspissate  by  evaporation,  and  form  a 
11 


162  AN  AMERICAN  TEXT-BOOK  OF  SURGERY. 

crust  ■which  increases  by  the  addition  of  successive  layers.  These  crusts  in 
superimposed  strata,  greenish  or  brown  in  hue,  imbricated  like  the  shell  of  an 
oyster,  dry,  resistant,  are  also  met  with  in  rupia,  having  the  same  configuration 
and  immediately  suggesting  syphilis.  Under  this  crust,  which  continues  to 
enlarge  antl  thicken,  the  pustule  itself  extends  in  breadth  and  dejtth.  The 
crust  overlaps  tiie  border  of  the  ulcer,  or,  when  the  latter  is  the  larger,  is  set 
within  it  like  a  watch-crystal  in  its  case.  When  it  falls  off  there  is  disclosed 
an  ulceration  extending  to  the  papillae  or  even  deeper  into  the  skin.  These 
pustules  are  sometimes  spread  singly  over  a  large  portion  of  the  body,  most 
fre(iuently  the  inferior  extremities ;  in  other  cases  they  are  grouped  in  the  form 
of  circles  or  crescents. 

The  diagnosis  of  syphilitic  ecthyma  from  scrofulous  ecthyma  is  frequently 
difficult.  The  latter  ulceration  is  often  deep  and  with  perpendicular  borders, 
as  in  the  syphilides ;  the  crusts,  however,  in  syphilis  are  drier,  darker,  and 
more  imbricated,  the  cachectic  lesion  suppurating  earlier  and  more  freely,  con- 
sequently permitting  of  less  adhesion  of  the  crusts.  This  is  not  an  invariable 
distinction,  as  in  certain  cases  syphilitic  ulcerations  are  attended  with  the 
formation  of  large  quantities  of  pus.  When  the  eruption  is  distributed  upon 
the  face  and  body  as  well  as  upon  the  limbs,  the  diagnosis  of  syphilis  should 
be  made,  as  the  ecthyma  due  to  scrofula  is  observed  only  upon  the  inferior 
extremities. 

The  history  and  concomitant  symptoms  almost  always  lead  to  a  recognition 
of  the  disease,  as  it  is  a  persistent  eruption,  lasting  for  months  or  even  for  a 
year,  and  often  reappearing  with  all  its  original  characteristics.  It  necessitates 
a  guarded  prognosis  on  account  of  its  persistence  and  of  the  continual  suppura- 
tion caused  by  it,  especially  when  it  is  widespread.  It  is  formidable  also 
because  it  indicates  a  grave  form  of  syphilis,  particularly  when  it  appears  soon 
after  the  initial  lesion. 

Rupia  manifests  itself  at  first  by  large  elevations  of  the  epidermis  filled 
■with  a  clear  or  bloodstained  serum,  soon  becoming  turbid  and  purulent.  The 
bulla  bursts,  allows  some  of  the  liquid  to  escape,  and  as  it  desiccates  is  covered 
with  a  crust,  which  dries,  accumulates  new  layers,  and  becomes  imbricated  with 
brown  and  greenish  strata,  as  in  the  variety  of  ecthyma  just  described.  Rupia 
is,  of  all  the  syphilides,  the  one  attended  with  the  largest,  thickest,  darkest, 
and  most  characteristic  crusts,  as  it  is  also  the  one  presenting  the  most  exten- 
sive ulcerations.  Under  these  crusts  the  papillary  layer  and  the  entire  derm 
are  undergoing  suppuration,  as  in  the  last  two  eruptions  considered. 

In  the  tubercles  and  gummata  of  the  skin  are  seen  the  latest  and 
deepest  manifestations  of  cutaneous  syphilis. 

Syphilitic  tubercles  and  gummata  have  striking  analogies.  They  appear 
at  the  same  stage  of  syphilis,  are  of  the  same  clinical  import,  and  are  caused 
by  the  same  pathological  changes ;  the  chief  distinction  being  that  the  tuber- 
cles are  more  superficial,  only  involve  the  derm,  do  not  extend  into  the  sub- 
cutaneous tissue,  and  give  rise  to  a  less  abundant  cellular  infiltration. 

Tubercular  syphilides  represent  deep  and  enormously  swollen  papules, 
and  are  intermediate  pathologically  between  the  papule  and  the  gumma.  They 
appear  as  single,  flattened  pimples,  attended  with  an  induration  of  the  entire 
skin,  from  the  superficial  epidermis  to  the  deepest  layer  of  the  derm  ;  they  are 
sometimes  solitary,  sometimes  in  groups,  and  may  be  scanty  or  may  be  widely 
extended.  Their  favorite  situation  is  upon  the  face,  at  the  mucous  outlets, 
upon  the  nose,  ears,  forehead,  back,  neck,  and  inferior  extremities,  especially 
the  legs. 

There  are  two  varieties,  the  dry  and  the  ulcerating.     The  dry  tubercular 


SYPHILIS.  163 

svpliilide  is  usually  copper-colored  and  covered  with  thick  scales,  almost  crusts; 
there  may  be  no  ulceration,  and  healing  may  occur,  with  the  production  of  a 
white  or  pigmented  cicatrix,  without  any  ulcerative  process  having  taken  place. 

The  ulcerative  tubercular  syphilides  are  more  grave  on  account  of  the 
abundant  sup})uration  caused  by  them.  They  may  be  isolated,  but  are  usually 
in  groups,  often  very  extensive. 

Histologically,  gummata  and  tubercles  consist  essentially  in  the  forma- 
tion of  embryonal  cells,  which  in  the  former,  the  gummata,  occupy  a  position 
deep  in  the  derm,  infiltrating  all  the  tissues,  and  in  some  instances  even  involv- 
in<^  the  deeper  structures,  bone,  cartilage,  etc.  The  tubercles  are  similar  in 
their  histological  structure,  but  are  limited  more  particularly  to  the  skin,  not 
affecting  the  subcutaneous  tissues. 

The  disease  for  which  an  ulcerating  tubercular  syphilide  is  most  likely  to 
be  mistaken  is  lupus  vulgaris,  which  is  a  cellular  new-growth  due  to  infection 
with  the  bacillus  of  tuberculosis,  and  results  in  various  papular  or  tubercular 
patches  which  are  usually  followed  by  ulceration.  It  has  no  relation  with 
syphilis,  and  should  be  carefully  distinguished  from  it,  as  the  treatment  bene- 
ficial in  one  case  is  useless  or  absolutely  harmful  in  the  other.  The  main 
diagnostic  points  may  be  tabulated  as  follows  : 

Tubercular  Syphilide.  Lupus  Vulgaris. 

Occurs  chiefly  among  adults.  Occurs  commonly  in  young  persons ;  when 

in  adults   there  is   often  a  history  of  a 
similar  eruption  in  childhood. 
Considerable  infiltration  of  skin.  Not  so  marked. 

Tubercles  opaque  and  of  a  deep  brownish-     Tubercles  often  translucent  and  lighter  in 

red  color.  color. 

The  characteristic  ulcer  produced  in  a  month     The  same  amount  of  ulceration  would  require 
or  two.  several  months  or  even  years  for  its  devel- 

opment. 
Ulcers  usually  distinct.  Ulcers  apt  to  be  confluent. 

Ulcers  deep  and  extensive.  More  superficial  and  involving  smaller  area. 

Ulcers  small,  circular,  punched  out.  No  regular  form  or  perpendicular  edges. 

Secretion  copious,  sometimes  ofi'ensive.  Secretion  slight,  inofl"ensive. 

Crusts  bulky,  greenish.  Crusts  thin  and  dark-colored. 

Scales  irregular  in  shape  and  attachment.  Scales  arranged  more  regularly,  attached  in 

the  centre  and  loosened  at  the  edges. 
Cicatrices  soft,  white,  circular.  Cicatrices  distorted,  irregular,  puckered. 

History  and  concomitant  symptoms  of  syph-     No  such  history  except  as  a  coincidence. 

ilis. 
Local  treatment  inefi"ective.     Internal   spe-     Eruption  disappears  only  under  very  active 
cific  treatment  effects  a  cure,  local  treatment,  as  curetting,  or  under  the 

influence  of  tuberculin. 

Gummata  of  the  skin  make  their  appearance  at  variable  intervals  after 
the  contraction  of  syphilis ;  sometimes  very  late — twenty  or  thirty  years  after 
the  chancre — sometimes,  on  the  contrary,  very  early,  during  the  first  year,  or 
€ven  in  the  first  four  or  five  months ;  this  occurs  in  the  grave  and  abnormal 
varieties  of  the  disease  ;  most  frequently  they  develop  three  or  four  years  after 
the  chancre.  The  favorite  localities  are  the  face,  scalp,  shoulders,  neck,  arms, 
thighs,  and  legs,  but  they  may  appear  in  any  region  of  the  body. 

Cutaneous  gummata  are  inflammatory  tumors  of  the  subcutaneous  tissue — ■ 
the  cellulo-adipose  connective  tissue— which  terminate  by  discharging  exter- 
nally :  they  cause  a  loss  of  substance  to  great  depths,  more  considerable  in 
extent  at  the  bottom  than  at  the  cutaneous  orifice,  the  disintegrated  tissue 
being  slowly  throAvn  off  like  the  core  of  a  furuncle. 

in  the  development  of  a  gumma  there  are  four  jJeriods,  which  include  the 
processes  of  formation,  softening,  ulceration,  and  repair.      The  first   period 


164  AN  AMEBIC  AN  TEXT- BOOK  OF  SUBCERY. 

is  of  lon^  duration,  and.  as  the  tumor  is  painless,  the  patient  usually  discovers 
it  by  chance  as  a  rounded  or  slii^htly  flattened  nodule  seated  deeply  beneath 
the  skin,  which  latter  is  slightly  raised  The  nodule  is  movable  in  the  sub- 
cutaneous tissue,  is  bard,  consistent,  and  gives  rise  to  no  subjective  symptoms. 
The  tumor  grows  slowly  until  it  acquires  a  volume  varying  from  one  centimeter 
in  diameter  to  that  of  a  hen's  egg.  Ordinarily  it  lias  a  diameter  of  from  one- 
half  to  three-quarters  of  an  inch.  The  skin  over  the  surface  of  the  gumma 
remains  normal,  until  suppuration  begins.  After  a  time  the  tumor  softens, 
becomes  doughy,  and  then  Huctuation  takes  place.  Soon  the  skin  reddens, 
grows  thin  at  the  most  prominent  point,  and  is  finally  perforated.  Tlie  small 
circular  opening  gives  exit  at  first  only  to  a  small  quantity  of  purulent  or 
gunnny  liquid ;  an  open  gumma  not  resembling  in  the  least  a  discharging 
abscess.  The  gumma  does  not  at  once  empty  itself  when  it  is  opened.  The 
inflamed  connective  tissue  adheres  by  its  deeper  portions  to  the  subcutaneous 
cellular  tissue,  which  is  thrown  off  in  the  form  of  small  sloughs.  Granulations 
forming  at  the  bottom  soon  fill  the  cavity,  the  solution  of  continuity  is  repaired, 
and  cicatrization  takes  place.  The  resulting  cicatrix  is  depressed,  often 
adherent  to  the  deeper  tissues  or  to  the  bone  itself. 

The  clinical  characteristics  of  the  group  of  cutaneous  syphilides  may 
be  stated  as  follows : 

1.  General  or  constitutional  symptoms  are  usually'  absent,  Avith  the  excep- 
tion of  the  syphilitic  fever  which  precedes  or  accompanies  the  early  eruptions. 

2.  Additional  evidences  of  syphilis  will  usually  be  found,  and  should  be 
carefully  searched  for — the  chancre,  its  cicatrix  or  its  induration,  the  buboes, 
sore  throat,  baldness,  mucous  patches,  etc. — if  an  early  eruption  be  in  ques- 
tion ;  osteocopic  pains,  nodes,  and  other  bone-lesions  in  the  later  stages. 

3.  The  eruptions,  especially  the  early  ones,  are  apt  to  be  polymorphous,  or 
to  present  at  the  same  time  a  variety  of  forms  of  cutaneous  lesion,  macules, 
papules,  and  pustules  being  usually  intermingled.  This  is  due  to  the  chronic, 
slow  evolution  of  the  disease,  which  permits  of  the  development  of  new  symp- 
toms during  the  gradual  fading  of  previous  ones. 

4.  The  patches  of  eruption  are  apt  to  have  a  rounded  or  crescentic  form, 
due  to  the  anatomical  arrangement  of  the  cutaneous  capillaries,  and  when 
seated  upon  the  extremities  occupy  the  side  of  flexion — the  anterior  surface  of 
the  forearm,  the  palm  of  the  hand,  the  sole  of  the  foot,  etc. 

5.  The  characteristic  color  of  the  syphilitic  eruptions  is  a  yellowish-red, 
usually  described  as  "  coppery."  Its  peculiar  dusky  tint  is  due  to  the  absence 
of  the  active  hyperemia  and  arterial  excitement  which  usually  exist  in  the  non- 
specific eruptions,  the  color  of  syphilides  being  the  result  of  slow  changes  in 
the  coloring  matter  of  the  blood  which  has  exuded  under  pressure,  and  not  the 
accompaniment  of  acute  inflammation. 

6.  There  is  an  absence  of  pain  and  itching  which  is  very  distinctive,  and 
which  is  also  due  to  the  non-inflammatory  character  of  the  eruption.  It  is  quite 
common  to  find  patients  who  are  not  aware  of  the  presence  of  an  extensive 
syphiloderm  until  their  attention  is  directed  to  it  by  the  surgeon. 

7.  The  early  eruptions  are  superficial,  general,  and  symmetrical,  indicating 
by  these  characters  the  infection  of  the  blood  to  Avhich  they  are  due.  During 
their  evolution  the  disease  is  transmissible  by  contagion. 

8.  The  early  eruptions  are  frequently  scaly,  the  pressure  of  the  cell-prolif- 
eration, which  is  always  present,  cutting  off  the  supply  of  nutriment  to  the 
superficial  epidermic  layers,  which  accordingly  dry,  desiccate,  and  are  exfoliated. 

9.  The  scales  are  Avhitish,  superficial,  and  usually  not  adherent,  there  being 
nc  plastic  or  inflammatory  exudation  to  fasten  them  to  the  subjacent  part. 


SYPHILIS.  ICO 

10.  The  later  eruptions  are  not  contagious,  are  irregular  in  distribution, 
extend  to  the  cutis  vera  or  beneath  it  into  the  connective  tissue,  and  are 
described  as  local  lesions  or  as  sequehc  following  the  acute  or  secondary  stage, 
and  due  either  to  relapses  in  parts  previously  diseased  or  to  new-growths  result- 
ing from  changes  effected  by  syphilis. 

11.  The  later  eruptions  have  thick,  irregular,  or  imbricated  crusts,  often 
occur  in  groups,  and  leave  scars  even  if  no  ulceration  has  occurred. 

12.  Ulcers  resulting  from  the  breaking  down  of  syphilitic  deposits  have 
rough,  abrupt  edges,  are  irregularly  crescentic  or  circular  in  shape,  covered 
with  an  unhealthy  greenish-yellow  secretion,  and,  as  a  rule,  are  painless. 

13.  The  cicatrices  caused  by  syphilis  are  at  first  pigmented,  then  whitish, 
shining,  rounded,  or  radiating,  and  depressed  below  the  level  of  the  surround- 
ing surface ;  they  often  show  very  small  apertures,  the  sites  of  pre-existing 
follicles. 

14.  The  therapeutic  test  in  all  very  doubtful  cases  is  an  extremely  valu- 
able one,  although  it  should  be  necessary  to  resort  to  it  only  in  extremely 
exceptional  instances.  The  amenability  of  nearly  all  the  cutaneous  symp- 
toms to  w^ll-directed  specific  treatment  often  renders  this  test  very  conclusive. 

The  tertiary  lesions  of  the  mucous  membranes  are  characterized 
by  growths  occupying  tlie  deeper  portion  of  tlic  mucous  membrane  or  extend- 
ing beyond  it,  and  by  gummata  identified  with  those  just  described.  They 
are  nearly  always  ulcerative,  but  are  not  covered  by  crusts,  owing  to  the  facility 
with  which  the  accumulated  secretions  are  detached  from  the  surface.  Thus, 
in  cases  where  upon  the  skin  there  would  be  a  scab,  upon  the  mucous  membrane 
there  is  found  an  ulcer  discharging  pus  more  or  less  freely.  Like  the  deep 
syphilodermata,  they  are  limited  and  localized,  for,  as  the  disease  grows  older, 
instead  of  being  extended  and  superficial  and  symmetrical,  it  becomes  limited 
to  a  special  locality  and  deeply  involves  and  destroys  its  tissues. 

The  most  important  mucous  membranes  affected  by  tertiary  lesions  are  the 
tongue,  soft  palate,  and  pharynx. 

Tertiary  Syphilis  of  the  Mouth. — The  most  important  of  the  late  man- 
ifestations of  syphilis  in  this  region  are  the  gummata  of  the  tongue,  which  may 
be  either  submucous  or  muscular  in  their  origin. 

The  submucous  gummata  are  of  the  size  of  a  pea  or  a  cherry-stone,  single 
or  multiple.  They  begin  as  small,  hard  tumors,  and  their  softening,  their  dis- 
charge through  a  small  aperture,  their  excavated  appearance  and  characteristic 
base,  do  not  diff"er  from  those  of  other  gummata :  this  is  also  true  of  their  dura- 
tion and  of  their  mode  of  healing. 

The  muscular  gummata  are  larger:  they  may  occupy  either  the  lateral 
or  median  aspects  of  the  tongue,  or  may  afiect  its  tip,  its  base,  or  its  edges. 
They  reach  the  size  of  a  hazel-nut.  They  open  by  what  is  first  a  very  nar- 
row channel,  which  enlarges  or  extends  in  the  direction  of  the  muscular  fibers. 

In  these  aff"ections  of  the  tongue  it  is  rare  to  find  enlarged  cervical  or  sub- 
maxillary lymphatic  glands,  and  the  same  is  true  of  gummata  of  the  pharynx. 

The  differential  diagnosis  of  syphilitic  diseases  of  the  tongue  is  one  of  some 
importance,  especially  in  regard  to  non-syphilitic  aifections  which  simulate  them. 
Gummata  of  the  tongue  may  be  mistaken  only  for  tubercular  ulcers  or  for  epithe- 
liomata.  From  tubercular  ulcers  it  would  be  difficult,  if  not  impossible,  to  make 
a  diagnosis  from  the  character  of  the  ulcer  alone.  The  sides  and  edges  of  ulcer- 
ating tubercles  often  .show,  however,  a  few  small  yellow  points  with  opaque 
centers,  which  are  tubercular  granulations  undergoing  caseous  degeneration. 
These  latter  are  finally  thrown  off"  by  ulceration,  and  are  never  seen  in  syphilis. 
The  evolution  of  tubercles  of  the  tongue  is  entirely  diff"erent  from  that  of  gum- 


106 


AN  AMERICAN  TEXT-BOOK  OF  SURGERY. 


mata.  The  gumma  bcfrins  as  a  single  mass,  submucous  or  muscular  in  position, 
opening  after  a  time  by  a  contracted  passage,  ulcerating,  and  discharging  like  a 
furuncle  and  having  a  sloughing  base.  The  tubercles,  on  the  contrary,  begin 
on  the  surface  as  small  nodules.  V>y  the  union  of  many  of  these  a  large,  irreg- 
ular ulcer  is  formed,  slower  in  its  evolution  than  a  gumma.  As  it  extends  in 
depth  there  are  successive  eruptions  of  tubercles,  too  minute  to  be  detected  by 
the  naked  eye,  and  situated  between  the  muscular  fibers.  The  ulcer  has  jagged 
edges  and  usually  suppurates  less  than  the  gumma.  In  cases  of  doubt  the  chest 
should  be  carefully  examined,  as  pulmonary  tuberculosis  often  exists  at  the 
same  time.     The  family  history  may  also  aid  in  the  decision. 

Lingual  epithelioma  may  always  be  detected  by  microscopic  examination 
of  the  fragments  of  tissue  from  the  cancerous  ulceration,  large  pavement-cells 
and  epidermic  nests  being  found.  In  addition,  the  epithelioma  never  becomes 
stationary  or  recedes,  that  of  the  tongue  being  especially  grave  and  rapid,  often 
running  its  course  and  terminating  in  death  in  a  year  or  eighteen  months. 

The  diagnosis  between  ulcerating  epithelioma  of  the  tongue  and  ulcerating 
gumma  of  the  tongue  has  been  tabulated  by  Fournier,  as  follows : 


Epithelioma. 

Chiefly  affects  persons  between  fifty  and  sev- 
enty years  of  age. 

Often  a  history  of  cancer  in  near  relatives  or 
ancestors. 

No  history  of  syphilis. 

The  appearance  which  has  been  described  as 
"lingual  psoriasis"  often  precedes  the 
cancerous  disease. 

Is  generally  single  and  confined  to  one  side.' 

Is  sometimes  found  on  the  under  surface  of 
the  tongue. 

Begins  as  a  hard  swelling  upon  the  surface 
of  the  organ,  and  ulcerates  rapidly  and 
superficially  :  sometimes  begins  as  a  fissure 
or  ulcer,  without  previous  swelling  or  in- 
duration. 

Induration  follows  cancerous  ulceration. 

No  cavity  resembling  that  of  an  abscess. 

Surface  bleeds  when  touched  or  spontane- 
ously. 

Edges  turned  outward,  with  the  border  ele- 
vated, irregular. 

Secretion  profuse,  offensive,  irritating. 

Lancinating  pain,  often  darting  toward  the 
ear,  thought  to  be  pathognomonic. 

Great  disturljance  of  deglutition,  mastication, 
speech,  etc. 

General  cachexia  supervenes. 

Microscopic  examination  shows  the  charac- 
teristic ingrowing  of  the  interpapillary 
epithelium,  the  large  squamous  cells, 
pearly  bodies,  and  other  histological  pecu- 
liarities of  epithelioma. 

Submaxillary  lymphatic  glands  progressively 
enlarged  and  indurated. 

Specific  treatment  useless  or  harmful. 


Gumma. 
Is  apt  to  occur  at  an  earlier  period  of  life. 

No  such  history,  as  a  rule. 

Such  history  almost  always  obtainable. 
Nothing  which  resembles  this  has  been  seen. 


May  Vjc  multiple  and  bilateral. 

Never  seen  except  upon  the  dorsum  or  side 
of  the  tongue. 

Begins  as  a  rounded  mass  beneath  the  sur- 
face, and  then  opens  like  a  furuncle,  leav- 
ing a  hollow,  deep  ulcer. 


Induration  precedes  ulceration. 

An  excavation  like  an  abscess-cavity. 

Ulcer  covered  by  an  irregular  slough  which 
does  not  bleed. 

Edges  abrupt, perpendicular,  "punched  out," 
sharply  defined. 

Secretion  moderate,  not  so  apt  to  be  offen- 
sive. 

Painless  or  nearly  so. 

Tongue  much  more  mobile  ;  functional  trou- 
bles not  so  marked. 

No  cachexia. 

The  microscope  shows  an  infiltration  of  the 
part  by  embryonal  cells  in  various  stages 
of  granular  degeneration. 

Glands  not  involved,  or,  at  the  most,  a  little 

swollen  and  tender. 
Specific  treatment  curative. 


Gummata  of  the  soft  palate,  or  of  the  palatine  arch,  usually  result  in 
a  perforation  of  the  palatine  bones,  causing  a  communication  between  the  oral 
and  nasal  cavities.     These  gummata  are  slow  and  insidious  in  their  onset. 


SYPHILIS.  167 

The  patient  experiences  no  pain  or  discomfort.  The  soft  palate  is  red,  thick- 
ened, and  either  noduhir  in  its  entirety  or  at  one  j)oint.  The  in(hiration  and 
thickening  may  be  felt  with  the  finger. 

If  the  patient  be  asked  to  utter  sounds  renuiiiiii:-  tlic  assistance  of  the 
soft  palate  for  their  production — ah,  for  example — wiiilst  the  throat  is 
being  examined,  it  will  be  seen  that  the  palate  is  elevated  incompletely  or 
not  at  all. 

The  immobility  of  the  palate  is  a  valuable  symptom,  and,  taken  in  conjunc- 
tion with  the  induration,  the  thickening,  and  the  prominence  often  presented 
by  the  gumma  itself,  permits  of  an  early  diagnosis,  Avhich  it  is  especially  import- 
ant to  make  as  soon  as  possible  in  order  to  avoid  perforation.  If  the  patient 
be  left  without  treatment,  the  gumma  ulcerates  and  discharges,  and  if  it  be  of 
the  kind  above  mentioned,  involving  both  the  anterior  and  posterior  mucous 
surface,  complete  perforation  of  the  palate  will  follow  with  great  rapidity,  often 
taking  place  in  a  single  day  or  night. 

A  gumma  of  the  soft  palate  does  not  invariably  give  rise  to  perforation, 
especially  if  mixed  treatment  (see  p.  176)  be  at  once  commenced.  It  may  affect 
only  one  surface  of  the  palate,  and  then  it  will  heal  Avithout  interfering  with 
function.  There  may  be  even  a  small  but  complete  perforation  at  the  moment 
of  the  evacuation  of  the  gumma,  Avhich  will  entii'ely  heal. 

Syphilis  of  Muscles. — Muscular  syphilis  is  rare;  it  may  manifest  itself 
by  contraction  due  to  myositis,  which  at  first  appears  to  be  idiopathic,  as  it  is 
not  accompanied  by  tumors  or  changes  in  size  or  apparent  lesions ;  in  other 
cases  gummata  develop  in  the  interior  of  the  muscles. 

Syphilitic  contracture  of  the  muscles  is  chiefly  an  affection  of  the  mus- 
cles of  the  arm,  and  more  particularly  of  the  biceps.  It  appears  about  six 
months  to  a  year  after  the  chancre.  The  first  symptom  is  a  stiffness  of  the 
elbow.  Gradually  extension  becomes  more  and  more  limited,  and  the  forearm 
remains  flexed  upon  the  arm  at  an  angle  varying  from  a  large  obtuse  angle  to 
one  quite  acute.  No  tumors  or  inequalities  of  surface  are  discoverable  :  if  the 
muscle  be  examined  during  forced  extension,  it  is  found  prominent  and  like  a 
tightly-drawn  cord. 

It  has  been  denied  that  this  affection  has  any  essential  relation  to  syphilis, 
and  it  has  been  attributed  to  rheumatism,  to  traumatism,  and  to  other  causes. 
The  weight  of  evidence  is,  however,  in  fiivor  of  its  syphilitic  origin ;  nine  out 
of  ten  cases  observed  by  Mauriac  had  a  distinct  history  of  syphilis  and  were 
accompanied  by  unmistakable  eruptions,  chiefly  papular  and  papulo-squamous. 
He  believes  it  to  be  a  subacute  myositis.  In  every  one  of  six  cases  reported 
by  Notta  syphilitic  symptoms  were  present.  In  none  of  them  was  there  any 
association  with  rheumatism. 

Grummata  of  muscles  have  a  more  important  significance  than  these  simple 
contractures.  They  consist  of  tumors,  often  of  considerable  size,  which  may 
discharge  externally,  may  give  rise  in  various  ways  to  serious  results,  and  may 
even  invade  the  caVdiac  muscles.  The  tongue  appears  to  be  the  muscle  most 
frequently  affected,  and  those  of  the  sides  and  nape  of  the  neck  are  often 
involved.  Murchison  has  recorded  a  case  of  gumma  of  the  diaphragm.  Some- 
times, instead  of  distinct  tumors,  a  general  infiltration  occurs.  White  has  seen 
a  case  in  which  all  the  posterior  cervical  muscles,  including  the  trapezius,  were 
thus  infiltrated.     Mixed  treatment  effected  a  rapid  cure. 

Syphilis  of  the  Bones. — Among  the  most  important  and  most  common 
late  effects  of  syphilis  are  the  osseous  lesions,  which  are  often  of  much  gravity. 
Both  in  adults  and  in  children  affected  with  hereditary  syphilis  the  order,  the 
seat  of  the  lesions,  and  even  the  anatomical  condition  of  the  diseased  bones, 


168  >1^V  AMERICAN  TEXT-BOOK  OF  SURGERY. 

are  so  characteristic  that  the  diagnosis  of  syphilis  is  rendered  easy.  Osseous 
syphilis  is  met  with  during  any  of  the  periods  of  the  malady. 

The  determining  cause  of  the  osseous  lesion  and  of  its  seat,  in  tertiary  as 
in  secondary  syphilis,  is  generally  some  form  of  traumatism,  which  is  usually 
slight,  but  fre([uently  rei)eated  at  the  same  point.  It  is  owing  to  this  fact  that 
the  superficial  bones,  as  the  frontal  bone,  clavicle,  sternum,  radius,  tibia,  etc., 
are  the  most  common  seats  of  the  disease.  Only  the  lesions  of  adults  are  here 
referred  to.  In  cases  of  infiintile  syphilis  traumatism  is  not  the  determining 
cause ;  the  active  development  of  the  bones  sufiiciently  accounts  fur  the  local- 
ization of  the  disease. 

Tlie  lesions  of  the  bones  from  an  anatomical  point  of  view  are  very  numerous, 
varying  from  simple  periostitis  and  osteitis  to  gunnnata ;  their  final  consequences 
also  vary  from  the  development  of  exostoses  to  tlie  formation  of  sequestraj  in 
pus-cavities. 

The  following  lesions  may  be  successively  described : 

1.  Simple  osteo-periostitis. 

2.  Rarefying  osteitis. 

3.  Intense  rarefying  osteo-myelitis  or  gummatous  osteo-periostitis. 

Then  the  consecutive  lesions  of  these  difierent  states,  which  are :  formative 
osteitis  or  eburnation,  the  exostoses,  the  necroses,  and  the  sequestrse ;  and 
finally  the  osseous  lesions  of  infantile  syphilis.     (See  p.  184.) 

1.  Syphilitic  osteo-periostitis  does  not  differ  materially  from  ordinary 
osteo-periostitis.  Limited  to  the  superficial  layers  of  the  bone  and  the  perios- 
teum, it  most  frequently  occurs  at  the  end  of  the  secondary  or  in  the  tertiary 
period,  attacking  the  tibia,  clavicle,  sternum,  bones  of  the  head,  etc. 

2.  When  the  inflammation  is  more  intense  there  occurs  a  rarefying  oste- 
itis. The  subperiosteal  inflammation  extends  into  the  Haversian  canals ;  the 
subperiosteal  tissue  and  the  osseous  marrow  contain  numerous  small  cells  with 
transuded  red  blood-corpuscles.  These  elements  are  free,  with  a  small  amount 
of  granular  intercellular  substance.  The  original  bone  is  eroded  or  destroyed. 
This  lesion,  which  is  observed  so  often  in  diseases  of  the  phalanges  and  short 
bones,  is  named  ^pina  ventom.     It  is  frequently  a  result  of  syphilis. 

3.  Gummatous  osteo-myelitis  and  gummatous  osteo-periostitis 
are  nothing;  more  than  a  rarefvino;  osteitis  in  which  the  abundant  subperiosteal 
embryonal  tissue  or  the  medullary  tissue  assumes  the  arrangement  tliat  is 
observed  in  the  gummata.  The  lesions  are  seen  in  the  form  of  tumors,  vary- 
ing in  size  and  having  a  tendency  to  become  caseous.  Gumma  of  bone  is 
thus  merely  a  circumscribed  osteo-periostitis  with  destruction  of  the  osseous 
lamella;  by  a  rarefying  osteitis.  It  is  the  localization  and  form  of  the  lesion 
which  sive  it  its  distinctive  characters. 

The  histological  changes  of  the  osseous  tissue,  as  met  with  m  the  various 
forms  of  syphilitic  lesions  of  the  bones,  therefore  resemble  similar  lesions  due 
to  other  causes.  In  osteo-periostitis  there  is  a  proliferation  of  the  cells  within 
the  Haversian  canals  or  the  medullary  elements  of  the  bone  which  causes  an 
increase  in  the  size  of  these  canals,  the  marrow  itself  becoming  embryonic  in 
nature.  A  continuation  of  this  same  process  in  a  more  intense  degree  results 
in  the  absorption  of  the  osseous  tissue,  an  enlargement  of  the  Haversian  canals, 
an  increase  in  the  amount  of  embryonal  marrow,  or,  in  brief,  a  rarefying  oste- 
itis, which  in  syphilis  constitutes  a  gumma ;  that  is,  a  gumma  of  bone  is  a  local- 
ized intense  osteo-periostitis  in  Avhich  there  is  a  destruction  of  the  osseous 
trabecule  by  the  formation  of  granulation  or  embryonal  tissue,  which  later 
undergoes  retrograde  metamorphosis  and  absorjjtion.  The  bone  in  which  the 
gumma  or  rarefying  osteitis  has  been  developed  after  the  absorption  of  the 


SYPHILIS.  109 

gummatous  tissue  takes  on  reparative  action,  and  there  occurs  a  formative 
osteitis,  in  which  there  is  a  new  formation  of  osseous  tissue,  the  process 
resembling  that  of  the  physiological  (lovelopment  of  bone.  This  process  con- 
tinuing, there  results  a  condensing  osteitis  of  the  part,  in  which  the  daminje 
surrounding  the  Haversian  canals  are  increased  to  such  an  extent  as  finally  to 
obliterate  the  lumina  of  the  canals  and  cause  a  sclerosis  or  eburnation  of  the 
bone.  An  exostosis  is  nothing  more  than  a  slow  formative  osteitis,  which 
results  in  the  gradual  addition  of  new  osseous  layers  to  the  original  bone ;  if 
the  process  becomes  active  there  is  produced  an  eburnation  of  the  new-formed 
bone,  or  if  very  intense  there  occurs  that  form  of  osteitis  known  as  rarefying, 
and  if  still  more  active  there  may  even  be  a  complete  destruction  of  the"  new 
osseous  tissue.  It  is  thus  seen  that  the  several  lesions  occurring  in  bones,  and 
due  to  syphilis,  are,  to  a  great  extent,  the  continuation  or  stages  of  one  process 
which  varies  in  its  intensity  and  results. 

Symptoms  of  Syphilitic  Osseous  Lesions. — The  osseous  lesions  of 
syphilis  are  not  ahvays  recognized  during  life,  but  in  ordinary  cases,  when 
subcutaneous  bones  are  involved,  the  symptoms  are  well  marked. 

The  essential  symptoms  of  syphilitic  osteo-periostitis  are  pain  and  swellincr. 
The  pain  is  peculiar  in  that  it  is  more  intense  during  the  night  than  during 
the  day.  It  is  very  acute  at  times.  It  prevents  sleep,  and  by  its  persistence 
may  become  of  considerable  gravity.  The  slightest  touch  to  the  tumor  causes 
exquisite  suffering.  After  two  or  three  days'  treatment  with  iodide  of. 
potassium  it  is  usually  relieved  and  often  is  entirely  removed. 

The  symptoms  of  syphilitic  osteitis  are  very  variable,  depending  upon  the 
bone  affected  and  its  connections.  They  differ,  of  course,  very  much  with  the 
variations  in  form  of  the  lesions,  which,  as  has  been  explained,  mav  vary 
from  a  simple  swelling  of  the  periosteum  and  bone  to  the  suppuration  and 
necrosis  with  fistulous  tracts  met  with  in  intense  gummatous  osteo-periostitis. 

The  most  simple  and  most  frequent  cases  are  those  of  osteo-periosteal 
tumors  of  the  superficial  bones — the  tibia,  clavicle,  sternum,  frontal  bone.  etc. 
The  nodular  swelling,  the  single  or  multiple  nodes  of  differing  size,  and  the 
special  pain  upon  firm  pressure  or  upon  percussion,  are  all  characteristic.  The 
pain  occurs  spontaneously  during  the  early  part  of  the  night,  before  retiring. 

The  periostoses  of  the  clavicle  are  readily  seen  on  account  of  the  position 
of  the  bone,  and  most  frequently  are  oval  in  shape,  with  their  long  axes  parallel 
to  the  long  axis  of  the  bone. 

Osteo-periostitis  of  the  anterior  surface  of  the  sternum  and  of  the  bones  of 
the  cranium,  Avhen  recent,  generally  appears  as  a  flattened  swelling,  varying 
in  size  and  of  the  shape  of  the  segment  of  a  sphere.  It  is  then  elastic  to  the 
touch,  and  may  disappear  under  mixed  treatment.  Later,  when  an  osseous 
formation  is  developed  around  its  circumference,  it  feels  hard  at  the  margins, 
while  its  central  part  is  relatively  soft. 

As  regards  bones  in  general,  the  differences  between  syphilitic  and  tuber- 
cular inflammations  may  be  stated  as  follows : 

Syphilitic  Osteitis.  Tubercular  Osteitis. 

Syphilitic  osteitis  occurs  in  persons  in  vary-  Osteitis   of   tuberculosis   occurs   in   persons 
ing  physical  conditions.  Avho  have  other  symptoms  of  this  disease. 

Begins  most  frequently  in  the  periosteum.  Begins  in  the  medulla. 

Tends  to  the  formation  of  new  bone  or  to  Tends  to  disintegration  of  the  parts, 
necrosis. 

Is  often  unaccompanied  with  suppuration.  Generally  terminates  in  the  formation  of  pus. 

Does  not  involve  neighboring  articulations.  Apt  to  do  so. 

Frequent  in  bones  of  the  cranium.  Almost  never  found  in  this  situation. 


170  AX  AM  KN /('AN    TEXT-BOOK  OFSlRdKRY. 

Syphilitic  Osteitis.  Tubercular  Osteitis. 

Histoloj^ically,  consists  of  a  rolutivcly  large  Made  up  of  a  varying  nuiiil)cr  of  tu])crcle- 
mass  of  granulation-tissue.  granulations  ami  surrounded  by  isolated 

granules. 

In  the  majority  of  eases  can  be  cured,  or  at  We  know  of  nothing  sliort  of  ojx'rativc  in- 
least  arrested,  if  taken  in  time,  by  judi-  terferenee  which  materially  affects  the 
cious  speeilic  treatment.  course  of  this  disease. 

Syphilitic  dactylitis  occurs  at  various  periods  of  tlio  disease,  and  in  two 
varieties.  One  of  these  aj)j)ears  usually  in  the  hite  seeonchiry  stage,  and 
involves  eliieliy  the  ])eriosteuni  and  the  fibrous  and  integumentary  tissues 
surrounding  a  joint.  It  is  characterized  by  slow,  almost  painless,  swelling  and 
discoloration  of  the  affected  member.  This  is  due  to  a  gummatous  infiltration, 
which,  upon  subsiding,  leaves  tlie  fiiiger  or  toe  temporarily  stif!",  but  not 
perm  an  en  t  ly  d  i  sa  b  1  cd . 

The  second  form  is  a  specific  osteo-myelitis  Avitli  accompanying  inilammation 
of  the  periosteum,  and  appears  from  five  to  fifteen  years  after  the  infection 
with  syphilis.  It  is  chiefly  limited  to  the  bones  and  periosteum,  the  integu- 
ment being  but  seldom  involved ;  erosion  of  the  articular  cartilages  often  takes 
place ;  the  ligaments  and  the  capsule  become  thickened,  and  the  function  of 
the  joint  is  sometimes  entirely  lost. 

The  absence  of  acute  symptoms  in  the  subcutaneous  variety  enables  us  to 
diagnosticate  it  from  paronychia,  Avhitlow,  and  gout,  l^heumatoid  arthritis 
begins  in  the  joints,  is  associated  with  other  sjnnptoms,  deformity  of  the  fingers 
comes  on  early  in  the  disease,  and  the  sheaths  of  the  tendons  are  involved. 

The  second  variety  might  be  taken  for  enchondroma  or  exostosis,  but 
these  swellings  involve  only  a  limited  portion  of  the  bone,  increase  very 
slowly,  and  present  dense,  circumscribed  tumors. 

Syphilis  of  the  Nervous  System. — The  dura  mater  is  frequently 
the  seat  of  tertiary  syphilis,  chiefly  owing  to  its  intimate  connection  with  the 
cranial  bones,  toward  which  it  bears  the  relation  of  a  periosteal  lining.  The 
internal  surface  of  this  membrane,  in  contact  with  the  pia  mater  and  m  ith  the 
surface  of  the  brain,  is  frequently  attacked  at  the  same  time — an  accident 
which  manifests  itself  by  various  cerebral  symi)toras :  intense  cephalalgia, 
trembling,  dulness,  intellectual  torpor,  loss  of  memory,  and  coma. 

Besides  these  peri-encephalic  lesions,  the  pia  mater,  and  even  the  brain- 
substance  and  the  spinal  cord,  may  be  the  seat  of  sclerosis  or  of  gummata. 

The  pia  mater  presents  two  varieties  of  lesions:  A  chronic  inflammation, 
followed  by  fibrous  thickening  and  by  adhesions  to  the  surface  of  the  brain  ; 
and  gummata,  lesions  much  more  characteristic  than  the  foregoing. 

Cerebral  gummata  may  be  found  in  two  forms: 

1st.  As  large  gummatous  masses  developed  on  the  surface  of  the  brain 
within  the  convolutions  and  in  the  gray  substance  or  encroaching  upon  the 
white  substance,  and  usually  attacking  the  base,  the  cerebral  peduncles,  the 
pons  Varolii,  and  the  optic  tract.  They  are  also  found  upon  the  cerebellum 
and  upon  the  superior  surface  of  the  cere])nnn. 

2d.  In  the  form  of  smaller  nodules  accompanying  the  cerel)ral  arteries,  and 
in  particular  the  middle  cerebral  arteries. 

These  two  varieties  of  syphilitic  lesions  do  not  differ  materially  as  regards 
their  structure ;  their  evolution  is  slightly  different.  The  latter  are  generally 
accompanied  by  endarteritis,  which  results  in  a  limited  anemic  softening  of 
the  brain. 

Symptoms  of  Cerebral  Syphilis. — The  symptoms  depending  upon  the 


SYPHILIS.  171 

different  alterations  of  tlie  meninges,  of  the  hrain,  and  of  the  vessels  diff"er,  it 
is  needless  to  say,  according  to  the  region  of  the  brain  which  is  affected  by 
them.  The  lesions  of  the  dura  mater,  of  the  pia  mater,  and  often  those  of  the 
cranial  bones,  coincide  with  gummata  or  with  more  or  less  extended  softening  in 
such  a  manner  that  nudtiple  manifestations  have  to  be  analyzed  and  explained. 
Despite  these  dilliculties,  the  progress  of  these  encephalopathies,  a  certain  num- 
ber of  characteristics  whicli  appertain  to  them,  and,  in  doubtful  cases,  the  ante- 
cedents of  the  patients  and  trial  of  the  iodide  treatment,  will  ordinarily  indicate 
their  nature. 

The  most  common  initial  phenomenon  is  headache,  which  is  frontal,  occipi- 
tal, or  parietal,  very  intense,  often  worse  during  the  night,  and  accompanied 
fre(iuently  by  vertigo  and  mental  dulness,  and  sometimes  by  convulsions.  This 
pain  is  at  times  intolerable,  or,  on  the  contrary,  there  may  be  a  stupor  resem- 
bling coma.  The  headaclie  may  last  for  a  long  time  before  any  other  symptom 
shows  itself.  If  syphilis  has  been  suspected  from  the  antecedents  of  the  patient, 
and  iodide  of  potassium  has  been  given  with  the  result  of  lessening  the  pain  or 
causing  it  to  cease,  the  diagnosis  is  assured.  During  the  headache  the  patients 
often  experience  a  diminution  of  their  intellectual  faculties,  forgetfulness  of  cer- 
tain words  or  of  their  actions  of  the  day  before,  etc.  Diff'erent  forms  of  paral- 
ysis supervene.  They  are  at  first  very  limited.  The  nerves  at  the  base  of  the 
cranium  are  those  most  frequently  attacked.  The  paralysis  of  muscles  sup- 
plied by  the  common  oculo-motor  nerve  produces,  for  example,  external  strabis- 
mus, diplopia,  etc.  The  diminution  of  the  sense  of  taste,  and  even  its  complete 
abolition,  the  loss  of  the  sense  of  smell,  the  diminution  or  the  loss  of  hearing, 
have  also  been  noted.  The  disturbances  of  vision  are  exceedingly  variable, 
and  depend  upon  the  seat  of  the  lesion — whether  it  is  localized  in  the  cuneus, 
in  the  optic  tracts  before  their  intercrossing,  at  the  optic  chiasm,  or  upon  the 
optic  nerves  beyond  the  chiasm.  Subjective  symptoms  are  observed,  such  as 
muscce  volitantes,  circles  of  fire,  etc.,  the  perception  of  only  a  portion  of  objects, 
hemianopsia,  or  a  partial  or  total  loss  of  vision.  These  conditions  are  fre- 
quently cured  by  iodide  of  potassium. 

The  partial  paralysis  first  shows  itself  in  a  limb — in  the  lower  extremity 
of  one  side,  for  example — and  is  followed  by  amelioration  if  iodide  of  potas- 
sium employed  in  time  has  produced  its  curative  action ;  if  the  lesion  contin- 
ues its  progress,  complete  hemiplegia  may  supervene.  This  is  generally  pro- 
gressive, slow  at  the  commencement,  with  incomplete  aphasia,  especially  if  the 
paralysis  is  on  the  right  side.  These  cases  of  hemiplegia  are  not  accompanied, 
like  those  of  copious  hemorrhages  or  of  apoplectiform  softening,  by  a  total  loss 
of  consciousness.  Patients  preserve,  on  the  contrary,  to  a  great  extent,  their 
consciousness,  as  is  the'  case  in  certain  forms  of  cerebral  softening,  and  the 
paralysis  affects  only  the  power  of  motion.  Finally,  along  with  several  other 
phenomena  connected  with  the  intelligence  or  the  poAver  of  motion,  convulsive 
symptoms  often  predominate — veritable  attacks  of  epilepsy. 

The  diagnosis  of  cerebral  syphilis  is  based  less  upon  the  symptoms 
taken  singly  or  in  groups  than  upon  the  progress  of  the  affection  and  upon  the 
therapeutic  action  of  iodide  of  potassium.  An  intense  headache  of  long  dura- 
tion, which  is  cured  or  benefited  by  the  iodide,  but  relapses,  and  which  is  accom- 
panied by  loss  of  memory,  hebetude,  slight  paralysis  ;  then  a  paralysis  very 
slow  in  progress,  ending  in  hemiplegia,  aphasia,  and  epileptiform  convulsion, — 
such  are  the  symptoms  upon  which  the  diagnosis  is  established.  These  symp- 
toms are  slow  in  showing  themselves,  and  they  grow  more  intense  very 
gradually.  At  their  commencement  they  are  benefited  or  cured  by  the 
iodide  of  potassium.     Each  of  them  presents  some  characteristic  peculiar  to 


172  AN  AMERICAN  TEXT-BOOK  OF  SURGERY. 

syphilis  in  such  a  way  that  recognition  of  the  cause  is  possible  in  the  great 
majority  of  cases.  The  diagnosis  from  apoplexy  and  softening  is  generally 
easy.  The  sudden  onset  of  an  attack  with  absolute  loss  of  consciousness  and 
complete  hemiplegia  excludes  the  idea  of  syphilis.  It  is  more  easy  to  confuse 
it  with  chronic  softening ;  but  in  syphilis  there  are  the  violence  of  the  head- 
ache, the  effects  of  the  iodide,  the  epileptiform  convulsions,  and  especially  the 
presence  of  old  syphilitic  lesions.  Cerebral  tumors  are  easily  confounded 
with  syphilis,  but  the  consideration  of  cerebral  tubercle  is  unnecessary,  as 
it  is  an  aft'ection  of  infancy.  Sarcomata  might  be  mistaken  for  gummata; 
however,  they  are  exceedingly  rare,  and  the  symptoms  which  characterize  them 
are  progressive,  without  its  being  possible  to  benefit  them  by  the  iodide  treat- 
ment. 

The  prognosis  of  cerebral  syphilis  is  very  grave. 

Syphilis,  wlien  it  affects  the  spinal  cord,  may  involve  the  meninges  by 
a  specific  pachymeningitis,  or  the  cord  itself  may  be  invaded  by  gummata 
originating  either  in  its  substance  or  in  the  membranes.  The  symptoms 
are  those  connected  with  pressure  upon  or  degeneration  of  the  cord  itself,  and 
the  diagnosis  is  to  be  made  chiefl}'^  by  the  presence  of  concomitant  lesions  of 
syphilis  or  by  the  effects  of  treatment.  The  interesting  question  of  the  rela- 
tion of  locomotor  ataxia  to  syphilis  is  not  yet  settled,  but  there  is  enough 
evidence  to  justify  the  following  recommendations  : 

In  every  case  of  ataxia  careful  and  minute  search  should  be  made  for 
evidences  of  antecedent  syphilis,  either  acquired  or  inherited.  If  this  be  found 
to  have  existed,  the  patient  should  be  placed  at  once  upon  vigorous  specific 
treatment,  and  should  be  directed  to  continue  it  through  long  periods.  If  only 
a  fair  presumption  of  previous  syphilis  exist,  the  same  treatment  should  be 
employed,  as  it  would,  at  the  most,  be  useless,  but  not  hurtful.  If  the  disease 
be  recognized  in  its  earliest  stages,  and  found  to  be  associated  with  s^^philis, 
and  treated  in  this  manner,  a  prognosis  may  safely  be  given  of  a  more  favor- 
able character  than  at  present  seems  justifiable  in  any  other  variety  or  under 
any  other  mode  of  treatment. 

Unlike  cerebral  syphilis,  in  which  the  question  of  operative  treatment  is 
often  discussed,  syphilis  of  the  intestinal  tract  in  the  a<lult  has  little  interest 
for  the  surgeon.  The  involvement  of  the  liver,  and  especially  that  of  the 
spleen,  in  newborn  children  are  of  great  diagnostic  importance,  but  will  be  fully 
considered  in  the  chapter  on  Hereditary  Syphilis. 

Syphilis  of  the  respiratory  tract  is  of  greater  surgical  interest  and 
importance,  on  account  of  its  relation  to  the  larynx,  where  it  may  simulate 
carcinoma  or  tubercle. 

Some  help  in  the  diagnosis  of  tertiary  Tilcers  of  the  larynx  from  those  of 
pthisis  and  cancer  may  be  found  in  the  points  which  have  been  tabulated  as 
follows  : 

Syphilis.                                 Phthisis.  Cancer. 

Development  of  ulcer  acute,     Development    slow ;    follows  Intermediate    in    time ;    ap- 

occupying  only  a  few  days.         throat  symptoms  after  sev-  pearance    of   ulcers    in    a 

eral  months.  few  weeks. 

Considerable     irregular    in-     Uniform,  pale  swelling,  look-  Nodular     excrescences     and 

flammatory  or  oedenuitous         ing  like  an  infiltration.  acute      inflammation      of 

swelling.  neighboring  mucous  mem- 
brane. 

Epiglottis  aflected,  if  at  all.     Lower  surface.  No  uniformity. 

on  upper  surface. 

Ulcer  solitary ;  rarely  more     Numerous.  Solitary, 
than  two. 


^SYPHILIS. 


173 


Syphilis. 

Proceeds  from  center  to 
periphery,  or  from  above 
downward. 

Deep,  round,  or  oval. 

Diameter  of  1  to  IJ  centi- 
meters. 

No  cachexia. 

Treatment  usually  highly 
beneficial. 


Phthisis. 
The  reverse  is  true. 

Generally  round. 
2  or  3  millimeters. 

Phthisical  appearance. 
Treatment     has     but 
moderate  effect. 


very 


Cancer. 

Irregular  in  their  course. 


Irregular  in  shape. 
2  or  o  millimeters. 

Cachexia. 
No  eSect. 


Syphilis  of  the  Testicles. — Syphilitic  lesions  of  the  testicles  may  consist 
in  gummatous  nodules  of  the  epididymis,  wiiich  appear  at  the  end  of  the  sec- 
ondary period,  or  later  in  orchitis,  which  may  be  either  interstitial  or  gum- 
matous.    There  is  also  a  syphilitic  interstitial  orchitis  of  newborn  children. 

Grummata  of  the  Epididymis. — Toward  the  end  of  the  secondary  period 
there  is  occasionally  observed  upon  the  epididymis  a  limited  induration,  gen- 
erally at  its  head,  varying  in  size  from  that  of  a  bean  to  that  of  a  walnut  or 
larger,  connected  with  the  testicle,  hard  and  indolent.  More  rarely  it  is  situ- 
ated upon  the  body  of  the  epididymis.  It  may  be  uni-  or  bilateral.  There 
is  no  accompanying  affection  of  the  tunica  vaginalis  or  of  the  skin.  The 
tumor  very  soon  disappears  under  treatment  by  mercury  and  iodide  of 
potassium. 

Interstitial  Orchitis. — Interstitial  orchitis  of  the  adult  belongs  to  the  period 
of  the  later  tertiary  lesions.  It  seldom  occurs  before  the  third  year.  It  may 
affect  one  or  botli  sides.  The  testicle  is  the  seat  of  a  chronic  interstitial  inflam- 
mation. The  epididymis  is  seldom  affected ;  if  it  be  involved,  it  is  its  head 
that  is  changed.  At  the  beginning  of  interstitial  orchitis  the  gland  is  a  little 
larger  than  normal,  but  its  shape  is  retained.  If  the  disease  is  not  treated, 
the  gland  gradually  atrophies,  still  remaining  indurated.  There  is  frequently 
a  notable  effusion  into  the  tunica  vaginalis,  which  is  inflamed. 

The  following  table  clearly  presents  the  main  points  of  difference  between 
syphilis,  encephaloid  carcinoma,  and  tubercle  of  the  testicle : 


Syphilitic  Orchitis. 
Syphilitic  history. 

Usually  occurs  at  about  twen- 
ty-five or  thirty  years  of 
age. 

Begins  in  the  testicle. 

Is  situated  primarily  in  the 
connective  tissue. 

Tends  to  fibrous  overgrowth. 


Slow  in  its  progress. 
Skin  of  the  scrotum  rarely 
involved. 

Ulceration     or    suppuration 

rare. 
Fistulae  uncommon. 
A  feeling   of  great   weight, 

with    only   such    pain    as 

results  from  dragging  on 

the  cord. 


Encephaloid  Carcinoma 

of  Testicle. 
No    history   of    any   special 

condition. 
Any  age. 

Begins  in  the  body  of  the 
organ. 

Begins  by  the  deposit  of 
small  nodules  in  the  semin- 
iferous tubules. 

Tends  to  formation  of  patches 
of  softened,  white,  pulta- 
ceous  material. 

Kapid  in  its  course. 

Skin  of  the  scrotum  finally 
involved. 

Ulceration  and  fungus  com- 
mon. 

Fistulas  common. 

Pain  severe  and  lancinating 
in  advanced  stages. 


Tubercular  Orchitis. 
Tubercular  history. 
Not  often  seen  after  thirty. 

Begins  in  the  epididymis. 

Exists  primarily  in  the 
tubules. 

Tends  to  fatty,  caseous,  or 
purulent  degeneration. 

Slow  in  its  progress. 

Skin  involved  only  just  be- 
fore the  formation  of  ab- 
scess. 

Suppuration  common. 

Fistulae  common. 
Little  pain. 


174 


A.y  AMKRICAX   TKXT-JIOOK  OF  SriiCEnv. 


Syphilitic  Orchitis. 
Tumor  very  lianl,  unilonii. 

Skin  of  scrotum  iiuridi-sh, 
l)ut  unafrt'ctcd. 

Of  moderate  size  ;  rarely  ex- 
ceeds twice  its  normal 
diameter. 

Painless  on  pressure. 

Both  testicles  often  affected. 

Fungus  rare. 

No  discharge  or  bleeding. 

Lasts  many  years. 

Curable. 

No  involvement  of  inguinal 
glands  as  a  rule. 


Encephaloid  Carcinoma        Tubercular  Orchitis, 
of  Testicle. 

Soft  and  fluctuating.  At  first  hard,  knotty,  irregu- 

lar. 
Network  of  large  veins  over     Skin    congested .    but    other- 
surface  of  tumor.  wise  unair»'iti-il. 


Attains  jfreat  size. 


Painless  on  pressure. 

General!}-  only  one  testicle 
affected. 

Fungus  alwa^'s  present  in 
advanced  stages. 

Bleeds  freely ;  offensive  dis- 
charge. 

Rarely  extends  beyond  twen- 
ty months. 

Usually  fatal. 

Inguinal,  iliac,  and  lumbar 
glands  and  cord  affected. 


Of  moderate  size. 


Often  painful  on  pressure. 
Often  both  testicles  affected. 

Fungus  common. 

Not   so   apt  to   bleed  ;    dis- 
charge not  so  offensive. 
Lasts  several  years. 

Generally  incurable. 
Usually  no  inflammation  of 
triands. 


TKEAT-MENT    OF    SYPHILIS. 

Serum-therapy  has  been  employed  in  the  treatment  of  syphilis,  but  the 
results  are  not  encouraging.  Scrum  of  animals  which  are  naturally  refractory 
to  syphilis  has  been  tried  (lambs,  horses,  dogs,  rabbits).  A'icrviorovsky  has 
injected  the  blood-serum  of  robust  individuals  who  had  passed  through  the 
secondary  stage.  Ricliet  and  Hdricourt  injected  an  ass  with  the  blood  of 
a  man  with  secondary  syphilis,  and  subsequently  used  the  ass's  serum  in  the 
treatment  of  active  syphilis.  Gilbert  and  Fonrnier  conclude  that  some  few 
cases  have  been  improved  by  serum-treatment,  but  that  many  others  have 
not  been  benefited  by  it. 

The  prejudice  which  for  many  years  existed  against  the  employment  of 
mercurials  in  syphilis  has  largely  disappeared.  A  careful  and  impartial  review 
of  the  testimony  as  to  the  results  of  the  mercurial  and  of  the  non-mercurial 
treatment  of  syphilis  will  prove  convincingly  the  far  superior  efficacy  of  the 
former  method.  Without  denying  that  certain  cases  of  syphilis  do  well  without 
any  treatment  or  with  simple  attention  to  hygiene,  diet,  etc.,  or  even  while  admit- 
ting that  in  the  majority  of  instances  at  the  present  day  the  disease  tends  to  a 
spontaneous  cure,  it  may  still  be  considered  as  well  established  that,  without 
detriment  to  health,  the  probability  of  that  cure  can  be  increased  and  the 
duration  of  the  active  stage  of  the  malady  lessened  by  a  careful  administration 
of  some  form  of  mercury.  Similar,  though  not  quite  so  conclusive,  evidence 
exists  in  favor  of  a  continuous  as  opposed  to  an  intermittent  plan  of  treatment, 
although  various  circumstances  may  render  the  latter  desirable.  The  reasons 
which  have  been  advanced  for  the  employment  of  mercury  in  syphilis  are — 

1.  The  clinical  evidence  of  its  usefulness  in  the  control  of  early  symptoms 
and  the  prevention  of  later  developments.  2.  Its  "tonic"  action,  which,  l)y 
counteracting  the  anemic  tendencies  of  syphilis,  lessens  the  severity  of  the 
disease.  3.  Its  action  as  a  physiological  antidote  to  the  syphilitic  poison,  which 
it  destroys  probably  through  its  antibacterial  or  germicidal  power.  4.  Its 
properties  as  a  promoter  of  destructive  metamorphosis  and  fatty  degeneration, 
through  which  it  renders  possible  the  absorption  and  removal  of  the  new  cell- 
growth  which  cau.ses  the  secondary  symptoms. 

With  regard  to  the  beneficial  influence  of  the  iodides  in  the  later  stages, 
a  therapeutic  fact  established  beyond  all  possibility  of  contradiction,  a  similar 


SYPHILIS.  175 

diversity  ot"  opinion  ;is  to  their  mode  of  action  prevails.  A  tonic  eflect  is 
again  claimed  as  one  of  the  causes  of  the  good  results  obtained  by  the  admin- 
istration of  these  preparations.  The  views  held  as  to  their  melius  operandi 
will  depend  upon  the  ])artieular  theory  of  the  tertiary  stage  which  is  adopted. 
However  this  may  be,  the  clinical  evidence  is  <{uite  sufficient  to  justily  the 
emph^yment  of  these  drugs,  and  the  })ropev  methods  of  administering  them  may 
be  epitomized  as  follows,  beginning  witli  the  a])pearance  of  the  initial  lesion: 

1.  Do  not  employ  mercurial  treatment  until  either  by  confrontation  or  by 
the  development  of  constitutional  symptoms  the  diagnosis  of  syphilis  is  assured. 
Mercury  always  retards  the  appearance  of  the  secondary  symptoms,  and  some- 
times prevents  it  altogether.  As  no  venereal  sore  can  with  al)solute  certainty 
be  pronounced  syphilitic,  it  is  unwise  to  add  an  element  of  uncertainty  to  the 
case  by  delaying  indefinitely  the  outbreak  of  unmistakable  symptoms.  There 
is  sufficient  evidence  to  prove  that  the  subsequent  course  of  the  case  is  not 
materially  affected  by  this  delay.  2.  When  the  time  has  arrived  for  the  admin- 
istration of  mercury,  it  is  well  to  explain  to  the  patient  the  necessity  for  long- 
continued  treatment  and  to  point  out  the  risks  of  neglect.  Having  done  this, 
in  the  majority  of  cases  the  most  satisfactory  method  of  giving  the  drug  will 
be  by  the  mouth,  a  useful  preparation  being  the  protiodide  of  mercury  in  pill 
form,  in  the  dose  of  ^  to  |^  of  a  grain,  three  or  four  times  daily : 

I|i.   Hydrarg.  iodid.  vir.,  gr.  xx  ; 

Confect.  rosae,  q.  s. 

M.  et  ft.  pill.  no.  Ix. 

If  these  should  disagree  with  the  stomach  and  produce  dyspeptic  symptoms,  or 
should  give  rise  to  colicky  pains  and  diarrhea,  from  -Jg-  to  -^  gr.  of  opium  may 
with  advantage  be  added  to  each  pill.  At  the  same  time  a  saturated  solution 
of  chlorate  of  potassium  should  be  given  as  a  mouth-wash,  to  be  used  twdce 
daily  as  a  prophylactic  against  salivation.  3.  To  ascertain  the  proper  dose  ol 
the  drug  in  each  individual  case,  continue  gradually  to  increase  the  dose  until 
slight  tenderness  of  the  gums  or  of  the  posterior  molars  is  noticed.  Then  dimin- 
ish it  to  two-thirds,  or  even  to  one-half,  of  that  dose,  when  its  further  adminis- 
tration for  an  indefinite  period  will  be  possible  with  no  unpleasant  results.  4. 
If  the  preparation  selected  agrees  with  the  patient  and  controls  the  symptoms, 
and  if  there  are  no  intercurrent  complications,  pursue  this  treatment  contin- 
uously for  two  years.  If,  however,  the  protiodide  gives  rise  to  persistent 
bowel  trouble,  as  it  does  in  a  small  number  of  cases,  substitute  for  it  the 
bichloride  in  solution  or  in  combination  with  a  tonic : 

I^.   Hydrarg.  chlorid.  corros.,          gr.  iss ; 
Tinct.  cinchonse  co.,  f§iv. 

M.  et  sig.  One  teaspoonful  in  water  after  meals. 

Hydrargyrum  cum  creta  in  one-grain  doses  four  to  six  times  daily  is  a  very 
useful  preparation  in  cases  of  gastro-intestinal  irritability.  A  half-grain  to  a 
grain  of  Dover's  powder  added  to  each  dose  will  often  control  any  tendencv  to 
diarrhea.  In  some  cases  of  irritable  stomach,  or  when  it  becomes  desirable  to 
intensify  the  mercurial  influence,  inunction  should  be  employed,  and  it  is  a 
useful  addition  to  the  routine  treatment  of  every  case  of  svphilis.  If  once 
in  six  weeks  or  two  months  the  administration  of  mercurv'bv  the  mouth  be 
intermitted  and  a  dram  of  mercurial  ointment  rubbed  into  different  portions 
of  the  cutaneous  surface  once  daily  for  a  week,  it  intensifies  the  mercurial 
influence  without  affecting  digestion  or  nutrition.  The  uncleanliness  of 
the    procedure    and    the    almost    certain    eczematous    ir^-itation  of  the  skin 


17G  AN  AMERICAN    TEXT-BOOK    OE  SURGERY. 

which  it  pro(hiees  render  it  unsuitahle  for  loii<i;-coMtinnc(l  use.  Vapor 
hat/is  of"  mercury  may  be  taken  in  various  "ways,  the  simplest  being  the 
vohitilization  by  means  of  an  alcohol  lamp  of  a  dram  of  calomel,  the 
a])paratus  being  placed  beneath  a  chair  upon  -which  the  patient  sits,  a 
blanket  extending  from  his  shoulders  to  the  ground  serving  to  retain  the 
fumes  in  contact  with  his  body.  5.  By  whatever  method  the  mercurial 
influence  is  kept  up,  the  dose  should  be  temporarily  raised  whenever  new 
symptoms  make  their  appearance,  and,  after  they  have  vanished,  should  be 
dropped  to  the  standard  dose  for  the  particular  patient.  0.  The  local  treat- 
ment of  symptoms  is  of  secondary  importance,  and  altogether  subservient  to 
the  constitutional  treatment.  It  may,  however,  be  useful  as  an  adjuvant. 
Mucous  patches  should  be  treated  with  sulphate  of  copper  or  nitrate  of  silver 
if  on  mucous  membranes ;  when  on  cutaneous  surfaces  they  sli.iuld  be  dusted 
with  powder  of  starch  and  calomel  or  of  calomel  and  lycopodium.  The  scaly 
and  tubercular  syphilides  will  be  benefited  by  the  application  of  a  salve  con- 
sisting of  equal  parts  of  citrine  ointment  and  cosmoline,  or  by  ammoniated 
mercury  and  cosmoline,  two  drams  to  the  ounce,  or  by  any  other  stimulating 
and  absorbent  ointment.  Ulcers  may  be  dressed  with  iodoform,  or,  when 
sluiTJzish,  touched  with  nitrate  of  silver  or  acid  nitrate  of  mercurv.  Enlarged 
glands  may  be  painted  with  iodine  or  let  alone ;  they  rarely  run  on  to  sup- 
puration. 7.  At  the  end  of  two  years  small  doses  of  iodide  of  potassium 
should  be  added  to  the  mercurial,  and  this  "mixed  treatment"  should  be 
persevered  in  for  six  months  longer.  If  during  this  period  any  symptom  of 
syphilis  makes  its  appearance,  the  six  months  of  mixed  treatment  should  be 
dated  from  that  time.     In  other  Avords,  some  such  formula  as  this : 

I^   Hydrarg.  biniodid.,        gr.  ij  ; 
Potass,  iodid.,  sij  ; 

Syr.  sarsaparillae  co. 
Aquae,  da.  fSiij- 

M.  et  sig.  A  dessertspoonful  in  water  after  each  meal, 

should  be  administered  for  the  last  six  months  of  the  treatment,  and  should  be 
recommenced  and  continued  for  six  months  if  any  symptoms  appear  later. 
Great  care  should  be  taken  to  give  the  mixture  largely  diluted,  and  so  to  vary 
it  as  to  do  away  as  far  as  possible  Avith  any  irritation  of  the  intestinal  tract. 
In  obstinate  tertiary  conditions  the  dose  of  the  iodide  may  Avith  impunity  be 
run  up  to  twenty,  thirty,  or  sixty  grains,  or  even  more,  four  times  daily.  If 
this  be  done,  the  cases  Avhich  refuse  to  come  under  its  control  Avill  be  very 
rare.  8.  At  the  end  of  two  and  a  half  years  the  patient  should  be  kept  under 
observation  for  another  full  year,  and  if  during  that  time  no  symptoms  are 
developed,  he  may  consider  himself  as  in  all  probability  cured.  If  such  symp- 
toms do  appear,  however,  he  sliould  recommence  treatment,  and  should  con- 
tinue it  for  at  least  six  months  after  their  subsidence. 


CHAPTER    XVIII. 
HEREDITARY  SYPHILIS. 


The  most  important  points  bearing  upon  the  general  subject  of  hereditary 
syphilis  may  be  enumerated  as  follows : 

I.  Is  syphilis  transmissible  in  all  its  stages  (a)  to  the  wife  or  husband,  or 


HEREDITARY  SYPHILIS.  177 

[h)  to  tlie  oftspring  ?     In  otlier  words,  is  it  ever  proper  to  consent  to  the  mar- 
riage of  a  person  who  has  had  syphilis?     If  so,  under  what  circumstances? 

II.  By  what  means  or  througli  what  cliannels  can  the  disease  of  the  parente 
reach  the  chikl? 

III.  What  are  the  pathology  and  symptoms  of  hereditary  syphilis? 

IV.  What  is  the  treatment — {a)  prophylactic,  applied  to  the  parents, 
(6)  curative  ?     We  shall  take  these  up  seriatim. 

I.  Is  Syphilis  Transmissible  in  All  its  Stages? — No  more  important 
questions  can  be  submitted  to  the  surgeon  than  those  pertaining  to  the  marriage 
of  syphilitics.  Involving  as  it  does  the  welfare  of  many  individuals,  modify- 
in  <t  or  fixing  the  conditions  of  one  or  more  lives,  his  opinion  should  be  excep- 
tionally definite  and  well  grounded. 

There  are  two  distinct  methods  of  arriving  at  an  answer  to  the  question 
under  discussion  :  First,  by  considering  the  probabilities  in  regard  to  the  essen- 
tial nature  of  syphilis ;  and  second,  by  carefully  weighing  the  clinical  evidence 
in  the  matter.  It  seems  evident  that  belief  in  any  particular  theory  of  syphilis, 
assi^^nino-  it  to  this  or  that  class  of  disease,  must  have  an  important  influence  in 
determining  the  opinion  which  is  held  as  to  its  curability,  or,  at  least,  as  to  its 
indefinite  transmissibility. 

In-  regard  to  the  first,  the  main  point  is  the  recognition  of  the  fact  that 
modern  syphilographers,  as  a  rule,  regard  the  tertiary  or  late  symptoms  as 
indicative"  of  damage  done  during  the  active  period — as  relapses  or  sequelae, 
and  not  as  fresh  outbreaks  of  a  highly  contagious  and  transmissible  disease. 
Their  time  of  appearance,  their  entire  want  of  symmetry,  their  non-contagious- 
ness, their  non-inoculability,  all  favor  this  view,  and  much  corroborative  evi- 
dence may  be  obtained  from  clinical  facts. 

It  is  necessary  to  admit  that  there  seems  to  have  been  but  little  doubt  in 
the  minds  of  many  syphilographers  that  in  rare  instances  syphilitic  children 
have  been  born  to  parents  who  had  long  passed  the  limits  of  the  secondary 
period.  At  least,  the  majority  of  writers  upon  this  subject  speak  confidently 
of  the  exceptional  occurrence  of  such  cases,  and  assert  that  syphilis  may  be 
transmitted  during  any  of  its  stages.  If,  however,  we  look  for  positive  evi- 
dence in  this  respect,  we  shall  find  very  little  that  is  entirely  satisfactory. 
Cases  are  reported,  to  be  sure,  in  which  eight,  ten,  tw^elve,  or  even  fifteen  or 
twenty  years  after  the  primary  sore,  syphilitic  patients  have  become  the  parents 
of  children  who  showed  unniistakable  indications  of  the  disease.  When  we 
examine  the  history  of  these  cases,  we  find  usually  that  many  important  points 
have  been  omitted  without  Avhich  it  is  impossible  to  be  certain  of  their  true 
character.  Were  both  parents  originally  affected  ?  If  not,  has  a  recent  case 
of  syphilis  occurred  in  the  one  who  at  first  escaped  ?  If  they  were  both  dis- 
eased originally,  has  either  been  subsequently  re-infected  ? — a  much  more  fre- 
quent accident  than  has  been  commonly  supposed.  On  applying  these  tests 
it  will  be  found  that  few  if  any  are  thoroughly  convincing. 

Fournier,  whose  immense  experience  and  acuteness  of  observation  entitle 
his  opinion  to  the  utmost  consideration,  says  that  in  cases  of  paternal  heredity  the 
duration  of  the  power  of  transmission  never  exceeds,  at  the  maximum,  three  or 
four  years.  Of  the  many  hundreds  he  has  observed,  in  no  case  has  he  known 
a  syphilitic  father  to  infect  a  child — the  mother  being  healthy — at  a  later  period 
than  the  one  mentioned.  And  he  is  equally  positive  that  the  gradual  diminu- 
tion and  final  extinction  of  the  syphilitic  reaction  of  the  parents  upon  the  chil= 
dren  constitute  a  veritable  pathological  law,  "absolutely  demonstrated."  Mr. 
Hutchinson  says  :  "  It  is  almost  an  acknowledged  law  that  parents  in  the  late 
tertiary  stages  do  not  transmit  tnint." 

12 


178  AN  AMi:in(A.\   'nixriiooK  of  srncKHY. 

Those  ((notations  indicate  what  is  now  the  prevailinir  view — viz.  that  tlie 
period  of  transniissibility  of"  syphilis  is  more  or  less  strictly  limited  even  when 
the  disease  is  allowed  to  pro<;ress  without  treatment.  As  to  the  fact  that  it 
becomes  milder  with  time,  so  that  with  each  succeeding;  year  after  the  termina- 
tion of  the  secondary  period  the  chances  of  escape  of  the  product  of  c<iiiception 
increase  in  a  rapidly  au<:mcntin^  ratio,  there  is  no  difference  of  opinion  whatever. 
Neither  is  it  seriously  disj)iited  that  the  length  of  time  during  which  the  disease 
remains  active,  as  well  as  the  degree  of  its  activity,  may  be  markedly  influ- 
enced by  treatment.  Under  proper  medication  patients  who  have  married  in 
the  height  of  the  secondary  period  have  had  children  born  healthy  who  never 
subse<iuently  manifested  any  symptoms  of  the  disease. 

We  may  therefore  assume  safely  that  syphilis  after  a  certain  period,  not 
extending  nmch  over  four  years  Avliere  the  disease  is  alloAved  to  run  its  own 
course,  and  probably  somewhat  reduced  by  treatment,  ceases  to  be  a  contagious 
disease,  and  at  about  the  same  time  or  somewhat  later  loses,  in  the  majority 
of  cases,  its  capability  of  being  transmitted  by  parent  to  offspring.  As  there 
are  ])robably  exceptions  to  the  rule  that  this  power  of  transmission  disappears 
spontaneously  within  any  specified  time,  it  is  never  safe  to  trust  altogether  to 
nature,  but  a  vigorous  and  sufficient  specific  treatment  must  be  employed. 

Given,  however,  the  lapse  of  a  sufficient  time — say  from  three  to  four  years 
as  a  minimum — and  the  history  of  a  proper  and  continuous  plan  of  treatment, 
the  risks  of  marriage  are  so  reduced  as  to  warrant  a  careful  surgeon  in  permitting 
it.  And,  conversely,  of  course  in  any  doubtful  case  Avhere  such  a  history  can 
be  elicited,  and  Avhere  all  these  precautions  have  been  observed,  it  is  improba- 
ble that  any  taint  of  syphilis  has  been  transmitted.  Beyond  this  in  positive- 
ness  it  is  not  safe  to  go.  There  may  be  exceptions  to  these  as  to  most  other 
hygienic  or  therapeutic  rules,  but  they  will  be  of  excessive  rarity. 

Before  considering  the  methods  by  which  syphilis  can  reach  the  child  from 
one  or  the  other  of  its  parents,  it  may  be  well  to  mention  the  modes  in  which 
the  parents  can  infect  each  other. 

The  man  can  derive  syphilis  from  the  woman  only  in  the  usual  way — /.  e. 
by  contagion  through  a  breach  of  surface  permitting  of  the  direct  absorption 
of  the  poison,  the  development  of  the  disease  being  attended  by  the  usual  phe- 
nomena— chancre,  lymphatic  enlargement,  skin  eruptions,  etc.  The  woman 
may — and  in  the  majority  of  cases  does — acquire  the  disease  from  the  man  in  a 
similar  manner.  But  the  mother  may  also  become  infected  through  the  medium 
of  the  child,  which  receives  its  syphilis  directly  from  the  father,  the  mother  up 
to  the  time  of  conception  having  escaped  contagion.  More  than  this,  it  appears 
to  be  highly  probable  that  no  woman  ever  bears  a  syphilitic  child  and  remains 
herself  absolutely  free  from  the  disease. 

No  surgeon  of  large  experience  in  this  class  of  cases  can  fail  to  have  seen 
some  in  which  the  husband,  having  had  syphilis  and  having  married  after  an 
insufficient  interval  or  an  imperfect  course  of  treatment,  has  infected  his  wife 
with  the  disease,  although  at  the  time  no  discoverable  symptom  is  to  be  found 
upon  his  body.  An  ecjually  careful  inspection  of  the  woman  will  also  in  such 
cases  be  attended  by  negative  results  as  regards  the  primary  sore,  and  yet  she 
will  be  found  with  immistakable  evidences  of  constitutional  syphilis.  There  is 
a  clue  to  all  such  cases  which  Avill  immediately  resolve  the  difficulty.  In  every 
instance,  provided  that  no  mistake  has  been  made  and  that  both  husband  and 
wife  are  really  free,  the  one  from  any  contagious  lesion,  the  other  from  any 
evidence  of  a  present  or  previous  primary  sore,  it  will  be  found  that  pregnancy 
has  occurred;  that  the  woman  has  either  been  delivered  of  a  syphilitic  child  or 
has  had  an  abortion  or  miscarriage  at  some  time  before  the  outbreak  of  the 


J I  /•;  /.'  i:i>  iTAin-  sYi'JuiJs.  i "  9 

symptoms  of  syphilis.     Another  arfrumcnt  lies  in  tlie  application  to  the  case 
in  (  uestion   of  the  well-known   "  law  of  Colics,"  which,  from  the  date  of  its 
first  enunciation    in   1887    down  to   the   present  day,  has   heen   found  to    be 
absolutely   without   exception.     It   may  he  fjiven   in  his   own  won  s :    'One 
fact  well  "deserving  our  attention  is  this:   that  a  child  horn  of  a  motlier  who  is 
without  obvious  venereal  symptoms,  and  which,  without  being  exposed  to  any 
infection  sul)sequent  to  its  birth,  shows  this  disease  when  a  few  weeks  old,— 
thi^  child  will  infect  the  most  healthy  nurse,  whether  she  suckle  it  or  merely 
h-uidlc  and  dress  it ;  and  yet  this  child  is  never  known  to  infect  its  own  mother, 
even  thou.^h  she  suckle  it  while  it  has  venereal  ulcers  of  the  lips  and  tongue. 
As  to  the" absolute  and  unvarying  truth  of  this  law  there  is  not  a  shadow 
of  doubt.     There  can  be  but  one  rational  explanation  of  these  tacts— viz. 
that  the  mothers   who   have   thus   acquired  immunity  have  done  so  by  hrst 
acquiring  the  disease  through  pregnancy.  /ix  t     .u^ 

We  may  conclude,  then,  that  the  husband  may  infect  his  wife— (1)  in  the 
usual  manner  or  by  direct  contagion  ;  (2)  through  the  medium  of  the  child,  or 
at  any  rate  by  the  production  of  conception.  _ 

There  is  no  proof  whatever  that  the  semen  of  a  syphilitic  man  is  contagious 
or  can  transmit  the  disease  in  any  way  but  that  above  discussed.  On  the  con- 
trary, it  has  been  shown  experimentally  that  it  is  entirely  non-inocu  able 
AU'other  theories  as  to  methods  of  contagion  are  so  entirely  hypothetical  and 
unsupported  bv  trustworthy  evidence  that  we  can  aflord  to  disregard  tlienu 

II.  We  may  now  consider  the  ways  by  which  syphilis  reaches  the 
child.     These  may  be  broadly  classified  into— 

1    Descent  from  father;  2.  Descent  from  mother ;   -3.   Direct  infection. 

1  As  a  matter  of  course,  the  influence  of  the  father  upon  the  child,  so  far  as 
recrards  heredity,  ceases  at  the  moment  of  conception,  or,  to  be  more  exact  no 
subsequent  condition  of  the  male  parent,  no  development  or  acquirement  of 
disease,  can  exert  any  further  effect.  That  the  existence  of  active  s>  phil.s  in 
the  father  mav  result  in  the  transmission  of  the  malady  to  the  chdd  cannot  be 
doubted.  The  relative  effect  of  paternal  as  compared  with  maternal  influence 
may  be  considered  after  we  have  described  the  latter. 

2  Descent  from  the  mother  may  occur  theoretically  in  consequence  of— 

a.  Infection  of  the  mother  previous  to  conception;  b.  Infection  of  the 
mother  at  the  moment  of  conception;  c.  Infection  of  the  mother  during  the 

period  of  utero-gestation.  .    .        .      ,.  ,,    _  •    i-..!^ 

a  As  to  the  first  of  these  methods  of  transmitting  the  disease  there  is  little 
if  any  difference  of  opinion.  Even  those  who  claim  the  most  for  paternal 
influence  include  among  the  conditions  which  may  give  rise  to  svphdis  m  the 
child  disease  of  the  ovule,  and  it  may  be  stated  as  incontrovertible  t^at  ecent 
or  active  syphilis  in  the  mother  at  the  time  of  conception  will  almost  ceitamly 
be  followed  by  syphilis  in  the  child.  The  cases  in  which  treatment  of  the 
father  has  resulted  in  healthy  children,  whereas  without  treatment  he  pro- 
created syphilitic  children,  the  mother  being  without  either  symptom  or  treat- 
ment hSe  been  urged  as'  evidence  of  the  direct  descent  of  -f  ^;"; 
father  to  the  child  without  the  intervention  or  participa  ion  of  the  mother 
But  it  does  not  follow  because  the  mother  has  latent  or  hidden  ^vp^^ibs  hat 
she  must  infect  her  child.  In  those  cases  in  which  she  does  not  do  so  he  t  eat 
ment  of  the  father  will  remove  the  only  active  source  of  ^yP^^^l^^^^,.  "f^^^.^X 
b.  The  second  method,  or  that  in  which  the  mother  becomes  syphilitic  at  the 
moment  of  conception,  is.  strictly  speaking,  an  example  of  paternal  heredity 
Tthe  resulting  germ  is  syphilitic,  not  because  the  ovule  of  he  mother  was 
infected,  but  on  account  of  the  disease  of  the  spermatozoid  of  the  fathei. 


ISO  AN  AMEJUCAX    TKXT-nnOh'    OF  SI'RC.'KJn'. 

c.  There  remains  for  consideration  the  influence  upon  the  child  of  a  syph- 
ilis acquired  by  tlie  mother  during  some  period  of  utcro-frestation.  That  under 
these  circumstances  the  child  can  become  infected  has  been  and  is  still  abso- 
lutely denied  by  some  very  respectable  authorities.  All  that  is  necessary  for 
proof  of  its  occurrence  is,  however,  (1)  freedom  of  both  parents  from  syj)hilis 
at  the  time  of  conception,  or,  in  other  ■words,  syphilis  must  have  been  acc^uired 
by  both — not  alone  by  the  mother — after  the  beginning  of  pregnancy ;  (2) 
that  the  syphilis  of  the  child  be  unmistakably  prenatal — that  is,  not  acquired 
by  some  accident  during  or  after  birth.  Several  cases  reported  by  acute 
observers  seem  to  combine  both  these  requisites,  and,  after  reading  them 
carefully,  there  seems  to  be  no  reasonable  escape  from  the  conclusion  that  in 
some  manner  the  poison  of  syphilis  may  find  its  "way  from  the  mother  to  the 
child.  The  old  idea  that  the  latter  was  directly  infected  in  utero  from  the 
semen  of  the  father  is,  of  course,  altogether  without  foundation. 

3.  Direct  infection  of  the  child  during  birth  does  not  properly  come  under 
the  head  of  Hereditary  Syphilis.  There  is  no  possible  reason  why,  when  the 
mother  has  contagious  lesions  of  the  genitals,  acquired  too  late  to  infect  the 
child  in  utero,  this  shoukl  not  occur,  but  as  a  matter  of  fact  no  such  case  has 
ever  been  recorded.  One  explanation  of  this  circumstance  may  be  found  in 
the  protective  covering  of  vernix  and  mucus  Avhich  coats  the  infant's  body  and 
lessens  greatly  the  risk  of  absorption.  This  hardly  accounts  satisfactorily, 
however,  for  the  entire  absence  of  such  cases  from  medical  literature,  and  it  is 
fair  to  suppose  that  in  all  except  those  cases  in  which  the  primary  sore  is  ac- 
quired during  the  last  month  of  gestation — Avhich  for  obvious  reasons  are  ex- 
cessively rare — the  infant  acquires  some  immunity  which  protects  it  from  its 
mother,  and  is  similar  to  that  which,  under  Colles's  law,  operates  in  her  favor. 
In  other  Avords,  even  though  apparently  free  from  syphilis  at  birth — a  not  un- 
common event,  as  we  shall  see — it  has  a  latent  or  modified  syphilis  which  pro- 
tects it  from  contagion.  (Profeta's  law,  see  p.  140.) 

We  may  now  briefly  restate  the  conclusions  at  which  we  have  arrived : 

1.  After  a  certain  interval,  not  less  than  four  years,  and  after  thorough 
specific  treatment,  a  person  Avho  has  contracted  a  syphilis  not  especially  severe 
or  malignant  in  its  type  may  be  permitted  to  marry.  The  assent  to  marriage 
will  then  be  based  on  a  belief  in  the  curability  of  syphilis  or  in  a  cessation  of 
its  contagiousness,  its  inoculability,  and,  in  the  vast  majority  of  cases,  its 
transmissive  power,  at  the  end  of  the  secondary  stage. 

2.  It  may  be  inherited  from  either  parent  or  from  both,  and  the  ])robability 
that  this  will  occur  increases  in  a  direct  ratio  with  the  nearness  of  the  time  of 
conception  to  the  date  of  their  infection  with  the  disease.  The  severity  of 
the  inherited  disease  in  the  child  increases  in  the  same  proportion. 

3.  It  is  undoubted  that,  tlie  father  being  healthy  and  the  mother  syphilitic, 
the  child  may,  and  in  all  probability  will,  have  the  disease. 

4.  It  is  probable,  but  less  so  than  in  the  preceding  case,  that,  the  mother 
being  healthy  and  the  father  syphilitic,  the  child  will  be  infected. 

5.  It  is  highly  probable  that  in  all  cases  where  a  child  becomes  syphilitic 
through  paternal  influence  the  mother  is  also  the  subject  of  syphilis,  which 
may,  however,  assume  a  latent  form,  the  only  evidence  of  its  presence  in  a 
few  cases  being  the  protection  which  it  affords  against  contagion  through  the 
medium  of  the  child. 

6.  Syphilis  may  be  transmitted  from  mother  to  child  even  when  it  is  ac- 
quired by  the  former  as  late  as  the  seventh  month  of  utero-gestation. 

III.  The  Pathology  and  Symptoms  of  Hereditary  Syphilis.— 
Syphilis  of  tlie  placenta  is  of  especial  interest  in  its  relation  to  the  abortions 


HEREDITARY  SYPHILIS.  181 

ami  stillbirths  so  tVe(jueiit  in  syi)liilis.  V wnvx  the  iiilluoiice  of  tliat  disease  cell- 
proliferation  begins  in  the  villi,  which  are  normally  only  sj)arin<5ly  supplied  with 
cells,  and  extends  to  the  connective-tissue  stroma  and  the  epithelium.  This 
proceeds  to  such  an  extent  that  it  leads  to  compression  of  the  vessels,  and  finally 
ol)literates  them.  The  vascular  spaces  into  which  the  villi  dip  become  filled 
up  and  narrowed,  and  often  disappear.  In  this  way,  and  also  by  reason  of 
the  thickening  of  the  epithelium,  the  interchange  between  the  maternal  and 
the  foetal  blood  is  interfered  with,  and  at  last  is  prevented.  If  this  process  is 
spread  over  the  whole  placenta,  the  foetus  perishes  before  it  is  complete.  If  it 
is  limited  to  circumscribed  areas,  it  may  live  for  a  shorter  or  longer  period. 

Syphilis  in  the  parents  will  manifest*  itself  in  the  children  in  one  of  several 
ways,  which  are  determined  chiefly  by  tAvo  factors — viz.  first,  the  length  of  the 
interval  between  the  infection  of  the  parent  and  the  date  of  conception  ;  and, 
second,  the  thoroughness  of  the  treatment  of  the  parents  during  that  interval. 
To  these  may  be  added  as  subsidiary,  but  still  of  definite  importance,  a  third, 
the  type  of  disease  which  has  affected  the  fiither  or  the  mother,  whether  mild 
or  severe,  benign  or  malignant. 

From  what  has  already  been  said  in  reference  to  the  question  of  marriage, 
it  will  at  once  be  understood  that  the  danger  to  the  offspring  in  untreated 
cases,  and  in  those  where  conception  has  occurred  during  the  early  secondary 
period  of  the  disease,  is  of  extreme  gravity.  In  such  cases  the  usual  result 
of  pregnancy  is  abortion  at  from  the  first  to  the  fifth  or  sixth  month,  the  foetus 
sometimes  exhibiting  the  evidences  of  syphilis  in  the  shape  of  large  bullae 
upon  the  palms  and  soles,  or  in  the  presence  of  characteristic  visceral  lesions, 
but  quite  as  often  showing  nothing  distinctive.  It  has  generally  undergone 
more  or  less  maceration,  and  the  skin,  which  is  readily  detachable,  is  of  a  con- 
gested, purplish  color.  At  least  one-third  of  syphilitic  children  are  dead-born. 
As  time  goes  on  and  other  pregnancies  follow,  either  the  abortion  occurs  at  a 
later  period  of  pregnancy  or  the  children  are  brought  alive  into  the  world. 
Even  then,  however,  and  although  at  birth  they  may  show  no  evidences  of 
the  disease,  their  chance  of  escape  is  but  small.  One-fourth  of  them  die  within 
the  first  six  months.  If  they  survive  that  period,  the  chances  for  life  are 
slightly  in  their  favor,  but  those  for  health  or  for  freedom  from  deformity  and 
disease  are  still  overwhelmingly  against  them. 

The  Primary  Stage  is  never  found  in  true  hereditary  syphilis.  Of 
course  in  congenital  or  infantile  syphilis,  in  which  by  direct  contagion, 
either  from  the'' mother  or  from  any  one  else,  the  disease  was  acquired  by  the 
child,  the  course  would  not  differ  materially  from  that  observed  in  the  adult, 
and  the  primary  sore  would  be  present.  But  as  this  stage  of  acquired  syphilis 
corresponds  to  the  period  during  Avhich  the  poison  is  finding  its  way  into  the 
system  through  the  lymphatics,  it  is  not  found  in  the  child  who  is  infected  from 
the  moment  of  conception  or  who  receives  the  poison  from  the  mother  directly 
into  the  circulation. 

The  Secondary  Stage. — For  from  one  to  three  weeks  the  newborn 
infant  often  shows  no  symptoms  of  the  disease.  In  158  cases  collected  by 
Diday,  86  manifested  symptoms  before  the  expiration  of  the  first  month,  and 
60  of  the  remainder  before  the  end  of  the  third  month.  When  to  these  are 
added  the  statistics  of  Roger,  we  find  that  of  a  total  of  172  cases  159  showed 
syphilitic  symptoms  before  the  end  of  the  third  month.  When  these  symptoms 
are  present  at  birth,  they  consist  largely  in  a  general  withered,  atrophied, 
weazened  appearance  of  the  child ;  a  hoarse  cry,  due  to  swelling,  with  sub- 
acute inflammation,  or  even  ulceration,  of  the  laryngeal  mucous  membrane ; 
a  coryza,   due  to  a  similar  condition  of  the   Schneiderian  membrane;   and 


182  .l.V  AMERICAN  TEXT-BOOK  OF  SURGERY. 

certain  cutaneous  eruptions,  tlie  most  common  of  wliicli  at  this  early  date  is 
the  hirfre  vesicuhn-  or  bullous  eru])tion  known  as  s_v])hilitic  pemphi^nis. 

J'l'/iiphii/ioi. — With  regard  to  the  specific  or  non-specific  character  of  tliis 
eruption  tiiere  has  been  much  difterence  of  o))inion,  and,  as  it  is  often  the 
earliest  distinctive  expression  of  syphilis,  a  diajmosis  of  which  could  liardly 
be  founded  on  the  general  appearance  of  the  child,  or  even  on  the  hoarse  cry 
and  the  coryza,  it  becomes  important  to  have  definite  ideas  upon  the  subject. 
Nearly  a  century  ago  it  was  denied  that  this  eruption  was  a  manifestation  of 
venereal  disease ;  and  this  view  has  found  sup])orters  down  to  the  present  day. 
The  progress  of  clinical  and  ])athological  knowledge  enables  us  now  to  assert, 
however,  that  although,  as  an  exception,  bulhc  may  sometimes  be  due  to  a 
profound  cachexia  not  dependent  on  syphilis,  yet  in  the  large  majority  of  cases 
they  are  specific  in  their  character. 

If  we  find  an  infiint  at  or  immediately  after  birth  presenting  on  the  soles, 
the  palms,  the  fingers  and  toes,  or  on  the  limbs  an  eruption  consisting  of  blebs 
more  or  less  perfectly  distended  with  a  licjuid  which  may  be  clear,  cloudy,  or 
bloody,  circular  or  oval  in  shape,  sometimes  irregular,  seated  on  inflamed,  red- 
dish skin,  and  surrounded  by  trifling  areolae,  we  may  strongly  suspect  the 
presence  of  syphilis  in  an  active  and  most  menacing  form.  And  this  suspicion 
becomes  a  certainty  if,  in  combination  with  such  an  eruption,  the  general 
cutaneous  surface  is  yellowish  or  muddy  in  hue,  is  hard  and  dry,  without 
elasticity  or  softness — owing  to  the  al)sence  of  subcutaneous  fat — and,  for  the 
same  reason,  is  furroAved  and  wrinkled  about  the  face,  imparting  an  appearance 
of  senility ;  if  the  child  has  a  hoarse  cry,  and  a  discharge  from  the  nostrils ; 
and,  of  course,  if  there  are  at  the  same  time  other  syphilodermata.  This 
eruption  is  specially  important,  however,  because  upon  the  recognition  of  its 
specific  character  in  cases  of  stillbirth  or  in  those  in  which  the  child  survives 
onlv  a  few  days — not  long  enough  for  the  development  of  further  symptoms — 
will  depend  the  opinion  as  to  the  cause  of  death,  which,  whether  expressed  or 
not,  will  determine  the  future  treatment  of  both  parents  during  the  interval 
between  pregnancies  and  of  the  mother  during  the  next  pregnancy. 

Goryza  is  one  of  the  most  characteristic,  and  at  the  same  time  one  of  the 
most  important,  of  the  early  symptoms  of  syphilis  in  its  influence  on  the  health 
of  the  child.  It  is  due  to  the  same  condition  of  the  mucous  mem])rane  lining 
the  nasal  fossae  which  manifests  itself  simultaneoush^  or  soon  afterward  on  the 
skin  in  the  shape  of  erythema,  roseola,  or  papules ;  in  other  words,  it  is  a 
hyperemia  with  papillary  infiltration.  The  excessive  supply  of  blood  to  the 
parts  induces  a  catarrhal  condition  which  shows  itself  in  a  thin,  watery  dis- 
charge. As  the  child  during  suckling  is  compelled  to  breathe  through  the 
nose,  this  discharge  is  rapidly  dried  into  crusts,  causing  the  peculiar  nasal, 
noisy  respiration  which  has  given  the  aff"ection  the  popular  name  of  nniifiieH. 

Roseola  is  apt  to  present  itself  about  the  second  or  third  week  after  birth. 
As  in  the  adult,  it  begins  upon  the  abdomen  in  the  form  of  little  oval,  circular, 
or  irregular  spots,  dull  red  in  color  and  disappearing  upon  pressure.  Later 
the  color  becomes  deeper,  the  eruption  extends  to  the  trunk  and  limbs,  and,  as 
exudation  and  cell-proliferation  succeed  to  simple  capillary  stasis,  it  ceases  to 
disappear  when  pressed  upon.  It  is  often  moist,  and  sometimes  excoriated, 
owing  to  the  thinness  of  the  epidermis.  Occasionally  it  is  confluent,  and  covers 
large  areas  with  an  almost  unbroken  sheet  of  deep-red  color. 

The  diagnosis  in  the  early  stage  is  often  difficult  on  account  of  the  resem- 
blance to  the  simple  erythema  of  infancy.  As  the  disease  progresses,  hoAvever, 
maculfe  form  here  and  there ;  the  cell-infiltration  involves  the  papillae,  several 
of  which  coalesce,  forming  flat  papules ;  the  nutrition  of  the  superficial  layers 


HEBEDITAIIY  HYPHIlJfi.  1»3 

of  the  epiaermis  is  interfered  «ith,  especially  where  it  is  thick,  as  on/ho  P^'™' 
ami  solcHn.l  the  crurtio,,  in  these   regions  hecomes  scaly:   and  then  the 

'"';:ti^»  ^^'"£'!>'«  V',..,./...-In  the  cdinary  evolution  of  the  dis- 
ease tlfe  next  manifestation  is  usually  the  devel<,,.n,ent  of  papules  on  the 
Zeril  cutaneous  surface  and  of  mucous  patches  on  the  tongue,  l,ps,  and 
ehoek  •  nroSlv  also  on  other  mucous  n.e.uhranes  not  exposed  to  exam  na- 
tion Tl~les  for  the  reason  already  mentioned-the  thmness  -"'>"«>»"••« 
If  ,h.  ivin-are  apt  to  be  of  the  broad,  flat  kind,  especially,  as  in  the  adult, 
of  the  ^1^'"  •"*•'?;.'  I, „  ..leuients  of  xvarmtli  and  friction  are  supera.lded  to 
llstre^afTtle^f  itof  skin  tbout  the  genitalia,  the  neck,  the  flexures 

""'"i;;S^  t,S;?Zt  are  due  to  hypertrophic  changes  in  tlie  papules 
whi  h'Serthe  inil'uence  of  heat  and  moisture  in  -ta.n  regions  coales^    and 

••^""^hTVirtchin'dL^S.^reirtX^rt^ndU^rrbya 
nror'by  an  olnXe  Te^S:.'    They  are  found  most  commonly  about  the 

'°X<tfa'^S,S«l!-A"Me  later  in  the  secondary  period,  usually  at 
abo.U  tt  tixrh'Cek,  but  sometimes  much  earlier   the  papules  may  become 

^-t^^X:^C%^X^^^^  of'-  develop^ 

mei't^^ftrer   oUrence   .h»^^^^^^ 

described,  is  iritis.     In  spjte  of  its  ^"'y' t^^^'^^^;';  g,^  tUt  occlusion  of 

Pn?treTnd.£^:LlXve|\he  .,■..«.«.  is  not  us^^^^^^ 

is  irregular,  especially  under  atropine;  f-e  =n.  freaks  o    I™  b,^j^^^ 

:::i'':Sy",re\et^nbllro;ir%;"e::n^^^^^^^^^ 

"''"The  progn^n.  depends  on  the  stage  at  which  the  P»«™*/°";f  nrobabJrt 
ment.  ^he^ymph,  \  recent  no  -"^rwiU^tert  ?grtCt  ev': 
absorbed  under  mercurial  treatment,  ivhich  will  o"™  »«  w  occurred 
in  those  cases  in  which  a  certain  am°«nt  "f  ^-"'f  ™  seconX"  period  of 
The  foregoing  symptoms  "^  f;™";^"-^,;  t  more  commonh^from  the 
hereditary  syphilis,  or  that  extending  "»">  ^f  ^  ^ 

age  of  three  or  f»'"7^;^l^^j°  ^''.'''''eorv.a  with  snufiles ;  'an  erythematous, 
be  agam  enumerated  »«. '°''™\;  ?-'.  mucous  patches  on  the  lips,  tongue, 
Set'etiratrkTrWt:t-ral  wasting  ^  a  hoarse  cry  or  cough  ; 


184  AN  AMERICAN  TEXT-BOOK  OF  SURGERY. 

senility  of  aspect;  iritis.  The  majority  of  syi)liilitic'  cliiMrcii  horn  alive  die 
during  this  stage. 

Before  its  termination,  sometimes  even  at  hirth,  other  lesions  have  been 
noticed  (especially  those  aftecting  the  liver),  which,  however,  may  be  better 
described  in  connection  with  the  special  organ  or  organs  involved. 

Succeeding  this  stage — /.  c  beginning  in  about  a  year  or  eighteen  months — 
comes  an  intermediate  period,  which  extends  to  second  dentition,  to  puberty, 
or  even  much  later,  and  which  is  characterized  rather  negatively — that  is,  by 
the  absence  of  symptoms — than  otherwise.  The  evidence  of  the  general  diath- 
esis will  of  course  be  present  in  the  shape  possibly  of  malnutrition,  stunted 
growth,  or  retarded  development,  perhaps  shown  in  the  weazened  or  withered 
face,  the  sunken  nose,  the  pallor  of  the  skin,  the  premature  loss  of  the  first 
upper  incisor  teeth,  or  the  malformation  of  the  others  if  they  have  erupted. 

There  is  but  little  tendency  to  recurrence  or  relapse  of  any  of  the  secondary 
symptoms :  and  in  certain  cases  this  stage  extends  through  life,  or,  in  other 
words,  as  is  freijuently  the  case  with  the  adult  w^ho  has  followed  a  proper  course 
of  treatment,  the  disease  appears  to  terminate  with  the  secondary  stage.  In 
other  cases,  however,  it  recurs,  and  the  symptoms  which  it  then  ))resents  may 
be  taken  up  in  connection  with  the  different  organs  or  tissues  involved. 

Syphilis  of  the  ear  is  for  obvious  reasons  not  often  discoverable  until  the 
patient  has  reached  an  age  at  which  interference  with  the  function  of  hearing 
becomes  a  noticeable  phenomenon.  The  only  symptom  likely  to  be  noticed 
during  the  stage  of  inherited  syphilis  which  we  are  now  considering  is  a  catarrh 
of  the  middle  ear.  This  may  lead  to  perforation  of  the  membrana  tympani, 
purulent  infiltration  of  the  m'astoid  cells,  etc.,  and  wdien  accompanied  by  an 
otorrhea  which  attracts  attention  to  the  ear  will  be  easily  discovered  by  the 
surgeon. 

The  affections  of  the  middle  ear  and  Eustachian  tube  are  said  to  be  contem- 
poraneous with  the  keratitis  which  appears  in  the  neighborhood  of  puberty, 
while  those  of  the  auditory  nerve  are  somewhat  later  in  point  of  time,  and  are 
almost  always  conjoined  with  retinitis,  choroiditis,  and  optic  neuritis. 

Syphilitic  disease  of  the  liver  in  newborn  children  is  distinguished 
especially  by  increase  in  size  and  weight  of  the  organ.  This  increase  depends 
upon  a  proliferation  of  cells  from  the  connective  tissue  between  the  acini,  or 
from  the  adventitia  of  the  interlobular  vessels,  this  growth  becoming  trans- 
formed into  connective  tissue.  The  change  is  quite  analogous  to  that  which  is 
taking  place  at  the  same  time  in  the  skin,  the  mucous  membranes,  and  other  tis- 
sues. It  does  not,  however,  go  on  to  organization,  but  may  be  just  as  suscepti- 
ble of  absorption  and  resolution  as  are  the  papules  or  maculne  of  the  skin.  A 
portion  of  the  enlargement  may  be  due  to  a  passive  congestion  caused  by  the 
presence  of  this  cell-accumulation. 

As  to  the  diagnosis  of  hepatic  syphilis  in  infants,  the  symptoms  are  indef- 
inite, or  they  are  identical  with  those  often  ol^served  in  chihb-en  who  have  poor 
or  insufficient  nourishment.  The  only  physical  sign  which  properly  belongs  to 
hepatic  syphilis,  when  it  exists  at  all,  is  increase  in  the  size  of  the  liver. 

Bone  syphilis  in  children  is  essentially  of  the  nature  of  the  syphilitic 
bone  troubles  with  which  we  are  ffimiliar  in  the  acquired  form  of  the  disease, 
consisting  primarily  and  throughout  of  an  unnatural  accumulation  of  cell-ele- 
ments, Avhich  in  the  later  stages  by  their  pressure  produce  various  degenerations 
of  surrounding  structures,  and  which,  as  they  occur  during  the  process  of  bone- 
formation,  are  accompanied  by  irregular  and  abnormal  deposits  of  lime-salts. 
They  especially  affect  the  junctions  of  the  epiphyses  and  diaphyses,  because  at 
that  time  those  points  are  the  seats  of  great  physiological  activity. 


HEREDITARY  SYPHILIS. 


185 


The  symptoms  wliicli  ohtuin  in  tliis  condition  of  syphilitic  osteochondritis  are 
as  follows.  There  is  a  swelling  at  the  (lia|)hyso-e])ij)hyseal  junction  of  one  of  tiie 
long  bones,  which  in  the  emaciated  subjects  of  liereditai-y  sypliilis  is  often  visible 
and  can  always  be  discovered  by  ])al|)ation.  This  consists  of  a  ring  or  collar 
which  more  or  less  completely  surrounds  the  bone,  is  apt  to  be  smooth  rather 
than  irregular,  and,  when  two  bones  situated  near  to  each  other  are  simulta- 
neously affected,  may  conjoin  them.  A  moderate  amount  of  synovitis  is  often 
present.  This  affects  chietly  the  elbow^  and  the  knee,  but  may  appear  in  any 
joint.  It  is  readily  influenced  by  specific  treatment  and  Avell-regulated  pres- 
sure. When  the  last  stage  is  reached,  or  tliat  of  the  formation  of  granu- 
lation-tissue, with  degenerative  changes  of  the  cartilages  and  of  the  bones 
themselves,  deformity  often  becomes  more  marked.  There  are  unnatural 
curves  or  angles  in  the  bones,  with  more  or  less  complete  separation  at  the 
point  of  junction. 

The  most  inn)ortant  differential  diagnosis  to  be  made  in  these  cases  is 
between  tlie  rhachitis  of  young  children  and  the  form  of  syphilis  in  (juestion. 
The  points  of  resemblance  are  manifest,  just  as  they  are  between  a  syphilitic 
and  a  variolous  pustule,  but  they  end  in  both  cases  when  we  come  to  study  the 
evolution  of  the  phenomena  either  from  an  anatomical  or  from  a  clinical  stand- 
point.    They  may  be  expressed  as  follows  in  tabular  form : 


Osseous  Lesions  due  to  Inherited 
Syphilis. 

The  swellings,  particularly  those  of  the  long 

bones,  show  themselves  at  or  soon  after 

birth. 
A  history  of  syphilis  or  evidence  of  existing 

syphilis  in  one  or  both  parents. 
Preceded  or  accompanied  by  snuffles,  coryza, 

and  cutaneous  and  mucous  lesions. 
No  such  prodromata  in  most  cases. 


Cachexia  absent  or  moderate. 

Physiognomical  peculiarities  of  syphilis  pres- 
ent. 

Circumscribed  tumors  on  frontal  and  parietal 
bones,  rarely  on  occiput. 

Ribs  not  markedly  affected. 

Disease  of  ribs,  vrhen  existent,  not  ordinarily 
coincident  with  that  of  other  bones. 

Fontanels  close  at  usual  period. 

Other  syphilitic  symptoms  present — enlarge- 
ment of  phalanges,  metatarsal  bones,  etc. 

Often  accompanied  by  sinuses,  synovitis,  ab- 
scesses, cutaneous  ulcers,  etc. 

Generally  disappears  by  resolution,  without 
leaving  any  permanent  change. 

Mortality  among  children  in  whom  many 
bones  are  involved  is  very  great. 

Specific  treatment  useful. 

In  the  first  stage  there  is  an  exuberant  cal- 
cification of  the  ossifying  cartilage,  caus- 
ing necrosis  of  the  new-formed  tissue  and 
a  consecutive  inflammation,  which  termi- 
nates in  the  separation  of  tlie  epiphyses.^ 


Rickets. 

Rarely  appear  before  six  months,  generally 

still  later. 

No  such  history  necessarily. 
No  such  prodromata. 

Pallor,  restlessness,  sweating,  nausea,  diar- 
rhea, etc.  constitute  a  combination  of 
symptoms  which  often  precede  the  bone 
disease. 

Cachexia  marked. 

Not  present  as  a  group. 

Cranial  bones   thickened  in  spots,  usually 

upon  the  occiput. 
All  or  nearly  all  involved. 
Nearly  always  so. 

Closure  delayed. 

Syphilitic  symptoms  absent. 

Little  external  or  surrounding  involvement. 

Usually  leaves  some  bending  of  shaft  and 

distortion  of  the  neighboring  joint. 
Much  less. 

Of  no  benefit. 

This  is  less  marked.  There  is  formed,  in- 
stead,  a   soft  and    non-calcified    osteoid 

tissue. 


^  This  table  is  founded  on  one  published  in  the  translation  of  Cornil  On  Syphilis,  by  Drs. 
Simes  and  White,  and  is  compiled  chiefly  from  the  excellent  work  of  Dr.  Taylor  on  thifi 
subject. 


1«G 


^l.Y  AMERICAN  TEXT-BOOK  OE  SURGERY. 


The  bone  lesions  of  hereditary  exostosis  ean  readily  be  reeo;^nized  by  the 
facts  that  they  are  stationary,  appear  later,  and  are  of  larger  size,  by  the  ab- 
sence of  syphilitic  history  or  symptoms  and  by  their  I'esistance  to  specific  treat- 
ment. The  diagnosis  from  accidental  separation  of  the  epiphysis  or  from 
fractures  may  be  made  from  the  history  of  the  case. 

In  cases  of  separation  of  the  epiphysis,  complicated  with  suppuration, 
sinuses,  etc.,  the  trouble  may  be  mistaken  for  a  similar  condition  due  to  non- 
specific inflammation.  In  all  the  recorded  instances,  however,  the  latter  has 
occurred  much  later  in  life,  is  attended  with  much  more  acute  inflammatory 
symptoms,  lymphangitis,  etc.,  and  is  of  course  without  concomitant  symittoms 
of  syphilis.  In  l)Otli  cases  there  is  a  decided  osteo-periostitis,  and,  as  so  much 
depends  on  the  early  and  vigorous  use  of  specific  treatment,  it  may  be  worth 
while  to  contrast  the  two  forms  of  the  disease. 


Syphilitic  Osteo-periostitis. 
Occurs  in  infants  under  three  montlis  of  age. 

History  of  syphilis  in  child  and  its  parents. 

Implication  of  other  bones. 

Coincident  with  the  development  of  the  shaft 
of  the  bone. 

Other  lesions  of  syphilis — nodes,  skin  ei-up- 
tions,  etc. 

All  the  local  symptoms  comparatively  mild. 

Disease  sharply  localized. 

Lymphatics  of  limb  unaffected. 

Beneficial  effect  of  specific  treatment  if  em- 
ployed early. 


Non-specific  Osteo-periostitis. 

Seldom  if  ever  occurs  in  children  under  one 
year  of  age. 

No  histoi-y  of  syphilis  ;  sometimes  a  history 
of  traumatism. 

Usually  confined  to  one  l)one. 

Coexists  with  the  ossification  of  the  epiph- 
yses. 

No  such  symptoms. 

Pain,  redness,  and  swelling  very  marked. 
Involves  neighboring  parts. 
Lymphangitis  sometimes  present. 
No  such  effect. 


Fifi.  2-5. 


Syphilitic  Dactylitis  (Fig.  25)  in  the  inherited  variety  of  the  disease,  as 
in  the  acquired,  consists  of  two  varieties.  The  one  of  these  which  generally 
appears  earlier  aff"ects  chiefly  the  periosteum  and  the  fibrous  and  integumentary 

structures  surrounding  a  joint,  usually  a  nieta- 
carpo- or  metatarso-phalangeal  articulation,  involv- 
ing a  phalanx,  and  is  characterized  by  slow,  almost 
painless,  swelling  and  discoloration  of  the  affected 
member.  This  is  due  to  a  gummatous  infiltration, 
which,  after  absorption  under  proper  treatment, 
leaves  the  toe  or  finger  temporarily  stiff,  but  not 
permanently  disabled. 

The  second  form  is  a  specific  osteo-myelitis, 
with  periostitis,  coming  on  later,  and  often  destroy- 
inec  the  bone  or  the  articulation  involved. 

The  absence  of  acute  inflanniiatory  symptoms 
in  the  first  variety  distinguishes  it  from  paronychia, 
whitlow,  and  gout.  Rheumatoid  arthritis  begins 
in  the  joints  and  is  associated  with  other  symp- 
toms ;  deformity  of  the  fingers  comes  early  in  the 
disease,  and  there  is  a  teno-synovitis  with  contrac- 
tion. 

The  second  variety  might  be  taken  for  enchon- 
droma  or  exostosis,  but  these  growths  increase  much  more  slowly,  involve  only 
a  limited  portion  of  the  bone,  are  of  greater  density,  and  are  much  more  strictly 
circumscribed. 


Ulcerated  Syphilitic  Dactylitis 
(original). 


HE  HE  I)  I T.  \I:Y  S  )  I'll  ILLS.  1 87 

As  a  rule,  especially  in  cases  ^vlli(•ll  aic  recognized  early  and  treated 
actively,  the  proi/mis/'s  is  n-ood. 

Syphilis  of  the  Teeth. — Syphilis  of  the  teeth  lias  its  chief  interest  from 
its  very  important  hearing  on  diagnosis.  Manifesting  itself  at  an  age  when 
the  child  is  not  apt  to  present  the  active  and  unmistakahle  cutaneous  and 
mucous  lesions  of  the  disease,  the  recognition  of  which  is  therefore  often 
extremely  difficult,  this  diagnostic  importance  is  greatly  increased. 

The  teeth  of  the  fin<t  denfitiott,  althouirli  exhihitin";  the  usual  sicrns  of 
interference  Avith  nutrition  in  their  irregular  development,  oi)a(jue  and  chalky 
enamel  deficient  in  (juantity  and  unevenly  distributed,  soft  and  friable  dentine, 
incongruity  of  size  individually  and  relatively,  and  proneness  to  decay,  do  not 
often  display  any  distinctive  evidence  of  syphilis.  The  same  conditions  may, 
and  often  do,  depend  on  other  causes,  and  are  commonly  associated  with 
various  cachexi.e. 

In  the  permanent  teeth,  likewise,  the  same  condition  may  be  due  to  the 
same  causes.  Stomatitis,  however  produced — by  mercury,  by  gastro-intestinal 
derangements,  by  local  irritation  of  any  kind — is  apt  to  result  in  imperfectly 
organized  dental  structures.  Mercurial  teeth,  for  example,  are  usually  irregu- 
larly aligned,  horizontally  seamed,  honeycombed,  scraggy,  malformed,  of  an 
unhealthy  dirty-yellow  color,  separated  too  widely,  and  deficient  in  enamel. 
The  diseases  of  childhood  by  temporarily  arresting  or  greatly  interfering  with 
nutrition  during  the  developmental  period  of  the  teeth  often  cause  horizontal 
furrows  across  their  crowns. 

None  of  these  conditions,  however,  are  in  the  least  degree  characteristic  of 
syphilis,  the  special  expression  of  which  in  the  mouth  is  to  be  found  only  in 
the  permanent  upper  median  incisors.    It  may  be  considered 
as  well  established  that  when  these  teeth  are  stunted,  abnor-  Fig.  26. 

mally  narrow  at  the  cutting  edge,  crescentically  rounded 
with  the  convexity  upward,  and  the  surface  inclined  upward 
and  forward,  instead  of  backward  as  in  normal  teeth,  widely     upper  Median  incisors 
separated,   but  converging  at  their  lower  edges,   they  are        !"  Hereditary  syph- 
pathognomonic  of  hereditary  syphilis  (Fig.  26).     They  are       vier). 
generally  known  as  '■'•  Hutehinson  s  teeth.''     They  are  often  Fig,  27. 

described  as  pegged,  having  been  likened  to  a  row  of  pegs 
stuck  in  the  gums.  This  appearance  is  due  to  the  facts 
that  they  are  shortened,  often  projecting  not  more  than 
half  the  normal  distance  from  the  gum,  and  are  also  Avidely 
separated;  which  abnormalities  often  affect  the  adjoining 
teeth,  and  sometimes  the  entire  denture.  A  mistake  which  is  frequently  made 
is  the  confusing  of  the  serrations  of  the  cutting  edges  of  recently-erupted  normal 
incisors  (Fig.  27)  Avith  the  peculiar  crescentic  edges  of  syphilitic  teeth. 

Interstitial  Keratitis. — The  frequency  of  this  form  of  diffuse  inflamma- 
tion of  the  cornea,  and  the  diagnostic  significance  which  has  been  so  positively 
attributed  to  it — and  as  positively  denied — render  it  of  special  interest.  It 
begins,  commonly,  as  a  slight,  diffused  haziness  situated  in  the  substance  of 
the  cornea  itself,  usually  not  far  from  the  centre,  and  at  first  affecting  only  one 
eye.  This  condition  may  persist  for  one  or  two  months,  after  which  the  other 
cornea  is  nearly  always  attacked,  and  is  similarly  affected,  although  the  disease 
is  apt  to  pass  through  its  different  stages  rather  more  rapidly  than  in  the  first 
eye.  When  the  height  of  the  disease  is  reached  the  cornese  are  nearly  opaque, 
a  bare  perception  of  light  remaining.  Then  the  cornea  Avhich  Avas  first  in- 
volved begins  to  clear ;  this  is  soon  folloAved  by  improvement  in  the  other  one, 
which  in  the  course  of  a  year  or  tAvo  results  in  a  return  to  fairly  good  sight, 


188  A^^  AMERICAN  TEXT-liOOK  OF  SURGERY. 

although  in  most  cases  there  remain  a  slight  haziness  and  an  abnormal  ex- 
pansion of  the  cornea. 

The  diagnosis  of  this  condition  may  generally  be  made  -with  ease.  The 
ground-glass  appearance  in  the  earlier  stages  and  the  dull  pink  or  salmon  color 
in  the  more  vascular  stage  are  very  characteristic.  The  vascularity  differs 
from  that  attending  other  chronic  forms  of  keratitis,  granular  lids, "etc.,  in 
which  the  vessels  are  large  and  superficial :  in  syphilitic  keratitis  they  are 
much  deeper  and  very  closely  interwoven,  so  that  the  effect  is  almost  that 
of  an  ecchymosis.  In  non-syphilitic  cases  both  eyes  are  not  so  apt  to  be 
affected  nor  is  the  tendency  to  spontaneous  cure  so  marked.  The  absence 
of  ulceration  and  the  very  slight  degree  of  accompanying  sclerotic  or  ciliary 
congestion  are  also  valuable  features.  The  chief  point  of  interest,  however, 
in  the  diagnosis  of  interstitial  keratitis  is  its  association  with  other  symptoms 
of  syphilis,  upon  which,  for  the  general  practitioner  at  least,  the  diagnosis  will 
usually  depend.  There  is  such  unequivocal  clinical  evidence  in  this  direction 
that  it  is  safe  to  say,  as  of  the  question  of  syphilitic  teeth,  that  the  burden 
of  disproof  rests  with  the  doubters,  and  we  may  venture  the  assertion  that 
interstitial,  diffuse,  or  parenchymatous  keratitis  is  a  symptom  of  inherited 
sy})hilis,  and  that  the  unmistakable  presence  of  the  former  disease  is  sufficient 
proof  of  the  existence  of  the  latter. 

Syphilis  of  the  Nerve-centres  and  Nerves. — Until  a  compara- 
tively recent  period  our  only  guide  to  the  course  of  the  nerve  diseases  of 
inherited  syphilis  was  to  be  found  in  analogy.  We  knew,  for  instance,  that 
in  acquired  syphilis  three  forms  of  cerebral  disease  could  be  recognized  in  a 
general  way :  one  characterized  by  a  sudden  attack  of  paralysis,  in  which  the 
lesion  was  usually  thrombosis  from  specific  endarteritis ;  one  in  which  the 
symptoms  of  brain-tumor  were  present,  and  in  Avhich  gummata  were  the  cause 
of  the  difficulty ;  and  one  in  Avhich  pain,  headache,  and  various  functional  or 
convulsive  disturbances — chorea,  epilepsy,  paralysis  of  single  nerves,  etc. — 
were  the  customary  phenomena,  and  in  which  periosteal,  meningeal,  or  neu- 
roglial thickenings  constituted  the  pathological  basis.  The  last  two  are  often 
intermingled  both  symptomatically  and  histologically. 

In  spite  of  certain  striking  differences — more  apparent  than  real,  however — 
between  inherited  and  acquired  syphilis  as  regards  cause,  duration  of  stages, 
etc.,  the  essential  pathological  changes  are  the  same.  When  syphilis  in  its 
later  periods  attacks  the  brain  or  spinal  cord  or  nerve-trunks  or  vessels  of  a 
foetus,  it  proceeds  just  as  in  the  adult,  the  same  characteristic  accumulation  of 
cells  taking  place  and  setting  up  an  arteritis  or  a  meningitis,  thickening  the 
sheaths  of  nerves,  or  constituting  a  pericranial  node  or  a  gumma,  according  to 
their  number  and  their  situation.  We  find,  thus,  that  in  these  patients  men- 
ingitis, growths,  and  arterial  disease  constitute  the  three  clinical  divisions  of 
the  disease  which  have  thus  far  been  distinctly  differentiated,  and  the  reported 
cases,  with  or  without  autopsy,  fall  natui'all}'-  into  these  classes. 

Syphilis  of  the  Spleen. — Disease  of  this  organ  in  inherited  syphilis  is 
especially  important  from  two  points  of  view.  It  is  a  valuable  aid  to  diagnosis, 
and  by  the  size  of  the  organ  and  the  degree  of  persistence  of  the  swelling  gives 
an  approximate  indication  of  the  severity  of  the  case.  Enlargement  of  the  liver, 
although  it  ought  to  be  noted  because  it  is  often  present  in  hereditary  syphilis, 
has  but  little  value  as  a  confirmatory  symptom :  first,  because  the  liver  is  dis- 
proportionately large  in  infancy,  and  it  is  difficult  to  state  the  limit  of  what  is 
actually  normal ;  and,  secondly,  because  other  causes  besides  congenital  syphilis 
lead  to  its  enlargement.  With  regard  to  enlargement  of  the  spleen  the  case  is 
different.     Gee's  observation,  that  in  the  early  stage  of  infantile  syphilis  somo 


HEREDITARY  SYPHILIS.  189 

enlargement  of  the  spleen  occurs  in  a  large  number  of"  cases,  has  been  abun- 
dantly confirmed.  The  importance  of  this  sign  is  greatest  when  noted  early, 
as,  for  example,  when  the  child  is  from  two  to  three  months  old,  for  at  that 
period  the  enlargement  of  the  spleen  due  to  rickets  can  hardly  come  into  ques- 
tion. The  condition  of'  the  spleen  during  this  })eriod  of  enlargement  seems  to 
be  simply  that  of  hyperemia,  or  at  the  most  of  hyper[jlasia. 

The  cause  seems  to  be  in  all  probal)ility  the  Avell-known  effect  of  syphilis 
on  the  glandular  system  in  general  and  on  the  lymphatic  system  in  particular^ 
to  which  the  spleen  is  now  usually  assigned.  The  analogy  between  this  slow^ 
persistent,  painless  enlargement  preceding  the  cutaneous  symptoms,  unaccom- 
panied by  inflammatory  symptoms,  unattended  by  any  breaking  down  of  tissue, 
subsiding  slowly  but  evenly  under  specific  treatment,  and  the  behavior  of  the 
buboes  of  acquired  syphilis,  is  certainly  very  striking. 

In  most  cases  of  hereditary  syphilis  there  are  evidences  of  disturbance  of 
the  gastro-intestinal  tract.  Vomiting,  diarrhea,  colic,  anorexia,  and  ema- 
ciation are  well-known,  but  of  course  not  at  all  characteristic,  symptoms. 

It  has  been  supposed  that  the  mucous  membrane  of  the  entire  tract  is 
probably,  during  the  early  period  at  least,  and  coincidently  with  the  cutaneous 
eruption,  in  a  condition  of  hyperemia  and  irritation  comparable  to  that  of  the 
skin.  Whether  this  is  so,  or  whether  it  is  due  to  associated  involvement  of 
the  glandular  apparatus,'  has  not  yet  been  determined. 

Syphilis  of  the  Larynx. — The  hoarse  cry  of  the  newborn  infant,  so  cha- 
racteristic of  hereditary  syphilis,  depends  upon  the  presence  of  hyperemia,  of 
mucous  patches,  or  even  of  extensive  ulceration,  in  the  larynx.  The  first  is 
probably  the  most  common,  as,  if  it  were  otherwise,  cases  of  death  from  oedema 
glottidis  or  other  forms  of  laryngeal  obstruction  would  be  oftener  met  with. 
When  ulceration  does  exist  it  is  generally,  but  not  invariably,  secondary  to 
pharyngeal  ulcers. 

Bronchial  catarrh,  giving  rise  to  cough,  and  sometimes  to  considerable 
embarrassment  of  respiration,  is  a  not  infrequent  complication  of  laryngeal 
syphilis.  Later  troubles  of  the  larynx  in  connection  with  inherited  syphilis 
have  not  yet  been  studied  carefully  enough  to  warrant  us  in  draAving  any  dis- 
tinction between  them  and  the  usual  symptoms  seen  in  the  acquired  disease. 

Syphilis  of  the  testicles  is  found  to  consist  of  a  true  interstitial  orchitis, 
very  closely  resembling  that  seen  in  the  syphilitic  testicles  of  adults.  The  dis- 
ease usually  occurs  at  from  two  months  to  three  years  of  age ;  both  testicles 
are  generally  involved,  and  are  enlarged,  hard,  inelastic,  and  frequently  nodu- 
lated. Mercurial  treatment  generally  causes  a  marked  improvement  unless  the 
inflammation  has  already  resulted  in  the  development  of  a  new  fibroid  forma- 
tion, in  which  case  it  Avill  be  likely  to  remain  unaffected  by  treatment.  Inunc- 
tions with  diluted  mercurial  ointment,  iodoform,  etc.  are  useful  adjuvants. 

The  Diagnosis  and  Prognosis  of  Inherited  Syphilis. — In  reviewing 
the  general  course  of  a  case  of  inherited  syphilis  it  seems  evident  that  the  differ- 
ences between  it  and  the  acquired  disease  which  have  been  so  much  dwelt  upon 
are  apparent  rather  than  real.  The  primary  stage  is  of  course  missing,  and  on 
any  theory  of  the  essential  nature  of  syphilis  this  is  readily  comprehensible. 
Whether  the  chancre  is  the  first  symptom  of  a  constitutional  disease,  or  is  the 
simple  accumulation  at  the  point  of  original  inoculation  of  the  cells  affected 
by  the  syphilitic  virus,  it  would  naturally  be  in  the  first  case  undiscoverable, 
in  the  second  non-existent. 

The  secondary  stage,  characterized  in  the  acquired  form  chiefly  by  lymphatic 
engorgement  and  symmetrical,  Avidely-spread,  polymorphic  cutaneous  and  mucous 
eruptions,  and  pathologically  by  a  marked  tendency  to  the  proliferation  of  cer- 


190  AS  AMK/i'JCAy   TF.XT-noOK  OF  SlJidKIiY. 

tain  new  small  round  inicleated  cells,  upon  the  {tresence  of  which  depen<l  all 
the  nianitestutioii.s  ot"  tlie  disease,  is  in  inherited  syphilis  strictly  analo;rous. 
The  lymphatic  engorgement  either  exists  in  the  infant  as  in  the  adult,  or  has 
its  analogue  in  the  eidargement  of  the  spleen  and  of  the  liver,  especially  the 
former. 

The  tertiary  stage,  except  in  the  fact  that  its  ]»lu'nomena  may  ajipear  unusu- 
ally early  and  may  be  connningled  with  those  of  the  secondary  period,  does  not 
widely  differ  in  the  hereditary  form  from  that  of  the  acquired  disease. 

In  considering  the  question  of  diagnosis,  therefore,  we  have  an  excellent 
guide  in  the  facts  that  the  disease  conforms  in  most  respects  to  the  general  laws 
of  acquired  syphilis,  and  that  our  knowledge  of  the  latter  affection  Avill  be  a 
valuable  aid  to  recognition  of  the  former. 

The  chief  elements  of  diagnosis  and  prognosis  of  inherited  syphilis  in  its 
various  stages  mav,  then,  be  summarized  as  follows:  A  history  of  sv))hilis  in 
either  parent  is  important  just  in  proportion  to  the  shortness  of  the  interval 
between  the  time  of  infection  and  the  date  of  conception.  If  both  parents 
were  syphilitic  at  or  before  the  time  of  conception,  the  probability  that  the 
disease  will  be  transmitted,  and  in  a  severe  form,  is  much  increased.  There  is 
no  sufficient  evidence  that  inheritance  from  one  parent  results  in  a  graver 
variety  of  the  disease  than  when  it  is  derived  from  the  other. 

A  history  of  abortion  or  miscarriage  on  the  part  of  the  mother  should  have 
weight  in  the  determination  of  any  given  case,  and  if  such  accidents  have  been 
very  frequent  their  diagnostic  importance  is  greatly  increased. 

Upon  examining  the  product  of  abortion  or  stillbirth  the  most  easily  observ- 
able symptoms  will  be  those  of  the  skin.  Maceration  of  the  epidermis  and  its 
elevation  into  bullae  are  in  themselves  hardly  characteristic,  though  both  of 
them — and  especially  the  latter — may  be  regai'ded  as  suspicious.  If  the  cuta- 
neous lesions  are,  however,  distinctly  papular  or  pustular  or  ulcerative,  or  if 
the  bullse  have  all  the  characteristics  of  syphilitic  pemphigus,  the  diagnosis  is 
assured. 

The  most  distinctive  symptom — one  whicli  may  really  be  considered 
pathognomonic — is,  however,  the  inflammation  of  the  diaphyso-epiphyseal 
articulations,  with  or  without  their  disjunction.  Distinct  enlargement  of  the 
spleen  or  of  the  liver  and  arachnitis  with  hydrocephalus  are  valuable  diagnostic 
points,  and  the  presence  of  gummata.  which  arc  not  very  infrequent,  Avould 
of  course  be  conclusive. 

At  birth  the  syphilitic  child  may  be  small,  stunted,  emaciated,  Aveazened, 
senile  in  appearance  :  this  would  properly  give  rise  to  suspicion,  but  might  be 
associated  with  any  disorder  of  nutrition  on  the  part  of  either  child  or  mother. 
It  may  also  disclose  cutaneous  or  mucous  eruptions  evidently  specific  in  charac- 
ter. In  any  event,  marked  symptoms  at  birth  render  the  prognosis  highly 
unfavorable. 

It  is  quite  common,  however,  for  the  subject  of  hereditary  syphilis  to  give 
no  evidence  of  the  disease  at  birth,  but  even  to  appear  healthy  and  well 
nourished.  In  such  cases  the  first  symptoms  of  the  disease  appear,  on  an 
average,  in  from  six  weeks  to  two  or  three  months,  and  consist  principally  of 
coryza,  snufl^es,  hoarseness  of  voice,  and  syphilodermata. 

Mucous  patches  on  the  tongue,  cheeks,  tonsils,  and  pharynx  are  common, 
often  extending  to  the  larvnx.  increasing  the  hoarseness,  and  to  the  nasal 
cavities,  aggravating  the  snuffles.  Both  of  these  occurrences,  bv  interfermg 
with  the  respiration  of  the  child  and  rendering  its  nursing  interrupted  and 
insufficient,  greatly  add  to  the  gravity  of  the  case.     Enlargement  of  the  spleen 


HEREDITAR  V  SYPHILIS.  191 

(common),  eulargoment  (jf  tlie  liver  (less  so),  and  iritis  (rare)  may  be  mentioned 
amon<!;  the  phenomena  of  this  stage  often  assoeiated  with  the  skin  eruptions. 

About  the  time  of  the  subsidence  of  the  rash  there  may  be  devehjped  the 
specific  infhunmation  at  the  junction  of  epiphyses  and  diaphyses  which  pro- 
duces a  swelling  of  the  long  bones  near  their  ends.  The  child  will  be  noticed 
to  cry  a  little  when,  for  example,  the  wrist  or  elbow  on  one  side  is  washed,  and 
not  to  use  these  joints  as  much  as  the  corresponding  ones  on  the  other  side. 
The  parts  are  slightly  tender,  and  as  yet  there  is  but  little  swelling.  Later, 
the  droop  and  disuse  of  the  aftected  limb  become  more  noticeable  and  simulate 
ififantile  paralysis.  There  is,  however,  no  wasting,  no  alteration  of  reaction 
by  faradism,  no  real  loss  of  power,  so  that  the  term  pseudo-paralysis  is  an  ap- 
propriate one.  In  a  w^eek  or  two  similar  symptoms  will  occur  in  the  bone  on 
the  opposite  side,  and  finally  the  ends  of  all  the  long  bones  will  be  aff'ected ; 
ordinarily  the  elbows,  wrists,  knees,  and  shoulders  are  the  joints  involved. 
Suppuration  is  rare,  disjunction  of  the  epiphysis  from  the  diaphysis  common. 
Recovery  is  apt  to  take  place  spontaneously  Avithin  a  month.  The  associated 
changes  are  chiefly  endosteal  at  the  junction  of  the  shaft  with  the  epiphysis, 
but  there  is  also  a  little  periostitis  or  perichondritis,  which  is  the  principal 
cause  of  the  external  swelling.     Moderate  deformity  may  ensue. 

Similar  changes  occurring  in  the  cranial  bones  give  rise  to  Avhat  has  been 
called  the  natiform  skull.  During  the  first  year  it  is  very  common  for  syphilitic 
children  to  develop  a  number  of  lenticular  swellings  on  the  cranium,  which 
appear  symmetrically  around  the  anterior  fontanel,  but  at  a  little  distance 
from  it — L  e.  one  on  each  frontal  and  one  on  each  parietal  bone.  They  are 
said  to  be  "  bossed."  They  are  originally  circumscribed,  and  in  a  child  nine 
or  ten  months  old  often  measure  from  three-quarters  of  an  inch  to  an  inch  in 
diameter.  They  are  at  first  circular,  afterward  more  irregular,  and  finally  tend 
to  organize,  becoming  difl"used  and  massive  and  causing  a  permanent  thicken- 
incr  of  the  skull. 

The  symptoms  which  have  been  described  are  the  prominent  ones  occur- 
ring during  the  first  six,  eight,  or  twelve  months  of  life.  If  they  do  not 
manifest  themselves  before  the  eighth  month,  it  is  highly  probable,  even  in  a 
case  with  a  syphilitic  parental  history,  either  that  the  child  will  escape  alto- 
gether or  that  the  secondary  stage  has  been  very  slight  and  altogether  intra- 
uterine and  unattended  w4th  noticeable  phenomena.  If  during  this  first  year 
the  child's  cachexia  is  marked,  if  there  are  any  intercurrent  diseases,  if  the 
symptoms  show  themselves  early,  if  the  nasal  or  laryngeal  affection  is  severe, 
if  the  eruptions  are  markedly  bullar  or  pustular  or  ulcerative,  if  the  enlarge- 
ment of  the  spleen  is  great  or  the  osseous  lesions  are  precocious  or  grave,  and 
if,  especially,  there  is  any  intermingling  of  tertiary  symptoms,  gummata,  nodes, 
etc.,  the  prognosis  will  be  unfavorable. 

From  adolescence  through  adult  life  the  diagnosis  of  inherited  syphilis  will 
depend  on  the  following  points :  First,  of  course,  the  history  of  parental  or  of 
infantile  syphilis,  or  of  both.  Then  a  group  of  physical  and  physiognomical 
peculiarities,  which  are  not  definitely  characteristic,  and  are  of  little  value  when 
taken  separately,  but  of  considerable  impoi'tance  when  all  or  a  majority  are 
present  in  any  given  case.  These  are  low  stature  or  puny  development  pro- 
portionate to  the  severity  of  the  intra-uterine  and  infantile  symptoms :  a  pasty, 
leaden,  or  earthy  complexion,  a  relic  of  previous  syphilodermata,  probably  also 
a  result  of  malnutrition ;  a  prominent  forehead,  bulging  in  the  middle  line  at 
and  within  the  frontal  eminence,  and  due  either  to  thickening  of  the  skull  or 
to  a  previous  arachnitis  and  hydrocephalus  before  the  ossification  of  the  fon- 
tanels ;   a  flat,  sunken  bridge  of  the  nose,  due  to  the  coryza  of  infancy  ex- 


192  AN  AMERICAN  TKXT-liOOK  OF  SI'IiGKRY. 

tending  to  the  periosteum  of  the  delieate  nasal  bones,  and  either  interfering 
with  their  nutrition  or  j)artially  destroying  them  ;  dryness  and  thinness  of  the 
hair,  with  brittleness  and  splitting  of  the  nails ;  synechia)  and  dulness  of  the 
iris  (rare) ;  ulcerations  of  the  hard  palate;  and  periosteal  thickenings  or  en- 
largements of  the  shafts  of  the  long  ])ones  near  the  ends,  or  slight  angular 
deformity,  the  result  of  the  osteochondritis  of  infancy. 

A  much  more  valuable  grouj)  of  symptoms,  however,  are  tlie  following, 
which  are  mentioned  in  the  order  of  their  importance,  any  one  of  the  first  three 
being  almost  or  quite  conclusive: 

Dwarfed  permanent  median  upper  incisors,  broader  at  the  top  than  at  the 
cutting  edge,  which  is  crescentically  notched,  separated  by  an  undue  interval, 
and  converging  toward  each  other. 

Evidence  of  past  or  present  keratitis — a  dusky  and  thin  sclerotic  in  the 
ciliary  region  and  slight  clouds  here  and  there  in  the  corneal  substance,  there 
being  no  scars  on  its  surface  ;  or  of  disseminated  choroiditis ;  patches  of  absorp- 
tion, especially  around  the  periphery. 

A  radiating  series  of  narrow  cicatricial  scars  extending  across  the  mucous 
membrane  of  tlic  lips,  or  a  network  of  linear  cicatrices  on  the  u])per  lip  and 
around  the  nostrils,  as  Avell  as  at  the  corners  of  the  mouth  and  on  the  lower  lip. 
Periosteal  nodes  on  one  or  many  of  the  long  bones ;  sudden,  symmetrical, 
and  complete  deafness,  without  otorrhea  and  unattended  by  pain  or  other  sub- 
jective symptoms. 

Late  or  tardy  hereditary  syphilis  is  rarely  dangerous  to  life.  The  prognosis 
is  almost  unvaryingly  favorable  unless  some  grave  visceral  complication,  such 
as  interstitial  pneumonia,  ginumata  of  the  brain,  liver,  or  kidney,  or  meningeal 
and  periosteal  inflammation  within  the  cranium,  should  occur. 

Treatment. — The  prophylactic  treatment,  or  that  directed  to  the  health 
and  sexual  relations  of  the  parents  previous  to  conception,  has  already  been 
sufficientlv  considered.  That  of  the  mother  during  pregnancy,  after  having 
conceived'^from  a  syphilitic  husl^and,  or  having  had  antecedent  syphilis,  or  hav- 
ing contracted  it  by  direct  contagion  subsequent  to  impregnation,  is  simply  that 
of  acquired  syphilis  in  either  adult  or  child.  Mercury  in  its  full  physiological 
dose  is  the  drug  indicated.  It  may  not  be  amiss  to  combine  with  it  iodide  of 
potassium  in  moderate  doses,  but  the  practice  of  employing  the  latter  to  the 
exclusion  of  the  former  is  both  theoretically  and  clinically  unsound.  Care 
should  especially  be  taken  to  give  it  in  such  a  manner,  either  by  inunction  or 
vaporization  or  so  guarded  Avith  opium,  that  it  shall  not  produce  any  irritating 
effect  on  the  intestinal  canal,  the  sympathy  betAveen  wlpcli  and  the  uterus  may, 
in  the  event  of  a  strong  purgative  action  being  set  up,  lead  to  an  abortion. 

As  we  have  seen  that  the  pathology,  the  stages,  and  the  general  course  of 
hereditary  syphilis  are  all  closely  related  to  or  identical  with  the  same  phe- 
nomena ill  the  acquired  disease,  and  so  know  that  they  both  deju'iid  upon  the 
same  ultimate  cause,  it  follows  that  the  same  principle  should  govern  us  in  the 
treatment  of  the  one  as  in  that  of  the  other. 

We  know  from  clinical  experience  that  mercury  exercises  an  almost  con- 
trolling influence  over  the  secondary  manifestations  of  acquired  syphilis.  '^^  e 
know  also  that  iodide  of  potassium,  probably  by  virtue  of  its  powerful  stimu- 
lating influence  on  the  lymphatic  system,  has  an  equal  power  over  the  tertiary 
growths.  In  hereditary  syphilis,  however,  there  are  two  elements  Avhich  should 
modify  the  treatment  somewhat,  and  must  be  taken  into  consideration.  These 
are — 1st.  The  existence  of  a  more  or  less  profound  cachexia  influencing  all  the 
nutritive  and  formative  processes,  and  in  itself,  entirely  apart  from  any  definite 
specific  involvement  of  vital  organs,  threatening  life.     2d.   The  not  infrequent 


HEREDITA BY  S YPHILIS.  1 93 

occurrence   during   the  secondary   period   of   symptoms — notably  gummata — 
belonging  to  the  tertiary  stage. 

Tlie  first  indication  is  met  by  making  the  treatment  from  first  to  last  not 
only  antisyphilitic,  l)ut  also  supporting  or  even  stinndating;  and  with  this 
object  in  view  especial  attention  should  be  paid  to  nutrition.  It  may  be  stated, 
axiomatically,  that  for  every  reason,  whenever  it  is  within  the  bounds  of  pos- 
sibility, the  nurse  of  a  syphilitic  child  should  be  its  mother.  To  her  it  is 
harmless ;  to  every  other  woman,  not  already  syphilized,  it  is  in  the  highest 
decree  dangerous.  If  neither  mother  nor  wet-nurse  can  be  had  to  suckle  the 
child,  it  nnist  be  fed  by  cow's,  goat's,  or  ass's  milk  or  by  artificial  alimenta- 
tion ;  but  its  prospect  of  life  will  be  immeasurably  reduced.  In  addition  to 
careful  feeding,  a  little  tonic  treatment  should  be  employed  from  the  first,  in 
conjunction  with  the  specific  remedies,  iodide  of  iron,  cod-liver  oil,  and  jjrepa- 
rations  of  the  phosphates  being  the  most  useful  drugs. 

The  existence  of  the  second  condition  wliich  exercises  a  modifying  influ- 
ence upon  treatment — the  early  appearance  of  tertiary  symptoms — is  probably 
due,  in  many  cases  at  least,  to  an  overwhelming  of  the  lymphatic  system  by 
the  new  cell-growth.  This  leads  us  to  combine  with  the  mercury  from  the 
beginning,  at  least  in  all  cases  where  bony  or  periosteal  involvement,  suppura- 
tion, or  the  existence  of  gummata  point  to  this  condition,  small  doses  of  iodide 
of  potassium  or  of  some' other  soluble  and  easily-decomposed  iodine  salt. 

The  principle  of  treatment  being  recognized,  the  routine  procedure  may  be 
thus  described :  Give  mercury  as  soon  as  the  diagnosis  of  syphilis  is  assured — 
preferably  by  inunction.  Sir  Benjamin  Brodie's  opinion,  expressed  many 
years  ago,  still  represents  that  of  the  profession :  "I  have  tried  different  ways 
of  treating  such  cases.  I  have  given  the  child  gray  powder  internally  and 
given  mercury  to  the  wet-nurse.  But  mercury  exhibited  to  the  child  by  the 
mouth  generally  gripes  and  purges,  seldom  doing  any  good,  and  given  to  the 
wet-nurse  it  does  not  answer  very  well,  and  certainly  is  a  very  cruel  practice. 
The  mode  in  which  I  have  treated  cases  for  some  years  past  is  this :  I  have 
spread  mercurial  ointment,  made  in  the  proportion  of  a  dram  to  an  ounce, 
over  a  flannel  roller  and  bound  it  around  the  child  once  a  day.  The  child  kicks 
about,  and,  the  cuticle  being  thin,  the  mercury  is  absorbed.  It  does  not  either 
gripe  or  purge,  nor  does  it  make  the  gums  sore,  but  it  cures  the  disease.  I 
have  adopted  this  practice  in  a  great  many  cases  with  signal  success.  Very 
few  children  recover  to  whom  mercury  is  given  internally,  but  I  have  not  seen 
a  case  where  this  method  of  treatment  has  failed." 

When,  for  any  reason,  as  irritation  of  the  skin,  this  cannot  be  employed, 
probably  the  best  form  of  giving  mercury  by  the  mouth  is  in  the  following 
formula : 

I^.   Hydrarg.  cum  creta,   gr.  j-vj  ; 
Sacch.  alb.,  gr.  xij. 

M.  et  div.  in  chart.  No.  xij. 
Sig.  One  powder  three  times  a  day,  to  be  taken  soon  after  nursing. 

Iodide  of  potassium  may  be  given  separately  in  a  syrupy  solution  in  doses 
of  a  half-grain  to  a  grain,  or,  if  there  are  any  marked  tertiary  symptoms,  even 
in  much  larger  doses,  three  or  four  times  daily.  The  treatment  of  course 
should  be  continued  long  after  the  disappearance  of  syphilitic  symptoms,  and 
it  would  probably  be  well  to  continue  the  mixed  treatment  intermittently  until 
after  puberty. 

The  cases  of  visceral  syphilis  in  very  young  children  are  generally  fatal. 
Those  that  recover  do  so  in  response  to  the  active  use  of  the  above  remedies. 

13 


194  AX  AMERTCAX  TEXT-BOOK  OF  SrUdEUY. 

Later,  the  pro^j^nosis  is  more  fiivorablc,  the  treatnient  the  same.  Of  course 
moist  eruptions  shouUi  be  dusted  with  some  astringent  or  absorbent  powder; 
mucous  patches  should  be  cauterized  or  stimulated ;  and  great  attention  should 
be  paid  to  avoidance  of  sources  of  cutaneous  irritation,  by  fre(|U('nt  clian^nng 
of  diapers,  etc.,  but  the  general  methods  are  the  same  as  in  the  adult. 


CHAP  T  E  R     XI  X 
TUMORS. 


A  TUMOR  is  a  new  growth  or  neoplasm  Avhich  produces  a  localized  enlarg(>. 
ment  of  a  part  or  an  organ,  has  no  tendency  to  spontaneous  cure,  has  no  useful 
function,  in  most  cases  tends  to  grow  during  the  whole  of  the  individual's  life, 
its  development  and  growth,  except  in  rare  instances,  being  uninfluenced  by 
druf^s  or  by  the  greater  or  less  general  vigor  of  the  individual.  The  exceptions 
to  which  the  above  definition  does  not  apply  are — first,  such  new  growths  as 
tubercle,  lupus,  etc. ;  second,  certain  epitheliomata  and  the  withering  scirrhus  of 
the  breast,  which  do  not  produce  enlargement;  and  third,  cysts  not  the  result 
of  new  growth.  Lymphadenoma  or  lympho-sarcoma,  a  malignant  disease  of 
the  lymphatic  glands,  in  a  few  instances  temporarily,  or  more  rarely  perma- 
nently, seems  to  have  undergone  cure  from  the  use  of  arsenite  of  sodium  given 
internally  in  increasing  doses. 

All  tiimors  originate  from  the  pre-existing  tissues  (except  when  of  meta- 
static origin),  and  are  composed  of  tissue-elements  resembling  those  of  these 
tissues  either  in  their  fully-developed  or  in  their  embryonic  state.  "When  limited 
to  the  tissue  in  which  it  starts,  the  tumor  merely  displaces  the  tissues,  and  is, 
almost  without  exception,  constituted  of  fully-developed  cells  similar  to  the 
tissue  from  wliich  it  started,  as  fat,  fibrou;:,  or  muscular  tissue :  to  this  class  of 
tumors,  which  are  generally  benign,  the  term  homologous  has  been  applied. 
When  the  new-growth  no  longer  remains  confined  to  the  tissue  in  which  it 
starts,  but  infiltrates  the  surrounding  tissues,  its  component  elements  tending 
to  be  more  embryonic  in  their  type,  it  is  usually  malignant;  such  growths 
have  been  termed  heterologous.  "  Nearly  all  secondary  tumors — i.  e.  those 
forming  in  parts  distant  from  the  primary  growth,  as  in  the  lymjihatics  or  the 
viscera — are  therefore  heterologous.  Both  innocent  and  malignant  growths  may 
be  multiple.  Multiple  malignant  growths  are  usually  the  result  of  lymphatic 
or  vascular  embolism,  but  cases  are  not  uncommon  where  more  than  one  primary 
focus  has  been  observed ;  thus  two  or  three  portions  of  the  lip  or  of  the  tongue 
may  be  simultaneously  attacked. 

Tumors  Originate  from  Many  Causes. — Some,  as  mvvi,  are  con 
genital,  or  the  tendency  to  their  development  in  later  life  is  inherited.  Of 
the  causes  initiating  those  occurring  in  later  life,  the  following  are  regarded  as 
most  effectiveand  un(|uestioned.  While  inflammatory  new  formations  cannot  be 
regarded  as  tumors,  there  is  little  doubt  that  injury — especially  that  following 
a  contusion  and  fractures — stands  in  fre(|uent  causative  relation  to  many  new 
growths,  notably  the  sarcomata.  Anything  which  acts  chemically  or  mechan- 
ically so  as  to  maintain  a  constant  but  slight  degree  of  undue  vascularity  of  a 
part,  such  as  the  irritation  of  soot  (scrotal  cancer),  the  hot,  rough  stem  of  a 
clay  pipe  (labial  epithelioma),  a  jagged  tooth  (carcinoma  lingua),  favors  the 
development  of  a  malignant  growth.  Abnormal  conditions  of  parts  where  the 
epithelial  elements  are  in  excess,  as  certain  benign  growths,  such  as  warts 
(cutaneous  papillomata),   pigmented   moles,   and  leucoma  of  the   tongue  (a 


TUMORS.  195 

clironic  inilaiiuiiatorv  atVcetioii  iiivolviii*^^  ilie  surface  of  that  organ),  prerlis- 
pcse  t»»  the  foniiatioii  of  lualignaiit  growths.  Age  and  sex  predispose  to 
tunior-forniation.  Thus  carcinoma  is  a  rarity  under  thirty  years  of  ao^e ; 
the  mannnary  gland  of  the  female  is  infinitely  more  liahle  to  carcinoma 
than  that  of  the  male,  owing  to  their  diflciing  functional  activity;  while,  on 
the  otiier  hand,  the  (esophagus,  lip,  and  tongue  in  the  male  seem  to  he  more 
lial)le  to  he  attacked  hy  malignant  disease  than  the  same  organs  in  the 
female.  The  depressing  emotions  long  continued,  such  as  sorrow  or  anxiety, 
generally  considered  as  predisposing  causes,  can  act  only,  as  does  age,  by  low- 
ering the  vitality  of  the  tissues,  inducing  as  it  were  premature  senescence :  their 
action  is  therefore  doubtful. 

Since  malignant  growths  present  some  slight  apjjarent  resemblances  to 
certain  ])henomena  of  the  infectious  diseases,  observers  have  of  late  years 
sought  to  ascribe  their  origin  to  bacteria.  Still  later,  microscopic  appear- 
ances simulating  those  presented  by  certain  parasitic  protozoa  have  led 
enthusiastic  observers  to  the  belief  that  the  spheroidal  or  irregular  bodies 
found  in  and  between  the  epithelial  cells  are  in  reality  developmental  forms 
of  certain  sporozoa,  and  that  their  presence  is  not  accidental,  but  causal. 
The  arguments  in  support  of  this  view  rest  upon  the  morphological  resem- 
blances of  these  bodies  to  psorospermige  and  to  the  corpuscles  of  molluscum 
contagiosum.  The  diversity  in  size,  form,  and  staining  qualities  of  the  sup- 
posed parasites,  the  lack  of  evidence  that  these  bodies  are  either  growing  or 
developing,  and  the  failure  of  all  culture  methods,  have  caused  most  authori- 
ties to  believe  that  the  alleged  sporozoa  of  carcinoma  are  really  degeneration- 
products  of  the  epithelial  cells.  The  possibility  that  carcinoma  may  yet 
prove  to  be  of  parasitic  origin  is  not  denied,  but  certainly  no  positive  evidence 
in  support  of  this  view  has  been  adduced. 

Growth. — This  is  dependent  upon  its  structure  primarily,  and  to  a  less 
degree  upon  the  part  in  which  the  tumor  starts.  Oceteris  jjaribus,  the  more 
embryonal  the  structure,  the  more  rapid  the  increase  and  the  more  malignant 
the  tumor,  but  tumors  of  similar  structure  pursue  widely  differing  courses  accord- 
ing to  the  organ  in  which  they  originate.  This  is  partly  due  to  their  lymphatic 
and  vascular  connections,  partly  to  the  importance  to  life  of  the  part  involved 
or  of  neighboring  parts  which  may  become  diseased  by  contiguity,  or  mechan- 
ically rendered  partially  or  wholly  useless  ;  thus  a  small  carcinoma  of  the 
pylorus  will  terminate  life  by  starvation ;  a  tumor  of  the  larynx  will  early 
endanger  life   by  suffocation. 

Clinically,  tumors  are  divided  into  the  benign  and  the  malignant.  A 
benign  tumor  is  usually  composed  of  tissues  resembling  those  in  which  it 
originates,  and  is  circumscribed,  because  »usually  encapsulated,  Avhence  its 
mobility  among  the  circumjacent  tissues.  Its  vascular  supply  is  small :  hence 
generally  it  grows  slowly.  It  is  painless ;  it  never  infiltrates  surrounding  tis- 
sues, but  displaces  them ;  it  does  not  recur  when  thoroughly  removed,  does  not 
give  rise  to  enlargement  of  the  lymphatic  glands  intervening  between  it  and  the 
venous  circulation,  and  consequently  does  not  affect  distant  parts.  A  malig- 
nant tumor  usually  consists  of  tissues  widely  different  from  those  in  which  it 
originates ;  its  growth  is  rapid,  and  therefore  often  painful ;  it  infiltrates  all 
the  surrounding  tissues,  however  resistant,  even  bone,  because  it  is  almost 
never  encapsulated  ;  it  thus  early  becomes  immovable  ;  the  superjacent  skin  is 
apt  to  become  adherent,  especially  when  the  breast  is  involved ;  sooner  or  later 
it  usually  infects  the  group  of  lymphatic  glands  intervening  between  it  and  the 
venous  circulation,  and  from  these  new  centres  or  directly  through  the  veins 
gives  rise  to  secondary  deposits  in  the  internal  organs. 


196  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

Diagnosis. — In  general  terms  this  must  depend  upon  the  history,  age, 
sex,  situation,  rate  of  growth,  fixity  to  the  surrounding  parts  and  overlying 
skin,  or  the  reverse,  lymphatic  or  visceral  involvement,  and  the  physical  cha- 
racters of  the  growth. 

Tlie  Jiahilitif  of  tumors  to  degenerations  resulting  from  disease  or  injury — 
since  morbid  growths  are  no  more  exempt  from  sucli  influences  than  normal 
tissues — should  be  clearly  recognized  and  constantly  kept  in  mind.  Thus  the 
vascular  supply  predisposes  to  the  occurrence  of  ulcerative  inflammation  in 
both  benign  and  malignant  growths.  For  instance,  an  ordinary  sessile  fatty 
tumor  (lipoma)  is  no  more  liable  to  be  attacked  by  ulceration  than  any  other 
portion  of  the  normal  fatty  tissue ;  but  when  such  tumors  become  jiendulous, 
with  narrow  pedicles,  the  blood-supply  is  often  interfered  with — especially  the 
venous  i-eturn — and  ulceration  may  occur  from  trivial  causes.  Again,  epithe- 
lial carcinomata  are  chiefly  formed  of  masses  of  cells  the  majority  of  which 
are  distant  from  any  direct  blood-supply ;  thus  they  readily  undergo  fatty  de- 
generation and  break  down  early  ;  the  overlying  skin  becomes  infected,  gives 
way,  and  ulceration  is  initiated.  This  process  is  often  so  active  that  the  major 
part  of  the  growth  ulcerates  or  sloughs  away,  while  at  the  periphery  the  disease 
extends  into  the  adjacent  tissues.  Very  rarely,  from  injury,  gangrene  of  the 
whole  growth  ensues,  resulting  in  its  total  destruction  and  the  cure  of  the 
disease.  One  most  important  class  of  malignant  neoplasms — viz.  the  sarcomata 
— are  liable  to  such  developmental  transformations  into  structures  resembling 
normal  tissues,  as  to  give  rise  to  errors  both  in  diagnosis  and  in  prognosis.  It 
must,  then,  never  be  forgotten  that  any  of  the  structures  normally  developed 
from  connective  tissue  may  form  either  the  bulk  of  some  of  the  most  malig- 
nant growths  or  isolated  portions  of  them :  thus  cartilage,  bone,  or  fibrous 
tissue  may  form  the  mass  of  a  malignant  growth ;  but  these  changes  into 
tissues  of  a  permanent  type  in  no  way  modify  the  malignancy  of  the  remain- 
ing tissues  of  the  embryonal  type.  Such  benign  groAvths  as  fibromata  may  un- 
dergo calcification :  cartilaginous  tumors  may  soften  (undergo  mucoid  change). 

Treatment. — The  only  effectual  treatment  is  removal  or  destruction  of  the 
growth.  Benign  growths  should  be  removed  if  much  inconvenience  or  deformity 
is  present,  or  if  disturbance  of  health  or  danger  to  life — present  or  prospective 
— is  undoubted.  It  is  needless  to  say  that  all  malignant  growths  should  be 
promptly  removed,  including,  when  possible,  the  whole  of  the  organ  attacked 
and"  the  neighboring  lymphatics  and  glands,  as  the  entire  breast  with  the  axil- 
lary contents  in  cancer  of  that  organ  ;  the  whole  tibia  by  amputation  in  sarcoma 
of  that  bone.  Special  therapeutic  indications  will  be  considered  when  treating 
of  each  particular  class  of  growths. 

Classification  of  Tumors. — Tumors  are  best  classed  according  to  their 
supposed  origin  and  their  histological  structure ;  thus — 

I.  Mesoblastic  or  Connective-Tissue  Tumors. 

A.  Those  conforming  to  the  types  of  fully-formed  connective  tissues  i 

1.  Fibrous  Tumors  (Fibroma,  plural  Fibromata) ; 

2.  Fatty  Tumors  (Lipomata) ; 

3.  Cartilaginous  Tumors  (Chondromata)  ; 

4.  Osseous  Tumors  (Osteomata) ; 

5.  Mucous  Tumors  (Myxomata). 

B.  Those  conforming  to  the  types  of  the  higher  connective  tissues : 

1.  Muscular  Tumors  (Myomata) ; 

2.  Vascular  or  Erectile  Tumors  (Angeiomata) ; 

3.  Lymphatic  (vessel)  Tumors  (Lymphangeiomata); 

4.  Nerve  Tumors  (Neuromata). 


TUMORS. 


197 


C.  Those  conform iiiii  to  the  type  of  embryonic  connective  tissue: 

1.  liound-cclletl  Sarcomata; 

2.  Spindle-celled  Sarcomata; 

3.  Myeloid  Sarcomata. 

D.  Tumors  intermediate  between  the  sarcomata  and  the  carcinomata : 

The  Endotheliomata. 

II.  Epiblastic  and  Ilypohlmtic  Tumors — i.  e.  those  conforming  to  the  type 

of  Epitlu'UaJ  Tissues : 

A.  Warty  or  Villous  Tumors  (Papillomata). 

B.  Glandular  Tumors  (xVdenomata). 

C.  The  Acinous  or  Spheroidal-celled  Carcinomata: 

1.  Hard  Spheroidal-celled  (Scirrhous,  or  Chronic  Carcinomata^ ; 

2.  Soft  Spheroidal-celled  (Encephaloid  or  Acute  Carcinomata) ; 

3.  Colloid  Carcinomata. 

D.  Epithelial  carcinomata : 

1.  Squamous-celled  Epitheliomata ; 

2.  Cylindrical-  or  Columnar-celled  Epitheliomata. 

III.  Tumors  composed  of  Epiblastic,  Hypohlastic,  and  Mesohlastic  Ele- 

ments : 
Teratomata,  tumors  containing  bone,  hair,  teeth,  etc.,  situated  in 
the  ovaries  or  testicles. 


I.  Mesoblastic  or  Connective-Tissue  Tumors. 

A.  Tumors  conforming  to  the  types  of  fully-formed  connective 
tissues  : 

1.  Fibrous  Tumors,  or  Fibromata  (Fig.  28). — Consisting  of  fibrous 
tissue,  they  may  be  as  dense  and  firm  as  a  tendon  or  as  soft  as  the  subcutaneous 
areolar  tissue.  They  commonly  possess  a  distinct  capsule ;  when  completely 
removed  they  neither  recur  locally  nor  become  generalized,  and  consequently 
are  absolutely  innocent  tumors.  They 
rarely  consist  solely  of  pure  white  fi- 
brous tissue,  but  the  firmer  varieties  are 
composed  of  a  dense  mass  of  interlacing 
bundles  of  this  tissue,  intermingled  with 
a  few  yellow  elastic  fibers  and  connect- 
ive-tissue corpuscles.  The  bundles 
may  form  concentric  circles  around  the 
blood-vessels  in  some  fibromata,  but 
usually  they  present  no  definite  arrange- 
ment. On  section  they  are  smooth, 
glistening,  firm,  and  of  a  grayish-white 
color.  Usually  the  blood-supply  is 
scanty,  the  vessels  being  small  and  thin- 
walled,  but  some  naso-pharyngeal  polypi 
are  excessively  vascular,  being  trav- 
ersed by  large  cavernous  blood-spaces. 
The  softer  varieties  consist  of  a  more 
or  less  loose,  succulent,  fibrous  tissue 
permeated  with  numerous  large  blood- 
vessels, and  according  to  the  propor- 
tions of  the  different  forms  of  fibrous  tissue  which  enter  into  their  composition 
they  will  appear  more  or  less  yellowish,  glistening,  semi-transparent,  or  gelatin- 


Fibro-cystic  Tumor  of  Parotid  Region  (original). 


108  jy  AMERICAN    TEXT-liOOk'   OF  SURGERY. 

ous;  a  serous  fluid  can  be  expressed  f'n.iii  their  cut  .surfaces.  When  super- 
ficial thoy  often  become  pedunculated. 

Fibrous  tumors  are  jiioue  to  uii(k'r<;o  certain  secondary  degenerative  changes 
— vi/.  caleificatioii.  luucdid  eliaiiLTc.  and  ulceration. 

Seats  of  Predilection. — Fil^-oniata  may  occur  wherever  filtrous  tissue  is 
found  in  any  of  its  forms,  but  the  commonest  seats  are  the  periosteum,  espe- 
cially that  of  the  jaws,  for  the  harder  forms,  when  the  tumor  is  called  a  fibrous 
epulis;  in  the  uterus;  in  the  neurilemma  of  nerves — then  miscalled  neuroma 
(false  neuroma)  ;  in  the  subcutaneous  tissue  on  terminal  nerve-fihuiients,  termed 
painful  subcutaneous  tubercles;  in  the  rectum  and  naso-pharynx,  forming 
fibrous  polypi.  Hard  fibromata  are  also  found  in  the  testis  or  may  sprin<r  from 
the  sheaths  of  tendons.  The  softer  forms  originate  chiefly  from  the  intermus- 
cular septa  or  the  subcutaneous  and  submucous  tissues,  and  are  oftenest  found 
in  the  scrotum,  labia  majora,  or  scalp.  The  soft  fibroma  was  formerly  called 
fibro-cellular :  the  ordinary  nasal  polypus  is  a  typical  example  of  this  variety. 
Fibromata  attack  adults  chiefly,  but  have  been  observed  at  all  ages ;  they  are 
usually  single,  but  may  be  multiple  when  springing  from  the  nerves  (false  neu- 
romata), the  skin  (molluscum  fibrosum),  and  the  uterus.  Pure  fibromata  and 
fibro-lipomata  sometimes  form  large  renal  tumors. 

Diagnosis. — In  general  terms,  fibromata  are  ovoidal,  hard,  nodular,  or 
bosselated,  of  uniform  consistence,  of  slow  growth,  painless — cxce})t  when 
involving  nerves — movable,  those  in  the  breast  and  subcutaneous  tissues  being 
unattached  to  the  skin  or  circumjacent  tissues.  In  these  situations,  or  when 
arising  from  the  jaws  or  other  bones,  in  their  earlier  stages  it  is  difficult  to  dis- 
tinguish them  from  the  harder  sarcomata,  the  latter  being  often  encapsulated. 
The  slow  growth,  the  regular  contour,  and  the  non-involvement  of  the  overlying 
tissues  in  the  case  of  fibrous  growths  are  the  chief  points  of  distinction.  Car- 
tilaginous and  bony  tumors  present  the  same  characteristics,  but  are  much  harder 
and  more  nodular.  The  softer  fibromata  are  smooth,  globular,  elastic,  soft,  and 
painless. 

Treatment. — When  possible,  they  should  be  completely  removed,  either 
by  enucleation  with  their  capsules,  as  in  most  of  those  occurring  in  the  breast, 
the  interior  of  the  jaAv,  etc.,  or  sometimes  by  a  dissection,  which  may  be  tedious. 
Recurrence  never  takes  place  except  where  a  sarcoma — portions  of  whose  mass 
in  certain  instances  consist  largely  of  fibrous  tissue — has  been  mistaken  for  the 
benign  growth. 

2.  Fatty  Tumors,  or  Lipomata,  consist  of  adipose  tissue  identical  with 
normal  fat.  They  are  innocent,  grow  slowly,  may  reach  a  large  size,  are  usu- 
ally single,  but  occasionally  multiple,  are  almost  never  painful,  occur  chiefly 
during  adult  life,  and  do  not  recur  after  removal.  Composed  of  masses  of  fat- 
vesicles  bound  together  by  delicate  connective  tissue  in  Avhich  the  blood-vessels 
ramify,  they  are  usually  surrounded  by  a  thin  capsule  which  is  attached  by 
fibrous  septa  to  the  skin.  Fatty  tumors  may  undergo  such  secondary  changes 
as  calcification,  mucoid  softening,  inflammation  from  pressure,  and,  as  a  result 
of  this  in  some  rare  instances,  ulceration. 

Seats  of  Predilection. — On  the  shoulders,  back,  nates — possi])ly  from 
the  hyperemia  induced  by  pressure  of  the  suspenders,  from  sitting,  etc. 

Diagnosis. — A  fatty  tumor  forms  a  circumscribed,  usually  painless,  lobu- 
lated,  soft,  pseudo-fluctuant,  inelastic,  flattened  growth — if  subcutaneous,  caus- 
ing dimpling  of  the  skin  when  this  is  pinched  up,  due  to  the  passage  of  the 
fibrous  septa  from  the  skin  to  the  capsule.  It  is  best  distinguished  from 
chronic  abscess — with  which  it  may  be  confounded — by  its  dimpling  and  by 


HEREDITARY  >sy/'JIJLI6'.  193 

occurrence  during  the  secondary  period  of  symptoms — notably  gummata — 
belonging  to  the  tertiary  stage. 

The  first  indication  is  met  by  making  the  treatment  from  first  to  last  not 
only  antisyphilitic,  but  also  supjjorting  or  even  stimulating;  and  with  this 
object  in  view  especial  attention  should  be  paid  to  nutrition.  It  may  be  stated, 
axiomatically,  that  for  every  reason,  whenever  it  is  within  the  bounds  of  pos- 
sibility, the  nurse  of  a  syphilitic  child  should  be  its  mother.  To  her  it  is 
harmless ;  to  every  other  woman,  not  already  syphilized,  it  is  in  the  highest 
degree  dangerous.  If  neither  mother  nor  wet-nurse  can  be  had  to  suckle  the 
cliiid,  it  must  be  fed  by  cow's,  goat's,  or  ass's  milk  or  by  artificial  alimenta- 
tion ;  but  its  prospect  of  life  will  be  immeasurably  reduced.  In  addition  to 
careful  feeding,  a  little  tonic  treatment  should  be  employed  from  the  first,  in 
conjunction  with  the  specific  remedies,  iodide  of  iron,  cod-liver  oil,  and  prepa- 
rations of  the  phosphates  being  the  most  useful  drugs. 

The  existence  of  the  second  condition  which  exercises  a  modifving  influ- 
ence upon  treatment — the  early  appearance  of  tertiary  symptoms — is  probably 
due,  in  many  cases  at  least,  to  an  overwhelming  of  the  lymphatic  system  by 
the  new  cell-growth.  This  leads  us  to  combine  with  the  mercury  from  the 
beginning,  at  least  in  all  cases  where  bony  or  periosteal  involvement,  suppura- 
tion, or  the  existence  of  gummata  point  to  this  condition,  small  doses  of  iodide 
of  potassium  or  of  some  other  soluble  and  easily-decomposed  iodine  salt. 

The  principle  of  treatment  being  recognized,  the  routine  procedure  may  be 
thus  described :  Give  mercury  as  soon  as  the  diagnosis  of  syphilis  is  assured — 
preferably  by  inunction.  Sir  Benjamin  Brodie's  opinion,  expressed  many 
years  ago,  still  represents  that  of  the  profession  :  "  I  have  tried  different  ways 
of  treating  such  cases.  I  have  given  the  child  gray  powder  internally  and 
given  mercury  to  the  wet-nurse.  But  mercury  exhibited  to  the  child  by  the 
mouth  generally  gripes  and  purges,  seldom  doing  any  good,  and  given  to  the 
wet-nurse  it  does  not  answer  very  well,  and  certainly  is  a  very  cruel  practice. 
The  mode  in  which  I  have  treated  cases  for  some  years  past  is  this :  I  have 
spread  mercurial  ointment,  made  in  the  proportion  of  a  dram  to  an  ounce, 
over  a  flannel  roller  and  bound  it  around  the  child  once  a  day.  The  child  kicks 
about,  and,  the  cuticle  being  thin,  the  mercury  is  absorbed.*^  It  does  not  either 
gripe  or  purge,  nor  does  it  make  the  gums  sore,  but  it  cures  the  disease.  I 
have  adopted  this  practice  in  a  great  many  cases  with  signal  success.  Very- 
few  children  recover  to  whom  mercury  is  given  internally,  but  I  have  not  seen 
a  case  where  this  method  of  treatment  has  failed." 

When,  for  any  reason,  as  irritation  of  the  skin,  this  cannot  be  employed, 
probably  the  best  form  of  giving  mercury  by  the  mouth  is  in  the  following 
formula : 

I^.  Hydrarg.  cum  creta,   gr.  j— vj  ; 
Sacch.  alb.,  gr.  xij. 

M.  et  div.  in  chart.  'No.  xij. 
Sig.  One  powder  three  times  a  day,  to  be  taken  soon  after  nursing. 

Iodide  of  potassium  may  be  given  separately  in  a  syrupy  solution  in  doses 
of  a  half-grain  to  a  grain,  or,  if  there  are  any  marked  tertiary  symptoms,  even 
in  much  larger  doses,  three  or  four  times  '^daily.  The  treatment  of  course 
should  be  continued  long  after  the  disappearance  of  syphilitic  symptoms,  and 
it  would  probably  be  well  to  continue  the  mixed  treatment  intermittently  until 
after  puberty. 

The  cases  of  visceral  syphilis  in  very  young  children  are  generally  fatal. 
Those  that  recover  do  so  in  response  to  the  active  use  of  the  above  remedies. 

13 


194  AX  A^fEliI<'AN  TEXT-BOOK  OF  SriidKUY. 

Later,  the  pro^no.sis  is  more  favoralde,  tlie  treatment  the  same.  Of  course 
moist  eruptions  shouhl  be  dusted  with  some  astriii<:eiit  or  al)Sorbent  pow(k'r ; 
mucous  patches  should  be  cauterized  or  stimuhited ;  and  great  attention  shouhl 
be  paid  to  avoidance  of  sources  of  cutaneous  irritation,  by  frequent  ciian<ring 
of  diapers,  etc.,  but  the  general  methods  are  the  same  as  in  the  adult. 


CMI  AFTER     XIX. 
TUMORS. 


A  TUMOR  is  a  new  growth  or  neoplasm  which  produces  a  localized  enlarg(>- 
ment  of  a  ])art  or  an  organ,  has  no  tendency  to  spontaneous  cure,  has  no  useful 
function,  in  most  cases  tends  to  grow  during  the  Avhole  of  the  individual's  life, 
its  development  and  growth,  except  in  rare  instances,  being  uninfluenced  by 
drugs  or  by  the  greater  or  less  general  vigor  of  the  individual.  The  exceptions 
to  which  the  above  definition  does  not  apply  are — first,  such  new  growths  as 
tubercle,  lupus,  etc. ;  second,  certain  epitheliomata  and  the  withering  scirrhus  of 
the  breast,  which  do  not  produce  enlargement ;  and  third,  cysts  not  the  result 
of  new  growth.  Lymphadenoma  or  lympho-sarcoma,  a  malignant  disease  of 
the  lymphatic  glands,  in  a  few  instances  temporarily,  or  more  rarely  perma- 
nently, seems  to  have  undergone  cure  from  the  use  of  arsenite  of  sodium  given 
internally  in  increasing  doses. 

All  tumors  originate  from  the  pre-existing  tissues  (except  when  of  meta- 
static origin),  and  are  composed  of  tissue-elements  resembling  those  of  these 
tissues  either  in  their  fully-developed  or  in  their  embryonic  state.  When  limited 
to  the  tissue  in  which  it  starts,  the  tumor  merely  displaces  the  tissues,  and  is, 
almost  Avithout  exception,  constituted  of  fully-developed  cells  similar  to  the 
tissue  from  Avhich  it  started,  as  fat,  fibrous,  or  muscular  tissue:  to  this  class  of 
tumors,  which  are  generally  benign,  the  term  homologous  has  been  applied. 
When  the  new-growth  no  longer  remains  confined  to  the  tissue  in  which  it 
starts,  but  infiltrates  the  surrounding  tissues,  its  component  elements  tending 
to  be  more  embryonic  in  their  type,  it  is  usually  malignant ;  such  growths 
have  been  termed  heterologous.  Nearly  all  secondary  tumors — i.  e.  those 
forming  in  parts  distant  from  the  primary  growth,  as  in  the  lymphatics  or  the 
viscera — are  therefore  heterologous.  Both  innocent  and  malignant  growths  may 
be  multiple.  Multiple  malignant  growths  are  usually  the  result  of  lymithatic 
or  vascular  embolism,  but  cases  are  not  uncommon  where  more  than  one  primary 
focus  has  been  observed ;  thus  two  or  three  portions  of  the  lip  or  of  the  tongue 
may  be  simnltanconsly  attacked. 

Tumors  Originate  from  Many  Causes. — Some,  as  njievi,  are  con 
genital,  or  the  tendency  to  their  develo])ment  in  later  life  is  inherited.  Of 
the  causes  initiating  those  occurring  in  later  life,  the  following  are  regarded  as 
most  effective  and  uncjuestioned.  While  intlammatory  new  formations  cannot  be 
regarded  as  tumors,  there  is  little  doubt  that  injury — especially  that  following 
a  contusion  and  fractures — stands  in  fre(juent  causative  relation  to  many  new 
growths,  notably  the  sarcomata.  Anything  which  acts  chemically  or  mechan- 
ically so  as  to  maintain  a  constant  but  slight  degree  of  undue  vascularity  of  a 
part,  such  as  the  irritation  of  soot  (scrotal  cancer),  the  hot.  rough  stem  of  a 
clay  pipe  (labial  epithelioma),  a  jagged  tooth  (carcinoma  linguae),  favors  the 
development  of  a  malignant  groAvth.  Abnormal  conditions  of  parts  where  the 
epithelial  elements  are  in  excess,  as  certain  benign  growths,  such  as  warts 
(cutaneous  papillomata),   pigmented   moles,   and  leucoraa  of  the   tongue  (a 


TUMORS.  195 

chroiiir  intliiiiiiiiatorv  affeetion  iiivolviiii^  the  surface  of  that  or<:an),  predis- 
pose to  the  formation  of  malignant  growths.  Age  and  sex  predispose  to 
tumor-formation.  Tiius  carcinoma  is  a  rarity  under  thirty  years  of  age ; 
the  mammary  ghmd  of  the  female  is  inlinitely  more  liable  to  carcinoma 
than  that  of  the  male,  owing  to  their  diftering  functional  activity  ;  while,  on 
the  other  hand,  the  tesophagus,  lip,  and  tongue  in  the  male  seem  to  be  more 
liable  to  be  attacked  by  malignant  disease  than  tlie  same  organs  in  the 
female.  The  depressing  emotions  long  continued,  such  as  sorrow^  or  anxiety, 
generally  considered  as  predisposing  causes,  can  act  only,  as  does  age,  by  low- 
ering the  vitality  of  the  tissues,  inducing  as  it  were  premature  senescence  :  their 
action  is  therefore  doubtful. 

Since  malignant  growths  present  some  slight  apparent  resemblances  to 
certain  phenomena  of  the  infectious  diseases,  observers  have  of  late  years 
sought  to  ascril)e  their  origin  to  bacteria.  Still  later,  microscopic  appear- 
ances simulating  those  presented  by  certain  parasitic  protozoa  have  led 
enthusiastic  observers  to  the  belief  that  the  spheroidal  or  irregular  bodies 
found  in  and  between  the  epithelial  cells  are  in  reality  developmental  forms 
of  certain  sporozoa,  and  that  their  presence  is  not  accidental,  but  causal. 
The  arguments  in  support  of  this  view  rest  upon  the  morphological  resem- 
blances of  these  bodies  to  psorospermire  and  to  the  corpuscles  of  molluscum 
contagiosum.  The  diversity  in  size,  form,  and  staining  qualities  of  the  sup- 
posed parasites,  the  lack  of  evidence  that  these  bodies  are  either  growing  or 
developing,  and  the  failure  of  all  culture  methods,  have  caused  most  authori- 
ties to  believe  that  the  alleged  sporozoa  of  carcinoma  are  really  degeneration- 
products  of  the  epithelial  cells.  The  possibility  that  carcinoma  may  yet 
prove  to  be  of  parasitic  origin  is  not  denied,  but  certainly  no  positive  evidence 
in  support  of  this  view  has  been  adduced. 

Growth. — This  is  dependent  upon  its  structure  primarily,  and  to  a  less 
degree  upon  the  part  in  which  the  tumor  starts.  Oceter is  paribus,  the  more 
embryonal  the  structure,  the  more  rapid  the  increase  and  the  more  malignant 
the  tumor,  but  tumors  of  similar  structure  pursue  widely  differing  courses  accord- 
ing to  the  organ  in  which  they  originate.  This  is  partly  due  to  their  lymphatic 
and  vascular  connections,  partly  to  the  importance  to  life  of  the  part  involved 
or  of  neighboring  parts  which  may  become  diseased  by  contiguity,  or  mechan- 
ically rendered  partially  or  wholly  useless  ;  thus  a  small  carcinoma  of  the 
pylorus  will  terminate  life  by  starvation ;  a  tumor  of  the  larynx  will  early 
endanger  life   by  suffocation. 

Clinically,  tumors  are  divided  into  the  benign  and  the  malignant.  A 
benign  tumor  is  usually  composed  of  tissues  resembling  those  in  which  it 
originates,  and  is  circumscribed,  because  usually  encapsulated,  whence  its 
mobility  among  the  circumjacent  tissues.  Its  vascular  supply  is  small ;  hence 
generally  it  grows  slowly.  It  is  painless ;  it  never  infiltrates  surrounding  tis- 
sues, but  displaces  them ;  it  does  not  recur  when  thoroughly  removed,  does  not 
give  rise  to  enlargement  of  the  lymphatic  glands  intervening  between  it  and  the 
venous  circulation,  and  consequently  does  not  affect  distant  parts.  A  malig- 
nant tumor  usually  consists  of  tissues  widely  different  from  those  in  which  it' 
originates ;  its  growth  is  rapid,  and  therefore  often  painful ;  it  infiltrates  all 
the  surrounding  tissues,  however  resistant,  even  bone,  because  it  is  almost 
never  encapsulated ;  it  thus  early  becomes  immovable ;  the  superjacent  skin  is 
apt  to  become  adherent,  especially  when  the  breast  is  involved ;  sooner  or  later 
it  usually  infects  the  group  of  lymphatic  glands  intervening  between  it  and  the 
venous  circulation,  and  from  these  new  centres  or  directly  through  the  veins 
gives  rise  to  secondary  deposits  in  the  internal  organs. 


196  ^l^V  AMERICAN    TEXT-BOOK    OF  SUROERV. 

Diagnosis. — In  general  terms  this  must  dt'j)end  upon  the  history,  age, 
sex,  situation,  rate  of  growth,  fixity  to  the  surrounding  parts  and  overlying 
skin,  or  the  reverse,  lymphatic  or  visceral  involvement,  and  the  physical  cha- 
racters of  the  growth. 

The  Uabi'Iifi/  of  tumors  to  degenerations  resulting  from  disease  or  injury — 
since  morbid  growths  are  no  more  exempt  from  such  influences  than  iK)rmal 
tissues — shouM  he  clearly  recognized  and  constantly  kept  in  mind.  Thus  the 
vascular  supply  predisposes  to  the  occurrence  of  ulcerative  inflajnniation  in 
both  benign  and  malignant  growths.  For  instance,  an  ordinary  sessile  fatty 
tumor  (lipoma)  is  no  more  liable  to  be  attacked  by  ulceration  than  any  other 
portion  of  the  normal  fatty  tissue ;  but  when  such  tumors  become  [)endulous, 
with  narrow  pedicles,  the  blood-supply  is  often  interfered  with — especially  the 
venous  return — and  ulceration  may  occur  from  trivial  causes.  Again,  ej>ithe- 
lial  carcinomata  are  chiefly  formed  of  masses  of  cells  the  majority  of  which 
are  distant  from  any  direct  blood-supply ;  thus  they  readily  undergo  fatty  de- 
generation and  break  down  early  ;  the  overlying  skin  becomes  infected,  gives 
way,  and  ulceration  is  initiated.  This  process  is  often  so  active  that  the  major 
part  of  the  growth  ulcerates  or  sloughs  away,  while  at  the  periphery  the  disease 
extends  into  the  adjacent  tissues.  Very  rarely,  from  injury,  gangrene  of  the 
whole  growth  ensues,  resulting  in  its  total  destruction  and  the  cure  of  the 
disease.  One  most  important  class  of  malignant  neoplasms — viz.  the  sarcomata 
— are  liable  to  such  developmental  transformations  into  stnictures  resembling 
normal  tissues,  as  to  give  rise  to  errors  both  in  diagnosis  and  in  prognosis.  It 
must,  then,  never  be  forgotten  that  any  of  the  structures  normally  developed 
from  connective  tissue  may  form  either  the  bulk  of  some  of  the  most  malig- 
nant growths  or  isolated  portions  of  them :  thus  cartilage,  bone,  or  fibrous 
tissue  may  form  the  mass  of  a  malignant  growth ;  but  these  changes  into 
tissues  of  a  permanent  type  in  no  way  modify  the  malignancy  of  the  remain- 
ing tissues  of  the  embryonal  type.  Such  benign  growths  as  fibromata  may  un- 
dergo calcification:  cartilaginous  tumors  may  soften  (undergo  mucoid  change). 

Treatment. — The  only  effectual  treatment  is  removal  or  dotruction  of  the 
growth.  Benign  growths  should  be  removed  if  much  inconvenience  or  deformity 
is  present,  or  if  disturbance  of  health  or  danger  to  life — present  or  prospective 
— is  undoubted.  It  is  needless  to  say  that  all  malignant  growths  should  be 
promptly  removed,  including,  when  possible,  the  whole  of  the  organ  attacked 
and  the  neighboring  lymphatics  and  glands,  as  the  entire  breast  with  the  axil- 
lary contents  in  cancer  of  that  organ  ;  the  whole  tiljia  by  amputation  in  sarcoma 
of  that  bone.  Special  therapeutic  indications  will  be  considered  when  treating 
of  each  particular  class  of  growths. 

Clas.sificatiox  of  Tumors. — Tumors  are  best  classed  according  to  their 
supposed  origin  and  their  histological  structure;  thus — 

I.  Mesohlastic  or  Connective- Tissue  Tumors. 

A.  Those  conforming  to  the  types  of  fully-formed  connective  tissues : 

1.  Fibrous  Tumors  (Fibroma,  plural  Fibromata) ; 

2.  Fatty  Tumors  (Lipomata) ; 

3.  Cartilaginous  Tumors  (Chondromata)  ; 

4.  Osseous  Tumors  (Osteomata) ; 

5.  Mucous  Tumors  (Myxomata). 

B.  Those  conforming  to  the  types  of  the  higher  connective  tissues : 

1.  Muscular  Tumors  (Myomata) ; 

2.  Vascular  or  Erectile  Tumors  (Angeiomata) ; 

3.  Lymphatic  (vessel)  Tumors  (Lymphangeiomata); 

4.  Nerve  Tumors  (Neuromata). 


TUMORS, 


107 


C.  Those  confunniiiji:  to  the  type  of  embryonic  connective  tissue: 

1.  Round-celled  Sarcomata ; 

2.  Spindle-celled  Sarcomata; 

3.  Myeloid  Sarcomata. 

D.  Tumors  intermediate  between  the  sarcomata  and  the  carcinomata  : 

The  Endotheliomata. 

II.  Epihlastic  and  Jiypohlastic  Tumors — /.  e.  those  conforming  to  the  type 

of  Epithelial  Tissues  : 

A.  Warty  or  Villous  Tumors  (Papillomata). 

B.  Glandular  Tumors  (Adenomata). 

C.  The  Acinous  or  Spheroidal-celled  Carcinomata: 

1.  Hard  Spheroidal-celled  (Scirrhous,  or  Chronic  Carcinomata) ; 

2.  Soft  Spheroidal-celled  (Encephaloid  or  Acute  Carcinomata) ; 

3.  Colloid  Carcinomata. 

D.  Epithelial  carcinomata : 

1.  Squamous-celled  Epitheliomata ; 

2.  Cylindrical-  or  Columnar-celled  Epitheliomata. 

III.  Tumors  composed  of  Epiblastic,  Hypohlastic,  and  Mesohlastic  Ele- 

tnents : 
Teratomata,  tumors  containing  bone,  hair,  teeth,  etc.,  situated  in 
the  ovaries  or  testicles. 


I.  Mesoblastic  or  Connective-Tissue  Tumors. 

A.  Tumors  conforming  to  the  types  of  fully-formed  connective 
tissues : 

1.  Fibrous  Tumors,  or  Fibromata  (Fig.  28). — Consisting  of  fibrous 
tissue,  they  may  be  as  dense  and  firm  as  a  tendon  or  as  soft  as  the  subcutaneous 
areolar  tissue.  They  commonly  possess  a  distinct  capsule ;  when  completely 
removed  they  neither  recur  locally  nor  become  generalized,  and  consequently 
are  absolutely  innocent  tumors.     They 

rarely  consist  solely  of  pure  white  fi-  Ft«.  28. 

brous  tissue,  but  the  firmer  varieties  are 
composed  of  a  dense  mass  of  interlacing 
bundles  of  this  tissue,  intermingled  with 
a  few  yellow  elastic  fibers  and  connect- 
ive-tissue corpuscles.  The  bundles 
may  form  concentric  circles  around  the 
blood-vessels  in  some  fibromata,  but 
usually  they  present  no  definite  arrange- 
ment. On  section  they  are  smooth, 
glistening,  firm,  and  of  a  grayish-white 
color.  Usually  the  blood-supply  is 
scanty,  the  vessels  being  small  and  thin- 
walled,  but  some  naso-pharyngeal  polypi 
are  excessivel}'  vascular,  being  trav- 
ersed by  large  cavernous  blood-spaces. 
The  softer  varieties  consist  of  a  more 
or  less  loose,  succulent,  fibrous  tissue 
permeated  with  numerous  large  blood- 
vessels, and  according  to  the  propor- 
tions of  the  difi'erent  forms  of  fibrous  tissue  w^hich  enter  into  their  composition 
they  will  appear  more  or  less  yellowish,  glistening,  semi-transparent,  or  gelatin- 


Fibro-cystic  Tumor  of  Parotid  Region  (original). 


198  AN  AMERICAN    TEXT-BOOK   OF  SURGERY. 

ous  ;  a  serous  fluid  can  be  expressed  from  their  cut  surfaces.  When  super- 
ficial  they  often  become  peduncuhited. 

Fibrous  tumors  are  prone  to  undergo  certain  secondary  degenerative  changes 
— viz.  calcifieation.  mucoid  change,  and  ulceration. 

Seats  of  Predilection. — Fibromata  may  occur  wherever  fibrous  tissue  is 
found  in  any  of  its  forms,  but  the  commonest  seats  are  the  periosteum,  espe- 
cially that  of  the  jaws,  for  the  harder  forms,  when  the  tumor  is  called  a  fibrous 
epulis;  in  the  uterus;  in  the  neurilemma  of  nerves — then  miscallod  neuroma 
(false  neuroma)  ;  in  the  subcutaneous  tissue  on  terminal  nerve-filaments,  termed 
painful  subcutaneous  tubercles ;  in  the  rectum  and  naso-pharynx,  forming 
fibrous  polypi.  Hard  fibromata  are  also  found  in  the  testis  or  may  spring  from 
the  sheaths  of  tendons.  The  softer  forms  originate  chiefly  from  the  intermus- 
cular septa  or  the  subcutaneous  and  submucous  tissues,  and  are  oftenest  found 
in  the  scrotum,  labia  majora,  or  scalp.  The  soft  fibroma  Avas  formerly  called 
fibro-cellular :  the  ordinary  nasal  polypus  is  a  typical  example  of  this  variety. 
Fibromata  attack  adults  chiefly,  but  have  been  observed  at  all  ages ;  they  are 
usually  single,  but  may  be  multiple  when  springing  from  the  nerves  (false  neu- 
romata), the  skin  (molluscum  fibrosum),  and  the  uterus.  Pure  fibromata  and 
fibro-lipomata  sometimes  form  large  renal  tumors. 

Diagnosis. — In  general  terms,  fibromata  are  ovoidal,  hard,  nodular,  or 
bosselated,  of  uniform  consistence,  of  sIoav  growth,  painless — except  Avhen 
involving  nerves — movable,  those  in  the  breast  and  subcutaneous  tissues  being 
unattached  to  the  skin  or  circumjacent  tissues.  In  these  situations,  or  when 
arising  from  the  jaws  or  other  bones,  in  their  earlier  stages  it  is  difficult  to  dis- 
tinguish them  from  the  harder  sarcomata,  the  latter  being  often  encapsulated. 
The  slow  growth,  the  regular  contour,  and  the  non-involvement  of  the  overlying 
tissues  in  the  case  of  fibrous  growths  are  the  chief  points  of  distinction.  Car- 
tilaginous and  bony  tumors  present  the  same  characteristics,  but  are  much  harder 
and  more  nodular.  The  softer  fibromata  are  smooth,  globular,  elastic,  soft,  and 
painless. 

Treatment, — When  possible,  they  should  be  completely  removed,  either 
by  enucleation  Avith  their  capsules,  as  in  most  of  those  occurring  in  the  breast, 
the  interior  of  the  jaw,  etc.,  or  sometimes  by  a  dissection,  which  may  be  tedious. 
Recurrence  never  takes  place  except  where  a  sarcoma — portions  of  whose  mass 
in  certain  instances  consist  largely  of  fibrous  tissue — has  been  mistaken  for  the 
benign  growth. 

2.  Fatty  Tumors,  or  Lipomata,  consist  of  adipose  tissue  identical  with 
normal  fat.  They  are  innocent,  grow  slowly,  may  reach  a  large  size,  are  usu- 
ally single,  but  occasionally  multiple,  are  almost  never  painful,  occur  chiefly 
during  adult  life,  and  do  not  recur  after  removal.  Composed  of  masses  of  fat- 
vesicles  bound  together  by  delicate  connective  tissue  in  which  the  blood-vessels 
ramify,  they  are  usually  surrounded  by  a  thin  capsule  which  is  attached  by 
fibrous  septa  to  the  skin.  Fatty  tumors  may  undergo  such  secondary  changes 
as  calcification,  mucoid  softening,  inflammation  from  pressure,  and,  as  a  result 
of  this  in  some  rare  instances,  ulceration. 

Seats  of  Predilection. — On  the  shoulders,  back,  nates — possibly  from 
the  hyperemia  induced  by  pressure  of  the  suspenders,  from  sitting,  etc. 

Diagnosis. — A  fatty  tumor  forms  a  circumscribed,  usually  painless,  lobu- 
lated,  soft,  pseudo-fluctuant,  inelastic,  flattened  growth — if  subcutaneous,  caus- 
ing dimpling  of  the  skin  when  this  is  pinched  up,  due  to  the  passage  of  the 
fibrous  septa  from  the  skin  to  the  capsule.  It  is  best  distinguished  from 
chronic  abscess — with  which  it  may  be  confounded — by  its  dimpling  and  by 


TUMORS. 


Plate  VII. 


Enormous  chondroma  of  ilium. 


TUMORS.  199 

the  slipping  away  of  the  edge  of  the  tumor  from  beneath  the  finger  when  pressed 
luxin  :  ])os!ril)lv  the  grooved  needle  may  be  requisite.  Certain  variations  should 
be  noted.  Tlius  there  is  a  diffuse  form,  producing  symmetrical  swellings  at  the 
back  of  the  neck,  or  beneath  the  chin,  forming  so-called  "  double  neck  "  and 
"double  chin."  Again,  the  presence  of  more  fibrous  tissue  than  usual  may 
render  lipomata  unusually  firm.  They  may  be  deep-seated,  springing  from 
the  intermuscular  septa  or  even  from  the  surface  of  a  bone.  Moreover,  they 
occasionally  become  pedunculated.  Lastly,  some  of  the  most  typical  cases  of 
"painful  subcutaneous  tubercle"  are  composed  of  fat.  The  average  case  can 
be  readily  diagnosticated  from  a  cyst,  a  chronic  abscess,  or  a  bursal  enlargement 
by  the  symptoms  given  above,  while  the  deeper-seated  can  hardly  be  mistaken 
for  any  other  than  soft  fibrous  or  myxomatous  growths— an  error  of  no  practical 
moment,  since  both  should  be  removed. 

Treatment. — For  the  circumscribed  variety  a  free  incision,  opening  the 
capsule,  should  be  employed,  when  the  tumor  will  usually  shell  out ;  if  more 
adherent,  some  dissection  with  the  knife  may  be  necessary :  all  portions  of  the 
growth  must  be  removed,  since  occasionally,  although  rarely,  the  portions  left 
have  formed  the  starting-point  of  a  new  tumor.  Multiple  growths,  unless  pain- 
ful ones,  seldom  require  removal.  The  diffused  form  should  not  usually  be 
attacked  with  the  knife.  The  prolonged  internal  use  of  liquor  potassne  m 
10-minim  doses,  t.  d.,  has  in  certain  instances  caused  their  disappearance. 

3.  Cartilaginous  Tumors,  Chondromata  or  Enchondromata  (PI.  YII.), 
are  composed  of  some  variety  of  cartilage,  forming  hard,  elastic,  slowly  enlarg- 
ing crrowths,  often  nodular  or  lobulated.  They  may  consist  of  a  single  mas? 
or'' of  a  number  of  small  masses  each  enclosed  in  its  capsule,  all  bound 
toc^ether  by  connective  tissue  and  blood-vessels.  They  are  homogeneous  or 
coarsely  granular  on  section,  presenting  a  translucent,  bluish-gray  or  pinkish- 
white  surface,  sometimes  marked  out  into  irregular  lobules.  Histologically, 
they  are  usually  composed  of  hyaline-  or  fibro-cartilage.  Where  unattached 
to  bone  their  fibrous  capsule  serves  as  a  perichondrium,  and  when  exposed  to 
friction  a  bursal  sac  often  forms  between  them  and  the  superjacent  parts. 
Fatty  or  mucoid  secondary  changes  may  render  some  of  the  nodules  centrally 
diffluent,  producing  cyst-like  cavities  "containing  synovia-like  fluid,  thus  so 
completely  metamorphosing  the  tumors  that  they  sometimes  are  hardly  recog- 
nizable as  chondromata;  while,  on  the  contrary,  some  become  calcified  or  ossified. 
This  latter  change  is  especially  apt  to  affect  chondromata  springing  from  the 
juxta-epiphyseaf  region  of  the  long  bones,  the  change  progressing  so  far  that 
only  a  thin"  layer  olf  cartilage  caps  them,  forming  what  are  termed  cancel- 
lous exostoses.  Chondromata  are  apt  to  be  single,  but  they  are  often  multiple 
and  symmetrical,  as  those  attacking  the  phalanges.  While  pure  cartilaginous 
growths  are  benign,  sarcomata  are  often  partly,  or  even  chiefly,  composed  of 
cartilaf^e.  especially  those  found  in  the  testicle  and  the  parotid.  Multiple  chon- 
dromata of  the  hand,  if  of  rapid  growth,  should  be  viewed  with  suspicion  as 
possibly  cartilaginous  sarcomata.  Occurring  at  any  age,  they  are  more  com- 
mon in  the  young,  especially  those  springing  from  the  long  bones  near  the 
epiphyses.  Sometimes  the  tendency  to  their  formation  seems  to  be  inherited, 
the  tumors  being  similarly  located  in  both  parents  and  children.  While  they 
often  attain  a  large  size,'^they  grow  slowly,  so  that  unusual  bulk  with  rapid 
growth  would  justify  a  strong  suspicion  of  the  intermixture  of  sarcomatous 
elements.     Mixed  tumors  containing  cartilage  have  been  already  referred 

Seats  of  Predilection.— The  bones,  especially  on  or  in  the  phalanges  of 


200  AN   AMERICAN    TEXT- HOOK    OE  ^SUIKJERY. 

the  fingers  or  tors  ;  the  lower  jiixta-opipliysoal  region  of  the  femur  ;  tlie  upj)er 
ends  of  the  tibia,  fibuhi,  and  humerus,  the  seapuhi  and  ilium,  on  or  in  tlie  jaw.s, 
especially  the  upper;  the  salivary  glands,  notal)ly  the  parotid  :  the  testicle  ;  in  or 
arouixl  joints  attacked  by  rheuniatoiil  arthritis;  and  the  subcutaneous  tissues. 

Diagnosis. — This  must  depend  on  the  hardness  yet  elasticity  of  the  tumor, 
its  nodular  circumscribed  outlines,  and  its  slow  continuous  growth ;  later, 
on  the  development  of  softened  spots  indicative  of  cystic  degeneration,  and  on 
the  location  of  the  tinnor,  as  upon  a  young  bone  near  an  epiphysis.  A  carti- 
laginous sarcoma — the  growth  with  which  chondromata  are  most  likely  to  be 
confounded — presents  less  definite  outlines — /,  e.  infiltrates  somewhat,  is  apt 
to  be  of  unequal  consistence  from  the  outset,  and  grows  with  much  greater 
rapidity. 

Treatment. — Complete  removal  of  a  pure  chondronui  will  secure  future 
immunity,  and  should  always  be  adopted  when  possible.  Mixed  chondromata 
containing  sarcomatous  elements  commonly  recur.  In  the  ])arotid  gland  and  sub- 
cutaneous tissues  they  can  usually  be  enucleated  with  their  capsules,  and  some- 
times this  can  be  done  when  the  phalanges  are  involved,  but  more  often  in  the 
latter  event  and  when  the  testicle  is  attacked  the  whole  part  or  organ  must  be 
sacrificed  :  usually  those  springing  from  the  surfaces  of  the  larger  bones  can  be 
removed  without  sacrificing  the  bone,  with  but  small  chance  of  their  recurrence. 

4.  Osseous  Tumors,  or  Osteomata,  are  formed  of  true  bone,  and  are  gene- 
rally composed  almost  solely  of  either  cancellous  or  compact  bone.  The  can- 
cellous have  been  just  described  as  resulting  from  the  ossification  of  chondro- 
matous  growths  springing  from  the  juxta-epiphyseal  portions  of  such  long 
bones  as  the  tibia,  femur,  humerus,  fibula,  etc.,  Avhere  they  form  exostoses. 
The  ungual  surface  of  the  distal  phalanx  of  the  great  toe  is  often  the  site  of 
such  a  tumor,  producing  a  subungual  growth.  The  compact  osseous  tumors 
rarely  grow  from  any  other  bones  than  those  of  the  cranium.  Certain  exostoses, 
called  from  their  hardness  "  ivory  exostoses,"  are  said  to  differ  from  other  bony 
growths  by  the  absence  of  Haversian  canals,  and  are  composed  of  "  layers  of 
bone  lamelh>2  laid  concentrically  over  a  central  point  or  pedicle,"  They  rarely 
attain  a  greater  size  than  that  of  a  small  walnut,  are  so  dense  that  they  can 
hardly  be  cut  by  any  instrument,  and  it  is  difiicult  by  the  exercise  of  great 
force  to  fracture  their  pedicles,  even  when  comparatively  slender.  The  ivory 
exostosis  sprintrs  from  the  exterior  of  one  of  the  cranial  bones,  while  the  more 
ordinary  forms  of  compact  osteomata  origniate  m  the  cranial  or  nasal  smuses, 
grow  slowly,  and  thrust  aside  or  cause  absorption  of  adjacent  structures,  thus  pro- 
ducing marked  deformities.  Although  usually  single,  osseous  tumors  in  some 
patients  may  be  multiple,  being  found  by  the  score,  in  such  cases  commonly 
commencing  at  a  very  early  age,  being  then  hereditary  and  often  symmetrical. 

Seats  of  Predilection. — These  have  been  mentioned  above  in  describ- 
ing these  growths. 

Diagnosis. — This  is  usually  easy,  depending  on  the  evident  connection  of 
the  tumor  with  bone  or  cartilage,  for  tumors  growing  apart  from  these  struc- 
tures in  the  connective  tissue  are  probably  tumors  of  some  other  class  which 
have  undergone  osseous  change,  or  are  structures,  such  as  tendons,  muscles,  etc., 
which  have  undergone  calcification  or  ossification.  The  jjcdunculated  form 
when  the  osteoma  occurs  as  an  exostosis,  the  dense,  hard,  irregularly  nodulated 
surface  when  the  tumor  is  non-pedunculated,  and  its  slow  growth,  serve  as  dis- 
tinguishing points.  The  more  rapid  growth  and  une((ual  consistence  of  the 
calcifying  or  ossif^nng  sarcomata  serve  to  distinguish  this  variety  of  malignant 
growth  from  the  benign  osseous  tumors. 


TUMORS.  2r)l 

Treatment. — Altliough  operation  alone  can  remove  these  growths,  not 
every  one  shoiihl  l)e  nK'thlled  witli,  l)ut  only  those  should  be  attacked  which 
are  steadily  growino;  and  are  painful  or  produce  great  deformity  or  loss  of 
function,  and  the  proposed  o})eration  on  -which  will  not  unduly  risk  the  life  of 
the  patient.  Thus,  most  of  the  exostoses  of  the  flat  and  long  hones  and  certain 
osteomata  of  the  upper  and  lower  jaAvs  should  be  removed,  for  valid  reasons, 
such  as  those  just  given.  Those  of  the  facial  and  cranial  bones,  which  are 
ill  defined  and  often  extend  so  deeply  as  to  involve  the  base  of  the  skull, 
should  not  be  touched.  It  was  formerly  taught  that  it  was  inadvisable  to  c.t- 
tempt  the  removal  of  non-pedunculated,  sessile  exostoses  of  the  long  bones, 
which  are  usually  covered  by  thick  masses  of  muscle,  because  of  the  risk  of 
profuse  and  deep-seated  suppuration  ;  but  with  modern  methods  of  operating 
such  complications  ought  to  be  avoided,  so  that  if  good  reasons  exist  for  their 
removal  such  tumors  should  be  subjected  to  operation. 

With  the  exception  of  the  cancellous  exostosis  of  the  ungual  phalanx  of 
the  great  toe,  a  pure  osteoma  when  removed  does  not  return,  even  Avhen 
some  of  the  surface  from  which  it  has  sjirung  is  allowed  to  remain.  An  ossi 
fying  sarcoma,  for  which  osteoma  has  sometimes  been  mistaken,  will  of  course 
return.  In  the  exceptional  case  mentioned  the  distal  portion  of  the  pha- 
lanx should  be  removed  with  the  tumor  to  obviate  any  risk  of  recur- 
rence. 

5.  Mucous  Tumors,  or  Myxomata,  resemble  both  to  the  naked  eye  and 
to  the  microscope  the  Whartonian  jelly  of  the  umbilical  cord  and  the  vitreous 
humor  of  the  eye.  They  grow  slowly,  and  may  attain  a  large  size,  but  are  in- 
nocent tumors,  not  returning  when  pure  and  if  completely  removed.  Sarcomata 
may  undergo  an  analogous  change — i.  e.  mucous  softening — and  of  course  such 
tumors  are  apt  to  recur.  Mucoid  softening  also  attacks  fibromata,  chondro- 
mata,  and  other  connective-tissue  tumors,  so  that  many  tumors  called  myxo- 
mata are  chondromata,  fibromata,  or  sarcomata  undergoing  mucoid  (myxo- 
matous) change. 

Structurally,  a  true  myxoma  is  soft,  gelatinous,  semi-translucent,  encapsu- 
lated, and  intersected  by  septa  of  fibrous  tissue.  Their  cut  surfaces  are  pinkish- 
or  vellowish-gray,  and  exude  large  quantities  of  glairy  fluid  containing  much 
mucin.  Microscopically,  they  are  seen  to  be  composed  of  numerous  anasto- 
mosing stellate  cells,  with  branching  processes  which  form  a  delicate  stroma 
in  which  the  gelatinous  basis-substance  is  contained :  some  round  and  spin- 
dle cells  are  also  found.  Inflammation,  fatty  degeneration,  ulceration,  and 
the  formation  of  blood-cysts  from  rupture  of  capillary  vessels  are  the  secondary- 
changes  to  which  these  tumors  are  liable. 

Seats  of  Predilection. — The  nasal  cavities,  in  which  they  form  gelatin- 
ous polypi ;  the  mammary  gland  ;  the  intermuscular  spaces  ;  the  submucous  and 
subserous  tissues ;  more  rarely  the  periosteum,  the  bone  medulla,  and  sheath? 
of  nerves. 

Diagnosis. — Before  removal  their  close  physical  resemblance  to  fatty  and 
fibro-cellular  tumors  renders  certainty  impossible,  since  they  present  the  same 
soft,  elastic  feel,  and  may  even  seem  to  fluctuate,  thus  simulating  a  chronic 
abscess :  in  such  cases  the  hypodermatic  needle  would  settle  the  diagnosis. 

Treatment. — This  should  be  removal  when  practicable.  This  is  usually 
readily  eff'ected,  the  growth  shelling  out  of  its  capsule ;  but  careful  dissection  is 
required  when  they  spring  from  large  nerves,  since  these  not  uncommonly  pass 
through  the  center  of  the  tumor,  so  that  sections  of  the  nerve  have  been 
accidentally  removed  when  excising  such  growths. 


202  AN  AMERICAN  TEXT- HOOK  OF  sriidERY. 

B.  Tumors  conforming  to  the  types  of  the  higher  connective 
tissues : 

1.  Muscular  Tumors,  or  Myomata. — Only  tliose  of  conjrcnital  oriiiin 
seeiu  to  be  composed  of  striated  innsele-eleineiits  (/•/i((b<h)-)/ii/<>)ii<i),  hut  even  in 
sueli  tumors  tlie  bulk  of  the  neoplasm  is  not  usually  composed  of  muscle-cells. 

New  "ijrowtlis  made  up  in  part  of  smooth,  iiott-xtriated  muscle-cells  {Jeio- 
myoma)  fre(iuently  occur  in  the  uterus,  forminj;  such  considerable  portions  of 
most  fibromata  of  that  organ  as  to  induce  many  writers  to  term  then)  myomata 
of  the  uterus.  In  like  manner  most  enlarged  prostates  are  composed  in  great 
part  of  unstriped  muscle.  Prostatic  enlargements  are  more  apt  to  be  due  to 
fibro-myomatous  growths  involving  the  whole  organ  or  an  entire  lobe,  altiiough 
distinct  pedunculated  growths  are  not  uncommonly  found;  while  those  of 
the  uterus,  often  very  large,  consist  usually  of  an  aggregation  of  separate 
tumors.  Uterine  fibromata  also  often  assume  the  polypoid  form,  from  the 
extrusive  efforts  of  the  organ  excited  by  the  presence  of  the  growth.  Situated 
elsewhere,  myomata  rarely  attain  a  great  bulk.  Wherever  situated,  they  grow 
slowly  and  are  quite  innocent,  although  from  their  size  or  position  they  often 
cause  the  utmost  inconvenience  or  even  danger  to  life.  They  are  firm,  some- 
times smooth,  but  more  often  nodular,  their  cut  surfaces  closely  resembling 
those  of  a  fibrous  tumor,  owing  to  the  presence  of  varying  quantities  of  true 
fibrous  tissue ;  glandular  structures  form  part  of  prostatic  tumors. 

Diagnosis. — As  they  are  at  the  outset  so  situated  as  to  be  inaccessible  to 
sight  or  touch,  the  reader  is  referred  to  the  sections  on  Diseases  of  the  Prostate 
and  the  Uterus.  When  the  oesophagus,  stomach,  or  intestines  have  been  the 
parts  aff'ected,  the  nature  of  the  tumors  has  rarely  been  diagnosticated. 

Treatment. — When  accessible,  they  should  be  removed.  Not  seldom  this 
may  require  total  hysterectomy. 

2.  Vascular  or  Erectile  Tumors,  or  Angeiomata. — Under  this  head 
are  classed  all  neoplasms  the  chief  constituents  of  which  are  blood-vessels, 
either  arteries,  veins,  or  capillaries,  or  in  which  tlie  blood  is  contained  in  cav- 
ernous spaces  not  true  vessels.  Many  sarcomata,  and  some  fibromata  and  car- 
cinomata,  are  permeated  Avith  enormous  (quantities  of  blood-vessels  or  channels 
of  large  caliber,  but  the  essential  element  composing  each  tumor  is  not  the 
vascular  tissue,  but  the  sarcomatous,  fibrous,  or  carcinomatous  element. 

3.  Both  Angeiomata  and  Lymphangeiomata  will  be  more  thoroughly  dis- 
cussed in  the  chapters  on  Diseases  of  the  Blood-vessels  and  Lym])hatics,  Avhere 
their  treatment  by  excision,  cauterization,  ligature,  or  electrolysis  is  described. 

4.  Nerve  Tumors,  or  Neuromata. — Such  growths  are  of  rare  occurrence, 
whether  composed  of  medullated  or  of  non-medullated  nerve-fibres.  To  a  void  repe- 
tition, the  student  is  referred  to  the  section  on  Injuries  and  Diseases  of  the  Nerves. 

C.  Tumors  conforming  to  the  type  of  embryonic  connective 
tissue. 

These  neoplasms,  called  Sarcomata  (PI.  VIII  and  Fig.  26),  closely  imi- 
tate in  their  structure  normal  embryonic  or  immature  connective  tissue, 
and  to  this  class  belong  the  fibro-nucleated,  fibro-plastic,  myeloid,  recur- 
rent fibroid,  and  many  of  the  encephaloid  cancers  of  the  older  authors. 
While  normal  embryonic  connective  tissue  goes  on  to  the  formation  of 
fibrous  tissue,  cartilage,  bone,  and  so  on,  the  sarcomata  always  retain  the 
embryonic  character  at  their  circumference — /.  e.  their  growing,  advancing 


TUMORS. 


Plate  VIII. 


Enormous  sarcoma  of  buttock. 


rrMORS. 


m.\ 


border,  and  therefore  their  youn^^est  and  least  mature  part— even  in  cases 
in  which  the  okler  portions  may  have  developed  almost  normally  into  fibrous 
tissue,  cartilage,  or  bone.  Therefore  any  rapidly-growing  tumor  of  the  connec- 
tive-tissue tvjie  must  have  its  periphery  especially  subjected  to  careful  micro- 
scopic examination  to  determine  whether  sarcomatous  elements  exist  there.  Wlnle 
the  sarcomata  vary  much  in  their  structure  and  clinical  course,  they  all  present  the 
following  characteristics.  The  component  cells  contain  one  or  more  nuclei,  the 
masses  of  protoplasm  of  which  they  are  formed  not  being  surrounded  by  any  dis- 
tinct cell-wall,  and  the  cell-bodv  is  large  as  compared  with  the  nucleus.  The  cells 
are  "  in  constant  relation  with"  the  stroma"— z.  e.  the  intercellular  cement,  that 
which  corresponds  to  stroma,  surrounds  each  cell,  varies  in  amount,  and  has  no 
definite  arrangement,  no  alveoli  being  formed  as  in  carcinoma.  The  blood-vessels 
ramify  among  the  cells,  not,  as  in  the  carcinomata,  running  in  the  stroma,  because 
of  the  absence  of  any  such  structure,  and  are  very  thin-walled.    Indeed,  they  often 

Fig.  29. 


Sarcoma  of  the  Arm  (Keenj. 

appear  to  be  nothing  more  than  mere  spaces  bounded  by  the  cells  of  the  growth 
themselves.  A  consideration  of  these  peculiarities  of  structure  and  of  the  dis- 
tribution of  the  blood-supply  readily  explains  the  frequent  occurrence  of  hemor- 
rhage into  the  substance  of  sarcomata.  The  fact  that  dissemination  takes  place 
almost  invariably  by  the  blood-vessels,  and  not  by  the  lymphatics,  as  is  the  case 
with  carcinomata,  is  also  explainable  by  the  peculiar  relation  of  the  vessels  and 
cells.  Again,  for  the  same  reasons,  the  lungs,  being  the  organs  first  reached  by 
the  blood  after  fragments  of  the  growth  have  been  swept  away  by  the  current, 
are  the  organs  most  often  the  seat  of  secondary  deposits.  The  metastatic  deposits 
are  usually  similar  in  structure  to  the  primary  growth.  Since  sarcomata  grow 
by  infiltrating  the  surrounding  tissues,  they  are  exceedingly  apt  to  recur  locally, 
doubtless  because  some  infiltrated  tissue  has  been  left.  Secondary  lymphatic 
glandular  involvement,  except  when  the  tonsil  or  testis  is  implicated,  is  the  rare 


204  AN  AMERICAN   TEXT-IK )()K    OF  SURGERY. 

exception — as  is  alleged,  because  of  the  absence  of  lymphatic  vessels  in  mo.st 
sarcomata:  if  tlii'  organs  just  mentionod  are  attacked,  glandular  involvtMucnt 
is  the  rule.  Their  growth  is  not  slow  and  steady  as  in  the  carcinomata,  but 
spasmodic,  now  fast,  now  slow.  While  carcinoma  attacks  old  or  senescent 
tissues,  sarcoma  most  frequently  occurs  in  organs  or  tissues  which  are  develop- 
ing, are  in  active  function,  or  are  at  least  in  their  prime ;  hence  it  is  a  disease 
of  youth  or  early  middle  life.  Another  point  in  which  it  differs  from  carci- 
noma is  that  scraping  a  freshly-cut  section  docs  not  yield  a  milky  juice  like 
that  obtainal)le  from  the  latter  form  of  malignant  growth.  Not  infrequently 
sarcomata  result  from  an  injury,  such  as  a  blow  or  a  fracture. 

So  closely  does  one  of  tlie  varieties  of  sarcoma — the  round-celled — resemble 
ordinary  granulation-tissue  that  they  cannot  be  distinguished  from  each  other 
microscopically.  They  both  consist  of  small  round  cells  similar  to  the 
white  cells  of  the  blood,  separated  from  one  another  by  a  very  small  amount 
of  homogeneous  intercellular  material  permeated  by  delicate  capillary  vessels 
arranged  in  the  form  of  loops.  The  sarcomata  exhibit  nearly  every  step  in 
the  development  of  the  connective  tissues,  from  this  round-celled,  immature 
tissue  to  bone.  Thus,  the  cells  become  elongated  and  spindle-shaped,  while  the 
intercellular  substance  may  show  an  attempt  at  fibrillation  ;  or  further  develop- 
mental changes  may  ensue,  converting  the  major  part  of  the  growth  in  some 
instances  almost  Avholly  into  fibrous  tissue,  cartilage,  or  even  bone,  although, 
as  has  been  already  said,  sarcomatous  elements  are  always  discoverable  at  the 
growing  margins,  while  its  malignancy,  as  shown  by  invasion  of  the  surround- 
ing tissues  and  dissemination  throughout  the  internal  organs,  is  in  no  way  less- 
ened. Calcification  is  often  mistaken  for  true  ossification,  which  is  seldom  met 
with  except  in  bone  sarcomata,  and  while  it  is  true  that  bone  may  form  part  of 
any  variety  of  sarcoma,  yet  it  is  most  common  in  the  spindle-celled  and  the  mixed 
forms.  Where  the  new  bony  spicule,  in  any  tumor  connected  with  a  long 
bone,  grow  at  ri^ht  andes  to  the  shaft  of  that  bone,  thev  will  usually  be  found 
to  be  surrounded  by  some  soft  tissues,  which  upon  microscopic  examination  will 
prove  to  be  of  a  sarcomatous  nature :  this  arrangement  of  the  bony  spiculne  is 
the  exact  reverse  of  that  commonly  prevailing  in  the  structure  of  true  osteo- 
mata.  where  they  pursue  a  course  parallel  to  the  long  axis  of  the  bone  and  are 
surrounded  by  cartilage  or  periosteum. 

Sarcomata  may  be  grouped  in  three  main  classes — viz.  the  round-celled,  the 
spindle-celled,  and  the  myeloid  or  giant-celled. 

1.  The  Round-celled  Sarcomata  usually  form  soft,  vascular,  and  very 
rapidly  growing  tumors,  often  becoming  very  large,  and  early  giving  rise  to 
metastatic  deposits  in  distant  parts  and  in  the  viscera.  Microscopically,  tliey 
consist  of  round  cells  of  varying  size  closely  resembling  leucocytes,  imbedded 
in  a  small  amount  of  granular  or  homogeneous  intercellular  basis-substance.  On 
section  they  so  much  resemble  brain-matter  in  consistence  and  vascularity  that 
the  old  terms  encephaloid  and  medullary  seem  not  inappropriate.  Many  of  those 
tumors  formerly  called  encephaloid  cancer  or  fungus  ha^matodes  were  really 
round-celled  sarcomata.  A  variety  of  round-celled  sarcoma,  where  the  cells 
lie  within  a  stroma  formed  of  delicate  meshes  closely  resembling  that  of 
lymphatic  tissue,  is  often  described  as  lymplio-sarcoma.  Such  tumors  must 
be  distinguished  from  irritative  enlargements  of  lymph-glands  and  the 
adenoid  hyperplasias  of  leukemia  and  Ilodgkin's  disease.  It  has  been 
thought  to  have  been  palliated,  or  even  to  be  curable  in  rare  instances,  by  the 
internal  use  of  arsenic.  ^lucoid  softening,  fatty  degeneration,  and  ulcera- 
tion are  common  secondary  changes,  together  w  ith  the  extravasation  of  blood 


TUMORS.  2().> 

into  their  substance,  resnltinc;  in  tlie  formation  of  cysts  (sarcomatous  blood- 
cysts). 

Seats  of  Predilection. — They  attack  most  freiiuently  the  periosteum, 
bone,  lymphatic  <,'lantls,  subcutaneous  tissue,  testicle,  eye,  ovary,  uterus,  lungs, 
kidneys,  and  more  rarely  the  skin,  although  they  may  originate  wherever 
fibrous  tissue  exists. 

Sub- varieties.  —  {a)  The  glioma  grows  from  the  connective  tissue  (neu- 
roglia) of  nerve-eenters,  and  its  basis-substance  resembles  that  structure ;  the 
cells  are  apt  to  be  small.  It  occurs  in  the  retina  and  brain.  According  to  the 
latest  investigations,  as  the  neuroglia  develops  from  the  epiblast.  gliomata  can- 
not properly  be  considered  sarcomata,  but  form  a  special  group  by  themselves. 
{b)  The  lymphosarcoma,  growing  in  lymphatic  glands,  is  composed  of  cells 
usually  of  large  size,  lying  in  a  reticulum  resembling  lymphoid  tissue,  (c)  The 
psammoma  or  nest-celled  sarcoma  is  of  rare  occurrence,  attacking  only  the 
pineal  gland,  (d)  The  alveolar  sarcoma  is  so  called  because  the  basis-sub- 
stance encloses  each  cell  in  a  separate  space  or  alveolus,  (e)  In  the  melanotic 
sarcoma  both  the  cells  and  the  intercellular  basis-substance  are  pigmented.  Both 
the  alveolar  and  the  melanotic  form  may  be  of  the  spindle-celled  variety.  The 
melanotic  form  is  found  as  a  primary  growth  only  in  parts  normally  contain- 
ing pigment,  as  the  skin  and  the  choroid  coat  of  the  eye,  becomes  rapidly  dis- 
seminated— the  secondary  growths  being  usually  also  pigmented — is  probably 
the  most  malignant  of  the  sarcomata,  and  by  the  older  writers  was  called 
melanotic  cancer  or  melanosis.  Warts  are  sometimes  pigmented,  and  thus  look 
like  this  form  of  sarcoma,  but  warts  are  firm,  often  pedunculated  or  lobulated, 
and  of  slow  growth :  in  rare  instances  pigmented  w^arts  undergo  epitheliomatous 
change,  when  their  rapid  growth  excites  the  suspicion  that  they  are  pigmented 
sarcomata,  but  in  the  epithelial  grow^ths  the  glands  early  become  implicated. 

2.  The  Spindle-celled  Sarcomata  are  formed  of  cells  varying  much 
in  size,  some  tumors  being  composed  of  very  small  oat-shaped  cells,  others  of 
greatly  elongated  bodies  with  long,  fine,  tapering  extremities.  Often  the  cells 
are  arranged  in  the  form  of  trabeculse,  w^hich  so  closely  imitate  fibrous  bands 
that  the  tumor  may  be  diagnosticated  as  a  fibrous  or  even  a  muscular  growth. 

The  sub-varieties  are  the  melajiotic,  ^nst  mentioned,  and  the  small-celled 
and  large-celled.  AVhen  portions  of  these  tumors  have  undergone  developmental 
changes  they  are  sometimes  called  chondro-sarcoma,  osteo-sarcoma,  etc. 

Seats  of  Predilection. — The  skin  and  subcutaneous  tissue,  the  fasciae 
and  intermuscular  septa,  the  periosteum  and  the  interior  of  bones,  the  eye,  the 
antrum,  the  breast,  and  the  testicle. 

Sarcomata  consisting  of  an  admixture  in  varying  proportions  of  round 
and  spindle  cells,  or  of  cells  of  many  diff'erent  forms  and  sizes,  are  sometimes 
called  mixed-celled  sarcomata.  To  the  naked  eye  they  present  the  same  cha- 
racteristics as  the  round-  and  spindle-celled  forms,  and  they  may  undergo  the 
same  developmental  and  degenerative  changes. 

Seats  of  Predilection. — Chiefly  the  bones. 

3.  The  Myeloid  or  Giant-celled  Sarcomata  consist  chiefly  of  large 
elements  formed  of  masses  of  protoplasm,  containing  two  or  more  nuclei — up  to 
twenty,  or  even  fifty — with  a  varying  number  of  round,  spindle,  or  mixed  cells. 
They  usually  spring  from  the  interior,  cancellous  tissue  of  bones,  and  vary  in 
consistence  from  that  of  jelly  to  almost  that  of  muscle.  A  section  appears 
smooth,  shining,  succulent,  but  presents  no  appearance  of  fibrillation,  and  is 
of  a  greenish  or  of  a  livid  red  or  maroon  color,  varied  by  pink  or  darker  red 


206  .i.v  AMi.incAX  Ti:xr-i'.<K)h'  or  srnar.m'. 

spots,  duo  to  oxtraviisatioiis  of"  hldod.  Tlicy  have  Ix'cii  coiiiijarr'd  in  color  to 
the  inusculiir  tissue;  of  tlio  heart. 

Seats  of  Predilection. — Tlie  lower  jaw,  the  lower  end  (»f  the  femur, 
and  the  he.id  of  the  tihia  ;   altlujugh  thoy  may  occur  el.'sewhere. 

The  courses  pursued  by  the  several  forms  of  sarcomata  are  partly  depend- 
ent upon  their  structure,  ]>artly  ujx)!!  the  organ  or  tissue  which  they  attack. 
For  exanii)le,  the  connuonest  form  attacking  the  mamma,  the  spindle-celled, 
occurs  most  frequently  between  thirty  and  forty  years  of  age,  is  at  first 
encapsulated — therefore  freely  movable — hard  and  nodular,  grows  with  great 
raj)idity,  and  sooner  or  later,  from  softening  or  the  development  of  cysts,  is 
apt  to  ])resent  points  of  une(iual  consistence,  some  of  the  conse((uent  bosses 
actually  feeling  fluctuant.  The  tumor  remains  for  a  considerable  time  isolable 
from  the  mammary  gland  ])roper,  thrusting  this  to  one  side.  The  skin 
does  not  usually  become  adherent,  even  when  intracystic  growths  fungate, 
after  having  caused  ulceration ;  although,  if  the  tumor  is  left  to  pursue  its 
natural  course,  in  time  not  only  the  skin  but  also  the  subjacent  parts  will  be 
infiltrated,  and  death  will  ensue  from  sloughing  or  involvement  of  the  lungs, 
liver,  or  other  viscera ;  the  axillary  glands  remain  uninvolved. 

Examine  the  other  extreme  as  exemplified  by  the  course  pursued  by  a 
giant-celled  sarcoma,  usually  occurring  in  an  adult  over  forty  years  of  age,  and 
attacking  the  body  of  the  lower  jaw,  slowly  expanding  the  bone  into  a  smooth 
tumor,  involving  both  its  inner  and  its  outer  surface,  the  bony  walls  of  which 
are  often  so  thin  as  to  crackle  under  pressure,  yet  growing  so  slowly  that 
years  may  elapse  before  it  attains  the  bulk  of  a  Avalnut ;  the  growth  does  not 
become  adherent  to  the  surrounding  tissues,  and  consequently  rarely  ulcerates; 
involvement  of  the  lymphatic  glands  seldom  occurs. 

From  the  preceding  remarks  it  Avill  be  seen  hoAv  difficult  the  diagnosis  of 
sarcoma  often  is,  varying  as  the  symptoms  do  with  the  organ  attacked.  Occur- 
ring at  all  ages,  sarcoma  is  more  apt  to  attack  the  young — i.  e.  the  tissues 
during  the  developmental  period.  Although  it  is  the  rule  for  sarcomata  to 
grow  rapidly,  especially  the  secondary  growths,  yet  some  of  the  primary  ones 
develop  slowly,  the  rate  of  growth  and  bulk  attained  depending  largely  upon 
the  tissue  attacked.  Those  of  the  eye  or  brain  are  apt  to  be  small,  while  those 
of  bone  often  reach  a  huge  size.  While  those  which  attack  the  subcutaneous 
tissue,  the  fascite,  an<l  the  intermuscular  ])lanes  are  usually  surrounded  with 
a  capsule,  there  is  none  for  those  springing  from  the  surfaces  of  bones,  nor  for 
those  arising  in  the  interior  of  such  organs  as  the  lymphatic  glands,  the  tonsil, 
etc.,  which  are  soon  entirely  infiltrated  by  the  growth. 

Infiltration  of  the  surrounding  tissues,  even  those  external  to  its  capsule 
(when  such  exists),  is  a  peculiarity  of  sarcoma :  this  is  especially  true  of 
the  small  spindle-celled  variety  (recurrent  fibroid  of  Paget),  which  occurs 
chiefly  in  the  subcutaneous  tissue  and  sometimes  in  the  breast,  recurring  in 
the  course  of  many  years  a  dozen  or  more  times,  while  distant  parts  and  the 
lymphatic  glands  rarely  become  infected.  Attention  has  already  been  called 
to  the  early  implication  of  the  glands  in  sarcomata  of  certain  organs,  as  the 
testicle,  etc.  The  subperiosteal  sarcomata  are  very  apt  to  give  rise  to  secondary 
tumors  in  other  bones,  the  skin,  the  subcutaneous  tissue,  and  the  viscera, 
lymphatic  involvement  being  the  rare  exception.  Finally,  certain  of  the  softer 
sarcomata  by  hemorrhage  into  their  substance  ])ecome  completely  broken  down 
and  converted  into  cyst-like  tumors  filled  with  blood,  ])artly  fluid,  jiartly 
coagulated.  These  if  punctured  bleed  profusely,  the  hemorrhage  being  often 
difficult  to  control ;  without  a  microscopical  examination  it  may  be  impossible 
to  distinguish  such  a  growth  from  a  true  hematoma  (blood-cyst). 


TUMOR.'S.  207 

Diagnosis. — Tliis  is  often  difficult,  and  must  depend  on  a  careful  con- 
sideration of  the  f()re<roin<2;  facts,  together  with  tliose  now  to  be  <»;iven.  The 
consistence  of  the  tumor  varies  much  in  difierent  parts;  cysts  are  of  fre(|uent 
occurrence,  especially  when  aftectin^  the  bones,  breast,  or  testicle ;  moreover, 
these  develop,  as  does  the  growth,  with  a  rapidity  unknown  in  benign  cystic 
growths ;  sarcomata  are  more  a{)t  to  ulcerate  than  benign  tumors — this  is 
peculiarly  true  of  recurrent  growths;  the  ulceration,  whether  the  giving  Avay 
of  the  skin  be  due  to  infiltration,  as  is  the  rule,  or  merely  to  advancing  pressure, 
is  apt  to  be  preceded  by  a  reddened,  tender,  hot  skin,  thus  presenting  such 
symptoms  of  intlannuation  as  will  embarrass  the  diagnosis  in  doubtful  cases. 
In  any  given  case  the  (juestions  to  be  considered  are — Is  it  an  inflammatory 
trouble,  or  is  it  a  malignant  growth  ?  If  a  malignant  groAvth,  is  it  sarcoma 
or  carcinoma?  The  first  (juestion  can  probably  be  answered  by  the  history, 
by  the  absence  of  the  systemic  indications  of  an  acute  sup})urative  inflammation, 
and,  above  all,  by  the  marked  differences  of  consistence  exhibited  by  different 
portions  of  the  tumor.  The  second  query,  as  to  the  class  of  malignant  disease 
to  which  any  given  growth  belongs,  can,  with  the  exception  of  primary  growths 
attacking  the  tonsil,  the  testicle,  or  the  lymphatic  glands  themselves,  be  settled 
by  the  early  involvement  of  the  lymphatic  glands  in  carcinoma  and  their  immu- 
nity in  sarcoma,  and  by  the  frequent  presence  of  cysts,  the  greater  mobility, 
the  freedom  of  the  overlying  skin,  the  enlargement  of  the  superficial  veins,  and 
the  greater  rapidity  of  growth  in  the  latter  disease.  Retraction  of  the  nipple 
in  a  case  of  tumor  of  the  breast  points  to  carcinoma  rather  than  to  sarcoma. 
The  peculiar  features  assumed  by  sarcoma  as  it  affects  each  organ  often  afford 
valuable  information,  and  for  this  the  student  is  referred  to  the  appropriate 
sections  of  this  work. 

The  prognosis  varies  with  the  site  of  the  disease;  thus,  a  myeloid  (giant- 
celled)  sarcoma  of  the  lower  jaw  is  not  uncommonly  curable  by  operation,  while 
a  sarcoma  of  the  tonsil  or  lymphatic  glands  destroys  life  with  great  rapidity. 
As  has  just  been  pointed  out,  recurring  small-celled  sarcoma  of  the  subcutaneous 
tissue  may  be  repeatedly  removed,  the  system  remaining  free ;  or  amputation, 
if  a  limb  be  involved,  will  probably  cure  the  disease.  It  also  varies  with  the 
variety  of  the  disease:  the  more  embryonic  the  form  the  greater  the  malignancy. 
Thus  the  round-celled  variety  is  by  far  the  most  malignant  form,  the  spindle- 
celled  usually  less  so,  and  the  myeloid  the  least. 

Treatment. — This  depends  partly  on  the  variety,  partly  on  the  organ 
attacked.  While  it  is  true  that  a  myeloid  tumor  of  the  lower  jaw  may  after 
thorough  enucleation  never  recur,  it  is  far  safer  to  remove  at  the  same  time  as 
much  of  the  surrounding  tissue  as  can  be  done  with  safety.  When  the  long 
bones  are  the  seat  of  sarcoma,  amputate  high  up — if  possible,  through  the  joint 
above :  this  is  likewise  good  practice  when  sarcomata  of  the  soft  parts  of  the 
extremities  recur,  especially  if  they  are  of  the  round-celled  type.  If  the  upper 
jaw  is  attacked,  the  wdiole  maxilla  of  that  side  must  be  removed,  but  the  prog- 
nosis will  be  bad.  Sarcomata  of  the  lymph-glands  or  of  the  tonsil  are  so  little 
influenced  for  good  by  operation  that,  except  as  a  mere  palliative,  removal,  as 
a  rule,  should  not  be  attempted.  Tumors  of  the  subcutaneous  tissue  or  inter- 
muscular fascia  should  be  removed  as  often  as  they  recur,  or  amputation  may  be 
resorted  to  when  a  limb  is  concerned.  It  has  been  long  known  that  occasion- 
ally an  attack  of  erysipelas  will  cure  a  sarcoma.  Lately,  the  treatment  of 
inoperable  sarcomata  by  hypodermatic  injections  of  the  toxins  of  erysipelas, 
instead  of  the  streptococcus  itself,  has  been  revived,  especially  by  Coley. 
The  toxin  of  the  bacillus  prodigiosus  added  to  that  of  erysipelas  increases 
the  reaction.     A  few  cases  of  apparent  cure  have  been  reported  by  Coley, 


208  AN   AMFJilCAN    TKXT-nOOK    OF  SlRaERY. 

Mynter,   aiul  .sevt-rul   others,   Ijiit  most  other  surireons  have  met  only   with 
failure. 

D.  The  Endotheliomata. 

Tliese,  as  yet,  little-kiiowii  tumors,  occupying  apparently  tlic  ])(»nlcr-land 
between  sarcomata  and  carcinomata,  must  be  l)riefly  considered,  sinee  it  ap- 
pears pro])ablc  that  some  sarcomata  of  tlie  testicle  are  of  this  nature,  and, 
deveh)ping  at  least  in  part  from  the  endothelium  of  the  lymphatics,  give  rise 
to  that  early  infection  of  the  glands  so  characteristic  of  testicular  sarcoma,  and 
yet  so  contrary  to  the  natural  history  of  the  disease  as  it  occurs  in  nearly  every 
other  situation. 

When  arising  in  the  pia  mater,  structurally  and  from  their  mode  of  origin 
many  of  these  endotheliomata  are  alveolar  sarcomata,  while  those  originating 
in  the  pleura  or  peritoneum  are  carcinomatous,  consisting  of  nests  and  clusters 
of  epithelial  cells  presenting  at  their  periphery  a  columnar  appearance,  these 
cell-masses  being  surrounded  by  a  dense  fibrous  stroma :  the  cells  follow  very 
exactly  "the  course  of  the  lymphatic  vessels."  They  present  themselves  in 
the  form  of  "  multiple  flattened  nodular  growths,  white  in  color,  and  either 
isolated  or  connected  by  neoplastic  bands,  the  intervening  serous  membrane 
being  more  or  less  thickened;"  metastasis  is  common,  giving  rise,  when  the 
pleura,  for  instance,  is  the  seat  of  the  primary  tumor,  usually  to  secondary 
growths  in  the  peribronchial  fibrous  tissue,  the  bronchial  glands,  and  the 
thoracic  muscles.  Attacking  as  they  do  chiefly  the  pleura  and  peritoneum, 
nothing  definite  can  be  said  concerning  their  diagnosis  or  treatment,  and  they 
have  been  mentioned  here  because  of  their  apparent  etiological  relations  to 
other  malignant  growths,  and  because,  although  rare,  recorded  cases  are  becom- 
ing more  frequent. 

A.  Warty  or  Villous  Tumors,  or  Papillomata,  closely  resemble  in  their 
structure  hypertrophied  papillae  of  the  skin  or  mucous  membrane,  some  of  the 
varieties  receiving  other  special  names,  as  condylomata,  mucous  tul>ercles,  and 
"benign  villous  tumors."  They  are  often  due  to  some  form  of  ii'ritation,  as  in 
the  case  of  those  which  develop  on  the  glans  penis  from  the  action  of  acrid 
discharges,  or  those  on  the  hands  from  dust  and  dirt.  Rarely  attaining  a  large 
size,  and  attacking  only  the  skin  or  the  mucous  membranes,  they  are  innocent 
growths,  although  during  the  cancerous  period  of  life  they  are  apt  to  degenerate 
into  epithelioma,  and  the  villous  tumor  of  the  bladder  may  destroy  life  by  the 
hemorrhage  to  which  such  a  growth  often  gives  rise.  Structurally,  they  are 
composed  of  a  varying  amount  of  connective  tissue  surrounding  one  or  more 
central  blood-vessels,  and  are  covered  in  by  one  or  several  layers  of  epithelial 
cells  resembling  those  of  the  skin  or  mucous  membrane  from  which  they  are 
developed ;  but  the  cells  never  transgress  their  connective-tissue  limit — i.  e. 
they  do  not  infiltrate,  as  epithelioma  does. 

Warts  or  warty  grotvths  either  occur  as  circumscribed  growths,  or  more 
rarely  form  cauliflower  masses,  large  relatively  to  the  size  of  the  part,  such  as 
those  occurring  in  the  larynx.  The  enlarged  papilbv  are  covered  by  a  layer  or 
layers  of  horny  epithelium,  and  their  vascular  supply,  as  a  rule,  is  small. 

Mucous  tubercles  and  condylomata  consist  of  flattened  elevations  composed 
of  enlarged  papillre  ;  their  connective  tissue,  of  rapid  growth,  is  infiltrated  with 
numerous  small  round  cells,  and  their  epithelial  covering  is  moist  and  sodden. 
They  are  most  commonly  due  to  syphilis. 

Villous  tumors,  when  springing  apparently  from  the  vesical  uuu-ous  mem- 
brane, where  papillae  do  not  normally  exist,  originate  from  the  subepithelial  con- 


TUMORS.  l^y 

the  slipping  away  of  the  edge  of  the  tumor  from  heneath  the  finger  when  pressed 
upon  :  possibly  the  grooved  needle  may  be  requisite.  Certain  variations  should 
be  noted.  Tlius  there  is  a  diffuse  form,  producing  symmetrical  swellings  at  the 
back  of  the  neck,  or  beneath  the  chin,  forming  so-called  "double  neck  "  and 
"double  chin."  Again,  the  presence  of  more  fibrous  tissue  than  usual  may 
render  lipomata  unusually  firm.  They  may  be  deep-seated,  springing  from 
the  intermuscular  septa  or  even  from  the  surface  of  a  bone.  Moreover,  they 
occasionally  become  pedunculated.  Lastly,  some  of  the  most  typical  cases  of 
"painful  subcutaneous  tubercle"  are  composed  of  fat.  The  average  case  can 
be  readily  diagnosticated  from  a  cyst,  a  chronic  abscess,  or  a  bursal  enlargement 
by  the  symptoms  given  above,  while  the  deeper-seated  can  hardly  be  mistaken 
for  any  other  than  soft  fibrous  or  myxomatous  groAvths — an  error  of  no  practical 
moment,  since  both  should  be  removed. 

Treatment. — For  the  circumscribed  variety  a  free  incision,  opening  the 
capsule,  should  be  employed,  when  the  tumor  will  usually  shell  out ;  if  more 
adherent,  some  dissection  with  the  knife  may  be  necessary :  all  portions  of  the 
growth  must  be  removed,  since  occasionally,  although  rarely,  the  portions  left 
have  formed  the  starting-point  of  a  new  tumor.  Multiple  growths,  unless  pain- 
ful ones,  seldom  require  removal.  The  diff"used  form  should  not  usually  be 
attacked  with  the  knife.  The  prolonged  internal  use  of  liquor  potassie  in 
10-minim  doses,  t.  d.,  has  in  certain  instances  caused  their  disappearance. 

3.  Cartilaginous  Tumors,  Chondromata  or  Enchondromata  (PI.  VII.), 
are  composed  of  some  variety  of  cartilage,  forming  hard,  elastic,  slowly  enlarg- 
ing growths,  often  nodular  or  lobulated.  They  may  consist  of  a  single  mas? 
or  of  a  number  of  small  masses  each  enclosed  in  its  capsule,  all  bound 
together  by  connective  tissue  and  blood-vessels.  They  are  homogeneous  or 
coarsely  granular  on  section,  presenting  a  translucent,  bluish-gray  or  pinkish- 
white  surfiice,  sometimes  marked  out  into  irregular  lobules.  Histologically^ 
they  are  usually  composed  of  hyaline-  or  fibro-cartilage.  Where  unattached 
to  bone  their  fibrous  capsule  serves  as  a  perichondrium,  and  when  exposed  to 
friction  a  bursal  sac  often  forms  between  them  and  the  superjacent  parts. 
Fatty  or  mucoid  secondary  changes  may  render  some  of  the  nodules  centrally 
diffluent,  producing  cyst-like  cavities  containing  synovia-like  fluid,  thus  so 
completely  metamorphosing  the  tumors  that  they  sometimes  are  hardly  recog- 
nizable as  chondromata ;  while,  on  the  contrary,  some  become  calcified  or  ossified. 
This  latter  change  is  especially  apt  to  affect  chondromata  springing  from  the 
juxta-epiphyseal  region  of  the  long  bones,  the  change  progressing  so  far  that 
only  a  thin  layer  of  cartilage  caps  them,  forming  what  are  termed  cancel- 
lous exostoses.  Chondromata  are  apt  to  be  single,  but  they  are  often  multiple 
and  symmetrical,  as  those  attacking  the  phalanges.  While  pure  cartilaginous 
growths  are  benign,  sarcomata  are  often  partly,  or  even  chiefly,  composed  of 
cartilage,  especially  those  found  in  the  testicle  and  the  parotid.  Multiple  chon- 
dromata of  the  hand,  if  of  rapid  growth,  should  be  viewed  with  suspicion  as 
possibly  cartilaginous  sarcomata.  Occurring  at  any  age,  they  are  more  com- 
mon in  the  young,  especially  those  springing  from  the  long  bones  near  the 
epiphyses.  Sometimes  the  tendency  to  their  formation  seems  to  be  inherited, 
the  tumors  being  similarly  located  in  both  parents  and  children.  While  they 
often  attain  a  large  size,  they  grow  slowly,  so  that  unusual  bulk  Avith  rapid 
growth  would  justify  a  strong  suspicion  of  the  intermixture  of  sarcomatous 
elements.  Mixed  tumors  containing  cartilage  have  been  already  referred 
to. 

Seats  of  Predilection. — The  bones,  especially  on  or  in  the  phalanges  of 


200  AX   A.VrjnrrAX    TEXT-BOOK   OF  ST^ROERV. 

the  fingers  or  toes  ;  the  lower  juxta-epiphyseal  region  of  the  femur  ;  the  upper 
ends  of  the  tibia,  fibuha,  and  humerus,  the  scapula  and  ilium,  on  or  in  the  jaws, 
especially  the  ujiper;  the  salivary  glands,  notably  the  parotid  ;  the  testicle  ;  in  or 
around   joinrs  attacked  by  rheumatoid  arthritis;  and  the  subcutaneous  tissues. 

Diagnosis. — This  must  de|)end  on  the  hardness  yet  elasticity  of  the  tumor, 
its  nodular  circumscribed  outlines,  and  its  slow  continuous  growth ;  later, 
on  the  development  of  softened  spots  indicative  of  cystic  degeneration,  and  on 
the  location  of  the  tumor,  as  upon  a  young  bone  near  an  epiphysis.  A  carfi- 
lai/inous  aarcoma — the  growth  with  which  chondromata  are  most  likely  to  be 
confounded — j)resents  less  definite  outlines — /.  e.  infiltrates  somewhat,  is  apt 
to  ])e  of  unequal  consistence  from  the  outset,  and  grows  with  much  greater 
rapidity. 

Treatment. — Complete  removal  of  a  pure  chondroma  will  secure  future 
immunity,  and  should  always  be  adopted  when  possible.  Mixed  chondromata 
containing  sarcomatous  elements  commonly  recur.  In  the  parotid  gland  and  sub- 
cutaneous tissues  they  can  usually  be  enucleated  with  their  capsules,  and  some- 
times this  can  be  done  when  the  phalanges  are  involved,  but  more  often  in  the 
latter  event  and  Avhen  the  testicle  is  attacked  the  whole  part  or  organ  must  be 
sacrificed  :  usually  those  springing  from  the  surfaces  of  the  larger  bones  can  be 
removed  without  sacrificing  the  bone,  with  but  small  chance  of  their  recurrence. 

4.  Osseous  Tumors,  or  Osteomata,  are  formed  of  true  bone,  and  are  gene- 
rally composed  almost  solely  of  either  cancellous  or  compact  bone.  The  can- 
cellous have  been  just  described  as  resulting  from  the  ossification  of  chondro- 
matous  growths  springing  from  the  juxta-epiphyseal  portions  of  such  long 
bones  as  the  tibia,  feumr,  humerus,  fibula,  etc.,  where  they  form  exostoses. 
The  ungual  surface  of  the  distal  phalanx  of  the  great  toe  is  often  the  site  of 
such  a  tumor,  producing  a  subungual  growth.  The  compact  osseous  tumors 
rarely  grow  from  any  other  bones  than  those  of  the  cranium.  Certain  exostoses, 
called  from  their  hardness  "ivory  exostoses,"  are  said  to  differ  from  other  bony 
growths  b}'  the  absence  of  Haversian  canals,  and  are  composed  of  "layers  of 
bone  lamellae  laid  concentrically  over  a  central  point  or  pedicle."  They  rarely 
attain  a  greater  size  than  that  of  a  small  walnut,  are  so  dense  that  they  can 
hardly  be  cut  by  any  instrument,  and  it  is  difficult  by  the  exercise  of  great 
force  to  fracture  their  pedicles,  even  wdien  comparatively  slender.  The  ivory 
exostosis  springs  from  the  exterior  of  one  of  the  cranial  bones,  while  the  more 
ordinary  forms  of  compact  osteomata  originate  in  the  cranial  or  nasal  sinuses, 
grow  slowly,  and  thrust  aside  or  cause  absorption  of  adjacent  structures,  thus  pro- 
ducing marked  deformities.  Although  usually  single,  osseous  tumors  in  some 
patients  may  be  multiple,  being  found  by  the  score,  in  such  cases  commonly 
commencing  at  a  very  early  age,  being  then  hereditary  and  often  symmetrical. 

Seats  of  Predilection. — These  have  been  mentioned  above  in  describ- 
ing these  growths. 

Diagnosis. — This  is  usually  easy,  depending  on  the  evident  connection  of 
the  tumor  Avith  bone  or  cartilage,  for  tumors  growing  apart  from  these  struc- 
tures in  the  connective  tissue  are  probably  tumors  of  some  other  class  which 
have  undergone  osseous  change,  or  are  structures,  such  as  tendons,  muscles,  etc., 
which  have  undergone  calcification  or  ossification.  The  pedunculated  form 
when  the  osteoma  occurs  as  an  exostosis,  the  dense,  hard,  irregularly  nodulated 
surface  when  the  tumor  is  non-pedunculated,  and  its  slow  growth,  serve  as  dis- 
tinguishing points.  The  more  rapid  growth  and  unequal  consistence  of  the 
calcifying  or  ossifying  sarcomata  serve  to  distinguish  this  variety  of  malignant 
growth  from  the  benign  osseous  tumors. 


Tr^fORs.  201 

Treatment. — Although  operation  alone  can  remove  these  growths,  not 
every  one  should  he  meddled  with,  hut  only  those  should  be  attacked  which 
are  steadily  growing  and  are  painful  or  ])ioduce  great  deformity  or  loss  of 
function,  and  the  ])roposed  o])eration  on  which  will  not  unduly  risk  the  life  of 
the  patient.  Thus,  most  of  the  exostoses  of  the  flat  and  long  bones  and  certain 
osteomata  of  the  upper  and  lower  jaws  should  be  removed,  for  valid  reasons, 
such  as  those  just  given.  Those  of  the  facial  and  cranial  bones,  which  are 
ill  defined  and  often  extend  so  deeply  as  to  involve  the  base  of  the  skull, 
should  not  be  touched.  It  Avas  formerly  taught  that  it  was  inadvisable  to  r^t- 
tempt  the  removal  of  non-pedunculated,  sessile  exostoses  of  the  long  bones, 
which  are  usually  covered  by  thick  masses  of  muscle,  because  of  the  risk  of 
profuse  and  deep-seated  suppuration ;  but  with  modern  methods  of  operating 
such  complications  ought  to  be  avoided,  so  that  if  good  reasons  exist  for  their 
removal  such  tumors  should  be  subjected  to  operation. 

With  the  exception  of  the  cancellous  exostosis  of  the  ungual  phalanx  of 
the  great  toe,  a  pure  osteoma  when  removed  does  not  return,  even  when 
some  of  the  surface  from  which  it  has  sprung  is  allowed  to  remain.  An  ossi 
fying  sarcoma,  for  which  osteoma  has  sometimes  been  mistaken,  Avill  of  course 
return.  In  the  exceptional  case  mentioned  the  distal  portion  of  the  pha- 
lanx should  be  removed  with  the  tumor  to  obviate  any  risk  of  recur- 
rence. 

5.  Mucous  Tumors,  or  Myxomata,  resemble  both  to  the  naked  eye  and 
to  the  microscope  the  Whartonian  jelly  of  the  umbilical  cord  and  the  vitreous 
humor  of  the  eye.  They  grow  slowly,  and  may  attain  a  large  size,  but  are  in- 
nocent tumors,  not  returning  when  pure  and  if  completely  removed.  Sarcomata 
may  undergo  an  analogous  change — i.  e.  mucous  softening — and  of  course  such 
tumors  are  apt  to  recur.  Mucoid  softening  also  attacks  fibromata,  chondro- 
mata,  and  other  connective-tissue  tumors,  so  that  many  tumors  called  myxo- 
mata are  chondromata,  fibromata,  or  sarcomata  undergoing  mucoid  (myxo- 
matous) change. 

Structurally,  a  true  myxoma  is  soft,  gelatinous,  semi-translucent,  encapsu- 
lated, and  intersected  by  septa  of  fibrous  tissue.  Their  cut  surfaces  are  pinkish- 
or  yellowish-gray,  and  exude  large  quantities  of  glairy  fluid  containing  much 
mucin.  Microscopically,  they  are  seen  to  be  composed  of  numerous  anasto- 
mosing stellate  cells,  with  branching  processes  which  form  a  delicate  stroma 
in  which  the  gelatinous  basis-substance  is  contained :  some  round  and  spin- 
dle cells  are  also  found.  Inflammation,  fatty  degeneration,  ulceration,  and 
the  formation  of  blood-cysts  from  rupture  of  capillary  vessels  are  the  secondary 
changes  to  which  these  tumors  are  liable. 

Seats  of  Predilection. — The  nasal  cavities,  in  which  they  form  gelatin- 
ous polypi ;  the  mammary  gland  ;  the  intermuscular  spaces  ;  the  submucous  and 
subserous  tissues ;  more  rarely  the  periosteum,  the  bone  medulla,  and  sheaths 
of  nerves. 

Diagnosis. — Before  removal  their  close  physical  resemblance  to  fatty  and 
fibro-cellular  tumors  renders  certainty  impossible,  since  they  present  the  same 
soft,  elastic  feel,  and  may  even  seem  to  fluctuate,  thus  simulating  a  chronic 
abscess :   in  such  cases  the  hypodermatic  needle  would  settle  the  diagnosis. 

Treatment. — This  should  be  removal  when  practicable.  This  is  usually 
readily  eff'ected,  the  growth  shelling  out  of  its  capsule ;  but  careful  dissection  is 
required  "when  they  spring  from  large  nerves,  since  these  not  uncommonly  pass 
through  the  center  of  the  tumor,  so  that  sections  of  the  nerve  have  been 
accidentally  removed  when  excising  such  growths. 


202  AN  AMERICAN  TEXT-HOOK   OFSl'IiOEIiY. 

V>.  Tumors  conforming  to  the  types  of  the  higher  connective 
tissues : 

1.  Muscular  Tumors,  or  Myomata. — Only  those  of  con<!;enital  origin 
seem  to  be  composed  of  striated  muscle-elements  {rhahdo-inyoma),  but  even  in 
such  tumors  the  bulk  of  the  neoplasm  is  not  usually  composed  of  muscle-cells. 

New  jrrowths  made  up  in  part  of  smooth.  7ton-!<triafn]  muscle-cells  (leio- 
mi/0))ia)  frc(iuciitly  occur  in  the  uterus,  formiiijr  such  considerable  portions  of 
most  fibromata  of  that  ort^an  as  to  induce  many  writers  to  term  them  myomata 
of  the  uterus.  In  like  manner  most  enlarged  prostates  are  composed  in  great 
part  of  unstriped  muscle.  Prostatic  enlargements  are  more  apt  to  be  due  to 
libro-myomatous  growths  involving  the  whole  organ  or  an  entire  lobe,  although 
distinct  pedunculated  growths  are  not  uncommonly  found;  while  those  of 
the  uterus,  often  very  large,  consist  usually  of  an  aggregation  of  separate 
tumors.  Uterine  fibromata  also  often  assume  the  polypoid  form,  fnmi  the 
extrusive  efforts  of  the  organ  excited  by  the  presence  of  the  growth.  Situated 
elsewhere,  myomata  rarely  attain  a  great  bulk.  Wherever  situated,  they  grow 
slowly  and  are  quite  innocent,  although  from  their  size  or  position  they  often 
cause  the  utmost  inconvenience  or  even  danger  to  life.  They  are  firm,  some- 
times smooth,  but  more  often  nodular,  their  cut  surfaces  closelv  resembling 
those  of  a  fibrous  tumor,  owing  to  the  presence  of  varying  quantities  of  true 
fibrous  tissue ;  glandular  structures  form  part  of  ])rostatic  tumors. 

Diagnosis. — As  they  are  at  the  outset  so  situated  as  to  be  inaccessible  to 
sight  or  touch,  the  reader  is  referred  to  the  sections  on  Diseases  of  the  Prostate 
and  the  Uterus.  When  the  oesophagus,  stomach,  or  intestines  have  been  the 
parts  affected,  the  nature  of  the  tumors  has  rarely  been  diagnosticated. 

Treatment. — When  accessible,  they  should  be  removed.  Not  seldom  this 
may  require  total  hysterectomy. 

2.  Vascular  or  Erectile  Tumors,  or  Angeiomata. — Under  this  head 
are  classed  all  neoplasms  the  chief  constituents  of  which  are  blood-vessels, 
either  arteries,  veins,  or  capillaries,  or  in  which  the  blood  is  contained  in  cav- 
ernous spaces  not  true  vessels.  Many  sarcomata,  and  some  fibromata  and  car- 
cinomata,  are  permeated  with  enormous  quantities  of  blood-vessels  or  channels 
of  large  caliber,  but  the  essential  element  composing  each  tumor  is  not  the 
vascular  tissue,  but  the  sarcomatous,  fibrous,  or  carcinomatous  element. 

3.  Both  Angeiomata  and  Lymphangeiomata  will  be  more  thoroughly  dis- 
cussed in  the  chapters  on  Diseases  of  the  Blood-vessels  and  Lymphatics,  where 
their  treatment  by  excision,  cauterization,  ligature,  or  electrolysis  is  described. 

4.  Nerve  Tumors,  or  Neuromata. — Such  growths  are  of  rare  occurrence, 
whether  composed  of  medullated  or  of  non-medullated  nerve-fibres.  To  avoid  repe- 
tition, the  student  is  referred  to  the  section  on  Injuries  and  Diseases  of  the  Nerves. 

C.  Tumors  conforming  to  the  type  of  embryonic  connective 
tissue. 

These  neoplasms,  called  Sarcomata  (PI.  Mil  aiid  Fig.  26),  closely  imi- 
tate in  their  structure  normal  embryonic  or  immature  connective  tissue, 
and  to  this  class  belong  the  fibro-nucleated,  fibro-plastic,  myeloid,  recur- 
rent fibroid,  and  many  of  the  encephaloid  cancers  of  the  older  authors. 
W'hile  normal  embryonic  connective  tissue  goes  on  to  the  formation  of 
fibrous  tissue,  cartilage,  bone,  and  so  on,  the  sarcomata  always  retain  the 
embryonic  character  at  their  circumference — i.  e.  their  growing,  advancing 


TUMORS. 


Plate  VIII. 


Enormous  sarcoma  of  buttock. 


rrMORS. 


20.) 


border,  and  therefore  their  youngest  and  least  mature  part— even  in  cases 
in  wliieii  the  ohler  portions  may  have  developed  almost  normally  into  fibrous 
tissue,  cartilage,  or  bone.  Therefore  any  rapidly-growing  tumor  of  the  connec- 
tive-tissue tyi)e  nmst  have  its  periphery  especially  subjected  to  careful  micro- 
scopic examination  to  determine  whether  sarcomatous  elements  exist  there.  AVhde 
the  sarcomata  vary  much  in  their  structure  and  clinical  course,  they  all  ])resent  the 
following  characteriiitics.  The  component  cells  contain  one  or  more  nuclei,  the 
masses  oi'  protoplasm  of  which  they  are  formed  not  being  surrounded  by  any  dis- 
tinct cell-wall,  and  the  cell-body  is  'large  as  compared  with  the  nucleus.  The  cells 
are  '^  in  constant  relation  with"  the  stroma"—/,  e.  the  intercellular  cement,  that 
which  corresi)oruls  to  stroma,  surrounds  each  cell,  varies  in  amount,  and  has  no 
definite  arrangement,  no  alveoli  being  formed  as  in  carcinoma.  The  blood-vessels 
ramify  among  the  cells,  not,  as  in  the  carcinomata,  running  in  the  stroma,  because 
of  the  absence  of  any  such  structure,  and  are  very  thin-walled.    Indeed,  they  often 

Fig.  29. 


.■sarcoma  of  the  Arm  ^Keun). 

appear  to  be  nothing  more  than  mere  spaces  bounded  by  the  cells  of  the  growth 
themselves.  A  consideration  of  these  peculiarities  of  structure  and  of  the  dis- 
tribution of  the  blood-supply  readily  explains  the  frequent  occurrence  of  hemor- 
rhage into  the  substance  of  sarcomata.  The  fact  that  dissemination  takes  place 
almost  invariably  by  the  blood-vessels,  and  not  by  the  lymphatics,  as  is  the  case 
with  carcinomata,  is  also  explainable  by  the  peculiar  relation  of  the  vessels  and 
cells.  Again,  for  the  same  reasons,  the  lungs,  being  the  organs  first  reached  by 
the  blood  after  fragments  of  the  growth  have  been  swept  away  by  the  current, 
are  the  organs  most  often  the  seat  of  secondary  deposits.  The  metastatic  deposits 
are  usually  similar  in  structure  to  the  primary  growth.  Since  sarcomata  grow 
by  infiltrating  the  surrounding  tissues,  they  are  exceedingly  apt  to  recur  locally, 
doubtless  because  some  infiltrated  tissue  has  been  left.  Secondary  lymphatic 
glandular  involvement,  except  when  the  tonsil  or  testis  is  implicated,  is  the  rare 


204  AN  AMERICAN   TEXT- HOOK   OF  SURGERY. 

exception — as  is  alleged,  because  of  the  absence  of  lymphatic  vessels  in  most 
sarcomata:  if  tlie  organs  just  mentioned  are  attacked,  glandular  involvement 
is  the  rule.  Their  growth  is  not  slow  and  steady  as  in  the  carcinomata,  but 
spasmodic,  now  fast,  now  slow.  AVhile  carcinoma  attacks  old  or  senescent 
tissues,  sarcoma  most  freijuently  occurs  in  organs  or  tissues  which  are  develop- 
ing, are  in  active  function,  or  are  at  least  in  their  j)rime ;  hence  it  is  a  disease 
of  youth  or  early  middle  life.  Another  point  in  which  it  differs  from  carci- 
noma is  that  scraping  a  freshly-cut  section  does  not  yield  a  milky  juice  like 
that  obtainable  from  the  latter  form  of  malignant  growth.  Not  infrequently 
sarcomata  result  from  an  injury,  such  as  a  blow  or  a  fracture. 

So  closely  does  one  of  the  varieties  of  sarconui — the  round-celled — resemble 
ordinary  granulation-tissue  that  they  cannot  be  distinguished  from  each  other 
microscopically.  They  both  consist  of  small  round  cells  similar  to  the 
white  cells  of  the  blood,  separated  from  one  another  by  a  very  small  amount 
of  homogeneous  intercellular  material  permeated  by  delicate  capillary  vessels 
arranged  in  the  form  of  loops.  The  sarcomata  exhibit  nearly  every  step  in 
the  development  of  the  connective  tissues,  from  this  round-celled,  immature 
tissue  to  bone.  Thus,  the  cells  become  elongated  and  spindle-shaped,  while  the 
intercellular  substance  may  show  an  attempt  at  fibrillation  ;  or  further  develop- 
mental changes  may  ensue,  converting  the  major  part  of  the  growth  in  some 
instances  almost  wholly  into  fibrous  tissue,  cartilage,  or  even  bone,  although, 
as  has  been  already  said,  sarcomatous  elements  are  always  discoverable  at  the 
grooving  margins,  while  its  malignancy,  as  sho^vn  l)y  invasion  of  the  surround- , 
ing  tissues  and  dissemination  throughout  the  internal  organs,  is  in  no  way  less- 
ened. Calcification  is  often  mistaken  for  true  ossification,  which  is  seldom  met 
with  except  in  bone  sarcomata,  and  while  it  is  true  that  bone  may  form  part  of 
any  variety  of  sarcoma,  yet  it  is  most  common  in  the  spindle-celled  and  the  mixed 
forms.  Where  the  ncAV  bony  spiculiTe,  in  any  tumor  connected  with  a  long 
bone,  grow  at  right  angles  to  the  shaft  of  that  bone,  they  will  usually  be  found 
to  be  surrounded  by  some  soft  tissues,  which  upon  microscopic  examination  will 
prove  to  be  of  a  sarcomatous  nature :  this  arrangement  of  the  bony  spicule  is 
the  exact  reverse  of  that  commonly  prevailing  in  the  structure  of  true  osteo- 
mata,  where  they  pursue  a  course  parallel  to  the  long  axis  of  the  bone  and  are 
surrounded  by  cartilage  or  periosteum. 

Sarcomata  may  be  grouped  in  three  main  classes — viz.  \h.Q  round-celled,  the 
spindle-celled,  and  the  myeloid  or  yiant-celled. 

1.  The  Round-celled  Sarcomata  usually  form  soft,  vascular,  and  very 
rapidly  growing  tumors,  often  becoming  very  large,  and  early  giving  rise  to 
metastatic  deposits  in  distant  parts  and  in  the  viscera.  ^Microscopically,  they 
consist  of  round  cells  of  varying  size  closely  resembling  leucocytes,  iml)cdded 
in  a  small  amount  of  granular  or  homogeneous  intercellular  basis-substance.  On 
section  they  so  much  resemble  brain-matter  in  consistence  and  vascularity  that 
the  old  terms  encephaloid  and  medullary  seem  not  inappropriate.  Many  of  those 
tumors  formerly  called  encephaloid  cancer  or  fungus  luematodes  were  really 
round-celled  sarcomata.  A  variety  of  round-celled  sarcoma,  where  the  cells 
lie  within  a  stroma  formed  of  delicate  meshes  closely  resembling  that  of 
lymphatic  tissue,  is  often  described  as  lymplio-sareoma.  Such  tumors  must 
be  distinguished  from  irritative  enlargements  of  lymph-glands  and  the 
adenoid  hyperplasias  of  leukemia  and  Hodgkin's  disease.  It  has  been 
thought  to  have  been  palliated,  or  even  to  be  curable  in  rare  instances,  by  the 
internal  use  of  arsenic.  Mucoid  softening,  fatty  degeneration,  and  ulcera- 
tion are  common  secondary  changes,  together  with  the  extravasation  of  blood 


TUMORS.  205 

into  their  suhstance,  resulting  in  the  formation  of  cysts  (sarcomatous  blood- 
cysts). 

Seats  of  Predilection. — They  attack  most  freciucntly  the  ])enosteum, 
bone,  lymphatic  glands,  subcutaneous  tissue,  testicle,  eye,  ovary,  uterus,  lungs, 
kidney's,  and  more  rarely  the  skin,  although  they  may  originate  wherever 
librous  tissue  exists. 

Sub-varieties.  — ('■0  The  gliomn  grows  iVoin  the  connective  tissue  (neu- 
ron;lia)  of  nerve-centers,  and  its  basis-suhstance  resembles  that  structure ;  the 
ceUs  are  apt  to  be  small.  It  occurs  in  the  retina  and  brain.  According  to  the 
latest  investigations,  as  the  neuroglia  develops  from  the  epiblast,  gliomata  can- 
not properly  be  considered  sarcomata,  but  form  a  special  group  by  themselves. 
{b)  The  li/mj)ho-sarcovia,  growing  in  lymphatic  glands,  is  composed  of  cells 
usually  of  large  size,  lying  in  a  reticulum  resembling  lymphoid  tissue,  (c)  The 
psananoma  or  nest-celled  sarcoma  is  of  rare  occurrence,  attacking  only  the 
pineal  gland,  (d)  The  alveolar  sarcoma  is  so  called  because  the  basis-sub- 
stance encloses  each  cell  in  a  separate  space  or  alveolus,  {e)  In  the  melanotic 
sarcoma  both  the  cells  and  the  intercellular  basis-substance  are  pigmented.  Both 
the  alveolar  and  the  melanotic  form  may  be  of  the  spindle-celled  variety.  The 
melanotic  form  is  found  as  a  primary  growth  only  in  parts  normally  contain- 
ing pigment,  as  the  skin  and  the  choroid  coat  of  the  eye,  becomes  rapidly  dis- 
seminated— the  secondary  growths  being  usually  also  pigmented — is  probably 
the  most  malignant  of  the  sarcomata,  and  by  the  older  writers  was  called 
melanotic  cancer  or  melanosis.  Warts  are  sometimes  pigmented,  and  thus  look 
like  this  form  of  sarcoma,  but  warts  are  firm,  often  pedunculated  or  lobulated, 
and  of  slow  growth :  in  rare  instances  pigmented  warts  undergo  epitheliomatous 
change,  when  their  rapid  growth  excites  the  suspicion  that  they  are  pigmented 
sarcomata,  but  in  the  epithelial  growths  the  glands  early  become  implicated. 

2.  The  Spindle-celled  Sarcomata  are  formed  of  cells  varying  much 
in  size,  some  tumors  being  composed  of  very  small  oat-shaped  cells,  others  of 
greatly  elongated  bodies  with  long,  fine,  tapering  extremities.  Often  the  cells 
are  arranged  in  the  form  of  trabecule,  which  so  closely  imitate  fibrous  bands 
that  the  tumor  may  be  diagnosticated  as  a  fibrous  or  even  a  muscular  growth. 

The  sub-varieties  are  the  melanotic,  pist  mentioned,  and  the  small-celled 
and  large-celled.  When  portions  of  these  tumors  have  undergone  developmental 
chancres  they  are  sometimes  called  chondro-sarcoma,  osteo-sarcoma,  etc. 

Seats  of  Predilection. — The  skin  and  subcutaneous  tissue,  the  fasciae 
and  intermuscular  septa,  the  periosteum  and  the  interior  of  bones,  the  eye,  the 
antrum,  the  breast,  and  the  testicle. 

Sarcomata  consisting  of  an  admixture  in  varying  proportions  ot  round 
and  spindle  cells,  or  of  cells  of  many  different  forms  and  sizes,  are  sometimes 
called  mixed-celled  sarcomata.  To 'the  naked  eye  they  present  the  same  cha- 
racteristics as  the  round-  and  spindle-celled  forms,  and  they  may  undergo  the 
same  developmental  and  degenerative  changes. 

Seats  of  Predilection.— Chiefly  the  bones. 

3.  The  Myeloid  or  Giant-celled  Sarcomata  consist  chiefly  of  large 
elements  formed  of  masses  of  protoplasm,  containing  two  or  more  nuclei — up  to 
twenty,  or  even  fifty — Avith  a  varying  number  of  round,  spindle,  or  mixed  cells. 
They  usually  spring  from  the  interior,  cancellous  tissue  of  bones,  and  vary  in 
consistence  from  that  of  jelly  to  almost  that  of  muscle.  A  section  appears 
smooth,  shining,  succulent,  but  presents  no  appearance  of  fibrillation,  and  is 
of  a  greenish  or  of  a  livid  red  or  maroon  color,  varied  by  pink  or  darker  red 


206  J.V    AMEnTCAX    TKXT-l\OOk'    OF   smCKliY. 

spots,  due  to  extravasations  of  blood.  'Tlioy  liave  been  (•(tiii]i;iicil  in  color  to 
the  muscuhir  tissue  of  the  heart. 

Seats  of  Predilection. — The  lower  jaw,  tlic  htwcr  cud  of  the  fcimir, 
and  tile  licad  of  the  tibia  ;   althouLlh  they  uuiy  occur  elsewhere. 

The  courses  ])ursued  by  the  several  forms  of  sarcomata  are  partly  depend- 
ent u})on  their  structure,  ])artly  upon  the  organ  or  tissue  which  they  attack. 
For  exam[)le,  tiie  commonest  form  attacking  the  mamma,  the  spindle-celled, 
occurs  most  frequently  between  thirty  and  forty  years  of  age,  is  at  first 
enca))sulated — therefore  freely  movable — hard  and  nodular,  grows  with  great 
rapidity,  and  sooner  or  later,  from  softening  or  the  development  of  cysts,  is 
apt  to  pi'esent  points  of  uneciual  consistence,  some  of  the  conse((uent  bosses 
actuallv  feeling  ilucfuant.  The  tumor  remains  for  a  considerable  time  isolable 
from  the  mauuuary  gland  ])roper,  thrusting  this  to  one  side.  The  skin 
does  not  usually  become  adherent,  even  when  intracystic  growths  fungate, 
after  having  caused  ulceration  ;  although,  if  the  tumor  is  left  to  pursue  its 
natural  course,  in  time  not  only  the  skin  but  also  the  subjacent  parts  will  be 
infiltrated,  and  death  will  ensue  from  sloughing  or  involvement  of  the  lungs, 
liver,  or  other  viscera ;  the  axillary  glands  renuiin  uninvolved. 

Examine  the  other  extreme  as  exemplified  by  the  course  pursued  by  a 
giant-celled  sarcoma,  usually  occurring  in  an  adult  over  forty  years  of  age,  and 
attacking  the  body  of  the  lower  jaw,  slowly  expanding  the  bone  into  a  smooth 
tumor,  involving  l)oth  its  inner  and  its  outer  surface,  the  bony  walls  of  which 
are  often  so  thin  as  to  crackle  under  ])ressure,  yet  growing  so  slowly  that 
years  may  elapse  before  it  attains  the  bulk  of  a  walnut ;  the  growth  does  not 
become  adherent  to  the  surrounding  tissues,  and  consequently  rarely  ulcerates ; 
involvement  of  the  lymphatic  glands  seldom  occurs. 

From  the  preceding  remarks  it  will  be  seen  how  difficult  the  diagnosis  of 
sarcoma  often  is,  varying  as  the  symptoms  do  with  the  organ  attacked.  Occur- 
ring at  all  ages,  sarcoma  is  more  apt  to  attack  the  young — i.  e.  the  tissues 
during  the  developmental  period.  Although  it  is  the  rule  for  sarcomata  to 
grow  rapidly,  especially  the  secondary  growths,  yet  some  of  the  primary  ones 
develop  slowly,  the  rate  of  growth  and  bulk  attained  depending  largely  upon 
the  tissue  attacked.  Those  of  the  eye  or  brain  are  apt  to  be  small,  while  those 
of  bone  often  reach  a  huge  size.  While  those  which  attack  the  subcutaneous 
tissue,  the  fascia,  and  the  intermuscular  planes  are  usitally  surrounded  with 
a  capsule,  there  is  none  fi)r  those  s|)ringing  from  the  surfaces  of  bones,  nor  for 
those  arising  in  the  interior  of  such  organs  as  the  lymphatic  glands,  the  tonsil, 
etc.,  which  are  soon  entirely  infiltrated  by  the  growth. 

Infiltration  of  the  surrounding  tissues,  even  those  external  to  its  capsule 
(Avlien  such  exists),  is  a  peculiarity  of  sarcoma :  this  is  especially  true  of 
the  small  spindle-celled  variety  (recurrent  fibroid  of  Paget),  which  occurs 
chiefly  in  the  subcutaneous  tissue  and  sometimes  in  the  breast,  recurring  in 
the  course  of  many  years  a  dozen  or  more  times,  while  distant  parts  and  the 
lymphatic  glands  rarely  become  infected.  Attention  has  already  been  called 
to  the  early  implication  of  the  glands  in  sarcomata  of  certain  organs,  as  the 
testicle,  etc.  The  subperiosteal  sarcomata  are  very  apt  to  give  rise  to  secondary 
tumors  in  other  bones,  the  skin,  the  subcutaneous  tissue,  and  the  viscera, 
lymphatic  involvement  being  the  rare  exception.  Finally,  certain  of  the  softer 
sarcomata  bv  hemorrhafie  into  their  substance  become  completely  broken  down 
and  converted  into  cyst-like  tumors  filled  with  blood,  partly  fluid,  partly 
coagulated.  These  if  punctured  bleed  profusely,  the  hemorrhage  being  often 
difficult  to  control ;  without  a  microscopical  examination  it  may  be  impossible 
to  distinguish  such  a  groAvth  from  a  true  heuuitoma  (blood-cyst). 


TUMORS.  207 

Diagnosis. — This  is  often  difficult,  and  must  depend  on  a  careful  con- 
sideration of  the  fore<:;oin^  facts,  to;i;ether  with  those  now  to  he  i^iven.  The 
consistence  of  the  tumor  varies  much  in  different  parts;  cysts  are  of  frequent 
occurrence,  especially  when  affecting  the  bones,  breast,  or  testicle ;  moreover, 
these  develop,  as  does  the  growth,  with  a  rapidity  unknown  in  benign  cystic 
growths;  sarcomata  are  more  apt  to  ulcerate  than  benign  tumors — this  is 
peculiai-ly  true  of  recurrent  growths;  the  ulceration,  whether  the  giving  way 
of  the  skin  be  due  to  infiltration,  as  is  the  rule,  or  merely  to  advancing  i)ressure, 
is  apt  to  be  preceded  by  a  reddened,  tender,  hot  skin,  thus  presenting  such 
symptoms  of  inffanunation  as  -will  embarrass  the  diagnosis  in  doubtful  cases. 
In  any  given  case  the  (questions  to  be  considered  are — Is  it  an  inflammatory 
trouble,  or  is  it  a  malignant  growth  ?  If  a  malignant  growth,  is  it  sarcoma 
or  carcinoma?  The  first  question  can  probably  be  ansAvered  by  the  history, 
by  the  absence  of  the  systemic  indications  of  an  acute  suppurative  inflammation, 
and,  above  all,  by  the  marked  differences  of  consistence  exhibited  by  different 
])ortions  of  the  tumor.  The  second  query,  as  to  the  class  of  malignant  disease 
to  which  any  given  growth  belongs,  can,  with  the  exception  of  primary  growths 
attacking  the  tonsil,  the  testicle,  or  the  lymphatic  glands  themselves,  be  settled 
by  the  early  involvement  of  the  lymphatic  glands  in  carcinoma  and  their  immu- 
nity in  sarcoma,  and  by  the  frequent  presence  of  cysts,  the  greater  mobility, 
the  freedom  of  the  overlying  skin,  the  enlargement  of  the  superficial  veins,  and 
the  greater  rapidity  of  growth  in  the  latter  disease.  Retraction  of  the  nipple 
in  a  case  of  tumor  of  the  breast  points  to  carcinoma  rather  than  to  sarcoma. 
The  peculiar  features  assumed  by  sarcoma  as  it  affects  each  organ  often  afford 
valuable  information,  and  for  this  the  student  is  referred  to  the  appropriate 
sections  of  this  work. 

The  prognosis  varies  with  the  site  of  the  disease;  thus,  a  myeloid  (giant- 
celled)  sarcoma  of  the  lower  jaw  is  not  uncommonly  curable  by  operation,  Avhile 
a  sarcoma  of  the  tonsil  or  lymphatic  glands  destroys  life  with  great  rapidity. 
As  has  just  been  pointed  out,  recurring  small-celled  sarcoma  of  the  subcutaneous 
tissue  may  be  repeatedly  removed,  the  system  remaining  free ;  or  amputation, 
if  a  limb  be  involved,  Avill  probably  cure  the  disease.  It  also  varies  with  the 
variety  of  the  disease :  the  more  embryonic  the  form  the  greater  the  malignancy. 
Thus  the  round-celled  variety  is  by  far  the  most  malignant  form,  the  spindle- 
celled  usually  less  so,  and  the  myeloid  the  least. 

Treatment. — This  depends  partly  on  the  variety,  partly  on  the  organ 
attacked.  While  it  is  true  that  a  myeloid  tumor  of  the  lower  jaw  may  after 
thorough  enucleation  never  recur,  it  is  far  safer  to  remove  at  the  same  time  as 
much  of  the  surrounding  tissue  as  can  be  done  with  safety.  When  the  long 
bones  are  the  seat  of  sarcoma,  amputate  high  up — if  possible,  through  the  joint 
above :  this  is  likewise  good  practice  wdien  sarcomata  of  the  soft  parts  of  the 
extremities  recur,  especially  if  they  are  of  the  round-celled  type.  If  the  upper 
jaw  is  attacked,  the  whole  maxilla  of  that  side  must  be  removed,  but  the  prog- 
nosis Avill  be  bad.  Sarcomata  of  the  lymph-glands  or  of  the  tonsil  are  so  little 
influenced  for  good  by  operation  that,  except  as  a  mere  palliative,  removal,  as 
a  rule,  should  not  be  attempted.  Tumors  of  the  subcutaneous  tissue  or  inter- 
muscular fascia  should  be  removed  as  often  as  they  recur,  or  amputation  may  be 
resorted  to  when  a  limb  is  concerned.  It  has  been  long  known  that  occasion- 
ally an  attack  of  erysipelas  will  cure  a  sarcoma.  Lately,  the  treatment  of 
inoperable  sarcomata  by  hypodermatic  injections  of  the  toxins  of  erysipelas, 
instead  of  the  streptococcus  itself,  has  been  revived,  especially  by  Coley. 
The  toxin  of  the  bacillus  prodigiosus  added  to  that  of  erysipelas  increases 
the  reaction.     A  few  cases  of  apparent  cure  have  been  reported  by  Coley, 


208  ^liV^  AMERICAN   TEXT-BOOK   OF  SURGERY. 

Mynter,  and  .several  others,   but  iiKj.st  other  surgeons  have  met  only  with 
failure. 

D.  The  Endotheliomata. 

The.^e.  as  yet,  little-known  tumor.s,  occupying  apparently  the  border-land 
between  sarcomata  and  carcinomata,  must  be  briefly  considered,  since  it  ap- 
pears probable  that  some  .sarcomata  of  the  testicle  are  of  this  nature,  and, 
developing  at  least  in  part  from  the  endothelium  of  the  lymphatics,  give  rise 
to  that  early  infection  of  the  glands  so  characteristic  of  testicular  sarcoma,  and 
yet  so  contrary  to  the  natural  history  of  the  disease  as  it  occurs  in  nearly  every 
other  situation. 

When  arising  in  the  pia  mater,  structurally  and  from  their  mode  of  origin 
many  of  these  endotheliomata  are  alveolar  sarcomata,  while  those  originating 
in  the  pleura  or  peritoneum  are  carcinomatous,  consisting  of  nests  and  clusters 
of  epithelial  cells  presenting  at  their  periphery  a  columnar  appearance,  these 
cell-masses  being  surrounded  by  a  dense  fibrous  stroma :  the  cells  follow  very 
exactly  "the  course  of  the  lymphatic  vessels."  They  present  themselves  in 
the  form  of  "  multiple  flattened  nodular  growths,  white  in  color,  and  either 
isolated  or  connected  by  neoplastic  bands,  the  intervening  serous  membrane 
being  more  or  less  thickened;"  metastasis  is  common,  giving  rise,  Avhen  the 
pleura,  for  instance,  is  the  .seat  of  the  primary  tumor,  usually  to  secondary 
growths  in  the  peribronchial  fibrous  tissue,  the  bronchial  glands,  and  the 
thoracic  muscles.  Attacking  as  they  do  chiefly  the  pleura  and  peritoneum, 
nothing  definite  can  be  .said  concerning  their  diagnosis  or  treatment,  and  they 
have  been  mentioned  here  because  of  their  apparent  etiological  relations  to 
other  malignant  growths,  and  because,  although  rare,  recorded  cases  are  becom- 
ing more  frequent. 

A.  Warty  or  Villous  Tumors,  or  Pai^illomata,  closely  resemble  in  their 
structure  hypertrophied  papillae  of  the  skin  or  mucous  membrane,  some  of  the 
varieties  receiving  other  special  names,  as  condylomata,  mucous  tubercles,  and 
"benign  villous  tumors."  They  are  often  due  to  some  form  of  irritation,  as  in 
the  case  of  those  which  develop  on  the  glans  penis  from  the  action  of  acrid 
discharges,  or  those  on  the  hands  from  dust  and  dirt.  Rarely  attaining  a  large 
size,  and  attacking  only  the  skin  or  the  mucous  membranes,  they  are  innocent 
growths,  although  during  the  cancerous  period  of  life  they  are  apt  to  degenerate 
into  epithelioma,  and  the  villous  tumor  of  the  bladder  may  destroy  life  by  the 
hemorrhage  to  which  such  a  growth  often  gives  rise.  Structurally,  they  are 
composed  of  a  varying  amount  of  connective  tissue  surrounding  one  or  more 
central  blood-vessels,  and  are  covered  in  by  one  or  several  layers  of  epithelial 
cells  resembling  those  of  the  skin  or  mucous  membrane  from  which  they  are 
developed  ;  but  the  cells  never  transgress  their  connective-tissue  limit — i.  e. 
they  do  not  infiltrate,  as  epithelioma  does. 

^  Warts  or  warty  groivths  either  occur  as  circumscribed  growths,  or  more 
rarely  form  cauliflower  ma.sses,  large  relatively  to  the  size  of  the  part,  such  as 
those  occurring  in  the  larynx.  The  enlarged  papillne  are  covered  by  a  layer  or 
layers  of  horny  epithelium,  and  their  vascular  supply,  as  a  rule,  is  small. 

Mucous  tubercles  and  condyhmata  consist  of  flattened  elevations  composed 
of  enlarged  papillse  ;  their  connective  tissue,  of  rapid  growth,  is  infiltrated  with 
numerous  small  round  cells,  and  their  epithelial  covering  is  moist  and  sodden. 
They  are  mo.st  commonly  due  to  .syphilis. 

Villous  tumors,  when  springing  apparently  from  the  vesical  mucous  mem- 
brane, where  papillae  do  not  normally  exist,  originate  from  the  subepithelial  con- 


TUMORS.  20i) 

nective  tissue  and  owe  their  ])apillarv  form  to  tlie  concentric  arrangement  of  the 
connective  tissue  and  epithelium  an)iin<l  the  hlood-vessels.  These  can,  however, 
best  be  described  here.  Such  groAvths  assume  the  branching,  dendritic  form  of 
the  villi  of  the  chorion,  and  are  very  vascular,  the  vessels  being  often  dilated 
and  thus  liable  to  give  way,  producing  the  frequent  and  serious  hemorrhages 
common  to  this  aifection  of  the  bladder.  Their  epithelial  layer  is  thin,  and 
often  removed  mechanically,  being  passed  in  the  urine,  where  it  can  be  detected 
by  the  microscope. 

Seats  of  Predilection. —  Warts  and  warty  grotvths  occur  most  fre- 
quently on  the  skin,  especially  of  the  hands  and  genitalia,  and  on  the  mucous 
membrane  of  the  larynx.  Mucous  tubercles  and  condylomata  are  most  com- 
monly found  about  the  anus  and  genitals  or  in  the  mouth  and  throat.  The 
villous  growths  attack  the  bladder,  rectum,  and  larynx. 

Such  secondary  and  degenerative  changes  as  pigmentation,  ulceration,  and 
atrophy  are  common,  while  with  advancing  years  the  epithelial  elements  may 
infiltrate  the  connective  tissue,  resulting  in  epithelioma. 

Diagnosis. — The  signs  and  diagnosis  of  tumors  attacking  such  diverse 
organs  cannot  be  profitably  discussed  here,  and  can  be  best  studied  in  the  arti- 
cles on  the  Skin,  Bladder,  Rectum,  Larynx,  and  Syphilis. 

Treatment. — As  this  varies  with  the  parts  involved,  it  can  only  be  said, 
in  a  general  way,  that  these  growths  should  be  removed  by  such  means  as  sul- 
phuric or  nitric  acid,  etc.,  which  will  destroy  the  base  from  which  they  spring; 
or  this  base,  after  their  excision  by  the  knife  or  scissors,  must  be  destroyed  by 
a  caustic  or  by  the  actual  cautery  in  some  form. 

B.  Glandular  Tumors,  or  Adenomata,  are  innocent  growths,  and 
originate  only  from  pre-existing  glandular  tissue,  which  they  closely  imitate.  As 
of  normal  gland-tissue,  so  of  these  tumors  there  are  two  types,  the  acinous  and 
the  tubular.  The  acinous  are  composed  of  acini  lined  with  spheroidal  epithe- 
lium, intercommunicating  by  duct-like  channels :  mammary  adenomata  are 
of  this  type.  The  acini  are  bound  together  by  a  varying  amount  of  connective 
tissue  in  which  the  blood-vessels  ramify.  Pure  adenomata  are  rare,  the  inter- 
acinous  tissue  usually  being  replaced  by  a  considerable  amount  of  fibrous  tissue 
(adeno-fibroma),  mucous  tissue  (adeno-myxoma),  or  sarcomatous  cells  (adeno- 
sarcoma) ;  again,  the  admixture  of  fibrous  tissue  with  the  sarcomatous  elements, 
or  of  mucous  tissue  similarly  disposed,  results  in  other  growths  (adeno-fibro-sar- 
coma,  adeno-myxo-sarcoma) ;  still  further,  from  obstructive  pressure  the  acini 
or  ducts  may  become  dilated,  forming  cysts  into  Avhich  proliferating  growths 
(intracystic  growths)  may  project:  such  growths  receive  their  names  from  the 
character  of  the  interacinous  and  intertubular  tissue,  being  termed  adeno-cys- 
toma,  cysto-sarcoma,  etc. 

The  Tubular  Adenomata  consist  of  tubules  lined  with  cylindrical  epithe- 
lium, and  therefore  spring  from  mucous  membranes  the  glands  of  Avhich  are 
similarly  constructed,  as  from  that  of  the  intestines.  Closely  resembling  carci- 
nomata  in  many  respects,  unlike  them  the  epithelial  elements  do  not  infiltrate 
the  connective  tissue. 

Seats  of  Predilection. — The  acinous  occurs  chiefly  in  the  mammae — 
generally  in  the  form  of  adeno-fibroma — in  the  lip,  ovary,  testis,  prostate, 
thyroid,  parotid,  lachrymal  gland,  the  cutaneous  and  sebaceous  glands :  the 
tubular  variety  occurs  in  the  intestine,  especially  the  rectum.  Secondary 
degenerations,  such  as  mucoid  softening  of  the  stroma  and  fatty  degeneration 
of  the  epithelium,  frequently  produce  cystic  changes  by  obstructive  pressure 
on  the  acini  or  duct-like  portions  of  these  growths. 

14 


210  ^.V  AMERirAX    TEXT-BOOK   OF  ^SURGERY. 


II.    EpIBLASTIC  AM)    IIvPOBLA^iTrC)    TUMORS,  OR  TROSE   CONFORMING  TO  THE 

Types  of  Epithelial  Tissues — the  Caucinomata. 

The  malignant  tumors  of  this  chiss  are  composed  of  cells  of  the  epithelial 
type  "in  constant  relation  with  one  another" — /.  e.  no  visible  intercellular 
matrix  is  discoverable — forming  nests  surrounded  by  more  or  less  fibrous 
stroma.  This  alveolar  arrangement  of  the  cells  is  due  to  the  fact  that  tlie  cells, 
having  broken  through  their  "connective-tissue  limit,"  now  occupy  the  inter- 
stices of  this  tissue — i.  c.  the  radicles  of  the  lymph-system — forming  inter- 
communicating cohimns  of  cells,  which  in  cross-section,  surrounded  with  their 
fibrous  stroma,  jjresenf  the  appearance  of  true  alveoli.  Unlike  adenomata,  the 
cell-groups  are  not  limited  by  any  basement  membrane,  while  tlie  vessels  differ 
from  those  of  sarcomata  by  having  walls  of  normal  thickness  and  construction  ; 
moreover,they  ramify  in  the  stroma,  not  among  the  cells  themselves.  Two  points 
should  be  noted — viz.  that  although  the  individual  cells  differ  somewhat  from 
one  another,  they  retain  the  type  of  the  parent  epithelium,  being  more  or  less 
spheroidal  when  originating  from  a  gland,  squamous  if  derived  from  the  skin, 
S({uamous  or  more  often  columnar  when  springing  from  a,  mucous  membrane. 
Still  further,  the  cells  of  the  secondary  growths  usually  closely  resemble  those 
of  the  primary  tumor.  The  normal  connective  tissue  of  the  part,  which  at  first 
forms  the  stroma,  is  infiltrated  with  numerous  cells,  which  later,  by  develop- 
ment into  fibrous  tissue,  produce  the  denser  stroma  characteristic  of  some  forms 
of  carcinomata. 

The  development  of  this  fibrous  tissue,  studied  in  connection  with  the  dispo- 
sition of  the  blood-vessels,  explains  the  differing  behavior  of  the  rapidly- 
growing  tumors  and  those  of  slower  growth.  In  the  former  the  vascular  supply 
is  rich  and  tolerably  evenly  distributed  throughout  the  growth,  while  there 
is  relatively  little  stroma,  Avhat  is  present  probably  being  not  much  more 
than  the  normal  connective  tissue  of  the  part  incapable  of  active  contraction 
and  consequent  obliteration  of  the  blood-vessels.  In  the  tumors  of  slower 
growth  the  blood-supply  is  more  scanty  originally,  and  is  found  chiefly  at  tlie 
periphery  of  the  growth,  having  been  obliterated  in  the  more  central  older 
portions  by  the  contraction  of  the  large  amount  of  newly-formed  fibrous 
tissue.  Hence  the  ftitty  degeneration  of  those  portions,  resulting  in  their 
breaking  down,  with  loss  of  substance,  when  occupying  a  free  surfice  or  after 
giving  way  of  the  skin  in  more  deeply  situated  growths  :  this  is  the  so-called 
ulceration  of  ncjv  growths.  Owing  to  the  abundance  of  blood-vessels  and  the 
lack  of  support  afforded  by  the  scanty  stroma  of  the  rapidly-growing  carcino- 
mata, hemorrhage  into  their  substance  is  not  uncommon,  with  free  bleeding 
from  the  surface  when  ulceration  has  taken  place.  Carcinomata  possess  no 
capsule  at  any  stage  of  their  development,  growing  by  endogenous  cell-division 
and  by  infiltration  of  the  surrounding  tissues,  as  a  rule  sooner  or  later  break- 
ing down  and  ulcerating.  As  the  cells  proliferate  in  the  lym])hatic  spaces 
of  the  connective  tissue,  or,  as  is  alleged  for  the  breast,  originate  in  what 
are  said  to  be  spaces  in  direct  continuity  with  the  lymphatic  vessels,  the  nearest 
lymphatic  glands  early  become  involved,  then  those  next  in  order,  and  finally 
the  viscera.  In  external  carcinoma  the  general  health  does  not  usually  suffer 
until  after  ulceration,  with  its  consequent  purulent  and  bloody  discharges,  or 
secondary  implication  of  one  or  more  of  the  important  viscera,  has  occurred, 
when  what  is  known  as  "the  cancerous  cachexia"  sets  in,  characterized  by  a 
peculiar  sallow,  earthy  hue  of  the  skin,  anxious,  careworn  facies,  and  more  or 
less  marked  emaciation.     Death  finally  results  from  the  combined  effect  of  the 


TUMORS.  211 

purulent  aiul  lieuiorrliii^ic  disehargcs,  from  tlic  impairment  of  nutrition  through 
involvement  of  important  viscera,  and  from  pain,  anxiety,  and  loss  of  sleep.  In 
internal  carcinoma,  especially  of  the  digestive  organs,  this  cachexia  soon  sets 
in,  inasmuch  as  the  general  nutrition  of  the  body  is  disturbed  very  early  in 
the  disease.  Possibly  filso  the  absorj)tion  and  diffusion  of  secondary  products 
of  the  carcinoma  may  have  some  influence  in  causing  this  cachexia. 

Carcinomata  are  divisible  into  two  itiahi  classes,  with  certain  sub-classes: 

(C)  The  acinous  or  spheroidal-celled  : 

1.  The  hard  spheroidal-celled  (scirrlms); 

2.  The  soft  spheroidal-celled  (encephaloid) ; 

3.  The  colloid,  probably  a  degenerative  form  of  one  of  the  preceding 

varieties. 

(D)  The  epithelial : 

1.  The  squamous-celled ; 

2.  The  cylindrical-  or  columnar-celled. 

(C)  Acinous  or  Spheroidal-celled  Carcinoma  originates  only  from 
the  epithelium  of  the  acinous  glands  or  from  that  lining  the  tubular  glands 
possessing  glandular  epithelium.  The  essential  difference  between  the  two 
chief  divisions  of  this  class  is  in  the  relative  amounts  of  stroma  and  cells, 
the  hard  form  containing  large  amounts  of  fibrous  tissue,  while  in  the  soft 
carcinomata  the  cells  preponderate.  The  term  Scirrhus  has  been  applied 
indiscriminately  to  the  harder  forms  of  spheroidal-celled  carcinomata  and  to 
the  whole  class. 

1.  Hard  Spheroidal-celled  Carcinoma,  or  Scirrhus,  appears  as  a  hard, 
irregular,  tuberous  growth  of  moderate  size  ;  if  originating  in  a  glandular  struct- 
ure, it  is  continuous  with  it;  at  the  outset  freely  moving  with  the  gland, 
but  later  by  infiltration  losing  this  mobility  because  adherent  to  the  skin,  fascia, 
muscles,  etc.  Implication  first  of  the  nearest  group  of  lymphatic  glands,  and 
next  of  the  viscera,  and  finally  ulceration  of  the  superjacent  tissues,  complete 
the  natural  history  of  the  growth.  The  carcinomatous  ulcer  is  irregular  in 
outline  and  depth,  has  hard,  nodular,  everted  margins,  while  the  base  is  indu- 
rated and  irregular,  sometimes  more  or  less  covered  with  sloughs,  and  but  rarely 
presents  any  evidences  of  granulations,  although  in  very  exceptional  cases  these 
exist  with  slight  attempts  at  cicatrization.  The  duration  of  life  in  this  affection 
is  about  two  years,  but  occasionally  patients  live  for  many  years,  even  twenty, 
during  much  of  which  time  ulceration  may  exist.  Of  course  these  remarks 
apply  only  to  external  tumors.  Owing  to  the  large  amount  of  newly-formed 
connective  tissue  in  the  hardest  forms  of  scirrhus,  in  some  instances  the  tumor, 
instead  of  frrowinji;  larger  as  time  goes  on,  becomes  smaller,  the  surrounding 
tissues  being  irregularly  puckered  and  drawn  in  toward  the  small  central 
shrivelled  lump  which  forms  the  tumor ;  this  is  the  so-called  witliering  or 
atrophic  scirrJtus,  best  seen  in  the  breast,  where  after  it  has  existed  for  years 
nothing  but  an  irregular  mass  resembling  a  cicatrix  is  to  be  found,  blending 
into  one  inseparable  growth  what  formerly  was  skin,  mammary  gland,  and  chest- 
wall.  Unfortunately,  the  malignant  tendencies  of  the  growth  are  not  abolished 
by  its  shrinkage,  for  secondary  tumors  develop  in  the  viscera,  destroying  the 
patient.     (See  Diseases  and  Injuries  of  the  Breast.) 

On  section,  hard  carcinomata  are  firm,  of  a  white  color,  often  traversed  by 
fibrous  septa,  and  creaking  under  the  knife;  the  cut  surface  is  cupped.  The 
section  is  succulent,  yielding  on  pressure  or  scraping  a  milky  fluid,  the  so-called 
cancer-Juice.  Howsoever  circumscribed  the  tumor  may  appear,  it  is  one  of  the 
rai'est  of  pathological  curiosities  to  find  it  encapsulated.     Islets  of  normal  tis- 


212  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

sue  or  fjit  can  often  be  detected  at  the  periphery  of  the  new  growth  surrounded 
by  carcinomatous  tissue ;  indeed,  no  definite  tumor  is  discoverable  in  certain 
cases,  the  neoplasm  being  disposed  throughout  the  affected  organ  in  the  form 
of  nodules  and  cord-like  bands. 

Seats  of  Predilection. — The  mammary  gland,  the  alimentary  tract, 
especially  the  pyloric  end  of  the  stomach,  and,  in  a  few  instances,  the  glands 
of  the  skin :  a  few  have  been  reported  in  other  localities. 

2.  Soft  Spheroidal-celled  (Medullary  or  Encephaloid)  Carcinoma. 
— Diff"ering,  as  already  said,  from  the  preceding  variety  merely  by  the  amount  of 
fibrous  tissue,  in  its  typical  form  soft  carcinoma  on  section  closely  resembles 
brain-tissue  both  in  appearance  and  in  consistence.  Clinically,  the  chief  points 
wherein  it  diff"ers  from  the  hard  form  are  the  greater  softness  of  the  growth — so 
soft  as  at  times  to  simulate  and  be  mistaken  for  abscess — the  greater  bulk 
attained,  the  short  time  required  to  reach  this  size,  and  the  rapidity  with  which 
it  runs  its  course.  In  form  the  soft  carcinoraata  differ  according  to  the  organ 
attacked.  Thus  those  of  the  testicle  form  large,  bossellated  masses,  while  mam- 
mary groAvths  tend  to  form  a  large  globular  mass  or  one  composed  of  an  aggre- 
gation of  rounded  masses.  When  ulceration  has  taken  place  a  fungating, 
readily-bleeding  mass  often  forms  ;  hence  the  old  name  of  '■''funyuH  Jicematodes." 
The  secondary  and  degenerative  change  which  these  carcinomata  undergo  is 
softening  at  their  central  older  portions,  due  chiefly  to  fatt}^  degeneration,  but 
partly  to  giving  way  of  the  blood-vessels,  which  often  results  in  the  formation 
of  such  large  fluctuating  areas  that,  as  has  been  said,  they  have  not  infrequently 
been  mistaken  for  abscesses.  Such  tumors  on  section  show  that  their  central 
portions  are  converted  into  a  soft,  diffluent  mass,  Avhile  the  periphery  of  the 
growth  presents  the  ordinary  grayish-white  or  cream-colored,  brain-like  surface, 
blotched  here  and  there  with  blood.  This  softening  also  results  in  cyst-like 
cavities  of  considerable  size,  giving  to  the  tumor  the  appearance  of  a  true 
cystic  growth.  In  some  carcinomata  of  the  testicle,  the  mamma,  and  other 
glands  true  retention-cysts  form. 

Locally,  carcinomata  extend  by  infiltration  of  the  circumjacent  tissues; 
this  accounts  for  the  clinical  phenomena  of  adhesion  of  the  tumor  to  neighbor- 
ing parts,  its  decreasing  mobility  as  it  grows,  and  its  final  absolute  fixation. 
With  occasional  exceptions,  as  in  some  carcinomata  attacking  the  e^'e,  the 
antrum,  or  the  pylorus,  early  secondary  lymphatic  involvement  is  the  rule,  the 
secondary  growths  usually  resembling  the  parent  one.  Occasionally  they  are  of 
the  soft  form,  even  though  the  primary  tumor  is  of  the  hard  variety,  thus  demon- 
strating the  essential  unity  of  both  forms.  The  organs  and  viscera  most  apt  to 
be  aff'ected  by  metastatic  deposits  are  the  skin,  the  bones,  especially  tlie  vertebrae, 
the  liver,  the  lungs,  the  kidneys,  and  the  brain.  Even  Avhen,  after  operation, 
no  local  recurrence  takes  place,  the  possibility  of  this  visceral  implication  must 
never  be  lost  sight  of,  especially  if  pains  in  the  lower  limbs  are  complained  of,  if 
so-called  "  spontaneous  "  fracture  of  a  long  bone  occurs,  preceded  or  not  by  pain 
or  tumor,  if  obscure  symptoms  of  vertebral  disease  or  if  jjoculiar  cerebral  symp- 
toms appear.  Among  surgical  rarities  is  the  secondary  carcinomatous  involve- 
ment of  the  medulla  of  many  bones  Avithout  the  formation  of  distinct  tumors 
in  any,  but  so  reducing  their  strength  that  numerous  fractures  occur,  either 
from  the  application  of  trifling  force  or,  as  it  is  said,  "  spontaneousl3\" 

Seats  of  Predilection. — The  testicle,  liver,  bladder,  kidney,  ovary, 
fundus  oculi,  and  more  rarely  the  breast. 

3.  Colloid  Carcinoma. — This  is  really  one  of  the  preceding  varieties 


TUMORS. 


Plate  IX. 


TUMORS.  2l;i 

the  cells  of  wliicli  have  undergone  mucoid  or  colloid  dejieneration  and  so  dis- 
tend  the  alveoli  that  these  can  be  seen  by  the  naked  eye.  1'he  colloid  material 
is  a  semi-translucent,  glistening,  jelly-like  substance,  in  some  parts  of  the 
growth  being  even  diffluent :  generally  here  and  there  a  few  spheroidal  cells 
are  found ;  it  pursues  a  course  similar  to,  but  somewhat  slower  than,  that  of 
other  carciiioniata. 

Seats  of  Predilection. — The  stomach,  intestine,  omentum,  ovary,  and 
occasionally  the  mammary  gland. 

Diagnosis  of  the  Carcinomata. — They  are  exceedingly  rare  before 
thirty  years  of  age,  and  are  common  after  forty  years  ;  early  lymphatic  involve- 
ment is  the  rule — contrary  to  what  is  true  of  the  sarcomata.  Innocent  growths 
occur,  as  a  rule,  in  younger  patients,  do  not  grow  so  rapidly,  do  not  infiltrate 
the  organ  or  neighboring  parts — i.  e.  do  not  become  adherent — and  almost 
never  ulcerate  ;  and  when  ulceration  does  occur,  the  characteristics  of  the  result- 
ino-  ulcer  diifer  widely  from  those  of  the  ulcer  attendant  upon  carcinoma. 
It  is  said  that  carcinoma  never  attacks  the  testicle  in  the  child,  but  that 
at  any  age  a  malignant  tumor  of  the  testicle  which  on  section  contains  either 
cartilage  or  bone  cannot  be  carcinomatous,  but  is  sarcomatous.  While  it  is 
usually  easy  to  make  the  diagnosis  of  carcinoma,  yet  at  times  this  is  difficult 
or  impossible,  competent  surgeons  having  removed  breasts,  believing  them 
to  be  carcinomatous,  when  the  disease  was  simply  cystic  or  merely  a  chronic 
abscess.  There  is  no  means  of  distinguishing  that  very  rare  condition,  encap- 
sulated carcinoma,  from  a  benign  tumor — e.  g.  a  fibroma.  Between  chronic 
mastitis  or  abscess  and  carcinoma  the  association  of  pregnancy  or  lactation  in 
most  instances  when  the  mamma  is  the  organ  involved  will  assist  in  the 
diagnosis,  while  the  greater  density  of  carcinoma  and  its  unequal  consistence 
in  its  different  parts  when  undergoing  softening  will  often  remove  all  doubt. 
Unfortunately,  the  skin  over  a  chronic  abscess  and  that  over  a  softening  car- 
cinoma are  not  so  dissimilar  in  appearance  as  to  preclude  all  chance  of  error, 
especially  as  the  glands  may  be  enlarged  in  both  affections.  The  decided 
elasticity  of  a  cyst,  even  if  fluctuation  cannot  be  detected,  its  circumscription, 
and  its  free  mobility,  serve  to  distinguish  this  class  of  tumors  from  carcinoma. 
It  is  far  better,  in  any  case  of  doubt  whether  the  tumor  is  really  an  abscess, 
a  cyst,  or  a  softening  carcinoma,  either  to  explore  with  a  hypodermatic  needle 
or  at  the  time  of  operation  to  make  first  an  exploratory  incision  directly  into 
the  tumor. 

(D)  The  Epitiielial  Carcinomata. — 1.  The  Squamous-celled  Epithe- 
LIOMATA  always  spring  either  from  free  epithelium-clad  sui'faces,  as  the  skin  or 
mucous  membranes,  or  from  the  glands  of  the  same,  since  the  hair  and  sebaceous 
glands  in  certain  instances  have  been  observed  to  take  the  initiative  in  the  carci- 
nomatous process.  These  growths  appear  w  ith  great  frequency  at  the  points  of 
junction  of  mucous  and  cutaneous  surfaces  (PI.  IX,  Fig.  1),  probably  because  there 
subjected  to  more  frequent  and  varied  forms  of  mechanical  and  chemical  irrita- 
tion. Structurally,  they  are  composed  of  pegs  or  columns  of  squamous  cells,  which 
infiltrate  first  the  subjacent  connective  tissue,  then  every  underlying  structure, 
including  bone,  in  their  track.  The  epithelial  ingrowths  contain  globular  masses 
of  flattened  cells,  the  so-called  "  cell-nests ' '  or  epidermic  pearls.  The  surrounding 
fibrous  stroma  is  usually  infiltrated  with  small  cells.  Epithelioma  commences 
either  as  a  wart-like  growth,  a  flattened  tubercle,  or  a  fissure,  ulceration  in  all 
these  forms  setting  in  early.  In  many  instances  this  proceeds  with  such  rapidity 
that  the  tumor-formation  barely  keeps  pace  with  it,  the  resulting  disease  resem- 


-^1  t  J.V   AMERICAN    TEXT-IIOOK    OF   sriiCEIiY. 

bling — luid  bciii;^  ofton  mistaken  for — an  ulcer,  the  indurated  hasc  and  margins 
either  escaping  detection  or  being  looked  upon  as  inflammatory.  The  other  ex- 
treme is  often  met  with  where  tumor-formation  is  in  excess,  only  supcrfuial  ulcer- 
ation obtaining  until  the  growth  is  of  considerable  size.  Epitheliimiata  are  not 
encapsulated,  although  upon  section  their  margins  ajipear  sharjdydeiiiicd  from  the 
surrounding  tissues,  while  the  cut  surface  is  white,  dense,  homogeneous,  poor 
in  juice,  but  if  compressed  laterally  giving  vent  to  milk-white,  tAvisted,  thread- 
like masses  which  have  been  likened  to  the  "  comedones  "  that  can  be  pressed 
out  from  the  sebaceous  glands  of  the  skin.  The  consistence  varies  much,  but  is 
distinctly  greater  than  that  of  the  surrounding  tissues,  and  the  part  feels  dense 
and  inelastic.  Although  an  epitheliomatous  ulcer  may  resemble  that  residting 
from  any  other  form  of  carcinoma,  yet  sometimes  it  is  a  mere  fissure  with  indu- 
rated margins,  a  relatively  indolent  ulcer  with  the  same  peculiarities,  or  has 
superadded  numerous  papillary  projections,  producing  a  warty  or  cauliflower- 
like growth.  When  originating  from  an  old  wart — a  not  unusual  occurrence — 
ulceration  is  apt  to  be  the  first  symptom,  with  subsequent  induration  of  the  base 
of  the  growth.  The  same  remarks  are  applicable  to  many  cases  of  c))ithelioma 
of  the  tongue,  where  an  indolent  ulcer  may  last  for  weeks  before  the  charac- 
teristic induration  of  its  base  and  margins  can  be  detected.  The  rate  of  growth 
varies  with  the  vascularity  and  looseness  of  texture  of  the  tissues.  Thus,  when 
attacking  the  lower  lip  the  progress  is  slow,  lasting  sometimes  for  a  year  or  more 
before  the  tumor  attains  a  size  greater  than  that  of  a  cherry,  Avhile  relativelv 
bulky  tumors  will  form  in  a  few  months  in  carcinoma  linguiie. 

"  Spontaneous  fracture  "  or  gradual  bending  of  the  tibia  is  not  unconnuon 
from  the  infiltration  of  that  l)one  by  cancerous  tissue,  either  when  an  old  ulcer 
undergoes  a  malignant  change  (Marjolin's  ulcer),  or  when  a  scar,  after  long-indo- 
lent ulceration,  commonly  starting  at  its  center,  becomes  similarly  diseased.  In 
like  manner  complete  solution  of  continuity  of  the  lower  jaw  may  result  from 
epithelioma  of  the  lip  extending  to  the  gums  and  thence  to  the  bone.  Local 
recurrence  is  common  after  operation  when  the  removal  has  been  imperfect,  and 
death  usually  results  from  the  exhaustion  incident  to  ulceration  and  hemorrhage. 
Secondary  lymphatic  involvement  occurs  with  most  squamous-celled  epithelio- 
mata,  but  usually  late  in  the  disease,  when  the  antrum,  the  interior  of  the  larynx, 
or  the  skin  of  the  eyelids,  nose,  and  other  parts  of  the  face  is  attacked.  In  these 
latter  situations,  indeed,  the  disease  being  apt  to  be  superficial  and  of  that  form 
called  "rodent  ulcer,"  the  glands  are  rarely  affected.  The  exception  in  the 
case  of  the  intrinsic  parts  of  the  larynx  is  the  more  striking  l)ecause  epithe- 
lioma of  the  extrinsic  parts  affects  the  glands  certainly  and  early.  Visceral 
involvement  is  rare,  the  liver,  lungs,  kidneys,  bone,  and  skin  suffering  most 
frequently. 

Seats  of  Predilection. — Any  cutaneous  or  mucous  surface  covered  with 
squamous  epithelium.  When  the  disease  attacks  the  skin,  the  parts  most  com- 
monly involved  are  the  nose,  the  lower  lip,  the  j)enis  and  scrotum,  the  vulva,  the 
anus,  and  more  rarely  the  hands  and  feet.  The  nnicous  surfaces  most  commonly 
affected  are  those  of  the  tongue,  palate,  gums,  tonsils,  larynx,  pharynx,  and 
oesophagus  down  to  the  cardiac  orifice  of  the  stomach,  the  bladder,  and  os  uteri. 

Diagnosis. — The  disease  is  very  uncommon  under  thirty  years  of  age ;  it 
is  quite  common  after  forty  :  it  is  limited  in  some  of  its  forms,  as  epithelioma 
of  the  lower  lip,  almost  exclusively  to  men,  and,  wherever  occurring,  attacks 
men  much  more  fret^ucntly  than  women.  If,  then,  a  man  of  from  forty  to 
seventy  years  of  age  develops  a  small  tumor  in  the  lower  lip  which  ulcerates 
early,  giving  rise  to  an  indolent,  slowly-extending  sore,  with  indurated  base  and 
margins,  no  evidence  of  surrounding  inflammation  being  detectable,  the  ulcer  per- 


TUMORS.  215 

hai)s  prescnitinp;  tliepoonliar  AN  artv,eanlillo\\  or  surface  mentiono(l,an(l  es])ecially 
if  the  subnuixilhiry  <fhiiids  are  enlarged,  the  disease  may  be  safely  considered  car- 
cinomatous. Or,  again,  an  obstinate  fissured  ulcer,  often  scabbed  over,  forms  in 
the  same  situation,  discharging  a  watery  matter,  ^s\i\\  induration  extending  in  all 
directi(uis  for  full  one-fourth  to  one-half  of  an  inch,  involving  notoidy  the  mucous 
and  cutaneous  tissues,  but  all  the  structures  of  the  lij);  perhaps  in  addition  the 
j)atient  states  that  the  disease  first  a])peared  as  a  Avart  Avhich  had  been  picked  off 
or  cauterized — /.  e.  had  been  irritated,  not  destroyed.  Epithelioma  of  the  tongue 
may  appear  at  an  earlier  age,  and  in  from  three  to  six  months  will  often  reach  a 
considerable  size  in  the  rarer  form,  -where  the  disease  appears  as  a  hardened,  non- 
inflauuMl  mass  on  the  free  border  of  the  tongue — not  uncommonly  near  a  broken 
tooth — its  surface  eventually  becoming  fissured,  ulcerated,  and  painful.  Or, 
again,  there  may  be  merely  an  indolent,  slowly-extending,  unhealthy  ulcer  with 
indurated  base  and  margins  situated  as  just  mentioned.  Although  the  diagnosis 
between  carcinoma  and  tubercle  or  syphilis  of  the  tongue  is  often  difficult,  coex- 
isting syphilitic  lesions  or  old  scars  of  the  tongue,  with  antisyphilitic  treatment, 
will  usually  settle  the  question,  while  signs  of  tubercle  elsewhere  ought  to 
arouse  grave  doubt  of  the  carcinomatous  nature  of  the  ulcer.  Further  diag- 
nostic points  are  given  in  the  section  on  Syphilis. 

Warts  on  the  hands  or  scrotum,  or  elsewhere,  in  elderly  chimney-sweeps 
or  in  coal-tar-  or  paraffin-workers  should  be  vicAved  with  suspicion,  especially  if 
they  are  growing  and  if  their  bases  are  becoming  indurated,  because  in  such 
cases,  sooner  or  later,  an  unhealthy  ulcer,  discharging  foul  matter,  usually  forms, 
presenting  all  the  clinical  evidences  of  epithelioma.  It  hardly  needs  to  be  said 
that  epithelioma  is  evidently  induced  by  persistent  irritation,  since  the  localities 
where  it  occurs  are  subjected  to  frequent  slight  traumatisms,  and  the  occupations 
which  give  rise  to  it  supply  constant  sources  of  mechanical  and  chemical  irritation. 

Local  recurrence  is  common  after  operation  as  a  consequence  of  imperfect 
removal  of  the  disease,  and  death  in  these  cases,  as  Avell  as  in  those  not  operated 
upon,  results  from  the  exhaustion  incident  to  ulceration  and  hemorrhage  rather 
than  to  dissemination,  which,  as  has  been  already  pointed  out,  is  of  rare  occur- 
rence. 

2.  Cylindrical-  or  Columnar-celled  Epithelioma. — This  is  a  less 
common  form  of  carcinoma  than  the  spheroidal-celled  or  the  squamous-celled 
varieties,  and  originates  from  either  the  cylindrical  surface  epithelium  of  a 
mucous  membrane  or  that  of  its  glands,  closely  imitating  these  structures  in 
microscopical  appearance;  no  "cell-nests"  are  found.  These  growths  form 
indurated,  infiltrating  masses  in  the  walls  of  the  organs  attacked,  and  vary 
much  in  the  rapidity  of  their  course,  producing  considerable  stenosis  of  the 
lumen  of  such  hollow  viscera  as  the  rectum  and  small  intestines,  which  may  ter- 
minate life  by  producing  more  or  less  intestinal  obstruction  ;  ulceration  occurs 
early.  Dissemination  throughout  the  liver,  lungs,  and  other  organs  occurs,  as 
a  rule,  only  after  infection  of  the  intervening  lymph-glands.  (See  Diseases  of 
the  Intestines  and  Rectum.) 

Seats  of  Predilection. — The  rectum,  uterus,  and  intestinal  tract. 

Diagnosis. — This  is  to  be  made  by  attention  to  certain  secondary  results, 
which  will  be  found  detailed  in  the  sections  on  Diseases  of  the  Intestines  and 
Rectum. 

Treatment  of  the  Carcinomata. — The  first  question  to  be  answered  is, 
Can  this  case  be  treated  radically,  or  does  it  admit  only  of  palliation  ?  If  it 
can  be  treated  radically,  the  whole  organ  should  be  excised,  including  as  much 


21(1  AN  AMERICAN   TEXT- HOOK    OF  SURGERY. 

as  can  safely  be  removed  of  tlie  surrounding  aj^j^arentlij  healthy  tissues,  before 
lymphatic  involvement  has  occwred,  if  possible :  after  this  involvement  lias  taken 
place  the  primary  growth  must  be  removed  with  an  unsparing  hand,  while  the 
lymphatic  glands  and  peri-adenoid  tissues  must  be  thoroughly  cleared  out. 
Indeed,  if  this  last  all-essential  recjuisite  cannot  be  secured,  removal  of  the  r)ri- 
mary  growth  is  indicated  only  for  the  relief  of  }>ain,  or,  if  ulceration  has  set  in,  to 
get  rid  of  a  disgusting  sore.  For  instance,  in  a  case  of  mammary  carcinoma,  if 
axillary  glandular  involvement  is  present,  and  there  is  any  question  as  to  the  pos- 
sibility of  clearing  the  axilla,  as  a  preliminary  to  further  operative  interference 
an  incision  should  be  made  into  the  armpit  to  determine  whether  all  diseased  tissue 
can  be  removed.  If  this  cannot  be  done — unless  the  breast  tumor  is  ulcerated, 
when  removal  may  be  indicated  as  a  palliative  measure — the  wouikI  should 
be  closed  and  the  breast  allowed  to  remain,  since  its  removal  would  add  a  risk 
with  no  compensating  advantage.  (See  Diseases  of  the  Breast.)  Amputation 
of  the  limb  high  up,  with  extirpation  of  any  diseased  glands,  is  always  in- 
dicated where  epithelial  carcinoma  has  invaded  the  bone  from  an  overlying 
tumor,  as,  for  instance,  the  tibia.  Malignant  disease  of  such  parts  as  the  penis 
and  the  tongue  is  properly  treated  by  amputation  of  these  organs,  even  Avhen 
secondary  glandular  disease  is  beyond  removal,  merely  as  a  palliative  measure 
to  secure  urination  in  the  former  case  and  painless  swallowing  in  the  latter. 

Epitheliomata  of  the  lips,  nose,  and  eyelids  can  often  be  successfully 
removed  by  the  knife  even  when  extensive,  and  the  defects  can  be  repaired  by 
plastic  operation  or  by  Thiersch's  method  of  skin-grafting.  The  more  super- 
ficial forms  can  often  be  effectively  handled  by  freezing  with  rhigolene  spray, 
thoroughly  curetting,  the  application  of  pyrogallic  acid,  and  an  after-dressing 
with  an  ointment  of  the  same  (grs.  x@3j),  until  healthy  granulations  are 
formed,  when  ordinary  measures  will  secure  healing  or  Thiersch's  skin-grafting 
may  be  used.  Potassa  fusa  or  the  actual  cauterj^  may  be  employed  as  the  destruc- 
tive agent,  and,  after  separation  of  the  slough,  the  defect  may  be  left  to  Nature's 
efforts  or  skin-grafting  may  be  resorted  to.  The  chances  of  cure  vary  with  the 
part  involved,  but  even  Avith  extensive  glandular  comi)lications,  where  complete 
extirpation  is  possible,  some  carcinomata  of  the  lip,  tongue,  and  breast  do  not 
recur  either  locally  or  in  the  viscera.  Carcinomata  of  the  testicle,  oesophagus, 
or  tonsil  are  rarely  benefited  by  operation,  except  for  the  palliation  effected. 
When  operation  is  concraindicated,  opium  to  relieve  pain,  local  aj)plications 
of  lead-Avater  and  laudanum,  extract  of  aconite  and  Ijelladonna  rendered  of  a 
proper  consistence  by  glycerin,  or  other  similar  remedies,  with  attention  to  the 
general  health,  constitute  the  treatment  in  non-ulcerated  carcinomata.  For 
ulcerated  carcinomata  measures  to  control  pain,  to  lessen  discharge  or  hemor- 
rhage, and  to  arrest  fetor  are  the  main  indications.  Iodoform  with  mor})hine  in 
proper  amount  dusted  over  the  surface,  cocaine  in  solution  apjdicd  either  by 
spray  or  by  painting,  solutions  of  carbolic  acid,  Labarraque's  solution,  or  a  solu- 
tion of  chloral  may  be  used,  as  far  as  possible  employing  dry  dressings  or  those 
which  favor  rapid  drying  of  the  discharges — i.  e.  lessen  putrefactive  changes. 
Esmarch's  arsenical  powder  also  serves  an  admirable  purpose.  No  internal 
remedies  of  the  many  recommended  having  as  yet  proved  of  any  real  value, 
none  need  now  be  mentioned.  Finally,  the  profession  should  clearly  under- 
stand, and  endeavor  to  educate  the  public  in  the  belief,  that  carb/  and  radical 
operations  ivill  cure  a  considerable  proportion  of  cases,  and  render  life  endura- 
ble in  many  more  where  a  cure  is  impossible. 

III.  Tumors  composed  of  Epiblastic,  Hypoblastic,  and  Mesoblastic 
Elements,  and  containing  bone,  hair,  teeth,  etc.  (Teratomata),  situated  in 


TUMORS.  217 

the  ovaries  and  testicles.     These  are  considered  with  these  organs,  especially 
with  the  ovaries. 

Cysts. 

A  cyst  may  be  defined  as  a  cavity  bounded  by  a  distinct  envelope  composed 
of  fibrous  tissue  lined  with  endothelium,  and  called  the  cyst-wall;  or  it  may 
be  covered  by  epithelium  and  contain  secreting  structures :  the  cyst-contents 
may  be  either  fluid  or  semi-fluid  ;  intracystic  growths  may  nearly  or  completely 
fill  the  cavity.  A  cyst  may  result  from  the  increase  of  the  normal  secretion  of 
an  already-formed  space  or  cavity  by  extravasation  into  it,  or  the  cavity  may 
be  of  new  formation. 

I.  Cysts  formed  hy  the  Distention  of  Preformed  Cavities  or  Sjjcices : 

{a)  Exudation  cysts ; 
(/>)  Retention  cysts ; 
((')  Extravasation  cysts. 

II.  Cysts  of  New  Formation : 

(a)  Simple  cysts ; 

(b)  Blood  cysts. 

III.  Cysts  of  Congenital  Origin. 

IV.  Cysts  due  to  Parasites. 

I.  Cysts  formed  by  the  Distention  of  Preformed  Cavities  or  Spaces. 

Exudation  Cysts  result  w'hen  excessive  secretion  takes  place  into  closed 
cavities,  such  as  bursse,  cysts,  bronchoceles,  etc. 

Retention  Cysts. — These  possess  a  distinct  fibrous  wall  lined  with 
epithelium,  and  are  caused  by  obstruction  of  the  duct  of  a  gland  or  portion  of 
a  gland,  the  continuous  secretion  producing  dilatation  of  the  duct  or  gland- 
acinus.  In  most  instances,  as  a  result  either  of  inspissation  of  the  contents 
or  of  the  mingling  with  them  of  exudation-products  from  the  cyst-walls,  the 
normal  character  of  the  secretion  is  totally  altered.  According  to  their  origin, 
three  sub-classes  are  usually  described — viz.  (1)  >S'<'irt<?^'o«s  (atheromatous)  cysts, 
formed  by  the  dilatation  of  sebaceous  glands ;  (2)  3Iucous  cysts,  due  to  the 
dilatation  of  mucous  glands ;  and  (3)  Cysts  formed  by  the  distention  of  large 
ducts — i.  e.  the  salivary,  lacteal,  hepatic,  renal,  etc. 

(1)  Sebaceous  (atheromatous)  Cysts  present  themselves  as  smooth,  flattened 
ovoidal,  sometimes  semi-fluctuant  tumors,  usually  movable  on  the  deeper  parts, 
but  often  adherent  to  the  skin.  At  times  the  orifice  of  the  obstructed  duct 
can  be  seen,  indicated  by  a  small  black  spot. 

Seats  of  Predilection. — The  scalp  and  face  chiefly,  but  they  may  be 
found  on  any  part  of  the  body,  and  are  often  multiple.  When  situated  in  the 
scalp  they  are  sometimes  apparently  hereditary.  Unlike  dermoid  cysts,  the 
pultaceous,  cheesy  contents — often  of  an  oft'eusive  odor — contain  no  hairs, 
while  the  cyst-wall  possesses  neither  papillie  nor  hair-follicles.  Certain  second- 
ary changes  may  greatly  alter  their  appearance  and  obscure  the  diagnosis. 
Thus  by  inflammation  a  sebaceous  cyst  may  be  converted  into  an  abscess : 
after  spontaneous  opening  the  thinned  coverings  may  ulcerate,  abundant  fungous 
granulations  may  form,  and  the  margins  and  base  of  the  sore  may  become  indu- 
rated and  elevated,  closely  resembling  epithelioma.  These  fungous  sores  may  also 
undergo  actual  epitheliomatous  change :  a  portion  of  the  coverings  ulcerating, 
the  secretion  may  be  gradually  forced  out,  drying  as  it  protrudes,  thus  in  time 


•2\^  AN  AMERICAN    TF.XT-HOOK    OF  SURGERY. 

forming  a  cutanoous  Lorn,  sometimes  inelies  iu  Icugth  ;  linally,  calcification  of 
the  cyst-wall  may  take  place. 

Diagnosis. — They  are  most  apt  to  be  mistaken  for  fatty  tumors  or  chronic 
abscess.  From  the  former  they  can  be  distinjfuished  by  the  fact  that  the  edge 
of  a  cyst  does  not  slip  away  from  the  finger  wjicn  pressed  upon,  l)y  the  absence 
of  dimpling  of  the  overlying  skin,  and  when  present  by  the  l)lack  punctum 
indicating  the  duct-mouth  ;  from  the  latter,  by  the  absence  of  symptoms  of 
inHannuation  and  by  the  use  of  the  grooved  needle.  When  suppuration  has 
occurred,  one  of  the  degenerative  changes  already  mentioned,  the  symptoms 
of  suppurative  inflanunation,  the  increase  in  size,  and  the  exploring  needle  if 
recjuisite,  will  demonstrate  the  condition.  In  those  rare  instances  where  a 
fungating  ulcer  follows  sujipuration  of  a  cyst,  proper  tlierapeutie  measures  will 
cause  it  to  heal  in  a  reasonable  time,  thus  demonstrating  tliat  it  is  not  epithe- 
liomatous.  If  healing  cannot  be  secured,  the  ulcer  has  probably  undergone 
epitheliomatous  change  in  whole  or  in  part.  When  such  change  has  attacked 
the  ulcer  before  the  surgeon  sees  the  case,  the  diagnosis  must  depend  upon  the 
})resence  of  the  characteristics  described  as  indicative  of  this  disease,  together 
with  the  history. 

Treatment. — AVhen  situated  upon  the  face,  if  the  orifice  of  the  obstructed 
duct  can  be  discerned,  it  may  be  dilated  with  a  small  probe  and  the  contents 
of  the  sac  pressed  out,  this  procedure  being  repeated  from  time  to  time,  thus 
avoiding  any  scar ;  but  final  success  is  rarely  attained,  and  the  method  is  of 
very  little  value.  Removal  of  every  portion  of  the  cyst-wall  is  usually  the  best 
treatment,  and  this  can  be  most  readily  done  by  transfixion  of  the  cyst  and  over- 
lying integument  with  a  curved  bistoury,  pressing  out  the  contents,  and  tlien 
grasping  the  edges  of  the  cyst-wall  Avith  two  pairs  of  forceps,  twisting  and  pull- 
ing out  each  half.     If  too  adherent  for  this,  careful  dissection  Avill  be  recpiired. 

2.  Mucous  Cysts  arise  from  dilatation  of  raucous  glands,  their  walls  being 
comparatively  thin  and  their  contents  a,  viscid  mucoid  fluid  in  Avhich  cholesterin 
is  sometimes  present.  They  form  in  the  mouth  one  variety  of  rcmula :  so-called 
dropsy  of  the  antrum  is  sometimes  due  to  cystic  dilatation  of  one  of  the  mucous 
glands  of  its  lining  membrane. 

Seats  of  Predilection. — The  lips,  mouth,  antrum,  labia,  and  indeed 
wherever  mucous  glands  exist. 

Treatment. — Excision  of  a  considerable  portion  of  the  cyst-wall,  and 
applications  to  tbe  interior  which  will  destroy  the  secreting  surface.  (See 
Diseases  of  the  Mouth  and  Antrum.)  Descriptions  of  cysts  formed  by  the 
dilatation  of  such  ducts  as  those  of  Wharton  (forming  ranula),  of  the 
breast  {(/alactocele),  etc.  will  be  found  in  the  sections  on  the  diseases  of 
those  organs. 

3.  Extravasation  Cysts  result  from  hemorrhage  into  closed  cavities, 
as  that  of  the  tunica  vaginalis  testis  (hematocele).  Some  authors  describe 
extravasations  into  softened  portions  of  solid  tumors,  or  into  the  cellular  tissue 
which  condenses  around  the  effusion,  as  extravasation  cysts. 

II.  Cysts  of  New  Formation. 

(a)  Simple  or  Serous  Cysts  (Fig.  30)  possess  a  thin  wall  lined  with 
endothelial  cells,  and  contain  a  serous  or  thick  mucoid  fluid.  They  originate 
from  effusion,  which  takes  place  into  the  lymph-spaces  of  the  connective 
tissue  from  the  local  irritation  of  pressure,  and  ])ush  aside  the  bundles  cov- 
ered with  endothelial  plates  until  they  are  condensed  into  a  cyst-wall  covered 


TUMORS. 


219 


Serous  Cyst  of  the  Neck  (original). 


more  or  less  complctoly  witli  eiidotliclial  cells :  this  is  the  method  of  forma- 
tion of  an  adventitious  hursa.      Sini])le  cysts  of  the  hi'cast  are  siiuihirly  pro- 
duced, and  ))ossibly.  some  of  the  neck,  although  most  of  these  are  of  congeni- 
tal origin,  the  result  of  abnormal- 
ities of  the  lymphatic  vessels  pro-  ^^o-  30. 
ducing    cavernous    changes.    Avhile 
those    occupying   the    nn-dian    line 
of  the  neck  arise  from  effusion  into 
some  of  the  normal  bursal  sj)aces 
of  that  region — /.  f.  antethyroid  or 
infrahyoid  bursse. 

{b)  Hkmatomata,  or  Blood- 
Cysts. — There  are  two  varieties, 
the  first  being  usually  found  in  the 
cervical  region,  and  consisting  of 
thin-walled  cavities  containing  pure 
blood :  their  mode  of  origin  is 
doubtful,  but  they  appear  to  have 
some  direct  communication  with 
the  veins,  because  if  tapped  or  in- 
cised they  often  bleed  profusely. 
The  second  variety  arises  from  the 
mechanical  and  inflammatory  con- 
densation of  the  tissues  around  an 
extravasation  of  blood,  which  may 
eventually  be  absorbed  or  undergo 
so-called  organization ;  or  the  blood  may  remain  liquid,  disintegrate,  and  be 
absorbed;  or  suppuration  may  ensue.  This  form  results  from  injury,  and  is 
situated  most  commonly  beneath  the  scalp,  especially  in  newborn  infants. 
(See  Cephalhematoma.) 

So-called  compound  proliferous  cysts,  such  as  those  found  in  the  breast  and 
ovary,  are  merely  instances  of  primary  cystic  change  in  these  organs,  Avhere, 
as  a  result  of  secondary  developmental  changes,  ingrowths  occur  arising  from 
the  cyst-walls. 

III.  Cysts  of  Congenital  Origin. 

These  result  either  from  inclusion  of  a  portion  of  the  epiblastic  layer  within 
the  mesoblast,  or  from  the  distention  of  the  cavity  of  some  persistent  foetal 
structure  which  should  normally  have  become  obliterated ;  for  instance,  broad- 
ligament  cysts  developing  from  the  parovarium,  and,  dermoid  cysts,  as  alleged, 
by  the  inclusion  of  a  blighted  ovum  in  either  the  testicle  or  the  ovary.  Since 
all  except  dermoid  cysts  of  the  external  parts  will  receive  special  mention 
elsew'here,  only  this  variety  of  cyst  Avill  be  here  described.  The  cyst-wall  contains 
hair-follicles  and  sebaceous  glands,  while  the  contents  are  formed  of  the  secretion 
of  these  structures,  of  disintegrated  epithelial  cells,  and  of  hairs  Avhich  have  been 
shed.  They  often  have  absolutely  no  connection  with  the  skin,  and,  occurring 
about  the  face  and  head  where  in  the  embryo  fissures  exist,  are  probably  the 
result  of  inclusion  of  a  portion  of  epiblast.  Similar  tumors  of  the  ovary  and 
testicle  which  contain  bone,  cartilage,  and,  in  the  case  of  the  ovary,  teeth,  as 
before  said,  have  been  ascribed  to  inclusion  of  a  blighted  ovum,  but  this  is  at 
least  non-proven. 

Seats  of  Predilection. — The  outer  angle  of  the  orbit,  over  the  root  of 
the  nose,  the  ovaries,  and  the  testicle. 


2'2y)  AX  AMEItrCAN   TEXT-BOOK   OF  .SURGERY. 

Diagnosis. — This  must  depend  ui)uii  the  detection  of  a  glohular,  tense, 
smooth  tumor,  usually  situated  at  the  outer  angle  of  the  orbit,  unattached  to 
the  skin,  trenerally  freely  movable  ui)on  the  deeper  parts,  if  overlyin;:  the  bone 
often  causing  its  partial  or  complete  absorption,  and  of  congenital  origin. 
Processes  of  these  cysts  sometimes  extend  deej)ly  into  the  orl)it,  or  even  into 
the  cranial  cavity.  (For  Ovarian  and  Testicular  Dermoid  Cysts,  see  the 
aj)pr(ii)riate  sections.) 

Treatment. — Removal  by  careful  dissection,  making  the  necessary  incis- 
ions in  such  a  manner,  if  possible,  that  they  shall  coincide  with  the  natural 
wrinkles  of  the  parts,  or  that  some  other  structure,  as  the  evebrow,  shall 
conceal  the  scar.  Removal  of  congenital  hydroceles  of  the  neck  bv  the  knife 
is  sometimes  impracticable.  From  their  great  extent  and  irregularities  any 
treatment  by  injection  and  drainage  requires  the  strictest  asepsis  lest  serious 
consequences  result. 

IV.  Cysts  due  to  the  Presence  of  Parasites. 

The  only  parasitic  cyst  of  surgical  importance — the  hydatid — is  that  pro- 
duced by  the  Taenia  echinococcus,  which  infests  the  intestines  of  the  dog. 
The  ova  reach  the  human  alimentary  tract  with  the  food  or  water,  are  there 
hatched,  migrate,  reach  the  blood-current,  and  lodge  in  some  organ,  develop- 
ing into  a  hydatid  tumor.  The  external  layer  of  the  cyst-wall  is  composed 
of  a  '"''  highly  elastic,  lamellar  cuticle  ;"  the  internal  layer  consists  of  "  granu- 
lar matter,  cells,  muscle-tissue,  and  a  water-vascular  system  "  (Sutton).  A 
more  or  less  complete  adventitious  fibrous  capsule  isolates  the  true  cyst-wall 
from  the  surrounding  tissues.  Upon  attaining  the  diameter  of  an  inch  or 
more,  from  the  mother-cyst  small  vesicles  or  '"  broad  capsules  "  form,  which 
develop  retractible  heads  or  ''scolices,"  each  about  0.3  mm.  long,  having 
four  '"sucking-disks  and  a  circlet  of  minute,  blunt  booklets."  Daughter- 
cysts  form  from  the  '"blood-capsules,"  and  possibly  from  the  '"  scolices, "  the 
rapid  enlargement  seen  where  pressure  does  not  interfere  resulting  from  the 
increase  in  number  of  these  capsules  and  daughter-cysts.  Sometimes  even 
large  cysts  contain  neither  capsules  nor  vesicles,  being  then  sterile,  but  are 
recognizable  by  the  characteristic  lamellation  of  the  cyst-wall.  Multiloeular 
hydatids  consist  of  aggregations  of  innumerable  small  vesicles — usually  ster- 
ile— varying  in  size,  few  larger  than  a  pea,  which  are  not  contained  in  a 
mother-cyst.  The  bones  and  spinal  cord  are  the  usual  sites  for  this  variety. 
Hydatids  eventually  cease  to  grow,  die,  shrivel,  and  become  calcified,  leaving 
only  the  booklets  to  enable  the  microscopist  to  determine  the  nature  of  the 
mortar-like  mass.  Rapid  growth  of  daughter-cysts  may  produce  necrosis  of 
the  mother-cyst  with  rupture.  "When  related  to  the  trachea,  stomach,  or 
intestines,  pressure-absorption  may  permit  osmosis  of  gas,  fluid,  or  air ;  the 
hydatid  dies,  septic  germs  gain  access,  and  suppuration  ensues.  Hydatids 
may  also  rupture  into  some  one  of  the  hollow  viscera,  a  termination  to  be 
dreaded,  as  possibly  productive  of  instant  death  or  secondary  changes  ulti- 
mately lethal,  although  cure  sometimes  results. 

Seats  of  Predilection. — Liver,  kidney,  omentum,  bones,  thyroid  gland, 
spinal  canal,  brain,  lungs,  and  connective  tissue. 

Treatment. — The  cyst,  when  possible,  must  be  removed  entire.  If  total 
removal  is  not  feasible,  incise,  evacuate;  when  possible  remove  the  cyst-wall, 
leaving  the  capsule,  and  carefully  drain.  Never  aspirate  or  merely  puncture 
except  for  diagnostic  p>urposes. 


BOOK  IT. 

SPECIAL   SURGERY. 


CHAPTER  I. 

SURGERY   OF  THE  VASCULAR  SYSTEM. 
SECTION   I.-DISEASES  OF  THE  HEART  AND  PERICARDIUM. 

The  diseases  of  tlie  heart  which  may  demand  surgical  interference  are 
those  which  are  accompanied  by  over-distention  of  the  ventricles  or  by  eflusion 
nto  the  pericardial  sac  In  order  to  understand  how  to  relieve  these  conditions 
by  surgical  means  it  is  necessary  to  study  the  anatomy  of  the  heart  and  of  its 
covering.  In  the  healthy  chest  the  heart  is  contained  m  a  space  extending 
oblique!y  in  front  from  the  third  to  the  sixth  costal  cartilage,  am  horizontally 
generallv  from  half  an  inch  to  the  right  of  the  right  border  of  the  sternum  to 
a  point  half  an  inch  to  the  right  of  the  left  nipple.  Posteriorly  it  occupies  the 
space  corresponding  to  that  between  the  fourth  and  eighth  dorsal  spines.  The 
au  cles  ai/on  a  Tevel  with  the  third  costal  cartilage.  The  pu  monary  artery 
covers  anteriorly  the  left  auricle.  The  right  ventricle  is  partly  behind  the 
steinum  and  partly  to  the  left  of  it.     The  left  ventricle,  except  at  its  apex,  is 

behind  the  right  ventricle.  ,  .  ,     ,     i        .  •  ^  ■     a       tv..:. 

The  pericSrdium  is  a  fibro-serous  sac  in  which  the  heart  is  contained  The 
base  of  the  sac  is  at  the  diaphragm,  and  the  apex  is  above  and  by  its  fibrous 
layer  is  connected  with  the  deep  cervical  fascia. 

^  OVER-DISTENTION  OF  THE  HEART  occurs  in  cases  of  pulmonaij  congestion 
of  an  acute  character.  The  operation  of  iai^ping  the  cavity  c>f  the  h<^^^rt  h^ 
been  suggested  with  the  view  of  relieving  the  dangerous  condition  under  which 
the  heaif  labors.  The  right  auricle  is  the  place  selected  for  punc.ui.  because 
the  position  of  that  cavity  is  less  sub  ect  to  alteration  m  its  relation  to  the  sui- 
rouifdi  .  parts,  and  because  the  antero-posterior  internal  diameter  is  greater 
San  tha°t  Jf  the  ventricle,  the  walls  of  which  are  also  much  thicker  than  those 

'^  'The  besf place  to  perform  paracentem  anricvli  is  the  third  intercostal  space 
at  the  ri'ht  edge  of  the  sternum.  The  needle  should  be  thrus  directly  back- 
wa  d!  The  op^eration  should  be  performed  as  quickly  as  possible  and  in  order 
To  abstract  a  sufficient  quantity  of  blood  with  celerity  it  is  necessar^  o  mt-du  ^ 
an  aspirating  needle  about  three  times  the  size  of  a  hypodermatic  needle.  Ihe 
needle  hould  be  rendered  perfectly  aseptic  before  it  is  thrust  into  he  auricle 
and  the  end  of  the  needle  should  be  attached  to  the  tube  of  an  aspirator  becau  e 
the  blood-pressure  is  not  sufficient  to  force  the  blood  out  through  a  canula.  The 
needle  must  pierce  the  skin  and  fascia,  the  edge  of  the  rig^lit  lung  and  the 
nleural  sac  covering,  it,  as  well  as  both  layers  of  the  pericardial  sac  before  it 
tZtrZi^^L-.^^^-  Tapping  the  cavity  of  the  heart  is  fraught  -th  ext  e 
dancer,  and  cannot  be  commended  except  in  special  and  unusual  cases,  and  even 
then  should  be  resorted  to  only  after  consultation. 


222  AN  AMERICAN    TEXT-BOOK   OE  SURGERY. 

Effusion  into  the  pericardium  occurs  as  a  result  of  acute  aiici  clironic 
pericarditis,  both  of  Avliich  conditions  may  arise  from  various  causes,  including 
traumatism.  Usually  the  effusion  is  moderate  and  undergoes  absorption.  Occa- 
sionally, however,  the  (juantity  becomes  excessive  and  gives  rise  to  alarming 
symptoms;  under  these  circumstances  ta])ping  of  tlie  pciicardial  sac  is  indi- 
cated. 

The  symptoms  dciioting  great  effusion  in  the  sac  are  precordial  oj)pres- 
sion,  syncojjc,  dysjjnea,  a])lionia,  feeble  and  irregular  pulse,  difficulty  of  deglu- 
tition, and  dilatation  of  the  veins  of  the  neck,  in  addition  to  the  signs  of  pericar- 
ditis during  the  different  stages.  An  inspection  of  the  chest  shows  that  the 
pericardial  sac  is  dilated  and  that  the  respiratory  movement  of  the  left  side 
is  impaired. 

The  physical  examination,  if  made  before  the  pericardial  surfaces  are  sep- 
arated by  the  fluid,  demonstrates  the  presence  of  a  pericardial  frictiori-sound, 
which  must  not  be  mistaken  for  an  endocardial  murmur.  The  distinKuishin<r 
feature  of  the  pericardial  friction-sound  is  that  it  does  not  possess  the  same 
regularity  of  rhythm  as  an  endocardial  murmur,  and  is  not  propagated  beyond 
the  limits  of  the  precordia.  Percussion  reveals  the  presence  of  flatness  over  an 
enlarged  precordial  space  both  laterally  and  vertically.  The  flatness  maps  out 
a  quadrilateral  or  a  pyriform  area  with  the  base  below  and  extending  to  both 
sides  of  the  heart-apex.  Auscultation  demonstrates  the  absence  of  vocal  reso- 
nance and  of  fremitus,  and  shows  muflling  of  the  heart-sounds.  The  apex-beat 
is  pushed  upward  and  to  the  left  on  account  of  the  eff"usion,  and  in  some  cases 
it  is  lost. 

Paracentesis  pericardii  should  be  employed  when  the  symptoms  threaten 
life.  For  purposes  of  positive  diagnosis  and  with  a  view  to  ascertaining  the 
character  of  the  fluid  an  aseptically  clean  hypodermatic  needle  can  be  introduced 
before  tapping,  after  which  an  aspirating  needle  can  be  used,  or  even  a  trocar, 
according  to  the  consistency  of  the  fluid.  The  best  point  for  introducing  the 
needle  is  at  the  fifth  intercostal  space,  two  inches  to  the  left  of  the  left  border 
of  the  sternum.  This  will  puncture  the  pericardium  external  to  the  internal 
mammary  artery.  The  direction  of  the  needle  should  be  backward.  The 
fluid  should  be  withdrawn  very  slowly,  and  the  eff"ects  of  the  removal  of  the 
eff'usion  carefully  watched.  The  operation  should  of  course  be  done  under  the 
strictest  antiseptic   precautions. 

Incision  and  drainage  of  the  pericardium  has  been  employed  in  cases  of 
empyema  of  the  pericardial  sac.  The  incision,  irrigation,  and  drainage  of  the 
sac  should  be  resorted  to  only  in  the  purulent  form  of  the  exudation.  The 
operation  should  be  performed  at  the  same  point  as  paracentesis  pericardii.  If 
necessary,  part  of  a  rib  may  be  resected.  Although  this  operation  has  as  yet- 
been  done  but  seldom,  the  great  mortality  of  empyema  of  the  pericardium  war- 
rants its  performance. 

SECTION   II.— INJURIES  OF  THE   HEART   AND   PERICARDIUM. 

Rupture  of  the  heart  has  followed  complete  obstruction  of  one  of  the 
branches  of  the  coronary  arteries,  the  obstruction  having  been  caused  by  a 
thrombus  or  by  an  embolus  in  the  artery.  Mechanical  distention  of  the  heart 
has  caused  rupture,  as  when  its  cavities  have  suddenly  been  filled  with  blood 
escaping  from  a  bursting  aneurysm,  or  when  an  a])scess  of  the  cardiac  walls 
has  burst  into  the  ventricles.  Rupture  of  the  heart  has  also  been  a  cause  of 
death  in  tetanus. 

Wounds  of  the  heart  are  not  infreciuent.     These  may  result  from  severe 


SURGERY   OF    THE    VASCULAR   SYSTEM.  22;i 

injury  of  the  chest-wall,  or  from  penetration  by  a  fragment  of  a  fractured  rib,  or 
by  a  stab  or  a  gunshot  wound.  A  wound  of  tlie  heart  is  not  necessarily  fatal, 
as  is  shown  in  the  case  where  a  needle  was  removed  by  Callender  from  the 
substance  of  the  heart.  Other  cases  of  like  nature  have  been  reported  by 
Halin,  Agnew,  Stelzner,  and  others. 

The  symptoms  of  wound  of  the  heart  are  not  characteristic.  Ilemor- 
rhai'e  is  usually  present,  but  a  stab  wound  may  occur  with  little  or  no  hemor- 
rhage. The  absence  of  hemorrhage  is  due  to  the  anatomical  arrangement 
of  the  muscular  fibers  of  the  heart.  Pain  is  present  as  a  constant  symptom, 
and  attacks  of  synco{)e  occur  at  frequent  intervals.  If  hemorrhage  has  taken 
place  into  the  pericardium,  the  percussion  note  is  flat  and  its  area  is  increased, 
owing  to  the  presence  of  the  fluid,  and  the  heart-sounds  are  less  distinct  than 
normal. 

Tlte  cause  of  sudden  death  in  wounds  of  the  heart  may  be  syncope  from 
pressure  on  the  heart  due  to  over-distention  of  the  pericardium  with  blood;  or 
the  inability  of  the  heart  to  contract,  owing  to  the  wound  of  the  cardiac  wall, 
may  produce  fatal  cerebral  anemia.  Shock  and  pulmonary  anemia  also  have 
caused  death  in  cardiac  wounds.  Death  is  not  always  sudden,  but  may  be 
deferred  for  hours  (Agnew). 

Treatment. — The  heart  has  been  sutured  successfully  in  several  re- 
})orted  cases. 

In  a  stab-wound  of  the  heart  Rehn  resected  the  fifth  rib,  and  exposed  a 
stab-wound  of  the  right  ventricle  1^  cm.  long.  He  sutured  the  wound  with 
«ilk  and  packed  the  pericardium  with  gauze,  and  the  patient  recovered.  Par- 
rozzani  sutured  a  stab-wound  of  the  left  ventricle,  and  the  patient  recovered. 
Durante  has  reported  a  case  in  which  a  stab-wound  of  the  left  ventricle  was 
•sutured  by  Fareni.  The  patient  lived  for  several  days,  and  died  from  a  cause 
unconnected  with  the  heart-injury.  Cappelan,  in  a  case  of  stab-wound  of  the 
heart,  resected  the  third  and  fourth  ribs  and  sutured  the  wound,  and  the 
patient  lived  for  two  and  a  half  days.  In  the  light  of  the  reports  of  Rehn, 
Parrozzani,  Durante,  and  Cappelan,  it  becomes  evident  that  wounds  of  the 
heart  should  be  sutured. 

Traumatic  Carditis  and  Pericarditis. — The  results  of  inflammation 
of  the  walls  of  the  heart  have  been  observed  in  cases  of  injury  of  the  organ 
where  the  patients  have  died  after  a  fortnight.  In  these  cases  the  substance 
of  the  heart  was  studded  with  inflammatory  exudates. 

Inflammation  of  the  pericardial  sac  is  a  more  frequent  result  of  traumatism 
than  inflammation  of  the  heart  itself.  The  physical  signs  of  a  pericarditis  of 
traumatic  origin  are  substantially  identical  with  those  of  an  ordinary  pericarditis. 

The  treatment  of  wounds  of  the  heart  and  of  traumatic  carditis  and 
pericarditis  includes  constitutional  as  well  as  local  measures.  The  patient 
should  lie  with  the  head  low,  in  order  to  prevent  syncope  from  cerebral 
anemia.  Absolute  quietude  should  be  insisted  upon,  and  opium  should  be 
administered  with  a  view  to  control  subsequent  inflammation,  to  tranquillize 
the  circulation,  and  to  relieve  pain.  Artificial  warmth  should  be  applied 
if  indicated  by  the  presence  of  collapse.  It  must  not  be  overlooked  that 
a  certain  amount  of  collapse  is  a  favorable  condition  through  its  influence  in 
checking;  hemorrhage  and  inflammation,  and  that  over-stimulation  must  be 
carefully  guarded  against.  In  some  cases  violent  reaction  follows  and  neces- 
sitates the  administration  of  cardiac  sedatives. 

If  a  patient  survives  beyond  the  period  of  reaction,  the  stage  of  inflamma- 
tion ensues.  This  condition  must  be  treated  in  the  same  manner  as  a  peri- 
carditis depending  upon  idiopathic  causes. 


224  ^^V   AMERICAN    TEXT-HOOK    OF  SURGERY. 

SECTION   III.— DISEASES  OF  THE  BLOOD-VESSELS. 
PART    I. DISEASES    OF    THE    VEINS. 

Before  discussing  diseases  of  the  veins  it  is  necessary  to  review  some  points 
in  tlie  anatomy  of  the  vessels.  A  vein,  like  an  artery,  has  three  coats.  The 
internal  coat  of  the  veins  is  the  same  as  the  internal  coat  of  the  arteric-s,  and  its 
continuation  forms  the  only  coat  which  the  capillaries  possess.  The  middle  coat 
is  composed  of  longitudinal  and  circular  elastic  fibers,  interlacing  with  which 
are  involuntary  mu.scular  fibers  that  are  not  so  abundant  in  the  veins  as  in  the 
arteries.  The  external  coat  is  composed  chiefly  of  white  fibrous  tissue.  The 
coats  of  the  veins  differ  from  those  of  the  arteries  in  the  thinness  of  the  mus- 
cular coat  and  in  the  presence  of  valves  in  the  internal  coat  of  the  superficial 
and  a  few  of  the  deep  veins ;  they  correspond  with  those  of  the  arteries  in  the 
presence  of  a  common  external  fibro-cellular  tunic  and  the  internal  endothelial 
coat.  The  thinness  of  the  muscular  coat  of  the  veins  prevents  them  from 
having  that  rotundity,  elasticity,  and  contractility  which  are  so  characteristic 
of  the  arteries ;  it  also  permits  the  temporary  distention  or  bulging  of  the 
vessels  when  there  is  some  mechanical  impediment  to  the  free  return  of  venous 
blood  to  the  heart.  To  serve  this  purpose  the  veins  possess  an  inherent 
capacity  of  limited  distention  which  is  never  required  in  the  case  of  the 
arteries.  It  is  important  to  remember  this  fact  when  the  subject  of  wounds 
of  veins  is  considered.  Notwithstanding  the  thinness  of  the  walls  of  the 
veins,  they  are  relatively  as  strong  as  those  of  the  arteries. 

The  jyresence  of  valves  is  a  peculiarity  of  veins.  These  valves  support 
the  column  of  blood  mechanically.  They  are  found  in  the  superficial  venous 
system,  and  especially  in  the  lower  extremities.  In  the  portal  and  hemor- 
rhoidal systems  there  are  no  valves ;  and  this  fact  has  an  important  influence 
upon  the  development  of  certain  di.seases  in  connection  with  these  veins. 

I.  Inflammatiox  of  Veixs,  or  Phlebiti.'^. — Inflammation  of  a  portion 
of  a  vein  produces  changes  in  its  coats  in  the  .same  manner  as  inflammation  of 
the  coats  of  an  artery  alters  the  arterial  coats.  The  disease  is  much  more 
common  than  arteritis.     Phlebitis  may  be  acute  or  subacute. 

Acute  Phlebitis  is  diffuse,  and  is  the  result  of  some  irritation  of  a  vein, 
as  puncture  or  any  other  injury  accompanied  by  infection;  sometimes  it  follows 
the  ligation  of  a  vein  in  its  continuity  or  after  an  amputation.  It  especially 
follows  any  septic  traumatism,  and  is  then  very  dangerous,  leading  generally 
to  pyemia. 

Subacute  Phlebitis  is  circumscribed,  and  is  not  ordinarily  so  dangerous 
as  the  acute  diffuse  form.  The  subacute  variety  generally  supervenes  upon 
some  chronic  disease  of  the  coats  of  the  vein  which  has  led  to  their  thickening 
by  deposit  of  fibrinous  matter,  thus  occluding  the  vein.  An  abscess  may 
develop,  and  must  be  opened  as  an  ordinary  abscess.  There  is  no  hemorrhage 
from  the  vein,  as  it  has  been  blocked  up  by  external  pressure  or  by  an  intra- 
venous inflammatory  product ;  hence  its  lumen  does  not  communicate  with  the 
abscess.  Should  the  fibrinous  deposit  break  down,  micro-organisms  and  their 
ptomaines  get  into  the  vein,  and  acute  diffuse  phlebitis  is  engrafted  upon  the 
chronic  variety  and  pyemia  results. 

The  symptoms  of  phlebitis  are  pain  and  tenderness  along  the  course 
of  the  vein,  with  discoloration  of  the  skin  and  acute  (edema  below  the  obstruc- 
tion. There  are  present  also  .symptoms  of  a  constitutional  nature,  such  as 
rapid  and  irritable  pulse,  rigors,  elevation  of  temperature,  dry  and  brown 
tongue,  and  pain  in  the  joints  if  pyemia  has  developed. 

Treatment  of  Phlebitis. — The  patient  .should  be  kept  perfectly  quiet, 


SURGERY    OF    THE    VASCULAR    SYSTEM. 


225 


the  affected  limb  elevated,  so  as  to  favor  the  return  circulation,  and  leeches 
applied  in  certain  cases  along  the  inflamed  veins.  Goulard's  extract  or  a  lead- 
and-opium  wash  should  be  used,  or  hot  antiseptic  fomentations,  if  a  circum' 
scribed  abscess  is  forming.  Opium  is  indicated  to  relieve  pain.  Abscesses 
should  be  opened,  for  if  they  are  not  incised  the  micro-organisms  and  the 
ptomaines  may  break  down  the  plug  in  the  vein  and  the  softened  thrombus 
obtain  access  to  the  general  circulation.  The  patient's  general  condition  must 
be  kept  up  with  nourishing  food  and  stimulants,  as  there  is  a  great  tendency 
to  exhaustion  following  certain  forms  of  phlebitis. 

II.  Varix,  or  Varicose  Veins. — By  this  is  meant  an  enlarged,  elongated, 
tortuous,  knotty  condition  of  the  veins.  The  term  "varicose  veins"  is 
restricted  in  general  use  to  the  veins  of  the  extremities,  and  especially  to 
those  belonging  to  the  lower  extremity.  The  internal  saphenous  vein  is 
the  one  most  freipiently  affected  (Fig.  31).  The  disease  begins  by  a  slow 
dilatation  of  the  vein,  which  gradually  becomes  thickened  and  tortuous. 
The  inner  lining  membrane,  or  endothelial  coat,  of  the  vein  is  altered, 
and  the  valves  are  shortened,  and  thus  rendered  insufficient  to  support 
the  column  of  blood.  Besides  these  alterations  in  the  inner  coat  of  the 
vein,  the  outer  coat  becomes  thickened  on  account  of  the  connective-tissue 
infiltration  and  of  the 

inflammatory  new  for-  ^'^^''-  '•^^■ 

mation  (periphlebitis). 

The  varicose  con- 
dition affects,  as  a 
rule,  chiefly  the  super- 
ficial veins.  When 
these  are  largely  di- 
lated the  circulation 
becomes  sluggish  and 
is  carried  on  by  the 
deep  veins.  Occasion- 
ally it  happens  that 
the  deep  veins  are  pri- 
marily affected.  In- 
stead of  the  outer  coat 
of  the  vein  being 
thickened,  this  coat 
sometimes  becomes  ex- 
cessively attenuated, 
and  separates  at  places, 
so  that  the  internal  coat 
protrudes  through  the 
slit  and  forms  a  protru- 
sion which  may  even 
become  pedunculated. 
This  pathological  con- 
dition is,  however, 
rare.  When  the  vari- 
cose veins  begin  where 
the  venous  radicles 
arise  from  the  capil- 
lary system,    the   varicosity  appears   as   a   fine   capillary  injection  with   an 

15 


Varicose  Veins  of  the  Legs  (original). 


■2-2i\  JiV  AMKincAy    TKXT-liOOK    OF   SURGERY. 

arl)Oi'c'sc('iit  Mppcanini't'.  Tliis  cninlition  is  more  f'lUMjiiciitlv  foiiinl  in  women. 
AVhen  the  lar;ie  trunks  are  aftected,  tlie  veins  are  dilated,  tortuous,  and  knotty. 
They  rise  above  the  level  of  the  skin,  and  if  pressure  is  made  over  them  the 
presence  of  blood  in  the  vessels  becomes  at  once  manifest.  When  the  disease 
has  existed  for  a  long  while,  they  may  burst  from  excessive  thinness  of  the  coats, 
and  a  serious  or  even  fatal  hemorrhage  may  result.  Again,  instead  of  the  veins 
standing  out  Itoldly  al)ovc  the  skin-level,  there  may  be  a  passive  exudation  into 
the  surrounding  eellular  tissue  of  the  limb,  which  causes  it  to  become  (edenuitous. 
This  is  not  the  ordinary  fjcdema  from  obstructed  venous  return,  but  a  s(jlid  non- 
resisting  tedema,  ^vhich  has  a  marble-like  appearance  and  does  not  pit  ui)on  light 
pressure.  Upon  this  peculiar  ^edematous  condition  there  is  often  engrafted  a 
most  obstinate  eczema.  If  the  eczema  is  allowed  to  j)rogress  without  any 
treatment,  it  will  degenerate  into  a  superficial  ulceration  which  will  beccnue 
chronic  and  may  extend  down  into  the  tissues  and  give  rise  to  "  varicose 
ulcer."     These  ulcers  may  involve  a  vein  and  give  rise  to  fatal  hemorrhage. 

There  is  another  condition  arising  from  the  presence  of  varicose  veins 
■which  does  not  appear  until  late  in  the  progress  of  the  disease.  ThromJii 
may  be  formed  within  the  vein,  which  may  become  disintegrated  and  break 
down,  forming  an  a])scess,  if  infection  takes  place  (suppurative  thrombo-])hle- 
bitis),  or  under  certain  conditions  they  may  organize  and  comijletely  occlude 
the  vein  (plastic  thrombo-])hlebitis),  and  thus  bring  about  a  radical  cure.  The 
thrombi  may  also  become  shrunken  and  contracted,  and  frequently  laminae  of 
fibrin  are  deposited  upon  them.  Small  hard  concretions  which  have  been  called 
veinstones  or  phleboliths  have  been  observed.  These  are  formed  of  laminated 
fibrin,  phosphate  of  calcium,  and  the  sulphates  of  calcium  and  potassium. 

Varix  of  the  internal  saphenous  vein  (Fig.  31)  may  give  rise  to  symptoms 
similar  to  those  of  femoral  hernia.  In  varix  there  is  a  tumor  at  the  saphenous 
opening  at  the  place  where  a  femoral  hernia  presents.  The  varix  disappears 
when  the  patient  assumes  the  recumbent  position,  as  in  femoral  hernia.  Both 
swellings  reapj)ear  u|)on  the  patient's  coughing  or  assuming  the  upright 
position.  The  differential  diagnostic  point  is  that  in  varix  of  the  saphenous 
vein,  if  pressure  is  made  at  the  saphenous  opening  while  the  patient  is  in  a 
recumbent  position,  the  swelling  will  reappear  when  he  assumes  the  upright 

f)osition,  even  though  pressure  is  maintained.     In  femoral  hernia,  on  the  other 
land,  the  tumor  will  not  reappear  under  the  same  conditions. 

The  causes  of  varicose  veins  are — I.  Predisposing,  and  II.  Exciting. 

I.  Among  the  predisposing  causes  may  be  mentioned — 

{a)  Sex.  Varicose  veins  are  most  frequent  in  the  female,  and  are  apt  to 
follow  uterine  enlargement  from  any  cause. 

(6)  Age.  The  tendency  to  the  production  of  varicose  veins  increases  as  age 
advances. 

{c)  Obstruction  to  the  free  return  of  blood  in  the  veins,  as  tight  garters  worn 
below  the  knee  or  other  constrictions  obstructing  venous  circulation. 

(d)   Occupations  which  re(juire  habitual  standing. 

II.  Among  the  exciting  causes  may  be  mentioned — 

(a)  Tumors  in  the  abdomen  or  pelvis.  It  is  evident  that  any  obstruction 
to  the  return  venous  circulation  has  a  tendency  to  develop  varicose  veins  ;  thus, 
tumors  of  any  variety  which  press  upon  the  iliac  veins  will  give  rise  to  varico.se 
veins  of  the  leg.  It  has  been  stated  that  the  left  leg  is  more  frequently  the 
seat  of  this  disease  than  the  right,  on  account  of  the  sigmoid  flexure,  which 
when  distended  presses  upon  the  left  iliac  vein.  The  caecum,  however,  when 
distended,  Avould  press  nearly  as  much  upon  the  right  iliac  vein,  and  as  a 
clinical  fact  the  right  leg  is  affected  with  equal  frequency. 


SURGERY   OF    Till-:     VASCULAR    Sl^STEM.  227 

(b)  Diseases  of  the  Heart  and  Lu)i(/s. — In  tbesc  conditions  there  is  found 
an  inij)ortant  exciting  cause.  It"  the  heart  is  t'eel)le  in  acti<jn,  tiie  po^ver  to 
drive  the  blood  back  is  lessened,  and  as  a  consequence  the  column  of  blood 
moves  very  slowly  and  becomes  stagnant  in  places.  The  develo[nnent  of  the 
ascites  (hydroperitoneum)  often  incidental  to  heart  affections  also  f(n"ms  by 
pressure  upon  the  veins  a  barrier  to  the  free  ivturn  of  the  venous  blood. 

(f)  PreiinatK-ji  by  pressure  of  the  gravid  uterus  upon  the  iliac  veins. 
In  a  first  pregnancy  the  veins  of  the  extremities  are  not  much  altered  patho- 
logically, and  if  attention  is  paid  to  this  incipient  stage  of  the  disease,  which 
is  amenable  to  treatment,  subsequent  pregnancies  will  not  be  so  likely  to 
produce  an   incurable  condition  of  varicose  veins. 

Treatment. — I.   Palllatirc,  and  II.  liadieal. 

Palliative  treatment  is  to  be  directed  to  the  removal  of  the  causes  of  the 
obstruction  and  also  of  their  efi'ects,  as  far  as  possible,  without  an  operation. 
This  object  is  best  fulfilled  by  attention  to  the  condition  of  the  bowels,  to  the 
state  of  the  liver,  to  the  affections  of  the  heart  and  lungs ;  by  enforcing  quiet 
and  rest  in  a  recumbent  position,  Avhich  favors  venous  return  circulation,  and 
by  attention  to  the  general  health,  and  often  by  out-door  exercise  in  a  suitable 
climate.  The  local  j)aniative  treatment  consists  in  the  application  of  an  elastic 
bandage  or  a  perfectly-fitting  silk  elastic  stocking  which  shall  afford  support 
to  the  vessels,  thereby  equalizing  the  circulation.  This  elastic  support  has  a 
tendency  to  turn  the  flow  of  venous  blood  from  the  superficial  veins  into  the 
deep  veins,  which  do  not,  as  a  rule,  become  varicose.  The  silk  stocking 
should  be  made  to  order  from  accurate  measurement  of  the  limb,  and  should 
extend  from  below  at  the  toes,  where  the  trouble  begins,  to  or  above  the  knee, 
where  it  should  be  loose. 

The  radical  treatment  has  for  its  object  the  complete  obliteration  of  the 
vein.     Many  surgical  procedures  have  been  devised  for  this  purpose. 

Multiple  ligatures  were  introduced  by  Phelps,  who  ties  the  vein  in  thirty 
or  forty  places.  Excision  of  the  vein  in  six,  eight,  or  more  places  is  a  suc- 
cessful procedure.  Trendelenburg  ties  the  saphenous  vein  just  below  the 
saphenous  opening.  Schede  makes  a  circular  incision  around  the  leg  down 
to  the  deep  fascia,  as  if  he  were  about  to  amputate,  ties  the  veins,  and  sutures 
the  wound.  All  such  operations  on  veins  must  be  done  with  the  most  strin- 
gent antisepsis,  or  an  acute  septic  phlebitis  and  pyemia  may  readily  follow. 

III.  An  Angioma  is  a  tumor  composed  of  a  congeries  of  blood-vessels 
lying  in  fat.  There  are  three  varieties  of  angioma — 1.  The  simple  nevus. 
2.   The  cavernous  nevus.      3.   The  plexiform  angioma  (J.   Bland  Sutton). 

Simple   Nevus. — This  is  situated  in  the 
skin  and  subcutaneous  tissue.     It  may  be  com-  Fig-  32. 

posed  of  arterioles  or  of  venules.  \Vhen  the 
nevus  affects  the  arterioles  there  is  a  slightly 
elevated  area  of  skin  of  a  scarlet  or  purple 
color.  Nevi  are  sometimes  found  upon  the 
trunk,  but  generally  upon  the  face.  They 
vary  in  size  from  that  of  a  pin's  head  to  that 
of  a  silver  dollar,  or  even  may  involve  an  area 
nearly  as  large  as  the  hand.  They  are  un- 
sightly, but  seldom  give  rise  to  any  physical 
discomfort  unless  they  undergo  ulceration,   in  Nevus  (original). 

which  event  a  troublesome  and  in  some  cases 

even  alarming  hemorrhage  ensues.      The  vessels  consist  of  capillaries  held 
together  by  areolar  tissue.      The  term  telangiectasis  is  often  applied  to  this 


228  AN  AMERICAN   TEXT- HOOK   OF  SURGERY. 

form  of  ucvus,  auJ  it  is  j)o})ularly  called  mother  h  mark  (Fig.  32).  A  nevus 
may  appear  as  a  "port-wine  stain,"  a  widespread  superficial  distention  of 
arterioles  or  venules,  varying  in  color  from  pink  to  blue. 

Cavernous  angiomata  are  composed  of  tissue  resembling  that  of  the 
corpora  cavernosa,  and  are  found  beneath  the  skin  as  well  as  in  the  skin. 
They  are  also  seen  in  the  orbit  and  in  the  liver  and  other  viscera.  Ihey 
pulsate,  and  are  much  larger  than  the  capillary  nevi.  They  can  be  made 
partially  to  disappear  by  pressure,  but  reappear  when  the  pressure  is  dis- 
continued. T'he  anatomical  structure  is  similar  to  that  of  carcinoma,  but 
instead  of  the  spaces  being  filled  with  epithelial  cells  they  contain  blood. 
They  are  painless.      If  punctured,  they  give  rise  to  alarming  iiemorrhage. 

A  plexiform  angioma  is  what  used  to  be  called  an  aneurysm  by 
anastomosis,  and  is  now  known  as  a  cirsoid  aneurysm  (see  Cirsoid  Aneur- 
ysm). 

Treatment. — The  operations  for  the  removal  of  nevi  are  many.  The 
best  recognized  surgical  treatment  includes  ligation,  excision,  electro-punc- 
ture, the  cautery,  and  coagulating  injections. 

Small  nevi  occasionally  disappear  spontaneously  a  few  weeks  after  birth. 
If  a  small  nevus  persists  or  begins  to  enlarge,  it  may  often  be  destroyed 
by  touching  it  with  a  glass  rod  moistened  with  fuming  nitric  acid.  A 
nevus  can  be  removed  by  ligation.  Ligation  is  done  by  passing  a  pin 
under  the  mass  and  throwing  a  ligature  around  the  base  of  the  nevus  below 
the  pin.  If  large,  a  double  ligature  can  be  passed  under  and  at  right 
angles  to  the  pin,  and  the  nevus  tied  in  two  halves.  Setons  lead  to  what 
may  be  a  dangerous  suppuration,  and  coagulating  injections  may  produce 
extensive  thrombosis  or  distant  embolism,  and  thus  cause  death.  Nevi  about 
the  face  and  scalp  should  never  be  injected,  on  account  of  the  danger  of 
thrombi  and  emboli.  The  best  treatment  for  a  nevus  is  excision.  The  sur- 
geon makes  two  elliptical  incisions  well  clear  of  the  growth,  ties  the  vessels 
of  supply,  and  sutures  the  Avound.  In  large  cavernous  angiomata  electrolysis 
and  excision  have  been  employed  Avith  good  results.  A  port-wine  stain  of 
small  size  can  be  destroyed  by  making  a  series  of  parallel  incisions  through 
the  vessels,  and  crossing  these  cuts  by  a  series  of  transverse  incisions.  Elec- 
trolysis may  be  successful.     A  port-wine  stain  of  large  size  cannot  be  cured. 

PART    II. — DISEASES   OP   THE    ARTERIES. 
ARTERITIS. 

I.  The  word  arteritis  signifies  inflammation  of  an  artery.  Each  coat  of  aft 
artery  may  be  primarily  separately  inflamed.  Thus  we  distinguish  inflammation 
of  the  internal  coat,  of  "the  middle  coat,  and  of  the  external  coat.  These  inflam- 
mations are  called,  respectively,  Endarteritis,  Mesarteritis,  and  Periarteritis. 
All  these  different  varieties  may  be  either  acute  or  chronic. 

1.  Acute  Arteritis. — This  is  a  rare  surgical  disease,  and  is  due  to  an 
inflammation  excited  by  an  infectious  or  poisonous  embolus  lodged  in  the 
artery.  The  internal  coats  become  swollen  and  infiltrated  with  pus-cells.  The 
suppurative  inflammation  is  transmitted  to  the  other  coats  of  the  artery  and  to 
the  surrounding  parts,  and  may  result  in  abscess. 

Acute  Periarteritis  is  also  usually  secondary  in  origin,  and  is  due  to  an 
extension  of  inflammation  from  the  surrounding  parts.  The  exudation  is  apt 
to  be  purulent.  In  these  destructive  inflammations  of  the  arterial  coats  the 
lumen  of  the  artery  generally  becomes  occluded  by  a  thrombus  before  perfora- 


SURGERY   OF    THE    VASCULAR   SYSTEM.  229 

tive  ulceration  occurs.  Sliould  this  thrombosis  not  take  place,  severe  and 
souK'tinies  fatal  hemorrhage  may  arise  if  the  artery  be  of  a  sufficient 
size. 

It  is  still  an  open  (question  whether  acute  arteritis  occurs  as  a  primary 
affection.  A  few  doubtful  cases  have  been  recorded  in  which  severe  pain  and 
tenderness  existed  along  the  course  of  an  artery,  in  some  instances  accompanied 
by  a  certain  amount  of  redness  and  swelling.  The  diagnosis  of  acute  arteritis 
has  been  made,  but,  as  the  termination  has  been  favorable,  the  pathological 
proof  of  its  existence  is  Avanting. 

2.  Chronic  Arteritis. — This  is  the  atheroma  of  most  authors,  and  its 
relation  to  the  production  of  aneurysm  is  a  subject  of  great  surgical  interest. 
By  atheroma  is  meant  a  chronic  inflammation  of  the  internal  coat  characterized 
by  a  fatty  degeneration,  Avith  a  tendency  to  cheesy  collections  and  calcareous 
deposits.  The  middle  coat  is  not  usually  involved  until  late.  The  external 
coat  becomes  affected  secondarily,  and  is  hypertrophied  and  inelastic.  As  a 
result  of  the  fatty  degeneration  the  inner  coat  of  the  artery  swells,  the  circula- 
tion is  disturbed  in  that  part,  and  an  ulcer  is  formed  by  the  rupture  of  a  caseous 
mass  into  the  lumen  of  the  artery. 

Traumatism  aff"ecting  the  artery,  alcoholic  excesses,  syphilis,  Bright's  dis- 
ease of  the  kidney,  gout,  and  rheumatism  are  among  the  diseases  which  are 
recognized  as  the  causes  of  atheroma.  This  condition  ordinarily  involves  the 
larger  arteries,  and  in  this  respect  differs  from  syphilitic  arteritis,  which,  as  has 
been  pointed  out,  aff'ects  chiefly  the  vessels  of  smaller  size.  Occasionally  the 
lime-salts  are  deposited  in  the  ulcer  and  a  calcareous  plate  is  formed.  Atheroma 
is  usually  seen  in  persons  of  advanced  age. 

Calcification  of  the  artery  consists  in  a  low  grade  of  inflammation  in  the 
middle  coat,  and  is  characterized  by  the  deposit  of  earthy  matter,  chiefly  car- 
bonate of  calcium  and  the  phosphates.  This  deposit  may  be  in  plates,  and  it 
is  then  termed  laminar  calcification,  or  it  may  be  arranged  in  a  concentric 
manner  around  the  muscular  fibers,  when  it  is  termed  annular  calcification,  and 
when  the  latter  form  is  spread  over  a  considerable  area  it  is  termed  tubular 
calcification.  This  disease  aff'ects  arteries  in  the  extremities,  and  as  a  result 
the  parts  beyond  are  inadequately  supplied  with  blood,  owing  to  the  narrowed 
lumen  of  the  vessel  and  to  its  loss  of  elasticity.  When  the  disease  is  extensive 
enough  completely  to  occlude  the  artery,  gangrene  of  the  limb  may  result. 
When  it  affects  the  vessels  in  the  extremities,  the  calcification  can  be  readily 
recognized  by  the  finger  placed  upon  the  vessel.  This  is  often  observed  in 
the  radial  artery,  the  vessel  becoming  roughened  and  rigid  and  hard  like  a 
pipe-stem. 

The  treatment  of  arteritis  depends  upon  the  variety.  If  due  to  syphilis, 
the  iodides  and  mercury  are  useful ;  if  to  rheumatism  or  gout,  the  remedies 
that  are  indicated  in  these  affections  should  be  employed.  Little  can  be  done 
to  cure  the  disease,  and  the  treatment  should  be  directed  toward  the  prevention 
of  any  extension  of  the  inflammation.  Great  importance  must  be  attached  to 
the  avoidance  of  all  kinds  of  violent  exercise,  which  might  lead  to  rupture  of 
the  vessel  with  its  attendant  consequences. 

ANEURYSM. 

The  word  aneurysm  is  derived  from  the  two  Greek  words  d.vd,  "through," 
and  eopOvco,  "  I  widen." 

An  aneurysm  is  a  tumor  containing  blood  and  communicating  with  the 
interior  of  an  artery.     There  are  some  forms  of  blood-tumor  which  do  not 


230 


AN  AMERICAN    TEXT- HOOK    OF  SURGERY. 


strictly  come  Avitliiii  the  limits  of  this  (U'liiiitioii.  'riicsc  -will  l)c  (lisciissctl 
before  taking  up  aneurysm  pro})er. 

The  fii'st  variety  is  arterial  varix.  Tiii.s  cun.sist.s  in  an  ebjn^ution  and 
dilatation  of  a  single  artery  of  medium  or  small  size.  The  vessel  is  pouched, 
sacculated,  and  tortuous.  Tliis  condition  is  similar  to  that  of  a  varicose  vein. 
The  superficial  temporal,  <)ccij)ital,  and  posterior  auricular  arteries  are  often 
the  seat  of  this  disease.  The  skin  over  the  dilated  vessel  is  exceedingly  thin, 
or  even  ulcerated,  and  this  condition  may  give  rise  to  alarming  hemorrhages. 

Cirsoid  aneurysm  is  the  next  variety,  and  consists  in  a  dilatation  and 
elongation  of  a  number  of  arteries  of  medium  and  small  size. 

If  a  single  artery  is  involved,  and  it  is  pouched  and  tortuous  and  dilated 
after  the  same  manner  as  a  varicose  vein,  the  term  arterial  varix  is  applied. 

If  a  munber  of  arteries  held  togetlier  by  connective  tissue  are  affected  by 
these  pathological  changes,  the  tumor  is  called  a  cirsoid  aneurysm  (Fig.  33). 
Such  an  aneurysm  usually  involves  also  the  capillaries  in  its  immediate  vicin- 
ity. The  cause  of  this  disease  is  supposed  to  be  an  injury  in  which  the  vaso- 
motor nerves  have  been  paralyzed.  The  tumor  thus  formed  is  irregular  in 
shape,  compressible,  bluish  in  appearance,  and  pulsating  in  character.  The 
temperature  within  the  circumscribed  area  of  the  outgrowth  may  be  elevated 
on  account  of  the  increased  vascular  supply.  Cirsoid  aneurysm  is  distin- 
guished from  a  true  aneurysm  by  the  situation  of  the  growth,  the  number 
of  vessels  involved,  the  superficial  bruit  and  pulsation,  the  peculiar  spongy, 
doughy  feel,  and  the  difference  in  the  pressure-effects. 

The  treatment  of  cirsoid  aneurysm  is  usually  unsatisfactory,  and  often 
attended  with  great  danger  from  hemorrhage.  The  lack  of  success  in  treat- 
ment is  in  part  due  to  a  lack  of  comprehension  of  the  nature  of  the  disease. 


Fig.  33. 


Cirsoid  Aneiirysui  iImuij 


Extirpation,  the  lines  of  incision  being  carried  wide  of  the  tumor,  multiple 
ligation  of  the  individual  afferent  arteries,  the  application  of  the  galvano- 
cautery,  the  injection  of  coagulating  ffuids,  the  introduction  of  the  electro- 
puncture  needle  alone  or  associated  with  circular  compression  of  the  afferent 


SURGERY    OF    THE     VASCULAR    SYSTEM. 


2;n 


vessels,  acupressure  of  the  luain  feeding  artery,  and  ligation  of  the  main 
trunk,  are  among  the  recognized  methods  of  treatment ;  often  two  or  more 
of  these  may  be  combined  with  advantage. 

Preliminary  ligature  of  afferent  vessels  followed  by  cutting  the  tissue 
around  the  tumor  has  proved  curative.  Removal  by  e.vcision  is  the  only 
method  which  offers  a  reasonable  certainty  of  cure,  and  this  operation  should 
be  immediately  preceded  by  the  ligation  of  every  tributary.  Bad  cases  of 
cirsoid  aneurysm  of  the  hand  require  amputation. 

All  aneurysms  may  be  divided  into  two  groups — the  idiopatJac  and  the 
tranmatir.  In  the  idiopathic  variety  there  is  a  sac  formed  of  one  or  more  of 
the  arterial  coats,  and  the  blood  within  the  sac  is  in  direct  communication  with 
the  lumen  of  the  artery.  In  the  traumatic  variety  there  is  also  a  sac,  but  its 
walls  are  composed  of  inflammatory  lymph  and  a  proliferation  of  the  con- 
nective-tissue cells. 

Idiopathic  aneurysms  are  divided  into — 
1.  Tubulated. 


2.  Sacculated 


f  a,  true, 
'  \  b,  false, 


1,  circumscribed. 

2,  diffused. 
3.  Dissecting. 

The  tiihrdatcd  aneurysm  (Fig.  84)  is  the  fusiform  aneurysm  of  some  authors. 
In  this  variety  the  three  coats  of  the  artery  are  simultaneously  dilated,  in  the 


Vui.  .31 


Tubulated  or  Fusiform  Aneurysm  (urigiiial). 


circumference  as  w-ell  as  in  the  length  of  the  vessel.     The  middle  coat  is  not 
preserved  as  a  continuous  layer,  but  its  elements  are  separated.    This  aneurysm 

Fig.  3.5. 


Sacculated  Aneurj'sm  (original). 


is  found  in  the  cranial,  thoracic,  and  abdominal  cavities.  The  tubulated  aneu- 
rysm rarely  grows  to  be  of  any  size,  and  scarcely  ever  ruptures  unless  a  saccu- 
lated aneurysm  is  engrafted  upon  it.    The  sac  in  this  form  of  aneurysm  seldom 


2:52  AN  AMERICAN   TEXT-BOOK    OE  SURGERY. 

contains  any  laminated  librin.  It,  however,  ;i;ives  rise  to  <^reat  discomfort,  iuid 
often  causes  severe  pain  by  pressure  upon  important  organs. 

Tlie  sacculated  aiwunjsin  (Fig.  35)  is  one  which  ])rojects  from  a  tubulated 
aneurysm  or  which  sj)rings  from  the  side  of  an  artery,  the  interior  of  which  is 
in  connnunication  with  the  sac  by  an  oj)ening  which  is  called  the  mouth. 

The  sacculated  aneurysm  is  subdivided  into  fnie  and  fahe.  The  true 
sacculated  aneurysm  is  one  in  which  all  three  of  the  coats  of  the  artery  are 
equally  expanded  to  form  the  sac.     It  seldom  grows  larger  than  an  orange. 

In  the  false  sacculated  aneurysm  the  inner  layer  is  the  thickened  and 
altered  intima  enlarged  by  successive  additions  so  as  to  cover  the  vastly 
increased  surface ;  traces  of  the  middle  coat  are  to  be  found  only  near  the  neck 
of  the  sac ;  the  wall  is  niaiidy  formed  by  the  condensed  and  nniltiplied  con- 
nective tissue  of  the  surrounding  parts.  In  short,  the  wall  of  the  aneurysm 
contains  little  or  nothing  of  the  original  wall  of  the  artery,  except  that  its 
internal  layer  is  continuous  with  and  similar  in  character  to  the  intima.  This 
variety  of  aneurysm  may  grow  to  an  enormous  size. 

False  sacculated  aneurysms  are  subdivided  into  the  circH)iiscn'l>cd,  in  which 
the  blood  is  confined  within  a  sac  composed  of  some  part  of  the  arterial  coats, 
and  the  diffuse,  in  which  the  sac  is  ruptured  and  the  blood  has  extravasated 
into  the  neighboring  tissue ;  or  else  the  sac  is  ruptured,  and  the  blood  is  con- 
fined Avithin  a  cavity  the  walls  of  which  consist  of  lymph  and  condensed  areolar 
tissue. 

The  dissecting  aneurysm  is  one  in  which  the  internal  coat  of  the  artery 
has  given  Avay,  owing  to  some  erosion  caused  by  an  atheromatous  patch,  and 
the  blood  dissects  or  makes  its  way  through  the  middle  coat  (Fig.  36).  The 
blood  may  burrow  for  some  distance  through  the  middle  coat  until  it  comes  in 
contact  with  an  eroded  patch  situated  upon  the  outer  coat,  through  which  it 
bursts,  and  finally  extravasates  into  the  surrounding  areolar  tissue ;  or  it  may 
burrow  for  some  time  through  the  substance  of  the  middle  coat  until  it  comes 
in  contact  with  an  eroded  patch  situated  upon  the  internal  coat,  and  then  the 

Fig.  sn. 


Plan  of  a  Dissecting  Aneurysm  (Holmes). 

blood  again  enters  the  artery ;  or  it  may  burrow  for  some  distance  and  meet 
no  eroded  patches  in  either  outer  or  inner  coat,  and  may  thus  remain  in  a 
small  sac  formed  by  the  circumscribed  separation  of  the  arterial  coats. 

Tlie  component  parts  of  an  aneurysm  are  (1)  the  sac,  (2)  the  contents. 
The  sac  is  composed  of  one  or  all  three  coats  of  the  artery,  unless  the  aneurysm 
is  traumatic,  in  which  case  the  walls  are  formed  by  lymph  and  condensed 
areolar  tissue.  The  sac  may  be  formed  by  the  internal  and  external  coats, 
the  middle  coat  having  been  ruptured ;  or  by  the  dilatation  of  the  external 
coat,  the  internal  and  middle  coats  having  been  ruptured ;  or  by  the  dilatation 
of  the  internal  coat,  the  middle  and  external  coats  having  given  way.  If  the 
latter  condition  is  ever  present,  which  has  been  denied,  the  aneurysm  would 
be  called  an  aneurysmal  hernia.     The  mouth  of  the  sac  is  the  narrow  opening 


SURGEliY   OF   THE    VASCULAR   SYSTEM,  233 

which  establishes  a  coinnmiiication  between  the  interior  of  tlie  sac  and  the 
lumen  of  the  artery  from  which  the  aneurysm  develops. 

In  the  fusiform  aneurysm  there  is  no  mouth,  as  the  aneurysm  results  from 
a  uniform  dilatation  of  the  coats  of  the  artery.  In  the  sacculated  variety  a 
mouth  is  present,  and  its  situation  relative  to  the  lumen  of  the  vessel  influences 
the  amount  of  fibrin  deposited,  as  well  as  the  j^rowth  of  the  aneurysm. 

The  contents  of  the  sac  vary  according  to  the  stage  of  the  disease.      In  the 
first  stage  the  sac  is  very  thin,  and  contains  only  iluid  l)lood.    In  the  second  stage 
the  wall  of  the  sac  is  very  thick,  and  contains  fluid  blood 
in  the  center  and  laminae  of  fibrin  (Fig.  37)  around  the  ^^^*-  ^'^• 

periphery. 

The  blood  is  in  greater  proportion  than  the  fibrin 
at  first,  but  later  the  coaguium  or  laminated  filtiin  is  in 
excess  of  the  fluid  blood.  These  laminae  of  fibrin  vary 
in  firmness  and  consistency  in  the  different  parts  of  the 
sac.  Thus  upon  the  extreme  periphery  the  layers  of 
fibrin  are  dry,  friable,  and  opaque,  while  the  layers  ap- 
proaching the  center  of  the  tumor  are  soft  and  of  a  red- 
dish color. 

In  the  sacculated  variety  the  fibrin  is  rapidly  de-  laminated  coaguium  (Key 
posited,  and  the  rapidity  with  which  it  is  formed  depends  and  Bryant). 

upon  the  relation  of  the  mouth  of  the  sac  to  the  sac  itself.  The  greater  the 
obstruction  to  the  free  flow  of  blood  into  the  sac,  the  greater  the  tendency  to 
the  deposition  of  fibrin. 

In  the  fusiform  aneurysm,  where  there  is  no  retardation  in  the  current  of 
blood  owing  to  the  absence  of  a  mouth  in  the  sac,  there  is  no  deposition  of 
fibrin,  or  at  least  it  is  deposited  in  exceptional  cases  only. 

The  natural  terminations  of  aneurysm  are — (1)  spontaneous  cure,  (2) 
death. 

The  spotitmieous  cure  of  aneurysm  is  occasionally  effected  by  nature 
unaided  by  the  surgeon.  Such  a  case  occurs  very  seldom,  but  that  a  cure 
under  certain  conditions  may  thus  be  brought  about  is  no  longer  open  to 
dispute.  In  the  cases  of  spontaneous  cure  the  aneurysm  has  always  been 
found  solid  and  firm, — which  leads  to  the  belief  that  a  deposition  of  fibrin  had 
already  taken  place.  A  deposition  of  fibrin  takes  place  in  consequence  of  the 
-slower  current  in  the  sac,  and  finally  fills  it.  The  clot  thus  formed  within  the 
sac  may  extend  into  the  vessel,  and  thus  add  to  the  permanence  of  the  cure. 
Occasionally  the  aneurysm  is  spontaneously  cured  by  an  embolus,  when  a  clot  is 
washed  out  of  the  sac  into  the  efferent  artery  and  occludes  it,  so  that  the  current 
is  completely  arrested  within  the  sac ;  the  latter  then  fills  with  a  firm  coaguium. 
Sometimes  a  spontaneous  cure  is  effected  when  the  sac  becomes  large  enough 
by  its  own  weight  to  cause  mechanical  pressure  upon  the  artery  sufficient  to 
retard,  or  even  to  arrest,  the  circulation  in  the  vessel.  Finally,  a  spontaneous 
cure  is  accomplished  in  some  cases  when  the  sac  becomes  acutely  inflamed  and 
the  coagulation  of  the  blood  within  it  is  thereby  promoted. 

Death  is  the  other  natural  termination.  There  are  various  ways  by  which 
an  aneurysm  destroys  life :  1st.  By  rujiture  of  the  sac.  The  aneurysm  extends 
to  the  surface  of  the  body  or  to  a  mucous  canal  or  a  serous  cavity.  When  the 
aneurysm  has  reached  the  surface  of  the  body  the  thin  skin  over  the  sac  sloughs, 
and  when  the  slough  comes  away  there  is  a  slight  hemorrhage  through  a  small 
opening.  This  hemorrhage  is  arrested  by  a  coaguium,  but  after  a  while  is 
renewed,  until  finally  the  patient  dies  from  repeated  hemorrhages.  In  case  an 
aneurysm  bursts  into  a  mucous  canal  the  process  is  the  same.     The  rupture 


2;u 


AN  AMERICAN   TEXT-BOOK   OF  .SUlKiERY. 


may  open  into  the  trachea,  oesophagus,  intestine,  or  bladder.  Here,  again,  the 
sac  is  first  rendered  thin  by  absorption,  and  when  the  sh)ugh  separates  tlie 
hemorrhage  occurs.  An  aneurysm  may  destroy  lite  by  bursting  into  one  of  the 
pleural  cavities,  generally  the  left,  or  into  the  ])erit(»neal  or  tbe  ])ericardial  sac. 
In  this  situation  the  serous  membrane  gives  way  in  a  rent,  and  death  follows 
instantly. 

2d.  Aneurysm  also  destroys  life  by  pressure  upon  important  orgarns.  If 
the  aneurysm  presses  upon  the  trachea  or  the  bronchi  or  the  lungs,  it  produces 
asphy.xia ;  if  upon  the  oesophagus  or  the  thoracic  duct,  it  causes  inanition;  if 
upon  the  vertebrae  and  the  ribs,  absorption  of  these  bones  results  (Fig.  38), 
followed  by  spinal  irritation  and  meningitis,  with  severe  neuralgia  from  pressure 
on  the  intercostal  nerves. 

Fig.  38. 


Absorption  of  the  Vertebrae  and  Ribs  from  Pressure  by  an  Aneurysm  (original). 

3d.  Aneurysm,  again,  destroys  life  by  septicemia  and  pyemia,  due  to  acute 
inflammation  and  suppuration  of  the  sac ;  also,  4th,  by  embolism,  in  which  case 
the  small  migratory  clot  is  carried  by  the  cerebral  arteries  to  the  brain  if  the 
situation  of  the  aneurysm  is  in  the  arch  of  the  aorta ;  finally,  5tli,  by  ;jan;/reiie 
of  the  extremity  caused  by  obstruction.  In  this  case  the  gangrene  causes 
blood-poison  and  death  results  from  septic  infection. 

Etiology  of  Aneurysm. — In  general  terms,  any  disturbance  of  the 
proper  relations  between  the  force  of  the  heart  on  the  one  hand  and  the  elas- 
tic resistance  of  the  artery  on  the  other,  especially  if  an  increase  of  the  former 
is  combined  with  a  diminution  of  the  latter,  will  give  rise  to  aneurysm. 

The  causes  of  aneurysm  may  be  divided  into  I.  Predisposing,  and  II.  Ex- 
citing. 

i.  Predisposing  Causes. — (a)  Degeneration  of  the  Arterial  Coats. — This  is 
tbe  principal  predisposing  cause,  since  in  some  form  it  is  always  present  except 
in  traumatic  aneurysm.  The  degeneration  most  commonly  associated  with  the 
development  of  aneurysm  is  the  atheromatous  and  fatty,  frequently  accompanied 
by  a  calcareous  deposit  that  renders  the  vessels  less  elastic.  As  a  result  of 
this  atheromatous  and  fatty  condition  the  artery  fails  to  contract  after  the 


tiURGERY    OF    THE    VASVULAU   >sy.S7EM.  235 

systolic  action  of  tlie  heart,  gradually  yields  and  dilates,  until  finally  an  aneurysm 
is  formed.  It  is  lield  by  Von  KecklinglKiiisen  and  others  that  the  influence  of 
atlieroma  upon  the  development  of  aneurysm  has  been  exaggerated.  It  is 
believed  that  changes  in  the  middle  coat,  either  inflammatory  or  degenerative, 
are  among  the  most  frequent  predisposing  causes. 

(h)  Si/pJiilis  is  a  freifuent  predisposing  cause  of  aneurysm,  in  consequence 
of  the  changes  in  the  arterial  walls. 

((•)  Over-action  of  t/ic  Hecoi. — Hypertrophy  of  the  heart,  by  increasing  the 
strength  of  the  impulse,  drives  the  blood  with  greater  force  into  the  arteries. 
These  are  likely  to  distend  under  the  impulse  of  an  hypertrophied  heart  if 
they  have  undergone  the  slightest  degenerative  changes.  Hypertrophy  of  the 
heart  associated  with  chronic  nephritis,  in  which  the  arterial  tension  is  increased 
and  the  vessels  are  weakened  by  atheroma,  affords  another  illustration  of  the 
combined  action  of  these  two  causes. 

{d)  Certain  violent  oceupations,  as  riding  and  hunting,  it  has  been  asserted, 
predispose  a  patient  to  aneurysm.  Thus  coachmen  and  postilions,  owing  to  the 
nature  of  their  occupations,  are  especially  liable  to  the  disease.  This  clinical 
fact  is  explained  by  the  obstruction  of  the  popliteal  arteries  on  account  of  the 
constant  bending  of  the  knee  in  horseback  riding  and  sitting  on  the  box,  as 
well  as  by  the  contractions  of  the  gastrocnemii  and  solei  muscles  when  the  feet 
are  placed  firmly  against  the  footboard  or  the  stirrups.  The  arteries,  too,  are 
bent  or  stretched  in  these  positions,  and  the  jar  and  motions  of  the  rider  or 
driver  must  increase  the  force  of  the  circulation. 

(e)  Age. — This  has  a  marked  influence.  Aneurysms  are  most  frequently 
found  between  the  ages  of  thirty  and  forty  years,  because  the  arteries  begin 
to  lose  their  elasticity  at  this  period,  while  the  heart  has  not  yet  lost  any  of 
its  force  or  the  muscles  any  of  their  strength.  Aneurysms  in  very  young 
people  are  merely  surgical  curiosities. 

(/)  Sex. — Seven  to  one  of  the  entire  number  of  aneurysms  are  found  in 
males,  presumably  because  of  their  more  active  occupations. 

II.  Exciting  Causes. — («)  A  partial  ruptiire  of  one  or  more  of  the  arterial 
coats,  produced  by  external  violence,  is  without  doubt  a  prominent  cause  of 
aneurysm. 

(b)  A  direct  wound  of  an  artery  also  produces  aneurysm,  since  it  leads  to 
extravasation  of  the  blood  from  the  artery  into  the  surrounding  tissues.  In 
this  case  the  aneurysm  is  termed  traumatic,  because  the  sac  is  not  formed  by 
the  coats  of  the  artery. 

(c)  Fractures  and  dislocations  are  exciting  causes  of  aneurysm,  since  the 
artery  is  torn  or  stretched  so  as  to  weaken  the  coats,  thus  permitting  subse- 
quent dilatation. 

(d)  Straiyis  have  been  considered  exciting  causes  of  aneurysm,  since  they 
produce  irregular  and  forced  action  of  the  heart.  Strains  may  also  act  directly 
upon  the  vessel  by  forcing  blood  through  it  while  it  is  under  unusual  tension, 
thus  causing  pressure  at  right  angles  to  the  axis  of  the  vessel,  or  by  stretching 
the  artery  in  its  long  axis. 

The  signs  and  symptoms  of  aneurysm  may  be  described  as  belong- 
ing to  two  stages  :  First  Stage. — This  includes  the  period  from  the  beginning  of 
the  formation  of  the  aneurysm  until  the  tumor  is  firm  from  the  deposit  of  fibrin. 
Second  Stage. — This  includes  the  period  after  the  aneurysm  has  become  firm 
and  resisting  by  reason  of  the  presence  of  the  deposit  of  laminated  fibrin.  This 
stage  may  be  absent,  as  in  some  aneurysms  no  such  deposit  takes  place. 

First  Stage. — {a)  Pulsation  which  is  distinct,  expansile,  and  synchronous 
with  the  action  of  the  heart.  * 


23()  AN  AMERICAN    TENT-JiOOK    OF  SURUEHY. 

The  pulsation  is  distinct  in  the  first  stage,  because  the  aneurysm  contains 
only  fluid  Mood  and  tiie  sac  is  thin,  'riie  pulsation  is  excentric  and  exj)ansile 
in  character.  If"  l)otli  hands  are  placed  upon  the  sides  of"  the  tumor,  they  will 
be  separated  from  each  other  with  every  pulsation.  The  pulsation  in  this  stage 
is  simultaneous  with  the  contraction  of  the  heart.  The  pulsation  of  an  abscess 
lying  on  an  artery  would  be  up  and  down  in  mass,  and  not  expansile. 

\l>)  Premure  on  the  artery  above  the  tiunor  diinhuHhcs  the  size  of  the  latter; 
when  applied  helow  the  tumor  inereases  its  size;  and  in  both  cases  cauKex  the 
pulsation  to  diminish  or  cease.  If  the  artery  above  the  sac  is  conii)resseil,  the 
flow  of  blood  into  the  sac  is  arrested,  the  blood  can  l)e  s([uee'/ed  out  of  the  sac, 
and  the  tumor  disappears.  This  can  be  beautifully  illustrated  in  the  first  stage 
while  the  contents  of  the  sac  are  composed  of  fluid  blood  and  the  walls  of  the 
sac  are  thin.  If,  after  having  compressed  the  artery  above  the  sac  and  emptied 
the  latter  of  blood,  the  hands  are  ])laced  firmly  over  the  sac  and  the  pressure  is 
removed  from  above,  the  l)lood  will  rush  into  the  sac,  and  as  soon  as  the  sac  has 
filled  pulsation  will  return  and  will  separate  the  hands.  In  abscess,  on  the 
other  hand,  the  instant  the  pressure  from  the  artery  above  is  relieved,  the  trans- 
mitted pulsation,  or  upheaval,  is  felt.  If  the  artery  below  the  sac  is  com- 
pressed, the  sac  will  rapidly  enlarge  and  the  pulsation  will  diminish  or  cease. 
If  the  pulsation  in  the  efferent  artery  at  some  distance  from  the  sac  on  its  distal 
side  be  felt,  it  will  not  be  simultaneous  Avith  the  ])ulsation  of  the  corresponding 
artery  of  the  opposite  side  of  the  body.  Besides  the  apjireciable  delay  in  pulsa- 
tion as  compared  with  the  opposite  artery,  the  force  of  the  pulsation  will  be 
markedly  diminished.  The  sphygmographic  tracing  of  the  pulse  upon  both 
sides  of  the  body  will  also  reveal  a  wide  difference  (Fig.  39). 

Fia.  39. 


Sphygmographic  Trnriiifrs  of  tlio  Kndinl  rnlso  of  ft  Patient  with  AniMirysni  of  tin-  llight  Hrachial  Artery: 
1,  Left  Kadiiil  I'ulse  ;  2,  KifilU  Kadial  I'lilse  (Malioiiudl. 

(c)  A  bruit  is  heard  over  the  aneurysm,  and  also  along  the  artery  for  some 
distance  from  the  sac.  The  bruit  is  a  noise  caused  by  the  rush  of  blood  into, 
through,  and  out  of  the  sac,  the  internal  lining  membrane  of  which  is  rough- 
ened.°  The  bruit  is  blowing  or  loud  and  rasping  like  the  noise  made  by  a  saw. 
This  blowing  murmur  is  not  always  present,  but  its  absence  will  not  exclude 
the  possible  existence  of  an  aneurysm.  In  malignant  vascular  tumors  the 
bruit  is  sometimes  present,  but  is  heard  only  over  the  area  of  the  tumor,  and 
is  never  transmitted  along  the  artery  leading  from  the  sac,  as  it  is  in  aneurysm. 

Second  Stage. — This  stage  "includes  the  period  after  the  aneurysm  has 
become  firm  and  resisting  by  the  (lei)osit  of  laminated  fibrin. 

(a)  Indistinct  Pulsation. — When  the  aneurysm  becomes  firm  and  its  sac  is 
lined  with  fibrin,  the  pulsation  is  indistinct  and  rnay  even  be  altogether  lost. 
There  are  certain  points  over  the  sac  where  the  pulsation  is  felt  more  distinctly 
than  at  others.  This  is  because  the  fibrin  is  not  equally  distributed  over  the 
interior  of  the  sac. 

(6)  Pressure. — Owing  to  the  deposition  of  fibrin,  the  tumor  cannot  be  effaced 
by  pressure  on  the  artery  above  the  sac,  as  in  the  first  stage. 


SUBGERY    or    THE    VASCULAR    SYSTEM. 


2;i7 


((•)  The  bruit  is  fjoiu'riilly  present,  althouj^h  it  is  heard  witli  varying  degrees 
of  distinctness  over  the  tumor,  and  also  can  be  heard  at  a  distance  from  the  sac. 

It  will  be  observed  that  these  symptoms,  which  were  so  marked  and  almost 
pathognomonic  in  the  first  stage,  are  of  rather  negative  character  in  the  second 
stage.     There  are,  however,  additional  signs  : 

((/)  Pain. — The  pain  is  sharp  and  lancinating,  like  that  of  carcinoma,  or 
aching  or  boring,  like  that  of  ulceration.  It  arises  after  the  aneurysm  has 
attained  some  size  and  makes  pressure  upon  the  nerves.  Thus  in  popliteal 
aneurysm  the  pain  is  intense  along  the  course  of  the  popliteal  nerve.  The 
nerve  is  sometimes  flattened  out  upon  the  sac.  Pain  may  be  at  times  an 
early  symptom  of  aneurysm,  but  it  is  generally  more  pronounced  later  on  in 
the  course  of  the  disease. 

{e)  (Edema. — This  is  produced  by  the  pressure  of  the  sac  upon  the  veins. 
(Edema  of  the  limb  is  constant  after  the  tumor  has  attained  a  certain  size. 
The  oedema,  if  excessive,  produces  a  great  deal  of  discomfort  to  the  patient, 
and  may  terminate  in  extensive  ulceration  and  sloughing. 

(/)  Gangrene  sometimes  occurs  late  in  the  course  of  the  disease,  and  gen- 
erally follows  the  oedema,  but  may  come  suddenly  as  the  result  of  an  embolus. 

[g)  Pressure-ejfects  vary  according  to  the  parts  pressed  upon  and  the 
amount  of  pressure  exercised  by  the  tumor. 

If  the  aneurysm  presses  upon  bone,  it  produces  a  severe  aching,  boring, 
gnawing  pain,  and  finally  causes  the  absorption  of  the  osseous  tissue  (Figs.  38 
and  40) ;   if  upon   glands,   it   destroys 

their   function  ;    if  upon    the    trachea,  ^^^'  '*^- 

respiration  is  rendered  difficult,  and 
there  is  an  obstinate  distressing  metallic 
cough  and  altered  voice  produced  by 
pressure  upon  the  I'ecurrent  laryngeal 
nerve.  This  is  termed  the  brassy 
cough  of  aneurysm.  If  the  aneurysm 
presses  upon  the  oesophagus  or  the 
thoracic  duct,  deglutition  or  nutrition 
is  interfered  with  and  the  patient  dies 
from  inanition.  If  the  pressure  be  on 
the  phrenic  nerve,  hiccough  often  is 
produced :  and  if  on  the  sympathetic 
nerve,  marked  capillary  congestion. 

Diagnosis  of  Aneurysm. — If 
the  aneurysm  has  not  consolidated,  the 
symptoms  which  have  been  enumerated 
will  enable  the  surgeon  to  establish  a 
diagnosis.  But  it  often  happens  that 
after  consolidation  of  the  aneurysm  by 
fibrin  many  of  the  signs  and  symptoms 
become  obscure  and  a  diagnosis  is  ren- 
dered somewhat  difficult.  Again,  cer- 
tain other  tumors  under  exceptional 
circumstances  may  present  signs  almost 
identical  with  those  of  an  aneurysm. 

In  a  case  of  consolidation  the  history 
of  the  disease,  and  occasionally  the  use  of  the  hypodermatic  syringe,  are  the 
only  safe  guides  for  the  surgeon.  In  pulsating  tumors  which  resemble  aneu- 
rysm the  diagnosis  must  be  made  with  great  care. 


Absorption  and  Perforation  of  the  Sternum  from 
Pressure  by  an  Aneurj-sm  (original). 


238  AN  AMERICAN    TEXT-BOOK   OF  SURGERY. 

The  (liffovent  tumors  Avitli  Avliicli  a  surgeon  may  confound  an  aneurysm  are 
the  ))ulsatinii;  eiice)»hah)i(l,  tlie  vascular  soft  sarcoma,  erectile  tumors  of  all 
kinds,  jiulsating  tumors  of  hone,  an  ahscess  over  an  artery,  and  hematocele  of 
the  neck. 

There  are  also  tumors  Avhieh  are  not,  strictly  speaking,  pulsating  which 
have  led  to  error  in  diagnosis  and  treatment,  such  as  lymphatic  enlargement 
and  cystic  disease  of  the  thyroid  gland,  and  certain  other  diseases,  as  neuralgia 
and  rheumatism,  the  pain  in  both  of  Avhich  has  been  mistaken  for  tliat  of 
beginning  aneurysm  in  the  thoracic  cavity. 

Duration  of  Aneurysm. — An  aneurysm  may  grow  very  ra|)idly,  but 
this  is  rare.  The  growth,  as  a  rule,  is  slow,  and  may  extend  over  several  years. 
The  aneurysm  is  likely  to  grow  as  long  as  the  cause  is  present.  Its  duration 
is  influenced  by  the  force  of  the  circulation,  its  situation,  the  size  of  the  mouth 
of  the  sac,  the  coagulating  tendency  of  the  blood,  the  nature  of  the  surround- 
ing parts,  the  condition  of  tlie  sac,  and  the  patient's  habits  and  manner  of 
living. 

Treatment. — The  surgeon  must  aim  in  his  treatment  to  effect  a  cure  by 
precisely  those  means  which  nature  adopts.  The  essential  conditions  for  suc- 
cess in  any  plan  of  treatment  are  obliteration  of  the  cavity  of  the  sac  and 
occlusion  of  the  afferent  and  efferent  vessels. 

There  are  several  ways  in  which  obliteration  of  the  sac  and  the  vessels  can 
be  accom{)lishe(l,  but  often  the  best  results  will  be  obtained  by  a  combination 
of  various  methods  of  treatment.  In  order  to  occlude  the  sac  it  is  necessary  to 
diminish  the  force  of  the  circulation,  thus  causing  coagulation  of  the  blood  in 
the  aneurysmal  sac.     When  this  has  been  eff'ected  a  cure  may  be  expected. 

The  methods  resorted  to  may  be  either  medical  or  surgical. 

The  medical  methods  which  have  met  with  the  greatest  success  in  curing 
aneurysm  arc  those  suggested  by  Langenbeck  and  l)y  Tufnell.  Laiu/cnbeck's 
method  consists  in  the  hypodermatic  injection  of  ergotin.  This  drug  slows 
the  action  of  the  heart,  and  hence  favors  deposit  of  fibrin  ;  it  contracts  the 
muscular  fibers  of  the  middle  coat  of  the  arteries  leading  into  the  sac,  and 
produces  increase  of  blood-pressure.  All  these  are  favorable  to  the  deposition 
of  fibrin  and  the  consolidation  of  the  aneurysm.  Iodide  of  potassium  has  also 
been  used  in  the  medical  treatment,  largely  upon  the  supposition  tliat  aneu- 
rysms are  due  to  the  eff"ects  of  syphilis,  but  it  probably  acts  as  a  lieart  depres- 
sant. Acetate  of  lead  has  been  employed  to  equalize  the  circulation.  Bromide 
of  potassium  has  been  used  to  relieve  the  cough  and  pain. 

TufnelVs  method  is  a  modification  of  a  plan  of  treatment  originally  suggested 
by  Valsalva.  It  is  especially  applicable  to  internal  aneurysms :  but  a  brief 
description  of  it  is  proper  here,  as  external  aneurysm  has  been  thus  successfully 
treated,  and  as  a  list  of  the  diff'erent  methods  of  curing  aneurysms  would  be 
incomplete  without  reference  to  this  peculiar  plan  of  treatment. 

In  1875,  Tufnell,  an  Irish  physician,  published  his  experience  in  what  may- 
be termed  the  rest  treatment  of  aneurysm.  Tufnell  required  his  aneurysmal 
patients  to  assume  the  recumbent  position  in  bed  for  several  months.  The 
object  of  the  treatment  was  to  reduce  the  watery  elements  of  the  l)lood  and 
to  increase  its  solid  constituents.  Rest,  regimen,  and  remedial  agents  Avere 
the  three  means  he  employed.  He  showed  that  in  the  recumbent  position  the 
circulation  Avas  tranquillized  and  the  action  of  the  heart  became  regular  and 
slow.  He  maintained  that  recumbency  placed  the  same  check  upon  the  circu- 
lation in  internal  aneurysm  that  mechanical  compression  does  in  the  treatnuMit 
of  external  aneurysm.  He  demonstrated  this  pro))osition  in  the  fi)llowing  way  : 
A  patient  before  assuming  the  recumbent  position  had  a  pulse  of  9(3  a  minute; 


SURGERY   OF    THE    VASCULAR   SYSTEM.  239 

after  a  few  d.ws'  lying  supine  in  bed  it  fell  to  66  a  minute.  Thus  there  was  a 
difference  of  30  beats  a  minute  caused  by  position.  ]\Iidtii)lying  30  beats  by 
00,  the  iiuuiber  of  minutes  in  an  hour,  the  result  is  1800  beats  an  hour,  and 
this  multiplied  by  24 — the  number  of  hours  in  a  day — gives  43,200  beats  per 
diem ;  that  is  to  say,  a  patient  suff'ering  from  aneurysm  and  occupying  the 
recumbent  position  has  his  aneurysmal  sac  distended  43,200  times  less  frequently 
in  a  day  than  it  would  be  if  he  remained  in  th(;  standing  position.  Tufnell 
held  that  there  was  no  remedial  agent  in  the  Pharmacopeia  that  would  produce 
such  an  action  upon  the  heart  without  injury  or  danger.  Recumbency  is  the 
secret  of  cure,  but  it  must  be  continued  for  three  months.  The  diet  was 
restricted  to  10  ounces  of  solid  and  6  ounces  of  fluid  in  the  twenty-four  hours. 
This  reduction  of  nourishment  diminished  the  action  of  the  heart  and  increased 
the  plasticity  of  the  blood,  and  hence  favored  the  consolidation  of  the  aneurysm, 
Tufnell  also  directed  certain  remedial  agents  to  be  combined  with  rest,  such  as 
lactucarium  to  quiet  the  patient  and  induce  sleep,  and  opium  to  soothe  pain. 
Compound  powder  of  jalap  was  used  at  intervals,  to  reduce  the  quantity  of  cir- 
culating fluid  by  withdrawing  the  serum  from  the  blood.  He  gives  an  analysis 
of  10  cases  treated  by  his  method :  7  were  cured,  and  3  died  during  treatment. 
One  of  the  successful  cases  was  an  aneurysm  of  the  popliteal  artery,  cured  in 
twelve  days. 

The  surgical  treatment  of  aneurysm  may  be  subdivided  into — 1st,  those 
methods  which  embrace  some  form  of  compression  ;  2d,  those  which  embrace  some 
form  of  surgical  operation ;  3d,  those  which  may  be  classed  as  miscellaneous. 

1.  Compression. — The  treatment  of  aneurysm  by  compression  was  employed 
over  two  hundred  years  ago,  but  only  in  cases  of  traumatic  aneurysm.  The 
manner  of  employing  compression  in  the  seventeenth  century  for  the  cure 
of  aneurysm  was  essentially  different  from  that  employed  at  the  present  time, 
both  in  its  principle  and  in  its  application. 

The  principle  upon  wdiich  surgeons  based  the  treatment  of  traumatic  aneu- 
rysm by  compression  in  the  seventeenth  century  was  this :  the  compression  was 
supposed  to  prevent  the  further  dilatation  of  the  aneurysm  and  to  squeeze  the 
blood  out  of  the  sac  into  the  arteries,  as  water  would  be  squeezed  out  of  a 
sponge ;  the  edges  of  the  cut  artery  were  thought  to  be  thus  brought  into 
apposition  and  to  become  adherent,  and  the  blood  to  pass  through  the  restored 
artery  as  if  nothing  had  happened.  From  this  description  it  is  evident  that 
little  was  known  of  the  nature  or  pathology  of  aneurysm.  That  the  prin- 
ciple upon  which  the  treatment  was  based  was  erroneous  Avill  be  seen  when 
we  study  the  subject  in  the  light  which  modern  pathology  has  thrown  upon  it. 

In  the  eighteenth  century  Heister  was  the  first  to  propose  to  extend  the 
plan  of  treatment  of  traumatic  aneurysm  by  compression  from  the  bi'achial 
artery,  to  which  compression  had  been  limited,  to  the  popliteal  artery,  but 
he  did  not  carry  his  plan  into  execution.  It  was  reserved  for  Guattani,  an 
Italian  surgeon,  in  the  year  1772  to  treat  the  first  case  of  popliteal  aneurysm 
by  compression.  He  applied  compression  directly  upon  the  sac  and  also  band- 
aged the  entire  limb,  believing  that  the  aneurysm  was  cured  upon  the  same 
principle  that  has  been  mentioned.  The  cases  treated  by  this  means  usually 
resulted  fatally.  By  direct  compression  a  circumscribed  aneurysm  Avas  often 
transformed  into  a  diffiise  one ;  the  sac  became  inflamed  and  suppurated ;  the 
limb  became  gangrenous,  and  half  of  the  patients  died.  This  was  the  state  of 
affairs  when,  in  l785,  John  Hunter  tied  the  femoral  artery  in  Hunter's  canal 
for  the  cure  of  a  popliteal  aneurysm,  and  announced  a  new  principle,  which 
changed  all  the  opinions  then  held  as  to  the  way  in  which  compression  cured 
an  aneurysm,  and  was  followed  by  a  complete  revolution  in  practice. 


240  ^l.y  AMERICAN   TEXT- BO  OK   OF  SURGERY. 

Desault  ligatcd  the  popliteal  at  some  distance  above  the  sac  earlier  in  the 
same  year,  and  a  claim  ot"  priority  has  been  based  upon  this  fact.  The  Ilun- 
terian  method  is  mentioned  in  this  connection  only  to  show  the  change  produced 
by  it  in  the  treatment  by  compression.  In  another  place  it  will  be  considered 
at  length.  The  new  principle  involved  was  this:  that  it  was  necessary  to  arrest 
only  partially,  and  not  completely,  the  current  of  blood  through  the  aneurysmal 
sac,  which,  from  its  own  inherent  elasticity,  tends  to  diminish  in  size  so  soon 
as  the  full  force  of  the  heart's  action  is  taken  off:  this  contractility  of  the  sac 
is  an  imj)ortant  element  in  the  cure  of  circumscribed  aneurysms  l)y  any  method, 
and  its  absence  in  diffused  as  in  traumatic  aneurysms  explains  the  failure  of 
ligation  and  compression  in  the  majority  of  such  cases.  Upon  this  i)rinciple 
and  after  Hunter's  time  compression  was  employed  above  the  aneurysm, 
instead  of,  as  always  before,  directly  over  it,  and  with  greatly  improved  results. 
When  this  method  is  employed,  the  cessation  of  pulsation  in  the  sac  after  the 
compression  is  relaxed,  the  absence  of  the  thrill  and  bruit,  together  with  the 
fact  that  the  collateral  circulation  is  fully  established,  indicate  that  the  aneu- 
rysm is  cured. 

The  enlargement  and  })ulsation  in  the  collateral  vessels  do  not  take  place 
until  the  aneurysmal  sac  is  obliterated  by  the  deposition  of  fibrin  ;  therefore  the 
establishment  of  the  collateral  circulation  is  in  itself  a  reason  for  supposing  that 
the  aneurysm  is  cured.  It  is  through  this  collateral  circulation  that  the  extrem- 
ity is  supplied  with  blood.  This  prevents  gangrene  from  attacking  the  parts 
below  the  sac.  The  collateral  vessels  soon  develop  into  vessels  of  important 
size.  The  pain  which  has  been  recorded  in  the  cases  in  which  spontaneous 
cure  was  effected,  as  well  as  in  those  cases  in  which  compression  accomplished 
a  cure,  has  been  said  to  have  been  due  to  the  sudden  enlargement  of  the  anas- 
tomosing vessels  consequent  upon  the  complete  solidification  of  the  sac,  and 
may  thus  occasionally  be  considered  a  favorable  symptom. 

Instrumental  conipi^ession  is  carried  out  by  the  employment  of  one  of  the 
many  different  varieties  of  tourniquets  or  compressors.  Whatever  instrument 
is  employed  for  the  purpose  (Figs.  41,  42),  only  the  artery  must  be  compressed, 

Fi(i.  41.  Fig.  42. 


Signorini's  Tourniquet.  Skey's  Tourniquet. 

and  at  no  time  during  the  period  in  which  the  instrument  is  applied  must  the 
pressure  be  greatly  relaxed.  A  piece  of  chamois-skin  should  be  placed  over 
the  artery,  so  that  the  pressure  of  the  instrument  shall  not  excoriate  the  skin. 
The  time  required  to  cure  an  aneurysm  by  compression  varies  from  one 
to  several  days.  The  instrument  must  be  kept  on  the  artery  until  the 
pulsation  in  the  sac  has  ceased,  and  then  the  amount  of  pressure  during  the 
following  twenty-four  hours  can  be  lessened  gradually.     This  gradual  diminu- 


SURGERY   OF   THE    VASCULAR   SYSTEM.  241 

tion  of  the  amount  of  compression  after  pulsation  has  ceased  is  necessary, 
because  otherwise  the  current  of  blood  might  disintegrate  the  clot  in  the  sac 
before  it  is  firm  and  solid. 

Digital  pri'ssior  was  first  employed  by  Jonathan  Knight  of  New  Haven, 
Conn.,  in  1848.  In  the  same  year  Dr.  Willard  Parker  and  Dr.  James  R. 
Wood  of  New^  York  City  each  cured  an  aneurysm  by  digital  pressure.  The 
pressure  is  maintained  by  relays  of  students  or  assistants  for  from  one  to 
two  days,  and  this  method  is  preferred  by  many  surgeons  to  all  other  methods 
of  compression.  The  same  principle  of  treatment  has  been  carried  out  by  the 
use  of  instrumental  pressure  instead  of  digital,  with  fairly  satisfactory  success. 
A  bag  of  shot,  suspended  over  the  bed  by  means  of  clastic  tubing,  has  been 
used  to  secure  uniform  pressure  upon  the  artery  above  the  sac. 

Flexion  of  the  joint  was  brought  to  the  attention  of  the  profession  in  1858 
by  Mr.  Hart  of  England.  The  })rinciples  involved  in  this  method  are  similar 
to  those  involved  in  compression.  The  plan  is  usually  applicable  only  to  aneu- 
rysm at  the  bend  of  the  elbow  and  in  the  ham,  although  it  has  been  success- 
fully employed  also  in  aneurysm  of  the  external  iliac.  The  leg  is  flexed  upon 
the  thigh  and  the  thigh  upon  the  pelvis ;  or  the  forearm  is  flexed  upon  the  arm. 
The  entire  extremity  is  bandagecl  before  flexion.  Flexion  causes  compression 
directly  upon  the  tumor  itself,  and  also  impedes  the  circulation  through  the 
sac,  and  probably  dislodges  a  small  clot  which  closes  the  mouth  of  the  sac. 
This  method  is  not  suitable  where  the  aneurysm  is  large,  because  of  the  liability 
of  the  sac  to  rupture,  and  is  contraindicated  if  there  is  much  oedema  of  the  leg 
or  inflammation  of  the  sac.  In  ordinary  cases  it  may  be  tried,  since  no  liarm 
follows  if  the  treatment  is  unsuccessful.  It  is  especially  applicable  to  cases  in 
w'hich  the  tumor  is  small,  the  sac  not  inflamed,  and  the  joint  not  involved. 

Rapid  Cure  by  EsmarcJis  Elastic  Bandage. — In  1864,  Murray,  an  English 
surgeon,  anesthetized  a  patient  suffering  from  an  aneurysm  of  the  abdominal 
aorta,  and  applied  an  instrument  which  completely  checked  the  flow  of  blood 
through  the  arteries  leading  into  the  sac.  The  treatment  resulted  in  cure.  In 
this  the  so-called  "rapid  method"  the  object  was  to  produce  complete  stag- 
nation of  a  mass  of  blood  in  the  sac  until  it  coagulated.  In  1875,  Reid  of  the 
British  navy  treated  aneurysms  successfully  by  the  rapid  method  by  employing 
Esmarch's  elastic  bandage.  The  formation  of  a  blood-clot  in  the  sac  is  essen- 
tial in  order  to  effect  the  cure  of  an  aneurysm  by  this  method.  That  variety 
of  blood-clot  which  is  formed  while  blood  is  at  rest  is  required  (the  red  blood- 
clot),  and  not  the  one  that  is  formed  while  blood  is  in  motion  (the  fibrinous  or 
"white  blood-clot).  In  order  to  accomplish  the  formation  of  a  blood-clot  in  con- 
tradistinction to  the  formation  of  fibrin  there  must  be  a  stasis  of  blood  in  the 
sac,  followed  by  coagulation  of  the  blood.  This  clot  does  not  finally  undergo 
organization,  but  contracts.  Its  chief  object  is  to  aid  in  the  formation  of  a 
thrombus  in  the  afferent  and  efferent  vessels  leading  into  and  out  of  the  aneu- 
rysm. Not  all  aneurysms  are  amenable  to  this  treatment.  There  should  be  no 
vascular  degeneration  except  in  the  aneurysm,  likewise  no  renal  disease,  and 
the  sac  itself  should  be  free  from  inflammation.  The  administration  of  the 
iodides  and  restricted  albuminous  diet  are  useful  adjuvants. 

The  patient  should  have  a  hypodermatic  injection  of  morphine  before  taking 
ether,  and  just  enough  of  the  anesthetic  should  be  administered  to  keep  him  quiet 
and  free  from  pain  during  the  treatment.  The  elastic  bandage  should  be  firmly 
applied  from  below  upward  till  the  aneurysmal  sac  is  reached,  then  carried  very 
lightly  over  the  sac  itself,  and  reapplied  firmly  above  it,  so  as  to  confine  a  quan- 
tity of  fluid  blood  in  the  sac.  The  patient  must  be  kept  under  ether  for  an  hour 
or  an  hour  and  a  half.     A  tourniquet  should  be  adjusted  above  the  aneurysm, 


242  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

to  moderate  tlie  hlood-curreiit  iind  prevent  its  disturbing  and  wasliing  out  the 
clot  in  the  sac  and  the  thrombi  in  the  afferent  and  efferent  arteries.  The 
tourni(iuet  ean  be  kept  on  the  linil)  for  from  sixteen  to  twenty-four  hours  after 
the  removal  of  the  bandage,  and  nmst  be  unscrewed  gradually,  so  as  to  restore 
the  blood-supply  in  proper  (juantity.  The  two  dangers  to  be  guarded  against 
are,  on  the  one  hand,  washing  out  the  clot  before  it  is  solid,  and  on  the  other 
the  production  of  gangrene  of  the  limb  by  too  long-continued  pressure.  The 
effect  of  the  arrest  of  the  blood-supply  must  be  carefully  watched  from  hour  to 
hour  as  the  tourni(|uet  is  gradually  unscrewed.  The  collateral  circulation  will 
soon  be  established.  The  risks  of  the  sudden  rise  and  fall  of  arterial  tension, 
the  compression  of  nerves,  the  rupture  of  the  sac,  the  development  <»f  kidney 
disease,  and  the  possibility  of  gangrene,  are  all  to  be  considered.  These  dan- 
gers also  accompany  other  methods,  but  perhaps  are  as  little  likely  to  occur 
after  this  plan  as  after  any  other  operative  interference  or  after  compression 
applied  in  any  one  of  the  many  ways  already  described. 

The  treatment  of  aneurysm  by  any  of  the  different  methods  of  compression 
is  not  without  difficulties.  If  the  instrument  is  not  adapted  to  the  exigencies 
of  the  case,  if  the  patient  is  irritable  and  cannot  bear  pain  well,  or  if  the 
aneurysm  is  unfavorably  situated  for  the  application  of  an  instrument  or  of 
digital  compression,  there  will  arise  difficulties  which  Avill  discourage  the 
patient  as  well  as  the  surgeon.  If,  hoAvever,  after  even  wrecks  of  perseverance 
no  good  has  been  accomplished,  both  patient  and  surgeon  should  remember 
that  no  great  risks  have  been  incurred  involving  the  life  of  the  patient,  and 
no  conditions  absolutely  contraindicating  a  trial  of  operative  measures  have 
been  produced.  Few  cases  in  which  the  treatment  by  compression  in  some 
form  has  been  faithfully  persevered  in  for  a  long  time  have  been  unattended  with 
improvement. 

2.    Those  metliods  tvhieh  embrace  some  form  of  surgical  operation. 

The  Old  Operation  of  Antyllus  (Fig.  43). — The  earliest  recorded  treatment 
of  aneurysm  is  that  devised  by  Antyllus,  who  lived  in  the  fourth  century.  At 
that  time  it  was  employed  only 

in    cases    of    small    traumatic  Fig.  43. 

aneurysms  situated  at  the  bend 
of  the  elbow.  The  method 
was  simple,  and  was  described 
by  him  as  follows :  an  incis- 
ion was    made  along  the  inner  Old  Operation  of  AntyUus  for  Aneurysm  (original). 

aspect   of  the   arm  over   the 

brachial  artery.  The  vessel,  having  been  exposed,  Avas  tied  on  each  side  of 
the  aneurysm.  The  aneurysm  Avas  then  laid  open  and  the  contents  of  the 
sac  Avere  turned  out. 

This  operation  Avas  performed  for  several  hundred  years,  and  it  Avas  not  until 
the  eighteenth  century  that  any  other  was  practised  even  in  idiopathic  aneurysm. 
The  great  mortality  in  this  form  of  aneurysm  Avas  due  to  the  fact  that  the 
artery  Avas  tied  immediately  above  and  beloAV  the  sac,  ivhere  the  vessel  tvas 
unsound,  and  hence  secondary  hemorrhage  and  exhaustive  suppuration,  with 
ankylosis  of  the  joint,  folloAved.  The  principle  involved  in  the  ohl  opera- 
tion, with  certain  omissions  and  modifications,  is  still  applicable  iu  axil- 
lary and  gluteal  aneurysms  and  in  traumatic  aneuysm  at  the  bend  of   the 

elboAv.  ,     .     1 

AneVs  Operation  (Fig.  44).— Anel  in  the  year  1710  (levised  anil  per- 
formed a  ncAv  operation  for  the  cure  of  aneurysm.  He  did  not  open  the 
sac  as  in  the  old  operation,  or  tie  the  artery  above  and  below  the  sac,  or 


SURGERY   OF    THE    VASCULAR   SYSTEM. 


243 


Fig.  44. 


Stuff  the   uonnd   with   myrrh.      lie  thou^lit  that  the  tumor  would  collapse 
if  the  main  artery  leading  into  it  were  tied  near  the  aneurysm.     He  was  suc- 
cessful,, and  thenceforward  the  treatment  of 
aneurysm  rested  upon  a  scientific  basis. 

Anel,  however,  did  not  ap))reliend  cor- 
rectly the  principle  which  his  operation  in- 
volved, lie  thought  the  tumor  simj)ly  col- 
lapsed, and  it  was  not  until  some  years 
afterward  that  the  true  principle  underlying 
this  operation  of  ligaturing  the  artery  upon 
the  cardiac  side  of  the  aneurysm  was 
brought  to  light — not  indeed  until  John  Hunter,  in  1785,  on  account  of  the 
many  failures  in  the  treatment  of  aneurysm   by  compression,  was  led  to 


Aiiel's  Operation  for  Aneurysm  (original) 


Fig.  45. 


Hunter's  Operation  for  Aneurysm  (original). 


investigate  the  subject  from  a  pathological  point  of  view,  and  devised  the 
operation  for  its  cure  which   has  made  his  name  immortal. 

Hunterian  Operation  (Fig.  45). — Hunter  demonstrated  by  experiments  upon 
dogs  that  weakness  alone  was  not  the  cause  of  dilatation  of  an  artery,  but  that 
there  must  be  some  previous  disease  of  the  coats  of  the  artery  itself  before  the 
force  of  the  circulation  would  develop  an  aneurysm.  He  proved  that  the  disease 
was  not  confined  to  the  artery  at  the  seat  of  enlargement  only,  but  extended 
some  distance  from  the  sac ;  and  this  fact,  he  thought,  explained  the  cause  of 
failure  of  treatment  by  Anel's  method,  in  which  the  artery  was  tied  at  a  point 
where  it  was  diseased,  permitting  the  ligature  to  come  away  too  soon  and  second- 
ary hemorrhage  to  occur. 

Hunter  proposed,  therefore,  to  tie  the  artery  at  a  distance  from  the  sac,  at  a 
point  where  the  vessel  w^as  healthy,  and  thus  diminish  the  risk  of  secondary 
hemorrhage.  He  thought,  moreover,  that  if  the  force  of  the  circulation  were 
taken  off  from  the  aneurysmal  sac  the  disease  would  be  arrested,  and  the 
sac  and  its  contents  would  be  absorbed.  The  conclusion  which  he  drew'  from 
his  observations  was  that  simply  taking  off  the  force  of  the  circulation  from 
the  aneurysmal  artery  is  sufficient  to  effect  a  cure  of  the  disease,  or  at  least  to 
put  a  stop  to  its  progress,  and  enable  the  processes  of  nature  to  restore  the  parts 
to  a  normal  state. 

The  conditions  under  which  the  Hunterian  operation  is  indicated  are  as 
follows:  the  aneurysm  must  be  of  moderate  size;  it  must  be  of  slow  growth; 
and  the  sac  mus"t  not  be  inflamed.  Slight  oedema  w^ould  not  contraindicate 
the  operation.     Gangrene  would  preclude  all  operations  except  amputation. 

The  accidents  following  the  Hunterian  operation  are — secondary  hemor- 
rhage, return  of  pulsation  in  the  sac,  inflammation  and  suppuration  of  the  sac, 
gangrene  of  the  extremity,  pyemia,  and  septicemia. 

Brasdors  Operation  (Fig.  46)  consists  in  ligating  the  artery  upon  the 
distal  side  of  the  sac,  so  that  the  circulation  upon  that  side  is  completely 


•2i\ 


AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 


arrested.     The  cases  in  which  this  method  can  be  adopted  are  aneurysms  of 
the  carotid  artery,  of  the  external  iliac,  etc. 

Wardrop's  Operation  (Fig.  47)  consists  in  tying  the  artery  or  one  of  its 
branches  upon  the  distal  side  of  the  sac,  the  principle  on  which  it  is  founded 


Fig 


Brasdor's  Operation  (Holmes). 


Wardrop's  Operation  (Holmes). 


being  the  same  as  that  in  Brasdor's.  It  arrests  the  circulation  to  a  great  extent, 
but  still  permits  the  escape  of  blood  through  one  or  more  branches.  It  is 
applicable  only  to  aneurysm  of  the  innominate  artery  or  of  the  arch  of  the 
aorta.  The  carotid  or  the  subclavian  alone,  or  both  of  these  vessels,  may  be 
tied,  and  the  two  operations  may  be  either  simultaneous  or  consecutive.  The 
branches  of  the  subclavian  between  the  ligature  and  the  aneurysm  keep  up  a 
diminished  circulation. 

Before  dismissing  the  subject  of  ligation,  the  advantages  of  compression 
over  ligation  will  be  considered.     These  advantages  are  that — 

1st.  Compression  effects  a  cure  in  accordance  with  nature's  laws.  The  sac 
after  compression  consolidates  just  as  in  spontaneous  cure;  only  the  sac  itself 
is  consolidated,  and  not  all  the  arteries  up  to  the  point  where  pressure  is 
made,  as  is  the  case  after  ligation. 

2d.  Compression  is  less  dangerous  than  ligation.  If  any  danger  arises 
during  compression,  the  treatment  can  be  discontinued  and  then  resumed. 
Not  so  with  ligation,  for  then  the  patient  may  be  in  great  danger  for  many 
days  after  operation. 

3d.  Compression  is  more  likely  to  be  attended  Avith  success  than  ligation. 
There  are  not  so  apt  to  be  complications,  such  as  secondary  hemorrhage,  slough- 
ing of  the  sac,  phlebitis,  gangrene,  or  pyemia,  occurring  during  compression 
and  preventing  a  cure. 

4th.  Compression  is  more  likely  to  be  permanent  than  ligation.  A  second 
aneurysm  has  been  known  to  form  after  ligation,  and  also  suppuration  to  be 
set  up  in  the  sac ;  neither  of  these  is  likely  to  occur  after  compression,  though 
both  are  possible. 

3,    Those  methods  which  may  he  classed  as  miscellaneous. 

Introduction  of  Foreign  Bodies  into  the  Sac. — This  method  consists  in 
puncturing  the  sac  with  a  canula  and  introducing  through  it  several  yards  of 
fine  wire.  Moore,  in  1864,  passed  twenty-six  yards  of  fine  wire  into  an 
aneurysmal  sac.  The  patient  died  of  pericarditis  and  inflammation  of  the  sac. 
Recently,  Loreta  introduced  some  silvered  copper  wire  into  the  sac  of  an 
abdominal  aneurysm.  A  firm  clot  was  formed,  but  the  patient  died  two  months 
after  the  operation.     Besides  wire,  other  materials  have  been  employed,  such 


SURGFAiV   OF    THE    VASCULAR   SYSTEM.  245 

as  catgut,  silk,  ainl  liorsc-liair.  AVliatcvcr  iiKitci-ial  is  used,  the  operation  is 
attended  with  some  danger;  l)ut  Stewart  has  re])orted  two  cases  of  aortic 
aneurysm  in  whieli  great  improvement  took  phiee  after  filling  the  sac  with  wire. 

Matupuhttid)!. — This  method  was  introduced  hy  Fergusson  in  1852.  The 
object  is  to  disphice  some  of  the  fibrin  in  the  sac  by  manipulating  the  aneur- 
ysm, and  thus  to  block  the  artery  upon  the  distal  side  of  the  sac.  The 
aneurysm  is  first  emptied  by  making  pressnre'on  the  afferent  artery,  and  then, 
the  sac  is  kneaded  and  rubbed  in  order  to  detach  a  small  embolus  which  shall 
be  swe])t  into  the  efferent  artery  and  thus  obstruct  it  mechanically.  The  ope- 
ration has  fallen  into  disuse,  owing  to  the  fact  that  emboli  were  carried  to  the 
brain,  causing  aphasia,  hemiplegia,  and  even  death. 

Galvrfno-pimcture  is  a  method  suggested  by  Phillips  in  1829.  The  object 
is  to  produce  coagulation  of  the  blood  in  the  sac  without  the  intervention  of 
any  foreign  body.  A  galvanic  current  of  5  or  6  milliamperes  is  passed  through 
an  insulated  needle  which  is  brought  near  to  but  not  in  contact  with  the  point 
of  another  insulated  needle  introduced  into  the  sac  about  an  inch  from  the  point 
of  entrance  of  the  first  needle.  The  needles  are  left  in  place  for  an  hour  after 
the  clot  is  formed.  Suppuration  of  the  sac,  hemorrhage  through  the  punctures 
in  the  sac-wall,  and  embolism  are  among  the  dangers  that  attend  this  method. 

AcHjmncfure  by  means  of  very  fine  gilded  needles  has  been  employed. 
They  are  introduced  into  the  sac  so  as  to  cross  each  other,  and  the  blood  coag- 
ulates around  them.    They  are  left  in  the  sac  several  days,  and  then  withdrawn. 

Extirpation  of  the  aneurysm  was  first  practised  by  Philagrius  of  Macedon 
in  the  fourth  century.  A  most  formidable  operation  in  those  days,  it  has 
been  revived  of  late  with  marked  success  by  the  aid  of  anesthetics  and  with 
the  certainty  of  aseptic  healing. 

The  technique  of  the  operation  consists  of  a  free  incision  over  the  site  of 
the  aneurysm,  so  as  fully  to  expose  the  continuity  of  the  vessel.  Two  liga- 
tures are  now  applied  to  the  artery  upon  the  proximal  side  of  the  sac,  a  short 
distance  from  it,  and  the  vessel  divided  between  the  ligatures.  The  same 
procedure  is  to  be  followed  upon  the  distal  side  of  the  aneurysm  after  care- 
fully dissecting  out  the  entire  sac  with  its  contents  and  severing  them  from 
their  connections. 

The  special  advantages  of  extirpation  of  the  aneurysmal  sac  over  proximal 
ligature,  compression,  or  any  other  method  are  the  removal  of  the  dangers 
of  emboli  which  might  cause  gangrene,  the  absolute  permanency  of  the  cure, 
the  absence  of  secondary  hemorrhage,  the  freedom  from  sepsis,  and,  finally, 
the  lessened  mortality — advantages  not  secured  by  the  other  methods. 

The  mortality  of  proximal  ligature  has  been  placed  by  Delbet  at  18  per 
cent.,  that  of  total  extirpation  of  the  sac  at  11  per  cent. ;  the  occurrence  of 
gangrene  after  proximal  ligature  about  8  per  cent.,  after  extirpation  onlv  3 
per  cent.  Ransohoff  collected  twenty-eight  extirpations  of  major  aneur3^sms 
of  the  extremities  without  a  single  death. 

Extirpation  of  the  aneurysm  is  especially  indicated  in  the  traumatic  vari- 
ety, notably  those  situated  upon  the  extremities.  It  is  also  indicated  when 
the  sac  has  ruptured  or  when  other  methods  have  ftiiled  to  cure  the  disease. 

Amputation  is  required  in  certain  aneurysms.  This  is  necessary  if  an 
aneurysm  has  burst,  if  hemorrhages  are  frequent,  if  a  joint  is  involved,  if 
caries  of  bone  has  ensued,  or  if  gangrene  of  the  extremity  has  occurred. 

Coagulating  Itijeetions. — In  this  method  injections  of  certain  drugs  are 
made  into  the  sac  with  a  view  of  causing  coagulation  of  the  blood.  Such 
injections  should  not  be  employed  in  aneurysms  situated  in  the  neck,  because 
emboli  may  be  transmitted  to  the  brain  and  cause  instant  death.     In  aneurysms 


246 


AX   AMERICAN   TEXT-BOOK   OF  SURGERY, 


involving  the  extremities,  injections  of  Monsel's  solution  of  iron,  tannin,  acetate 
of  lead,  and  otlior  dnijjs  have  hcon  finployod.  Whatever  injection  is  used,  pres- 
sure should  he  made  for  some  little  time  ujM»n  liotli  the  allcrcnt  and  the  efferent 
arteries,  to  prevent  end)oli  from  hein<i;  swept  into  the  circulation. 

Maceivens  Methud,  which  consists  in  inducing  the  formation  of  white 
thrombi  within  the  sac,  is  a  recent  plan  of  treatment  which  will  sometimes 
be  useful.  The  formation  of  these  thrombi  is  accomplished  by  irritating  the 
lining  membrane  of  the  aneurysmal  sac  in  such  a  way  as  "  to  induce  infiltration 
of  the  parietes  with  leucocytes,  and  a  segregation  of  them  from  tlie  blood- 
stream at  the  point  of  irritation."  The  amount  of  irritation  should  be 
sufficient  to  cause  merely  a  reparative  exudation,  as  any  irritation  beyond  this 
stage  would  result  in  softening  of  the  sac-W'all,  which  in  turn  might  lead  to 
rupture.  The  irritation  should  be  evenly  applied  within  the  whole  surface  of 
the  sac,  or  at  least  from  many  foci  distributed  uniformly  throughout  its  interior. 
The  techni({ue  of  the  operation  is  as  follows.  The  skin  over  the  sac  having 
been  made  aseptic,  a  long,  strong  cylindrical  needle,  also  rendered  aseptic,  is 
introduced  into  the  interior  of  the  sac.  The  point  of  the  needle  should  be 
allowed  to  impinge  upon  the  opposite  wall  of  the  sac,  so  as  to  irritate  the  lining 
membrane,  or  else  the  needle  should  be  held  lightly  in  this  position  for  a  few 
moments,  so  as  to  allow-  the  impulse  of  the  blood-current  to  phiy  on  it.  It 
should  be  shifted  to  otlier  parts  of  the  sac  at  intervals  of  ten  minutes,  until  the 
whole  sac  has  been  uniformly  irritated.  The  simultaneous  use  of  a  second  or 
even  a  third  needle  at  distant  points  may  be  necessary.  The  time  ref(uired  to 
irritate  the  Avhole  sac  varies  from  a  few  hours  to  forty-eight  hours.  "While  the 
needle  is  left  in  situ  in  the  sac,  an  antiseptic  gauze  dressing  should  be  applied 
to  the  surrounding  region.  It  may  be  necessary  to  repeat  the  operation  from 
time  to  time  for  weeks  or  even  for  months.     This  method  should  not  be  employed 


Fic4.  48 


Difftise  Traumatic  Aneurysm  of  the  Brachial  Artery  (White). 

if  there  is  any  inflammation  in  the  walls  of  the  sac,  any  superficial  ulceration, 
or  any  erysipelatous  induration. 

Traumatic  Aneukysm  (Figs.  48,  49). — This  variety  of  aneurysm  differs 

Fig.  49. 


Traumatic  Aneurysm  hiiil  open  and  Vesbcls  tied  (White). 

from  all  the  others  in  the  manner  of  its  causation,  as  well  as  in  the  condition 
of  the  parts  involved.     In  all  varieties  of  aneurysm  except  the  traumatic,  the 


SURGERY   OF   THE    VASCULAR   SYSTEM.  247 

disease  is  situated  in  tlie  coats  of  the  arteries.  In  the  traumatic  variety  the 
lesion,  as  its  name  implies,  is  the  result  of  a  direct  injury  to  tlie  vessel,  and 
an  arterial  hematoma  results. 

This  form  of  aneurysm  is  caused  by  a  stab  or  gunshot  wound,  or  by  the 
giving  way  of  cicatricial  tissue  Avhich  has  imperfectly  healed  a  wound  of  an 
artery.  The  blood  escapes  from  the  injured  artery,  and  extravasates  through- 
out the  tissues  until  by  mechanical  [)ressure  the  hemorrhage  is  arrested. 
The  pressure  of  so  much  extravasated  blood  in  the  tissues  with  superadded 
infection  by  pyogenic  microbes  causes  an  inflammation  of  the  parts,  and  if 
not  treated  an  abscess  may  possibly  form,  the  opening  of  which  may  result 
in  an  alarming  hemorrhage. 

The  symptoms  of  traumatic  aneurysm  depend  upon  its  situation  and 
the  size  of  the  vessel  wounded.  The  presence  of  a  tumor  suddenly  devel- 
oped after  an  injury  to  a  vessel,  accompanied  by  severe  pain  and  tension, 
with  pulsation  and  bruit,  and  absence  of  pulsation  beyond  the  aneurysm,  is 
indicative  of  this  form  of  aneurysm.  In  addition  to  these  signs,  a  certain 
redness  of  the  skin  from  inflammatory  tension  soon  appears,  and  unless  this 
tension  is  relieved  sloughing  is  apt  to  occur,  and  in  some  cases  even  gangrene 
of  an  extremity. 

Traumatic  aneurysm  must  not  be  mistaken  for  an  abscess,  which  it  often 
resembles.  The  diagnosis  between  the  two  conditions  can  be  made  by  the 
history,  by  the  symptoms,  and,  if  necessary,  by  introducing  a  hypodermatic 
needle.  Fluid  blood  indicates  an  aneurysm,  while  pus  suggests  an  abscess. 
The  fact  that  an  abscess  may  be  the  direct  result  of  a  traumatic  aneurysm  must 
not  be  overlooked. 

The  treatment  of  traumatic  aneurysm  is  based  upon  the  same  principles 
that  would  guide  the  surgeon  in  the  management  of  a  primary  wound  of  an 
artery.  If  in  an  extremity,  an  Esmarch  elastic  bandage  should  be  applied 
and  the  tumor  cut  down  upon  until  the  injured  artery  is  found.  The  vessel 
should  be  completely  divided  and  the  two  ends  securely  ligatured.  The  wound 
should  then  be  thoroughly  disinfected  and  dressed  antiseptically,  in  order  to 
secure  healing  by  primary  intention.  In  cases  in  which  an  elastic  bandage 
cannot  be  employed — e.  g.  in  the  neck — a  serious  difficulty  arises.  When  this 
is  the  case  the  surgeon  should  carefully  dissect  down  to  the  aneurysm,  and 
make  an  opening  sufficiently  large  to  admit  his  finger  into  the  tumor,  by  which 
he  should  seek  for  the  opening  into  the  artery  on  the  proximal  side  of  the 
aneurysm,  in  order  to  arrest  the  hemorrhage  by  pressure.  The  finger  may  be 
guided  to  the  opening  in  the  vessel  by  feeling  the  current  of  warm  arterial 
blood  impinge  upon  it.  When  the  opening  has  been  occluded,  the  surgeon  can 
enlarge  the  wound  so  that  he  may  be  enabled  quickly  to  turn  out  the  fluid 
blood  and  the  coagula  in  the  false  sac.  The  vessel  is  then  tied  between  the 
finger  and  the  heart  by  means  of  a'  curved  aneurysm  needle  armed  W'ith  a 
catgut  or  silk  ligature.  The  artery  on  the  distal  side  of  the  aneurysm  must 
then  be  secured  by  a  similar  ligature,  otherwise,  if  the  collateral  circulation  has 
been  established  before  the  operation  is  done,  very  troublesome  hemorrhage 
would  arise  from  this  point.  If  the  vessel  is  in  an  extremity,  is  very  large, 
and  the  traumatic  aneuiysm  is  situated  near  the  trunk,  an  amputation  may  be 
necessary,  especially  if  the  injury  to  the  vessel  has  been  caused  by  a  gunshot 
wound. 

An  Aneurysmal  Varix  is  a  communication  between  an  artery  and  a  vein 
without  the  intervention  of  a  sac.  It  may  result  from  unskilful  venesection, 
from  the  thrust  of  a  sharp  instrument,  from  a  pistol-shot  wound,  etc.  If  an 
artery  and  a  vein  have  been  wounded  by  venesection,  for  example,  so  that 


24S  AX  AMERICAN   TEXT- HOOK    OF  SURGERY. 

a  communication  is  cstahlislicd  hctwocii  them,  an  anciirvsiii:il  varix  is  f'oniMMl. 
When  this  accident  happens,  a  ])a(l  or  compress  is  hiid  Hrml  v  over  the  wounded 
part,  so  as  to  arrest  the  hemorrliajre.  The  walls  of  the  artery  and  vein  in  con- 
sequence of  the  slight  inflammatory  action  become  adherent  to  each  other  at 

Fuj.  50. 


J( 


Plan  of  an  Aneurysmal  Varix  (original i.  Varicose  Aneurysm  (Spence). 

the  margins  of  the  Avound,  but  the  wound  itself  does  not  lieal.  since  at  each 
pulsation  of  the  heart  a  stream  of  arterial  blood  is  thrown  through  the  opening 
into  the  vein.  The  blood  thus  projected  from  the  artery  into  the  vein  finally 
dilates  the  latter  (Fig.  50).  The  blood  as  it  enters  the  vein  comes  in  contact 
with  the  opposing  venous  stream,  and  so  produces  a  Avhizzing  sound  Avhich  is 
pathognomonic  of  an  aneurysmal  varix.  Once  heard,  the  sound  will  never  be 
mistaken.  It  has  been  compared  to  many  noises.  One  of  the  best  compari- 
sons (which  is  as  ludicrous  as  it  is  forcible)  was  suggested  by  tlie  late  Mr. 
Spence — viz.,  the  noise  which  a  bluebottle  fly  imprisoned  in  a  thin  paper  bag 
makes  in  its  efforts  to  regain  its  freedom.  Valentine  Mott  compared  the  noise 
to  the  purring  of  a  kitten. 

Aneurysmal  varix  may  exist  for  years  and  give  rise  to  no  serious  disturb- 
ance. There  is  some  alteration  in  the  coats  of  the  vein  and  of  the  artery,  but 
none  that  Avould  offer  resistance  to  the  flow  of  blood,  as  is  the  case  in  an  aneu- 
rysm. There  is  dilatation  of  the  vein,  but  not  enough  to  cause  ulceration  or 
rupture.  The  veins  beyond  the  varix  are  always  more  or  less  dilated  and 
enlarged. 

Treatment. — In  some  cases  of  aneurysmal  varix  no  operative  interfer- 
ence is  called  for.  All  that  is  then  nece.ssary  is  to  apply  an  elastic  bandage, 
which  prevents  further  enlargement.  The  disease,  however,  sometimes  extends 
and  occasions  pain  and  disturbance  in  the  circulation.  In  these  cases  pressure 
by  means  of  a  firm  compress  should  be  made  upon  the  artery  above  and  upon 
the  vein  below,  and  also  directly  over  the  aneurysmal  varix.  If  this  does  not 
cure  the  disease  after  a  fair  trial,  the  tumor  should  be  treated  by  operation. 
The  aneurysm  should  be  exposed  l)y  dissection,  a  ligature  placed  above  and 
below  the  opening  in  both  the  artery  and  the  vein,  and  the  aneurysm  extirpated. 
In  aneurysmal  varix  of  the  carotid  and  the  internal  jugular  and  of  the  common 
femoral  vessels  operative  interference  should  be  undertaken  only  when  the 
reasons  are  very  urgent. 

Varicose  Aneurysm. — A  varicose  aneurysm  is  similar  to  an  aneurysmal 
varix,  since  in  both  there  is  a  communication  between  an  artery  and  a  vein  ;  but 
in  the  varicose  aneurysm  there  is  a  sac  between  the  artery  and  the  vein.  The 
arterial  blood  is  projected  into  this  sac,  and  from  the  sac  into  the  accompany- 
ing vein  (Fig.  51). 

Both  aneurysmal  varix  and  varicose  aneurysm  are  often  called  arterio- 
venous aneurysm. 

A'aricose  aneurysm,  like  aneurysmal  varix,  is  the  result  of  a  wound  both  of 
the  artery  and  of  the  vein ;  but  in  the  case  of  varicose  aneurysm  if  not  treated, 
or  if  the  compress  which  was  placed  over  the  wound  at  the  time  of  the  acci- 
dent was  not  firm  enough,  blood  will  have  extravasated  between  the  walls  of 


SURGERY   OF   THE    VASCULAR   SYSTEM.  241) 

the  artcrv  and  the  vein  and  se])arated  the  two  vessels.  InHannnatory  lymph 
has  then  been  deposited  around  this  space,  and  thus  a  false  aneurysm  has  been 
fornuMl.  coniniunifating  with  both  vessels;  its  sac  consists  of  condensed  effused 
lyni])h.  This  intervening  sac  which  comes  from  the  false  aneurysm  must  not 
be  confounded  with  an  ordinary  false  aneurysm  the  result  of  a  wounded  artery 
alone.     In  the  ordinary  false  aneurysm  there  is  no  communication  with  a  vein. 

On  account  of  the  slight  arterial  pressure  exerted  by  the  force  of  the  circula- 
tion upon  the  walls  of  the  sac  of  a  varicose  aneurysm,  the  sac  is  not  subject  to 
great  enlargement.  In  an  ordinary  aneurysm  the  force  of  the  blood-current 
impinges  directly  upon  the  aneurysmal  sac;  in  a  varicose  aneurysm  the  blood- 
current  finds  its  way  through  the  aperture  into  the  vein,  and  thus  its  force  is 
distributed  into  the  vein  instead  of  impinging  directly  upon  the  sac.  While, 
then,  enlargement  of  the  sac  is  not  common,  yet  in  view  of  the  liability  of  the 
sac  to  slough,  and  the  danger  of  gangrene  of  the  limb  or  of  the  false  aneurysm's 
becoming  diffuse,  the  indication  for  surgical  interference  is  plain. 

The  symptoms  are  nearly  the  same  as  in  aneurysmal  varix,  with  the 
exception  of  the  presence  of  a  sac,  which  sometimes  can  be  made  out  by  pal- 
pation, and  over  which  can  be  heard  a  soft  bruit. 

Treatment. — Varicose  aneurysm  must  not  be  left  to  itself,  for  it  will  finally 
ulcerate  and  become  diffuse.  Compression  is  not  suitable,  as  the  already  dilated 
and  varicosed  veins  would  become  greatly  enlarged,  and  finally  cause  much 
oedema  and  expose  the  patient  to  the  risk  of  gangrene.  In  most  cases  of  vari- 
cose aneurysm,  especially  if  the  aneurysm  is  small,  ligature  of  both  vessels 
above  and  below  the  disease,  followed  by  extirpation,  is  a  well-recognized  opera- 
tion. In  cases  of  varicose  aneurysm  situated  in  the  neck  or  in  the  anterior 
femoral  region,  this  procedure  would  be  attended  with  great  danger.  The  Hun- 
terian  operation  of  tying  the  femoral  artery  above  the  sac  in  healthy  tissue  has 
been  tried  in  two  cases,  and  death  followed  in  both  instances.  The  reason  for 
the  failure  of  ligation  of  the  artery  by  Hunter's  method  is  that  the  conditions 
in  an  ordinary  aneurysm  and  in  the  varicose  aneurysm  are  different.  In  the 
ordinary  aneurysm  the  ligation  of  the  artery  causes  deposition  of  fibrin  in  the 
sac  on  account  of  the  lessened  amount  of  blood  slowly  entering  the  sac ;  in  the 
varicose  aneurysm  the  communication  through  the  sac  with  the  vein  offers  an 
unimpeded  passage  of  the  blood  into  the  venous  circulation,  and  the  return 
venous  circulation  through  the  sac  prevents  coagulation,  for  blood  in  motion 
will  not  coagulate. 

The  late  Mr.  Spence  of  Edinburgh  devised  and  carried  into  successful 
execution  an  operation  for  varicose  aneur^^sm  which  meets  the  theoretical  as 
well  as  the  practical  indications.  To  use  his  own  words,  he  cuts  down  upon 
the  artery  above  the  sac,  and  then  below  the  sac,  but  does  not  open  the  sac  or 
disturb  the  vein.  The  application  of  two  ligatures  to  the  artery  at  the  places 
mentioned  removes  the  disturbino;  influence  in  the  retrograde  current  of 
arterial  blood,  and  thus  permits  the  blood  in  the  sac  to  remain  unagitated  by 
the  meeting  of  tAvo  currents  and  to  coagulate,  causing  the  consolidation  of 
the  tumor. 

ANEURYSMS    OF    SPECIAL   ARTERIES. 

Carotid  aneurysm  is  usually  situated  at  the  point  where  the  artery 
bifurcates  upon  either  side  of  the  neck.  Upon  the  right  side  the  aneurysm 
may  develop  at  the  origin  of  the  vessel.  It  begins  with  the  appearance  of  a  small 
tumor,  which  may  groAv  slowly  or  very  rapidly.  The  symptoms  of  carotid 
aneurysm  are  those  common  to  any  other  aneurysm,  with,  in  addition,  dyspnea, 
difficult  deglutition,  vertigo,  hoarseness,  brassy  cough,  and  ringing  in  the  ears. 


2.J)  AN  AMERICAN    TEXT-BOOK   OF  SURGERY. 

The  diagnosis  of  carotid  aneurysm  is  often  attended  with  great  difficulty. 
The  affections  for  which  this  disease  may  be  mistaken  have  ah'cady  l)ecn  con- 
sidered under  tlie  differential  diagnosis  of  Aneurysm. 

Tlie  treatment  of  carotid  aneurysm  is  hest  carried  out  hy  means  of  a 
ligature  upon  the  ju-oximal  side  of  the  sac  if  there  is  sufficient  room,  otherwise 
upon  the  distal  side.  Among  the  accidents  that  may  follow  ligature  of  the 
carotid  may  be  mentioned  embolism,  cerebral  softening,  hemiplegia,  syncope, 
secondary  hemorrhage,  and  suppuration  of  the  sac. 

If  it  becomes  necessary  to  ligate  both  carotid  arteries,  they  should  not  be 
tied  simultaneously,  as  this  double  operation  has  been  attende<l  ])\  fatal  coma. 

Subclavian  aneurysm  is  found  most  frequently  in  the  third  portion 
of  the  vessel.  The  tumor  appears  under  the  clavicular  origin  of  the  sterno- 
cleido-mastoid  muscle,  the  direction  of  its  long  axis  corresponding  with  the 
direction  of  the  artery.  Besides  all  the  syra])toms  common  to  aneurysm  in 
general,  subclavian  aneurysm  has  some  special  signs.  Among  these  may  be 
mentioned  pain  along  the  nerves  belonging  to  the  bracliial  ])lexus,  if  on  the 
right  side  a  brassy  cough  from  irritation  of  the  recurrent  laryngeal  nerve,  a 
varicose  condition  of  the  jugular  veins,  delayed  radial  pulsation,  and  finally 
oedema  of  the  arm  and  hand.  These  symptoms  increase  in  severity  as  the 
tumor  enlarges. 

The  diagnosis  of  a  subclavian  aneurysm  in  the  third  portion  of  the  artery 
from  one  involving  the  lower  portion  of  the  carotid  or  the  subclavian  in  its 
first  portion,  or  even  the  innominate,  must  be  made.  The  chief  diagnostic 
points  of  subclavian  aneurysm  in  its  third  portion  are  the  simultaneous 
pulsation  of  the  carotid  arteries  and  the  delayed  radial  pulsation  upon  the 
affected  side.  The  simultaneous  delay  of  the  carotid  and  radial  pulsations  of 
the  right  side  indicates  an  aneurysm  of  the  innominate  artery  instead  of  the 
third  portion  of  the  subclavian. 

Treatment. — If  the  aneurysm  is  small  and  limited  to  the  third  portion, 
digital  pressure  upon  the  proximal  side  of  the  subclavian,  although  difficult  for 
anatomical  reasons,  may  be  attempted  in  conjunction  with  constitutional  treat- 
ment. Pressure  directly  upon  the  sac  has  been  successful  in  a  few  cases.  If 
compression  fails,  the  artery  should  be  ligated  upon  the  distal  side,  since  prox- 
imal ligation  has  rarely  proved  effectual.  It  may  be  necessary,  where  other 
means  have  failed,  to  ligate  the  artery  on  the  proximal  side  as  a  preparatory 
step,  and  then  immediately  to  amputate  at  the  shoulder-joint. 

Axillary  aneurysm  may  be  idiopathic  or  traumatic.  The  idiopathic 
variety  may  be  developed  by  the  stretching  of  the  vessel  in  reducing  an  old 
dislocation  or  by  a  too  free  movement  of  the  shoulder-joint,  or  by  atheroma 
of  the  vessel.  This  variety  of  aneurysm  grows  very  raj)idly,  owing  to  the 
laxity  of  the  surrounding  tissues,  which  permits  it  to  dilate  without  early 
mechanical  obstruction.  It  quickly  attains  a  large  size,  and  the  situation 
of  the  sac  renders  it  especially  prone  to  inflammation.  The  pressure  of  the 
aneurysm  soon  causes  venous  obstruction,  and  (edema  of  the  forearm  ensues. 
The  pain  is  often  very  severe,  on  account  of  the  irritation  of  the  brachial 
plexus.  The  pulse  at  the  wrist  corresponding  to  the  side  of  the  aneurysm  is 
delayed  when  compared  with  that  of  the  opposite  side.  If  the  sac  continues 
to  grow,  the  shoulder-joint  is  invaded,  the  ribs  are  eroded,  and  the  correspond- 
ing lung  is  compressed.  The  movement  of  the  arm  is  soon  interfered  with, 
and  ankylosis  of  the  shoulder  follows.  This  variety  of  aneurysm  may  cause  a 
dry  pleurisy  or  a  hyperplastic  pneumonia. 

The  treatment  consists  in  applying  digital  or  instrumental  compression  to 
the  third  portion  of  the  subclavian  artery,  and,  in  the  event  of  failure,  in  tying 


SURGERY   OF   THE    VASCULAR   SYSTEM.  251 

this  portion  of  the  vessel.  The  a})})lie!iti()ii  of  an  ehistic  ])aii(lage  to  tlie 
arm,  eonil)ined  Avith  jiressiire  uj)on  the  proximal  side  of  tlie  sac.  can  also  be 
tried.  Other  methods  of  treatment  in  this  form  of  aneurysm  are  fraught  with 
danger,  and  must  not  be  undertaken  without  deliberate  consideration. 

In  the  traumatic  variety  of  axillary  aneurysm  the  injury  may  be  produced 
by  a  stab  or  gunshot  wound,  or  even,  as  has  been  said  above,  by  external  vio- 
lence in  atteiiijiting  to  reduce  an  old  dislocation.  In  the  treatment  of  traumatic 
aneurysm  Mr.  Syme  has  suggested  a  modification  of  the  old  operation  of  Antyl- 
lus.  The  subclavian  is  compressed  firmly  in  its  third  portion,  and  the  axillary 
sac  is  then  opened,  the  coagula  turned  out,  the  wound  found,  the  artery  com- 
pletely divided,  and  both  ends  ligated. 

Brachial  aneurysm  may  be  situated  either  along  the  course  of  the  artery 
or  at  the  bend  of  the  elbow.  The  most  frequent  variety  of  aneurysm  is  the 
traumatic  ;  but  aneurysmal  varix,  and  also  varicose  aneurysm,  are  found  at  the 
bend  of  the  elbow  as  a  result  of  unskilful  venesection.  For  the  treatment  of 
these  varieties  of  aneurysm  see  pp.  229-249. 

In  idiopathic  aneurysm  of  the  brachial  artery  compression  or  the  modified 
operation  of  Antyllus  or  the  Hunterian  operation  may  be  employed.  In  rare 
cases  gangrene  of  the  forearm  may  result  from  an  aneurysm  in  this  situation. 
This  condition  calls  for  amputation. 

Iliac  aneurysm  may  involve  the  common  trunk  of  the  vessel,  the  internal 
or  the  external  iliac  artery,  or  their  branches.  In  aneurysm  of  the  common 
iliac  artery  the  treatment  consists  in  compression  upon  the  cardiac  side  of  the 
aneurysm.  The  pressure  should  be  made  as  much  as  possible  over  the  artery, 
and  not  over  the  sac.  The  results  of  ligation  of  the  common  iliac  for  aneurysm 
Bhow  a  mortality  of  nearly  75  per  cent. 

The  internal  iliac  artery  is  seldom  the  seat  of  idiopathic  aneurysm.  The 
sciatic  and  gluteal  branches  have,  however,  been  the  seats  of  aneurysm  both  of 
the  traumatic  and  the  idiopathic  variety.  If  the  aneurysm  is  idiopathic,  the 
treatment  should  consist  in  proximal  compression,  and,  if  this  fails,  in  the  injec- 
tion of  remedies  with  a  view  to  coagulating  the  blood.  Recently,  ligation  of 
the  vessel  by  a  median  laparotomy  has  been  employed. 

If  the  gluteal  or  sciatic  aneurysm  is  traumatic,  compression  must  be  made 
above  upon  the  main  artery,  the  sac  be  laid  open,  the  clots  turned  out,  and 
the  vessel  tied  above  and  below  the  wound. 

The  external  iliac  arterj^  is  often  the  seat  of  idiopathic  as  well  as  of  trau- 
matic aneurysm.  In  the  idiopathic  variety  the  method  by  compression  should 
be  first  employed,  and  if  this  fails  the  ligature  of  the  vessel  above  the  sac  is 
indicated.  The  vessel  can  be  reached  by  a  median  laparotomy.  If  the 
aneurysm  is  of  the  traumatic  variety,  the  modified  operation  of  Antyllus  is 
indicated. 

Femoral  aneurysm  may  be  traumatic  or  idiopathic.  From  the  exposed 
situation  of  the  femoral  artery,  fjilse  aneurysms  are  of  frequent  occurrence. 
The  treatment  should  consist  in  the  application  of  a  tourniquet  to  the  artery 
as  it  passes  over  the  brim  of  the  pelvis,  incision  of  the  sac,  and  ligation  of 
both  ends  of  the  divided  artery.  If  the  aneurysm  is  idiopathic,  compression 
above  the  sac  should  be  first  tried,  and  in  the  event  of  failure  the  Hunterian 
operation  should  be  employed. 

Popliteal  aneurysms  are  usually  idiopathic,  but  occasionally  the  trau- 
matic variety  is  seen.  The  latter  should  be  treated  according  to  the  rules 
given  for  the  management  of  this  form  of  aneurysm  situated  in  any  other  part 
of  the  body.  The  idiopathic  variety  can  be  treated  by  the  flexion  method,  by 
the  Hunterian  method,  by  proximal  compression,  or  by  the  elastic  bandage. 


252  AN  AMERICAN   TEXT-JiOOK    OF  SURGERY. 


SECTION    IV. — INJURIES    OF    THE    BLOOD-VESSELS. 

Hemorriiace  is  iiivari:il)ly  present  wlien  a  vessel  is  wounded.  The  blood 
may  escape  tlirou<2;h  tlie  broken  skin,  or  may  extravasate  beneath  the  skin  and 
form  a  hematoma.  The  oeeurrenee  of  severe  hemorrha<:e  is  always  attended  with 
great  danirer  to  life,  and  the  larger  the  caliber  of  the  wounded  vessel  the  greater 
the  immediate  danger.  There  is  no  other  emergency  which  the  surgeon  is 
called  upon  to  meet  that  requires  so  much  judgment  and  presence  of  mind  as 
the  proper  management  of  alarming  hemorrhage. 

There  are  four  varieties  of  hemorrhage  : 

1.  Arterial  hemorriiauk,  cliaiacteri/ed  by  bright-red  blood  sjiurting 
out  in  jets  synchronously  with  the  action  of  the  heart.  The  bright-red  color 
is  due  to  the  presence  of  oxygen  in  the  blood.  Arterial  blood  may  be  deprived 
of  its  characteristic  color  when  the  oxygen  is  greatly  diminished  and  carbonic 
acid  gas  is  present  in  excess,  as  in  profound  narcosis  or  when  an  operation  is 
undertaken  to  avert  death  from  apnea.  During  an  operation,  therefore,  the 
surgeon  should  always  look  to  the  anesthetic  if  the  blood  from  the  wound 
becomes  dark-colored. 

2.  Venous  hemorrhage,  characterized  by  the  blood  flowing  in  an  unin- 
terrupted stream  and  by  its  dark  color.  The  steady  flow  of  the  blood  from 
the  veins  is  due  to  the  fact  that  the  intermittent  cardiac  impulse  is  lost.  For 
the  same  reason  blood  from  the  distal  end  of  a  wounded  artery  also  flows  in  a 
steady  stream.  The  dark  color  is  caused  by  the  non-oxygenation  of  the  blood 
and  by  the  presence  of  carbonic  acid  gas.  The  walls  of  the  veins  collapse, 
with  the  exception  of  the  veins  of  the  liver ;  the  portal  system,  however,  is 
seldom  taken  into  account  by  the  surgeon. 

3.  Capillary  hemorrhage,  characterized  by  its  constant  oozing  on  the 
one  hand,  and  by  its  spontaneous  arrest  on  the  other.  This  variety  of  hemor- 
rhage is  alarming  in  exceptional  cases  only,  but  its  persistence  often  makes  it  a 
troublesome  variety  to  treat.  The  ca])illaries  in  the  mucous  membranes  bleed 
more  profusely  than  those  situated  in  the  integument.  This  is  due  to  the  fact 
that  in  the  former  the  capillaries  are  larger  and  more  abundant.  Hemor- 
rhage from  capillaries  situated  in  the  skin  usually  ceases  owing  to  the  con- 
traction of  the  wound. 

4.  Parenchymatous  hemorrhage,  characterized  by  absence  of  the 
features  Avhich  distinguish  the  other  three  varieties,  and  also  by  the  foct  that 
it  is  found  where  there  is  a  peculiar  anatomical  arrangement  of  the  blood- 
vessels, or  among  diseased  tissues,  as  when  the  main  vein  is  thrombosed.  This 
variety  of  hemorrhage  is  seen  in  those  organs  or  parts  of  the  body  where  the 
small  arteries  empty  into  small  veins  without  the  intervention  of  a  capillary 
system.  Such  an  arrangement  is  found  in  the  corpora  cavernosa  and  in  the 
erectile  tissue  of  the  female  genitalia,  as  well  as  in  the  spleen. 

Hemorrhage  may  be  divided  upon  another  basis  than  an  anatomical  one — 
viz.  a  clinical  one.  It  may  be  termed — I.  Primary  ;  II.  Intermediary ;  III. 
Secondary. 

I.  Primary  hemorrhage  occurs  immediately  after  the  wound  in  the  vessel. 
The  characteristics  of  a  primary  hemorrhage  vary  according  as  it  is  arterial, 
venous,  or  capillary,  as  above  described. 

II.  Intermediary  or  reactionary  or  consecutive  hemorrhage  occurs  shortly 
after  an  injury  to  a  vessel  or  after  a  surgical  operation,  during  what  is  termed 
the  period  of  reaction.  This  variety  of  hemorrhage  usually  takes  place  within 
twenty-four  hours,  and  is  caused  by  a  ligatures  coming  away,  or  by  the  action 


;subgi:Ji'v  of  ti/e   vascular  system.  'iry.i 

of  till'  lioart  \n  driving  out  coa^ulii  IVoiii  tlu'  dividod  cud  ol"  a  vosscl,  or  by  some 
movt'UR'Ut  of  the  wouuded  part. 

III.  S'rrttndan/  Iie)norrIi<i(/e  occurs  after  twenty-four  hours  and  before 
oro;anizati()U  (^f  tlio  thrombus  and  cicatrization  of  the  wound,  and  most  fre- 
quently between  the  fiftli  and  tenth  days.  It  usually  occurs  durin<f  suppura- 
tion, and  is  caused  by  disease  of  the  walls  of  the  vessel,  by  slou<^hing  of  the 
wound,  by  ulceration  of  the  v^essel,  by  sepsis,  or  by  the  too  rapid  absorption  of 
a  catgut  ligature.  Secondary  hemorrhage  is  often  seen  in  gunshot  injuries  and 
in  wounds  wlicre  there  have  been  extensive  contusion  and  sloughing. 

The  constitutional  symptoms  of  hemorrhage  are  rapid,  feeble 
pulse;  subnormal  temperature;  frei^uent  and  irregular  respiration;  convulsive 
movements ;  lividity  of  the  lips  and  blueness  of  the  finger-nails ;  dilatation  of 
the  i\\x  nasi ;  nausea  and  vomiting  ;  pale  face  and  pallid  mucous  surfaces ;  great 
dvspnea ;  jirofuse  f)erspiration ;  muttering  delirium;  tinnitus  aurium  ;  syncope; 
colhqjse  ;   disturbances  of  sight  and  hearing  ;   unconsciousness. 

The  symptoms  just  enumerated  are  present  to  a  greater  or  lesser  degree 
according  to  the  amount  of  blood  lost,  the  size  of  the  vessel  injured,  and  the 
general  condition  and  the  age  of  the  patient.  Infants  and  children  do  not 
tolerate  the  loss  of  blood  well,  but  they  recuperate  rapidly.  Aged  people  like- 
wise are  seriously  affected  by  the  loss  of  blood,  and,  unlike  children,  do  not 
rally  (|uickly.  Adults  in  health  endure  well  the  loss  of  blood,  and  women 
during  parturition  tolerate  hemorrhages  which  under  other  circumstances  would 
prove  rapidly  fatal. 

After  hemorrhage  has  been  arrested  and  the  patient  has  rallied,  the  symp- 
toms denoting  the  existence  of  hemorrhage  change  and  a  slight  febrile  disturb- 
ance follows.  To  this  condition  the  term  "hemorrhagic  fever"  has  been 
applied.  The  elevation  of  temperature  is  due  to  the  nervous  irritation  conse- 
quent upon  the  hemorrhage  and  to  the  absorption  of  the  "fibrin  ferment," 
as  after  operation.  (See  p.  35.)  The  pulse  is  accelerated  and  often  irregular, 
and  its  wave  is  apparently  more  distinct  than  normal,  owing  to  the  relaxation  of 
the  coats  of  the  vessel  due  to  the  absence  of  the  natural  stimulus  of  the  blood. 

The  patient  is  in  an  asthenic  condition  from  exhaustion  consequent  upon 
the  loss  of  blood,  and  septic  pi'ocesses  are  likely  to  develop  under  these  circum- 
stances. The  lowered  vitality  in  hemorrhagic  fever  predisposes  the  patient  to 
unhealthy  inflammations,  and  great  care  must  be  exercised  to  guard  against 
the  onset  of  these  pathological  changes.  The  mental  condition  in  hemorrhagic 
fever  is  characteristic.  The  patient  is  affected  with  a  low  form  of  muttering 
delirium,  never  becoming  maniacal  or  violent.  The  intellect  is  restored  in 
proportion  to  the  general  improvement  in  the  symptoms.  The  distinguishing 
feature  of  hemorrhagic  fever  is  that  it  is  not  due  to  absorption  of  any  septic  mate- 
rial, but  is  due  chiefly  to  an  altered  nervous  condition  consequent  upon  the  loss 
of  blood,  Avhich  fails  to  supply  the  proper  nutriment  to  the  great  nerve-centers. 

Spontaneous  arrest  of  hemorrhage  may  be  effected  by  a  combina- 
tion of  several  agencies.  Contraction  and  retraction  of  the  divided  vessel  and 
coagulation  of  the  blood  are  among  the  means  which  nature  adopts.  Cardiac 
syncope  is  also  sometimes  a  most  important  factor  in  bringing  about  an  arrest 
of  hemorrhage,  because  this  condition  of  the  heart  reduces  the  force  of  the 
blood-current,  and  thus  permits  coagulation  in  the  wounded  vessel.  Con- 
traction of  the  middle  and  internal  coats  and  retraction  of  the  entire  vessel 
within  its  sheath  help  to  form  a  barrier  to  the  exit  of  blood  at  the  divided  end 
of  the  artery.  Coagulation  of  the  blood  is  brought  about  by  the  diminished 
flow  of  blood  and  also  by  its  exposure  to  atmospheric  influences.  The  hemor- 
rhage after  laceration  of  the  vessel  is  controlled  by  nature,  owing  to  the  fact 


254  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

that  the  internal  and  middle  coats  curl  up  and  the  external  cDat  and  .-^lieatli  are 
twisted  over  the  open  mouth  of  the  vessel.  This  phenomenon  explains  the  small 
amount  of  blood  lost  in  cases  where  the  extremities  are  torn  from  the  body. 

The  diagnosis  of  hemorrhage  is  attended  with  no  diHiculty  when  blood 
makes  its  appearance  externally.  ^Vhen  the  hemorrhage  occurs  within  the 
great  cavities  of  the  body,  and  is  therefore  concealed,  the  diagnosis  is  fraught 
with  uncertainty.  Hemorrhage  into  the  pleural,  peritoneal.  ])elvic,  or  cranial 
cavity  must  be  diagnosticated  u})on  the  special  evidences  manifest  in  each  case. 
The  "general  symptoms  of  hemorrhage  are  present,  but  in  numy  resi)ects  they 
are  so  similar  to  those  found  in  shock  that  a  discrimination  must  l)e  made  with 
great  care.  (See  p.  92.)  The  aseptic  hypodermatic  needle  can  sometimes  be 
utilized  Avith  great  advantage.  If  the  hemorrhage  is  within  the  cranial  cavity, 
the  study  of  the  nervous  phenomena  will  aid  in  the  diagnosis.  (See  Intra- 
cranial Hemorrhage.)  If  it  is  within  the  pleural,  peritoneal,  or  pelvic  cavity, 
physical  signs  wilt  establish  the  diagnosis  when  taken  in  connection  Avith  the 
history  of  the  case. 

The  treatment  of  hemorrhage  is  divided  into  constitutional  and 
local.  The  constitutional  treatment  consists  in  the  judicious  administration 
of  cardiac  stimulants,  such  as  strychnine,  tincture  of  digitalis,  carbonate  of 
ammonium,  nitro-glycerin,  and  hypodermatic  injections  of  ether,  brandy,  or 
whiskey.  As  a  rule,  the  remedies  to  excite  the  action  of  the  heart  should  be 
given  hypodermatically  in  order  to  secure  an  immediate  eftect,  and  great  care 
should  be  taken  lest  the  patient  be  suddenly  over-stimulated.  Ergot  of  rye  has 
been  used  to  cause  contraction  of  the  involuntary  muscular  fibers  of  the  vessels. 
In  view  of  the  subnormal  temperature,  artificial  heat  should  be  applied  to  the 
surface  of  the  body.  This  can  be  accomplished  by  warm  blankets,  bottles  of 
hot  w^ater,  and  hot-air  baths.  In  the  use  of  bottles  of  hot  water  or  hot-water 
bags  care  must  be  exercised  lest  the  patient  be  burned,  an  accident  as  unfortu- 
nate as  it  is  frequent.  An  enema  of  brandy,  or  of  turpentine  and  hot  water, 
can  be  employed  as  a  valuable  adjuvant. 

The  head  should  be  placed  low,  to  prevent  cerebral  anemia,  and  the  patient 
kept  as  quiet  as  possible.  An  abundance  of  fresh  air  should  be  supplied  to  a 
patient  suffering  from  profuse  hemorrhage.  The  application  of  Esmarch's 
elastic  bandage  to  the  extremities,  elevation  of  the  arms  and  legs,  and  raising 
the  foot  of  the  bed  should  be  employed,  in  order  to  increase  the  amount  of 
blood  in  the  brain  and  internal  organs.  Galvanism  or  sinapisms  may  be  applied 
over  the  precordial  region.  Towels  wrung  out  of  hot  water  and  applied  to  the 
head  will  help  to  bring  about  reaction.  Warm  fluids  can  be  given  as  soon  as 
the  patient  is  able  to  swallow,  and  a  good  nutritious  diet  as  soon  as  possible. 
Opium  should  be  administered  during  reaction,  especially  if  nervous  excitement 
is  present. 

Transfusion  of  normal  salt  solution  after  hemorrhage  has  been  resorted 
to  in  cases  in  Avhich  sudden  loss  of  a  large  amount  of  blood  has  occurred. 
The  operation  of  transfusion  as  formerly  employed  consisted  in  the  injection 
of  blood  from  a  healthy  person  into  tlie  blood-vessels  of  a  patient  suffering 
from  hemorrhage.  It  Avas  attended  Avith  a  high  death-rate,  and  investigation 
into  the  causes  of  death  demonstrated  the  fiict  that  the  mortality  Avas  due  to 
the  presence  of  emboli.     Entrance  of  air  Avas  another  source  of  danger. 

The  local  treatment  of  hemorrhage  consists  in  the  arrest  of  the  bleeding 
either  by  compression,  ligation,  torsion,  or  acupressure.  If  the  hemorrhage 
proceeds  from  an  injured  vein,  compresses  should  be  placed  over  the  Avound 
Avith  uniform  e(piabie  compression  of  the  limb.  Tiiis  will  suffice  to  control 
the  bleedinj:  in  venous  hemorrhage.     If  the  hemorrhage  is  from  a  Avounded 


SURGERY    OF    TIIK     VASCULAR    SYSTEM. 


2.J5 


artery  tlu'  l)U'c<lin<r  vessel  must  be  sought  for  iuid  tied  at  both  ends.  The 
divided  en.l  of  the  artery,  without  any  surrounding  tissue,  shouhl  be  seized 
Avith  a  pair  of  artery  forceps  or  hemostatic  forceps,  and  the  ligature  should 
then  be  tied  by  means  of  the  reef  knot  (Fig.  52).  Catgut  and  sterilized 
silk  are  the  materials  employed  for  tying  wounded  arteries,  iorsion  ot 
the  vessel  is  applicable  especially  after  amputation,  as  the  vessel  in  this 
case  is  completely  divided.  In  a  wound  in  the  continuity  of  the  artery 
the  vessel  must  be  divided  before  torsion  is  applied.  If  the  wound  is  a 
lacerated  one,  it  can  be  converted  into  an  incised  one  and  the  divided 
vessel  caught  and  ligated  or  twisted.  In  applying  torsion  the  vessel 
should  be  seized  with  the  torsion  forceps  as  if  to  ligate  it  (J^ig.  o-^). 
A  second  pair  of  forceps  may  be  placed  upon  the  artery  at  right 
ancrles  with  and  a  short  distance  above  the  first  pair.  The  open  end  of 
the  artery  is  now  to  be  twisted  by  the  forceps  on  the  long  axis  of  the  artery, 
which  is  held  securely  by  the  second  pair  of  forceps.     Only  a  few  turns 


Fig.  52. 


Fig.  53. 


Trunk  of 
Artery. 


The  Reef  Knot. 


Fk;.  54. 


Tirinted  end 
I  if  Artery. 


Everted  end  -i/'  Inner  Coats. 

Effects  of  Torsion  on  Femoral  Artery. 
(Bryant). 


Artery  laid    open  to    show  Turning  Up  of   Inner  and 
Middle  Coats  from  Torsion  (Erichsen). 

should  be  made  or  the  end  of  the  artery  may  be  twisted  off.     The  effects  of 
torsion  on  the  inner  and  middle  coats  of  an  artery  are  shown  in  Fig.  54. 

Acupressure  (Fig.  55)  is  occasionally  useful ;  one  method  consists  m  passing 
^  a  needle  under  the  vessel 

Fig.  55.  and  compressing  it  pre- 

cisely in  the  same  manner 
as  the  stem  of  a  rose  is 
fastened  in  the  lapel  of  a 
coat  by  a  pin. 

If  the  hemorrhage  is 
capillary,  gentle  pressure 
can  be  employed.  Hot 
water  at  120°  F.  will  act 
as  an  astringent,  and  is 
one  of  our  most  con- 
venient and  reliable  means  of  arresting  hemorrhage.  Ice  is  sometimes  employed. 
Heat  and  cold  both  act  by  stimulating  the  muscular  fibers  of  the  vessels  to 
contract.  The  actual  cautery  is  a  powerful  hemostatic,  but  it  has  the  great 
disadvantage  of  causing  a  slough.  Styptic  cotton,  though  generally  objection- 
able, may  be  useful  in  hemorrhage  from  places  Avhere  the  ligature  is  inadmissible. 
The 'position  of  the  part,  according  to  the  laws  of  hydraulics,  should  be  such  as 
to  diminish  the  force  of  the  circulation  and  to  favor  venous  return.  Elevation 
of  the  limb  will  accomplish  this  result  if  the  wound  is  in  an  extremity. 


Diiferent  Modes  of  Applying  Acupressure  (Bryant). 


250  ^i.v  A  mi:/: /(AX  rr.XT-iiook'  or  scudKRY. 

In  hemophilia  bleeding  does  not  occur  from  large  vessels,  but  there 
is  a  continuous  ca|tillarv  oozing.  Many  expedients  have  been  suggested, 
from  elevation  and  pressure  to  the  actual  cautery.  The  internal  admin- 
istration of  chloride  of  calcium  is  advised  by  Wright.  The  local  appli- 
cation to  the  wound  of  blood  from  a  healthy  man  has  been  recently 
advised.  Carnot  uses  a  solution  of  gelatin  in  normal  salt  solution  (1 : 
16).  Continual  compression  with  sponges  soaked  in  hot  water  may  prove 
efficient. 

Comparative  Merits  of  Various  Methods  of  Treatment. — In  all 
cases  of  heiuorrhage  the  constitutional  treatment  is  the  same.  The  local  treat- 
ment, however,  is  subject  to  certain  variations.  The  ligature  or  torsion  is  the 
preferable  method.  If  catgut  or  sterilized  silk  is  used  for  ligatures,  both  ends 
may  be  cut  short,  the  wound  closed,  and  primary  union  obtained.  Acupressure 
possesses  no  special  advantage  over  ligature  or  torsion  since  the  principles  of 
antiseptic  surgery  have  been  applied  to  wound  treatment. 

Transfusion  should  be  employed  in  any  case  of  hemorrhage  in  which  the 
symptoms  become  alarming.  A  patient  may  have  lost  a  great  quantity  of 
blood,  and  may  even  be  apparently  moribund,  but  if  the  heart's  action  is  per- 
ceptible, transfusion  is  indicated.*^  It  has  often  saved  life  even  under  these 
extreme  circumstances. 

In  the  after-treatment  of  hemorrhage  the  patient  should  be  kept  perfectly 
quiet  both  physically  and  mentally,  and  all  visitors  should  be  excluded. 
Any  tendency  to  syncope  must  be  combated  by  lowering  the  head,  and  cardiac 
stiniulants  should  be  judiciously  employed.  The  surface  of  the  body  should 
be  kept  warm  by  artificial  means,  and  warm  drinks  be  given  until  the  eciuilib- 
rium  of  the  circulation  is  restored.  A  nutritious  diet,  fresh  air,  and  hygienic 
surroundings  should  be  provided.  After  the  alarming  symptoms  have  passed 
away,  attention  must  be  directed  to  the  use  of  iron  in  some  form,  wine  in  mod- 
erate quantities,  and  a  free  diet.  Oxygen  may  be  inhaled  several  times  a  day 
with  advantage.  If  the  wound  has  been  antiseptically  dressed  and  drained, 
union  by  primary  intention  should  follow.  If  it  has  been  improperly  dressed, 
or  if,  owing  to  some  condition  for  which  the  surgeon  is  not  responsible,  suppu- 
ration is  likely  to  follow,  the  wound  should  be  thoroughly  disinfected  and  free 
drainage  provided,  so  as  to  repair  the  damage  with  as  little  constitutional  and 
local  disturbance  as  possible.  From  what  has  already  been  said  in  regard  to 
the  treatment  of  hemorrhage  the  following  rules  may  be  formulated: 

1.  (a)  If  primary  hemorrhage  is  serious  and  bleeding  is  actually  going  on, 
apply  an  Esmarch  bandage  or  a  tourniquet  above  the  injury  to  the  vessel,  open 
the  wound,  turn  out  the  blood-clot,  find  the  wounded  artery,  divide  the  vessel 
at  this  point,  unless  it  has  been  already  divided,  and  tie  the  proximal  and  distal 
ends  with  aseptic  catgut. 

{h)  If  primary  hemorrhage  is  serious,  but  bleeding  is  not  actually  going  on 
and  the  patient  is  in  collapse,  apply  a  toilVniquet  above  the  wound  and  stuflF 
into  it  sponges  soaked  in  hot  1 :  4000  bichloride  solution,  administer  stimulants, 
and  when  everything  is  in  readiness  relax  the  tourniquet  and  proceed  as  already 
described  under  the  first  rule. 

(c)  In  general  oozing  apply  hot  water  (120°  F.)  by  compresses.  If  an  artery 
spurts  from  the  sawn  end  of  a  bone,  introduce  an  acupressure  needle  and 
lacerate  the  vessel  or  plug  it  Avith  a  strand  of  catgut. 

2.  {a)  In  secondary  hemorrhage,  if  it  is  slight,  open  the  wound  or  stump, 
turn  out  the  coagula,  and  apply  a  compress. 

{h)  If  the  hemorrhage  is  alarming,  apply  a  tourniquet  or  an  Esmarch 
bandage,  open  the  wound,  and  tie  the  ends  of  the  vessel  if  possible.     If  this  is 


SURGERY    OF    THE     VASVIJLAR    SYSTEM. 


257 


not  prac-ti cable  on  account  of  diseased  or  sloughing  tissue,  ligate  the  vessel 
above  in  its  continuitv  according,  to  the  Iluntcrian  method. 

(c)  If  secondary  hemorrhage  occurs  after  ligation  of  a  vessel  in  its  continu- 
ity, apply  a  tourniquet,  ojjcn  the  wound,  turn  out  the  clots,  and  tie  the  artery 
above  and  below  the  bleeding  point  if  the  tissues  are  not  too  much  lacerated. 

{d)  If  this  fails,  tie  the  artery  higher  uj)  in  its  continuity,  or  amputate. 

WOUNDS    OF    ARTERIES. 

These  may  be  punctured,  contused,  lacerated,  gunshot,  or  incised.  Besides 
the  varieties  just  mentioned  there  may  also  be  rupture. 

A  piinctured  wound  is  caused  by  the  penetration  of  the  artery  by  a  sharp 
or  a  thin  blunt  instrument.  If  the  opening  is  very  small  hemorrhage  may  not 
result,  but  if  the  puncture  is  of  any  size  bleeding  occurs.  A  punctured  wound 
of  an  artery  usually  gives  rise  to  a  traumatic  aneurysm,  and  must  be  treated  as 

such.  1       f      i? 

A  contused  wound  of  an  artery  may  be  insignificant,  or  it  may  be  ot  sut- 
ficient  magnitude  to  cause  gangrene  by  obliteration  of  the  vessel  or  death  by 
secondary  hemorrhage.  A  slight  contusion  of  tlie  arterial  wall  may  be  fol- 
lowed by  an  inflammation  which  leads  to  a  thickening  of  the  walls  of  the 
vessel  and  complete  occlusion.  This  condition  may  give  rise  to  gangrene. 
If  a  thrombus  forms  in  a  contused  artery  which  supplies  some  internal  organ 
with  blood,  the  viscus,  having  been  deprived  of  its  nutriment.  Avill  undergo  de- 
generation. The  contusion  may  be  extensive  enough  to  destroy  the  coats  of  the 
vessel,  so  that  a  fatal  secondary'^hemorrhage  follows  the  separation  of  the  slough. 

A  lacerated  wound  of  an  artery  deserves  special  attention,  because  the 
results  are  likely  to  become  serious.  If  an  artery  is  stretched  or  torn  suf- 
ficiently, the  middle  and  internal  coats  snap.  In  the  middle  coat  the  circular 
fibers  separate  from  each  other  so  as  to  leave  a  space,  and  the  separated  circu- 
lar fibers  contract  upon  the  internal  coat,  which  is  torn  completely  across 
and  curls  up  within  the  lumen  of  the  vessel  in  the  same  manner  as  it  does 
after  the  application  of  a  ligature.  In  a  lacerated  wound  of  an  artery  the 
external  coat  is  draAvn  out  so  as  completely  to  lose  its  normal  elasticity,  in  the 
same  manner  as  a  piece  of  rubber  tubing  will  lose  its  elasticity  when  it  is 
overstretched.  Such  an  injury  to  an  artery  of  large  or  small  size  may  occur 
without  any  bleeding.     The  vessel  is,  hoAvever,  permanently  injured. 

A  gunshot  wound  of  an  artery  derives  its  special  importance  from  the  fact 
that  secondarv  hemorrhage  is  likely  to  occur.  The  vessel  may  be  only  contused 
by  a  bullet,  aitid  no  bleeding  occur  until  some  days  after  the  injury,  when  serious 
hemorrhage  supervenes  as  a  result  of  sloughing.  A  gunshot  wound  of  an  artery 
is  often  associated  with  injury  to  the  accompanying  vein,  and  an  aneurysmal 
varix  is  formed.  In  case  an  extremity  is  bloAvn  off  by  shot  or  shell,  the  hemor- 
rhage is  often  slight,  on  account  of  the  fact  that  the  vessels  are  lacerated,  the 
middle  and  internal  coats  contract,  curl  up,  and  a  plug  is  formed  at  the  open  end 
of  the  vessel.  If,  however,  a  rifle  bullet  enters  the  body  when  it  is  travelling 
at  great  speed,  it  may  cut  an  artery  like  a  knife,  causing  immediate  and  alarm- 
ing hemorrhage.  In  addition  to  the  primary  or  secondaiy  hemorrhage  which 
may  be  produced  by  a  gunshot  Avound  of  an  artery,  the  contusion  of  the  vessel 
may  lead  to  the  formation  of  a  thrombus,  which  may  cause  occlusion  of  the 
artery  and  be  followed  by  gangrene.  Pyemia  is  also  a  serious  complication  in 
gunshot  wounds  ;  and  often  a  secondary  hemorrhage  ushers  in  a  fatal  septicemia. 

An  incised  wound  of  an  artery  is  an  injury  inflicted  by  some  sharp  cutting 
instrument.     The  hemorrhage  is  always  profuse  in  such  a  wound,  because  there 

17 


258  AN  AMF.h'IVAX    TEXT-BOOK    OF  SURGERY. 

is  no  mechanical  obstacle  to  tlic  oiitllow  of  hlood  through  the  ()]K'iiiii<f,  such  as 
is  often  found  at  the  open  mouth  of  a  torn  artery,  and  also  because  the  con- 
traction of  the  two  ends  of  the  vessel  causes  the  "svound  in  the  artery  to  gape. 
The  direction  of  the  incised  wound  may  be  transverse,  oblique,  or  longitudinal. 
The  hemorrhage  is  very  profuse  in  a  transvei'se  cut  of  an  artery,  while  it  is 
not  so  abundant  in  an  oblique  incision.  If  the  artery  is  upon  the  stretch  and 
is  wounded  longitudinally,  the  bleeding  is  very  slight,  but  may  become  very 
alarming  wlien  tiie  artery  is  relaxed.  In  case  of  a  partially  divided  artery  the 
proper  rule  to  follow  is  to  divide  the  vessel  completely  and  tie  botli  ends. 

Rupture  of  one  or  all  of  the  coats  of  an  artery  is  an  injury  that  occurs 
under  certain  circumstances.  The  rupture  may  be  partial,  for  example,  wlien 
the  internal  and  middle  coats  are  torn  and  the  external  coat  is  stretched.  This 
accident  is  not  followed  by  hemorrhage,  but  it  is  a  condition  favorable  to  the 
production  of  secondary  hemorrhage  by  sloughing,  or  to  the  development  of  an 
aneurysm.  The  same  condition  may  also  cause  thrombosis  or  embolism  of  the 
vessel",  and  gangrene  of  the  extremity  or  part  may  result.  The  rupture  may 
be  complete,  in  which  case  the  artery  is  in  the  condition  of  a  lacerated  vessel. 
If  it  is  subcutaneous,  a  traumatic  aneurysm  develops.  If  the  rupture  is  partial 
and  a  clot  has  formed  sufficient  to  occlude  the  vessel,  then  the  pulsation  below  is 
lost  and  gangrene  may  supervene. 

The  treatment  of  wounds  of  arteries  must  necessarily  vary  according  to 
the  character  of  the  injury.  If  the  opening  is  of  any  size,  the  vessel  should 
be  completely  divided  and  both  ends  tied.  In  case  a  traumatic  aneurysm  has 
developed  as  a  result  of  a  punctured  wound  of  an  artery,  the  rules  prescribed 
for  the  management  of  this  condition  must  be  followed — i.  e.  it  is  a  wounded 
artery,  and  should  be  treated  as  such. 

If  the  wound  is  a  contmed  one,  the  treatment  consists  in  securing  as  much 
physical  rest  for  the  artery  as  possible  by  tranquillizing  the  circulation.  This 
is  eftected  by  absolute  rest  and  the  administration  of  cardiac  depressants.  The 
possibility  of  the  occurrence  of  secondary  hemorrhage  must  not  be  forgotten, 
and  measures  to  arrest  it  must  be  instituted  immediately  if  it  appears.  The 
area  or  extremity  which  may  be  deprived  of  blood  as  a  result  of  a  contusion  of 
an  artery  must  be  kept  artificially  w^arm  in  order  to  encourage  the  determination 
of  blood  to  the  part  and  to  stinmlate  the  collateral  circulation. 

If  the  wound  is  a  lacerated  one,  the  primary  hemorrhage  is  usually  slight  on 
account  of  the  curling  up  of  the  internal  coat  and  the  contraction  of  the  mid- 
dle coat,  and  the  coagulation  of  the  blood  at  the  torn  end  of  the  vessel ;  but  on 
account  of  the  danger  of  secondary  hemorrhage  both  ends  of  the  vessel  should 
be  diligently  sought,  by  a  careful  dissection  if  necessary,  and  securely  tied. 

If  the  wound  is  a  gunshot  one,  the  primary  hemorrliage  must  l)e  treated 
according  to  the  same  principles  that  would  guide  the  surgeon  in  the  manage- 
ment of  an  ordinary  wounded  artery.  If  the  vessel  is  one  of  large  size,  digital 
pressure  directly  upon  the  artery  and  in  the  wound  is  indicated  for  the  instan- 
taneous arrest  of  tlie  bleeding ;  in  no  case  should  styptics  be  employed.  An 
Esmarch  elastic  bandage  should  now  be  applied,  and  tlie  surgeon  should  cut 
down  immediately  u])on  the  bleeding  vessel,  completely  divide  it  at  the  seat  of 
injury,  and  tie  both  ends  of  the  artery  with  aseptic  catgut.  If  the  hemorrhage 
comes  from  an  artery  situated  in  the  neck,  or  in  any  other  place  where  the 
application  of  an  elastic  bandage  is  impracticable,  the  surgeon  must  be  guided 
by  the  rules  for  the  management  of  traumatic  aneurysm.  The  dressing  of  such 
a  wound  should  be  conducted  with  the  most  rigid  adherence  to  the  principles 
of  aseptic  surgery  in  order  to  prevent  secondary  hemorrhage,  a  danger  which  is 
peculiarly  frec^uent  after  gunshot  wounds.     The  occurrence  of  gangrene  is  also 


8URGERY   OF    THE    VASCULAR   SYSTEM. 


259 


a  coinplit-atiou  of  an  exceedingly  fatal  character  in  gunshot  wounds,  since  septi- 
cemia rapidly  develops.  If  the  main  artery  of  the  limb  is  injured,  and  also  its 
accompanying  vein  and  nerve,  even  without  "a  fracture  of  the  bone,  as  a  rule 
amputation  is  necessary  to  avert  gangrene,  which  would  almost  surely  follow. 

If  secondary  luMuorrhage  occurs,  it  will  be  during  the  second  or  third  week — 
that  is,  at  tlie  time  when  the  sloughs  separate.  The  l)]eeding  should  be  arrested, 
if  possible,  at  the  site  of  the  hemorrhage;  but  when  this  is  impossible,  a  ligature 
should  be  applied  according  to  the  Hunterian  principle — ^'.  e.  in  healthy  tissue 
upon  the  proximal  side  of  the  wound.  If  the  hemorrhage  is  alarming  and  it 
comes  from  several  points,  and  the  suppuration  is  extensive,  with  sepsis,  ampu- 
tation of  the  limb  is  indicated.  The  best  way  to  prevent  secondary  hemor- 
rhage is  to  keep  the  wound  aseptic  and  to  provide  sufficient  drainage.  Good 
nutritious  diet  is  required  in  order  to  maintain  a  high  standard  of  vitality, 
which  conduces  to  repair  of  the  wound  and  averts  the  dangers  of  exhaustion, 
suppuration,  and  septicemia. 

If  the  wound  is  an  incised  one  and  involves  the  neck  or  axilla,  digital  pres- 
sure must  be  promptly  employed,  and  at  once  preparations  should  be  made  to 
search  for  the  wounded  vessel.  This  should  be  completely  severed  at  the  point 
of  injury  and  a  proximal  and  distal  ligature  of  aseptic  catgut  or  silk  should  be 
applied.  If  the  incised  artery  is  in  an  extremity  an  Esmarch  bandage  can  be 
applied  in  the  same  mariner  as  already  described  in  the  management  of  primary 
hemorrhage  in  gunshot  wounds.  The  application  of  the  bandage  permits  the 
surgeon  to  make  a  bloodless  dissection  and  secure  with  certainty  and  ease  the 
wounded  vessel. 

In  ease  of  a  riiptured  artery  the  treatment  is  practically  the  same  as  would 
govern  the  surgeon  in  the  management  of  a  contused  or  lacerated  vessel. 

Murphy  of  Chicago  has  recently  sutured  wounds  of  arteries  and  veins. 
The  chief  points  to  be  insisted  upon  are  rigid  asepsis,  the  exposure  of 
the  vessel  with  as  little  damage  as  possible,  the  temporar}^  arrest  of  the 
blood-stream,  the  control  of  the  vessel  during  the  anastomosis  or  sutur- 
ing, the  approximation  of  the  walls  of  the  vessel,  and  absolute  freedom 
from   hemorrhage  after  removal   of  the  temporary   hemostasis.      The  most 


Method  of  Sutiiring  a  Blood-vessel  (Murphy). 


rigid  asepsis  must  be  observed,  as  the  tunica  intima,  like  the  peritoneum, 
is  a  serous  membrane.  External  septic  infection  may  penetrate  the  ves- 
sel wall  and  cause  such  a  change  in  the  endothelial  coat  as  to  produce 
thrombosis. 

The  hemorrhage  at  the  time  of  operation  may  be  controlled  with  Bill- 
roth forceps  provided  with  a  graduated  catch  and  broad  blades,  over  which 
is  passed  a  section  of  rubber  drainage-tube,  to  prevent  injury  to  tlie  vessel, 


260  AN  AMERICAN   TEXT- BOOK   Of    SURGERY. 

or  the  vessel  may  be  occluded  witli  tcinporary  li<^atur('s.  The  pressure  must 
not  be  too  great,  and  tlio  knot  must  not  be  tied  so  tightly  as  to  cause  injury 
of  the  tunica  intima.  Fine  cambric  needles  and  silk  are  used.  The  vessel 
wall  is  seized  with  fine  rat-tootlied  forceps.  The  best  material  for  suture 
is  the  twisted  silk  to  fit  exactly  the  eye  of  the  needle.  In  longitudinal 
wounds  the  sutures  are  placed  one-sixteenth  of  an  inch  apart,  and  enter 
and  emerge  at  the  same  distance  from  the  Avound.  The  needle  should,  of 
course,  never  touch  the  tunica  intima,  but  only  the  outer  and  middh'  coats 
are  traversed  by  the  suture.  In  transverse  wounds  the  same  technitjue  is 
used.  The  sutures  must  be  exactly  o]>i>osite  each  other.  Murphy  recom- 
mends the  insertion  of  the  first  one  in  the  middle,  and  the  next  at  the  two 
angles. 

If  more  than  one-half  of  the  vessel  is  cut,  a  resection  must  be  done 
and  the  proxiuuil  end  anastomosed  by  invagination.  The  sutures  should 
penetrate  only  the  outer  and  the  middle  coats.  Fig.  56  shows  Murphy's 
method  of  inserting  the  sutures.  If  any  oozing  occurs  after  the  removal 
of  the  temporary  hemostatics,  the  bleeding  can  be  controlled  by  gentle 
pressure  with  the  fingers  or  a  sponge  until  a  small  clot  forms  at  the 
point  of  entrance  of  the  needle. 

WOUNDS    OF    SPECIAL   ARTERIES. 

The  carotid  artery  may  be  wounded  as  a  result  of  gunshot  injury,  a  stab, 
or  other  wound,  or  during  the  performance  of  an  operation  upon  the  neck. 
The  wound  of  so  large  a  vessel  is  necessarily  a  most  serious  event.  If  the 
vessel  is  entirely  cut  across,  the  patient  usually  (but  not  always)  expires  in  a 
few  minutes ;  but  if  the  carotid  is  partially  wounded,  the  hemorrhage  may  be 
arrested  by  compression  until  the  vessel  is  secured  and  ligatured.  This  artery 
is  seldom  divided  in  an  attempt  at  suicide,  especially  when  the  head  is  thrown 
back,  because  of  its  anatomical  situation  deep  in  the  neck  ;  but  the  superior 
thyroids  lying  in  front  and  more  superficially  are  often  wounded  ;  the  incision 
rarely  extends  deeper  than  these  vessels.  In  all  cases  of  Avounds  of  these 
larger  vessels  of  the  neck  the  treatment  is  based  upon  the  general  principles 
which  govern  the  surgeon  in  his  management  of  hemorrhage.  A  ])riniary 
hemorrhage  should  be  treated  by  dividing  the  vessel  at  the  point  of  injury, 
if  not  already  divided,  and  instantly  tying  both  ends  of  the  vessel.  A  secondary 
hemorrhage  must  be  controlled  by  methods  already  mentioned.  In  wounds 
of  the  carotid  and  its  branches  the  possibility  of  the  occurrence  of  oedema 
glottidis  must  not  be  overlooked,  and  a  projdiylactic  tracheotomy  should  be 
performed  if  this  occur. 

The  vertebral  artery  may  be  injured  in  any  of  the  ways  mentioned  in 
reference  to  wounds  of  other  vessels.  Compression  has  effected  an  arrest  of 
the  hemorrhage ;  but,  as  a  rule,  a  search  for  the  wounded  vessel  may  be  made, 
and  if  possible  the  artery  be  divided  and  tied  at  both  ends.  There  is  danger 
of  escape  of  blood  into  the  spinal  canal  and  compression  of  the  cord  when  a 
wound  of  the  vertebral  artery  occurs. 

The  subclavian  artery  has  been  wounded  in  the  various  ways  that  have 
been  described,  and  possibly  by  a  puncture  from  a  fragment  in  fracture  of 
the  clavicle  or  of  the  first  rib.  A  wound  of  this  vessel  is  most  serious  on 
account  of  its  size  and  its  situation.  A  large  traumatic  aneurysm  is  developed, 
and  must  be  treated  after  the  manner  described  in  the  management  of  such  an 
aneurysm. 

The  axillary  artery  is  subject  to  the  same  injuries  as  other  vessels,  and 


SURGERY   OF    THE    OSSEOUS  SYSTEM.  2(11 

is  additionally  exposed  to  the  danger  of  rupture  in  reducing  old  dislocations 
of  the  shoulder-joint.  Fortunately,  in  the  wounds  of  the  axillary  artery  due 
to  complete  laceration  of  the  vessel  the  artery  retracts  and  contracts  and  the 
hemorrhage  may  be  spontaneously  arrested.  In  injuries  of  this  artery,  as  a 
rule,  the  vessel  should  be  exposed,  completely  divided,  and  botli  ends  secured 
by  a  ligature.  In  rupture  from  attempts  at  reducing  an  old  dislocation  this 
procedure  has  been  uniformly  fatal,  and  should  be  replaced  by  compression, 
ligature  of  the  subclavian,  or  amputation  at  the  shoulder-joint. 

The  femoral  artery  is  often  exposed  to  injury,  and  on  account  of  its 
superficial  situation  the  hemorrhage  is  easily  controlled.  The  same  rules 
govern  the  surgeon  in  the  management  of  wounds  of  this  vessel  as  in  those 
of  other  arteries.  After  ligation  of  the  artery  the  limb  should  be  elevated  and 
artificial  warmth  should  be  applied  to  prevent  gangrene. 

The  popliteal  artery  is  seldom  wounded,  owing  to  its  deep  situation  and 
to  the  protection  which  is  afforded  to  it  by  the  joint  in  front.  In  case  of  an 
injury  to  the  vessel  an  Esmarch  bandage  should  be  applied,  the  vessel  found, 
and  both  ends  of  the  divided  artery  ligated. 

In  case  of  a  wound  of  any  of  the  other  arteries  in  the  body — in  the  fore- 
arm, arm,  leg,  or  foot,  or  upon  the  trunk — the  principle  of  searching  for  the 
bleeding  vessel  and  ligating  it  at  both  ends  must  always  be  kept  in  mind- 
The  hemorrhage  from  an  intercostal  or  from  the  internal  mammary  is  serious, 
because  generally  some  of  the  thoracic  viscera  are  also  implicated.  It  has  been 
suggested  to  introduce  a  finger-shaped  tampon  made  of  a  piece  of  antiseptic 
gauze,  which  is  pushed  between  the  ribs  with  a  probe,  and  then  to  fill  the 
tampon  with  strips  of  iodoform  gauze  and  draw  the  entire  mass  outward,  so 
as  to  make  firm  pressure  against  the  inner  wall  of  the  thorax  and  the  two 
corresponding  ribs.  It  is,  however,  best  to  secure  the  two  ends  of  the  divided 
vessel  by  ligatures  in  the  manner  already  described.  A  rib  may  be  resected  if 
necessary. 

WOUNDS    OF   VEINS. 

A  wound  of  a  vein  is  in  some  respects  less  dangerous  than  a  wound  of  an 
artery  of  the  corresponding  size ;  but  serious  complications  may  readily  follow  a 
wound  of  a  vein,  unless  kept  aseptic.  The  hemorrhage  from  a  small  vein  is 
less  than  that  from  an  artery  of  the  same  size,  because  the  vein  collapses  and 
the  force  of  the  circulation  is  not  so  great  as  in  the  corresponding  artery.  A 
considerable  quantity  of  blood  is  extravasated  in  the  surrounding  tissues,  so 
that  external  pressure  will  also  contribute  to  the  arrest  of  the  hemorrhage. 
The  loss  of  blood  from  a  large  vein,  however,  is  so  rapid  and  excessive  as  to 
endanger  life  in  a  few  minutes. 

The  symptoms  of  venous  hemorrhage  upon  which  the  diagnosis  is 
based,  are — 1st,  the  escape  of  dark-colored  blood  in  a  continuous  stream  ;  2d, 
the  special  eff'ects  of  pressure :  if  applied  upon  the  distal  side  of  the  wound,  it 
causes  the  hemorrhage  to  cease ;  but  it  causes  it  to  increase  if  the  pressure  is 
applied  upon  the  cardiac  side  of  the  wound. 

The  complications  that  follow  an  injury  to  a  vein  depend  chiefly  upon  the 
size  of  the  vessel  and  upon  the  septic  or  aseptic  conditions  attending  the  injury. 
Among  the  complications  are  phlebitis,  oedema,  thrombosis,  embolism,  ulcera- 
tion, metastatic  abscesses  in  organs  directly  connected  with  the  wounded  vein, 
gangrene,  and  secondary  hemorrhage. 

The  treatment  of  a  wounded  vein  depends  upon  the  size  and  situation  of 
the  vessel.  If  the  vessel  is  small  and  situated  superficially,  elevation  of  the 
limb,  a  compress  applied  upon  the  distal  side,  and  rest  will  be  all  that  is  neces- 


262  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

sary.  If  the  vein  is  large  and  deeply  situated,  the  injured  vessel  should  be 
found  and  both  ends  of  the  divided  vein  secured  by  an  aseptic  ligature.  Of 
course  thorough  asepsis  of  the  Avound  must  be  secured.  If  the  Avounded  vein 
is  "within  one  of  the  tln-ee  great  cavities  of  the  body,  an  operation  of  great 
magnitude  may  be  indicated  in  order  to  reach  the  bleeding  vessel.  If  a  vein 
is  wounded  laterally,  the  slit  can  be  picked  up  with  a  pair  of  forceps  and  a 
ligature  applied  to  it,  so  that  the  lumen  of  the  vessel  will  not  be  obliterated. 
In  the  case  of  a  large  vein  Avliere  the  tissues  are  abundant  this  method  of  treat- 
ing a  wounded  vein  has  many  advantages.  Hemostatic  forceps  may  be  applied 
and  left  in  sitd  for  forty-eight  hours.  They  should  of  course  be  entirely 
covered  by  the  dressing. 

Wounds  of  Special  Veins. — A  wound  of  the  internal  jugular  vein  is 
generally  quickly  fatal  from  the  loss  of  blood  or  occasionally  from  the  entrance 
of  air  into  the  vein.  The  direction  of  the  wound  influences  the  prognosis, 
because  a  longitudinal  slit  Avill  not  gape,  while  a  transverse  one  is  held  wide 
open  by  the  action  of  the  deep  cervical  fascia.  If  the  internal  jugular  is 
wounded  near  its  entrance  into  the  skull,  besides  the  dangers  arising  from  the 
loss  of  blood  and  also  the  entrance  of  air,  there  is  the  additional  danger  of 
cerebral  septic  infection  and  venous  and  sinus  thrombosis. 

Injuries  of  the  subclavian  and  axillary  veins  are  also  very  serious,  for  the 
same  reasons  that  have  been  mentioned  in  reference  to  the  jugular  vein. 

A  wound  of  the  femoral  vein,  besides  the  loss  of  blood,  has  an  additional 
danger — gangrene  of  the  leg — which  may  follow  the  ligation  required  to  arrest 
the  hemorrhage.  Ligation  of  the  popliteal  vein  may  also  be  attended  with  the 
same  complication.  After  either  of  these  ligations  the  limb  should  be  elevated 
to  help  the  venous  return,  and  be  enveloped  in  cotton  and  hot-water  bottles  to 
keep  up  the  temperature  of  the  leg.  If  gangrene  intervenes,  amputation  must 
be  done. 

For  Wounds  of  the  Cerebral  Sinuses  see  Injuries  of  the  Head. 


CHAPTER   II. 

SURGERY  OF  THE  OSSEOUS  SYSTEM. 


As  the  ossous  tissue  differs  in  no  material  respect  from  the  soft  parts  except 
in  the  added  lime-salts  that  give  it  firmness,  its  injuries  and  diseases  are  in  the 
main  of  like  character  and  course,  wounds,  inflammations,  and  tumors  termi- 
nating in  more  or  less  complete  return  to  the  normal  state  or  in  constructive  or 
destructive  changes.  The  soft  structures  in  the  cancellous  and  medullary  spaces, 
in  the  Haversian  canals,  and  upon  the  exterior  of  the  bone,  though  for  con- 
venience' sake  and  with  a  seeming  anatomical  and  pathological  basis  they  may 
be  separately  considered,  are  but  parts  of  a  common  whole,  a  lesion  of  which 
may  be  general  or  limited  according  to  its  nature  and  intensity. 

The  most  numerous  and  important  affections  are  the  inflammations  conse- 
quent upon  injury;  upon  the  existence  of  special  diathetic  states,  as  the  tuber- 
cular or  syphilitic;  upon  a  general  infective  disease,  as  typhoid  fever;  or  upon 
the  presence  and  action  of  pyogenic  organisms.  They  may  be  acute  or  chronic^ 
and  end  in  resolution,  in  organization  of  an  exudate,  or  in  destruction,  limited 
or  extensive,  molecular  or  in  mass,  of  the  part  involved.  According  to  the 
presence  or  absence  of  the  pyogenic  microbes  suppuration  will  or  will  not  occur. 


SURGERY   OF   THE    OSSEOUS  SYSTEM.  2G3 

Liquefaction  to  a  greater  or  less  extent  is  an  ordinary  effect  of  the  syphilitic 
invasion,  still  more  of  the  tubercular.  'We  intensity  of  the  symptoms  is  always 
greater  in  the  suppurative  than  in  the  non-suppurative  affections.  The  pyo- 
genic organisms  (generally  the  staphylococcus  aureus  or,  but  much  less  fre- 
quently, the  streptococcus  pyogenes)  gain  admission  to  the  diseased  area  either 
through  an  open  wound  or  by  the  blood-stream,  having  been  taken  up  at  some 
distant  and  often  small  pus-depot,  or  by  the  lungs,  or  the  intestinal  canal,  to 
which  they  have  been  brought  from  without  the  body. 

These  inflammations  may  be  considered  under  the  general  heads  of  osteo- 
periostitis and  osteo-mi/elitis,  since  pure  periostitis  is  of  very  infrequent  occur- 
rence, perhaps  is  only  met  with  as  a  syphilitic  manifestation,  and  pure  myelitis 
is  equally  infre(i[uent. 

OSTEO-PEEIOSTITIS. 

This  condition  usually  exists  in  cases  commonly  thought  to  be  examples 
of  periostitis,  in  which  not  only  the  periosteum,  but  the  superficial  layers  of 
the  bone  also  are  diseased.  It  may  be  acute  or  chronic,  plastic  or  suppurative, 
limited  or  diffused.  It  is  the  result  of  cold,  of  wounds  or  contusions,  of 
strains  from  undue  traction  on  inserted  tendons,  of  contiguous  inflammations, 
as  from  old  ulcers,  or  of  special  infections,  syphilitic,  tubercular,  or  pyogenic. 
The  more  superficial  the  bone,  the  more  likely  is  osteo-periostitis  to  occur, 
because  of  the  greater  exposure  to  injuries  and  the  action  of  cold.  The  perios- 
teum both  in  its  outer  and  inner  layers  is  thickened  and  reddened  and  its  cells 
increased  in  number.  More  or  less  of  the  surface  of  the  underlying  bone  is  simi- 
larly affected,  and  its  blood-supply  may  be  so  diminished  in  consequence  of  the 
separation  and  occlusion  of  the  vessels  by  the  swollen  periosteum  as  superficially 
to  destroy  its  vitality.  When  neither  suppurative  nor  tubercular,  the  disease 
terminates  either  in  resolution  or  in  permanent  thickening  with  new  formation 
of  bone,  or,  but  much  more  rarely  (and  chiefly  on  the  head  in  cases  of  syphilis), 
in  thinning  and  absorption. 

When  suppurative  and  limited,  after  evacuation  of  the  pus  repair  takes  place 
with  either  little  or  no  thickening,  with  decided  hypertrophy,  or  with  some  loss 
of  substance.  When  diffused,  unless  very  promptly  arrested,  extensive  destruc- 
tion of  membrane  and  bone  commonly  follows.  These  purulent  varieties  are 
rarely,  if  ever,  primary,  though  the  antecedent  deeper  inflammation  may  be  but 
slight. 

The  symptoms  vary  somewhat  according  to  location  and  cause,  being 
least  marked  in  the  traumatic  non-suppurative  cases,  but  pain  and  swelling 
are  always  present,  the  former,  as  a  rule,  severe  and  worse  at  night.  If  it  is 
a  deeply-situated  bone  that  is  affected,  it  is  often  impossible  to  recognize  the 
swelling,  but  if  a  subcutaneous  one,  for  example  the  tibia,  as  is  so  frequently 
the  case,  the  spindle-shaped  thickening  can  be  readily  felt ;  there  is  much  ten- 
derness on  pressure  and  the  overlying  soft  parts  are  oedematous  and  reddened. 
In  the  suppurative  varieties  constitutional  symptoms  are  present,  and  are  of  a 
high  grade  in  the  diffused  phlegmonous  form.  In  the  chronic  syphilitic  inflam- 
mations the  pain  is,  as  a  rule,  not  acute. 

The  treatment  in  the  beginning  is  by  rest  and  the  application  of  either 
cold  or  heat  as  is  more  comfortable  to  the  patient. 

If  speedy  resolution  does  not  take  place  and  the  pain  is  great,  subcutaneous 
punctures  of  the  swelling  should  be  made,  or,  if  pus  is  present,  the  parts  should 
be  freely  laid  open.  When  the  disease  is  due  to  syphilis,  the  knife  should  not 
be  used,  but  reliance  should  be  placed  upon  the  administration  of  the  ordinary 
antisyphilitic  remedies. 


264  AK   AMI.L'ICAX    TKXT-liOOK    OF  SURGERY. 

OSTEO-MYELITIS. 

Osteo-myelitis  (wliicli  includes  both  osteitis  and  mcdnllitis — i.  e.  myelitis  of 
bone)  is  the  more  common  form  of  bone  inflammation,  the  cause  of  ■which  may 
be  either  local,  general,  or  septic. 

As  in  inflammation  of  the  soft  tissues,  the  parts  are  congested,  the  blood- 
vessels dilated,  oftusion  and  exudation  take  place,  and  there  is  increased  cell- 
growth.  If  the  disease  is  slight  and  due  to  traumatism,  and  if  resolution  quickly 
tbllows,  no  organic  change  is  produced  in  the  bone-layers ;  but  ordinarily  there 
occurs  more  or  less  destruction,  either  in  mass  (necrosis)  or  molecular 
(caries),  limited  or  extensive  according  to  the  degree  of  the  inflammation 
and  its  exciting  cause.  In  necrosis  the  dead  part  is  called  a  scf/iiestnim 
(p.  269).  When  perforation  of  the  overlying  tissues  has  taken  place,  upon 
})robing  necrosed  bone  is  to  be  recognized  by  its  hardness  and  its  sharp,  clear 
percussion  note  when  struck,  carious  bone  giving  out  a  dull  sound,  if  any, 
and  being  generally  readily  penetrated  by  the  instrument. 

These  two  forms  of  bone-death  are  to  the  osseous  system  what  gangrene 
and  ulceration  are  to  the  soft  parts — necrosis,  like  gangrene,  being  due  to  a 
cause  which  directly  or  indirectly  cuts  off"  the  blood-supply  to  or  interrupts 
the  outflow  from  an  area  large  enough  to  be  recognizable  by  the  unaided  eye; 
while  in  caries,  as  in  ulceration,  the  cells  of  an  abnormally  succulent  part 
melt  down  and  are  discharged. 

As  met  with  in  practice,  necrosis  is  commonly  due  to  a  non-traumatic 
infective  inflammation.  At  times  it  is  consequent  upon  injuries  (e.  g.  frac- 
tures permitting  of  the  entrance  of  pyogenic  organisms  or  severe  contusions), 
or,  less  often,  exposure  to  severe  cold  or  high  heat.  In  the  bones  of  the 
head  and  face  it  not  rarely  is  of  syphilitic  origin. 

Caries — the  ulceration  of  bone — is  almost  always  due  to  tubercular 
infection. 

Osteo-myelitis  is  either  acute  oi%  more  frequently,  chronic.  If  the  inflam- 
mation is  acute  and  severe,  the  resistance  of  the  rigid  walls  of  the  central 
cavity  and  of  the  Haversian  canals  generally  causes  such  compression  of  the 
vessels  (which  often  become  strangulated  by  the  newly-formed  cell-masses) 
that  the  vitality  of  the  part  cannot  be  preserved ;  necrosis  then  necessarily 
results  (Fig.  57).  Such  death  in  mass  in  greater  or  less  measure  is  always 
to  be  looked  for  in  the  acute  infective  or  suppurative  inflammations. 

When  the  process  is  a  slower  one,  there  may  still  be  an  arrest  of  circulation 
with  resulting  necrosis,  but  generally  the  death  of  the-  bone-layers  is  a  molec- 
ular one,  due  in  part  to  the  disintegrating  action  of  the  excess  of  fluid,  but 
chiefly  to  the  pressure  made  by  the  enlarged  vessels  and  the  newly-formed  cells 
and  to  the  destructive  action  of  the  latter.  These  are  especially  abundant  in 
the  Haversian  canals  over  the  flexures  of  the  vessels,  and  as  a  consequence  the 
■walls  of  such  canals  break  down  unevenly  and  are  pitted,  the  depressions  being 
commonly  spoken  of  as  the  Hoivship  laeunce.  As  the  result  of  the  softening 
and  disappearance  of  the  bone  the  cancellous  spaces  enlarge,  the  central  cavity 
widens,  and  the  Haversian  canals  increase  in  diameter,  granulation-tissue 
becoming  more  and  more  abundant  and  progressively  occupying  the  places 
from  which  the  bone  has  been  removed.  In  other  words,  a  condition  of  osteo- 
porosis has  been  developed,  and  the  affection  is  a  rarefying  osteitis,  which  may 
be,  on  the  one  hand,  of  very  limited  extent,  or,  on  the  other,  involve  a  large 
part  of  the  bone,  even  from  center  to  cortex.  Outside  the  area  of  rarefaction 
there  will  often  be  found  a  space  of  greater  or  less  width  in  which  formative 
changes  have  occurred,  the  bone  being  thicker  and  denser  than  normal,  osteo- 


SURGERY    OF    THE    OSSEOUS  SYSTEM. 


265 


Fig.  57 


sclerosis  instead  of  osteo-porosis  being  present.  Sueli  secondary  changes  may 
affect  parts  of  limited  extent  previously  in  a  state  of  rarefaction,  which  when 
the  inllannnation  has  entirely  disappeared  will  remain  unduly  hard,  with  their 
Haversian  canals  abnormally  narrow. 

During  the  rarefying  action  small  pieces  of  bone  may  be  destroyed  and 
separated  (necrotic  caries).  The  great  majority  of  the  cases  of  caries,  nine- 
tenths  if  not  more,  are  of  tubercular  origin,  the  deposit  taking  place  readily, 
as  the  result  of  slight  traumatisms,  in  the  cancellous  tissue,  the  vessels  of  which 
are  numerous  and  thin-walled  and  the  capillaries  very  large  in  proportion  to  the 
size  of  their  associated  arteries  and  veins.  It  is  during  the  years  of  growth 
in  the  parts  of  the  bone  in  which  such  growth  chiefly 
occurs,  as  about  the  ej)ipliyscal  lines  and  in  those 
portions  of  the  skeleton  particularly  subject  to  blows, 
shocks,  and  the  action  of  cold,  that  this  form  of  dis- 
ease is  ordinarily  observed. 

Here  as  everywhere  else  the  bacilli  cause  soften- 
ing of  the  parts  immediately  about  them.  If  few  in 
number  and  limited  in  action,  they  may  be  rapidly 
destroyed  or  shut  in,  so  that  either  by  cicatrization 
or  encapsulation  recovery  takes  place.  This  often 
occurs  ;  in  the  great  majority  of  cases,  however,  the 
disease  is  not  so  arrested,  but  infected  granulation- 
tissue  continues  to  be  developed  in  the  cancellous 
spaces,  in  the  Haversian  canals,  and  in  the  central 
medulla,  more  and  more  bone  is  softened  down  or 
pieces  of  appreciable  size  are  deprived  of  their  blood- 
supply,  and  consequently  die.  Thus  the  tubercular 
area  grows  larger  with  accompanying  liquefaction 
and  caseation,  and  the  rarefaction  extends  farther 
and  flirther. 

When  it  is  the  presence  and  action  of  the  pyo- 
genic microbes  that  excite  the  inflammation  the  osteo- 
myelitis may  be  either  acute  or  chronic,  limited  or 
widespread,  with  accompanying  destruction  of  bone 
and  corresponding  intensity  of  local  and  general 
symptoms.  Though  there  are  a  number  of  the  pyo- 
genic organisms  that  may  cause  these  septic  diseases 
of  bone,  the  staphylococcus  aureus  is  the  one  most 
commonly  met  with,  and  next  to  it  the  streptococcus 
pyogenes. 

Associated  with  certain  of  the  acute  infectious 
diseases,  especially  typhoid  fever,  there  occurs  an 
inflammation,  generally  superficial,  which  causes  a 
necrosis  commonly  of  limited  extent  and  with  a 
strong  tendency  to  become  symmetrical — e.  g.  to  si- 
multaneous or  consecutive  development  in  like  parts 
on  both  sides  of  the  body.  Whether  because  the  dis- 
ease-germ is  itself  pyogenic  or  because  of  a  double  infection,  these  typhoid 
inflammations  are  as  a  rule  suppurative.  Osteo-sclerosis  is  a  very  frequent 
eff'ect  of  syphilitic  infection,  but  both  necrosis  and  caries  often  occur,  and  in 
different  portions  of  the  same  skeleton  the  three  forms  of  osteitis,  condensing, 
rarefying,  and  hypertrophic,  may  be  observed. 

In  phosphorus-workers  severe  and  extensive  necrosis  of  the  jaws  is  at  times, 


Necrosis  of  the  Diaphysis,  follow- 
ing Acute  Osteo-myelitis  of  the 
Humerus  (Duplay  and  Reelus). 


266  AN   AMERICAN    TKXT-IKX >k'    OF   smCEin'. 

though  now  very  rarely,  produced  by  the  action  of  the  poison  that  has  gained 
access  to  the  bone  throu<^h  decayed  teeth. 
Acute  osteitis  is  eitlicr  H'nnpli'  or  septic. 

Simple  acute  osteitis  is  consecjuent  upon  traumatism,  and  occurs  in  parts 
protected  against  the  action  of  the  pyogenic  micro-organisms  either  by  an 
unbroken  soft  covering  or  by  antiseptic  treatment.  It  is  of  comparatively  lit- 
tle importance,  aTid  usually  terminates  by  resolution  in  a  short  time.  Its  symp- 
toms are  few.  J*ain  is  the  most  j)rominent  symptom,  and  is  often  not  severe  ;  it 
is  apt  to  be  deep-seated,  boring  or  gnawing,  worse  at  night,  aggravated  by  the 
dependent  position,  and  increased  by  pressure.  If  it  is  superficially  located — 
when,  indeed,  it  is  an  osteo-periostitis  rather  than  a  simple  osteitis — it  may  be 
associated  with  some  oedema  of  the  soft  parts  and  discoloration  of  the  skin. 
Rest,  elevation  of  the  limb,  fomentations,  and  moderate  compression  are  the 
local  remedial  measures  to  be  adopted,  pain  being  controlled  by  opiates.  If 
the  suftering  is  very  severe  and  does  not  quickly  subside,  the  overlying  soft 
parts  should  be  incised,  and  if  this  does  not  relieve,  the  bone  should  be  asepti- 
cally  drilled  at  one  or  more  points,  thus  lessening  the  tension. 

Of  the  septic  inflammations  of  bone  there  are  tivo  varieties:  (1)  the  one 
associated  with  an  open  wound,  originating  ordinarily  in  the  shaft  of  a  long 
bone  and  generally  met  with  in  adults ;  (2)  the  other,  without  such  associated 
wound,  beginning  in  the  parts  near  the  epiphyseal  line.  The  latter  is  pecu- 
liarly a  disease  of  childhood.  It  may,  however,  occur  later  in  life,  and  is  then 
in  the  great  majority  of  instances  a  recurrence  of  a  similar  inflammation  of 
early  life,  some  of  the  causative  germs  of  which  had  been  encapsulated. 
Boys  are  attacked  three  times  as  often  as  girls,  and  nearly  half  of  the  patients 
are  adolescents  between  the  ages  of  thirteen  and  seventeen. 

The  first  variety,  since  the  introduction  of  antiseptic  surgery,  is  compara- 
tively rare.  Typical  examples  in  former  years  Avere  often  seen  in  cases  of 
compound  fracture,  especially  gunshot  fractures,  and  after  amputations,  infec- 
tion of  the  wound  having  taken  place  at  the  time  of  injury,  during  the  opera- 
tion, or  later.  The  severity  of  the  inflammation  varies,  from  that  in  which 
there  are  but  little  suppuration  and  limited  destruction  of  bone  to  that  in  which 
the  parts  quickly  become  putrid ;  the  whole  bone  is  destroyed,  and  the  patient 
dies  early  of  septicemia  or  pyemia,  even  within  twenty-four  or  forty-eight  hours, 
in  the  most  malignant  of  the  latter  cases. 

"When  associated  Avith  a  compomid  fracture,  in  addition  to  the  ordinary 
conditions,  such  as  congestion,  extravasations,  and  cell-development,  following 
an  injury  of  this  character,  pus  is  present,  with  the  general  symptoms  com- 
monly attendant  upon  suppuration.  Since  the  great  danger  lies  in  the  develop- 
ment of  septic  infection,  the  local  treatment  should  consist  in  securing  free 
drainage  and  in  rendering  the  diseased  area  aseptic. 

When  the  disease  arises  after  amjmtation,  the  medulla  appears  discolored 
by  extravasated  blood,  and  in  the  severer  cases  bleeds  upon  slight  pressure 
and  protrudes  beyond  the  level  of  the  sawn  surface,  at  times  to  a  large  extent, 
covering  the  end'of  the  bone  Avith  a  fungous  mass.  The  discharge  is  al)undant 
and  sero-purulent,  often  having  a  very  off'ensive  odor.  As  the  result  of  the 
inflammation,  Avhen  the  constitutional  infection  is  not  such  as  to  cause  early 
death,  the  bone  about  the  medullary  cavity  necroses,  and  after  a  time  is  sepa- 
rated in  the  form  of  a  tubular  sequestrum  (Fig.  60),  much  worm-eaten  on  its 
exterior,  of  greater  or  lesser  length,  thick  at  the  base,  irregularly  thinning  out 
higher  up,  and  ending  in  sharp  points.  The  constitutional  symptoms,  increase 
of  temperature,  acceleration  of  pulse,  mental  hebetude,  etc.,  are  of  varying 
intensitv. 


SURGERY    OF    TUN    OSS  NO  IS   SYSTEM. 


2G7 


The  local  treatment  sliould  consist  in  the  free  removal  ot"  the  infected 
medulla  and  in  curetting  the  avails  of  the  cavity,  followed  by  its  thorough  dis- 
infection and  drainage  and  by  antiseptic  dressing  of  the  stump,  thus  limiting, 
as  far  as  possible,  the  extension  of  the  septic  inflammation.  When  the  dead 
bone  has  been  loosened  from  the  living,  chiefly  by  a  process  of  rarefying  osteitis 
in  the  latter,  it  should  be  ])r()iiii)tly  removed,  since,  its  extrusion  unaided  by 
surgery  Avould  be  eflected  slowly,  and  while  in  {)rogress  there  would  be 
liability  to  extension  of  the  suppurative  inllaunuation,  with  further  destruction 
of  bone. 

The  second  variety,  acute  epiphysitis,  arises  when  the  pyogenic  organ- 
isms have  not  found  entrance  through  an  open  wound,  but  have  been  brought 
to  the  affected  area  in  the  blood-stream.  The  eflect  then  produced  is  very 
variable.  In  a  comparatively  small  projjortion  of  cases  intense  and  rapidly- 
destructive  inflammation  of  the  bone  follows.  It  is  this  variety  of  osteo- 
myelitis that  is  most  frequently  met  with  at  the 
present  time,  wounds  involving  bone,  however  pro- 
duced, being  protected  in  the  great  majority  of 
cases  against  the  action  of  the  pyogenic  cocci  by 
aseptic  and  antiseptic  treatment,  provided  they 
come  under  the  care  of  the  surgeon  before  infec- 
tion has  taken  place.     • 

As  has  been  stated,  it  is  a  disease  of  childhood 
and  adolescence,  and  has  its  starting-point  in  the 
tissues  near  an  epiphyseal  line,  due  to  the  frequency 
of  juxta-epiphyseal  strains,  the  femur  and  the  tibia 
being  the  bones  most  commonly  affected.  Fig.  58 
shows  arrest  of  development  of  the  ulna  followed  by 
deformity  of  both  ulna  and  radius  consequent  upon 
such  an  inflammation  near  the  epiphyseal  line  of  the 
ulna. 

The  symptoms  are,  in  the  beginning,  high 
fever  (with  often  an  initial  chill),  delirium,  and 
great  pain,  gnawing  or  boring  in  character  and  located 
ordinarily  near  the  end  of  a  long  bone,  with  a  pe- 
culiar helplessness  of  or  inability  to  move  the  limb 
by  its  own  muscles.  The  attack  comes  on  suddenly, 
generally  at  night,  after  exposure  to  cold  and  damp- 
ness, combined  sometimes  with  unusual  exertion. 
Sitting  on  a  stone  doorstep  and  unduly  prolonged 
swimming  are  common  causes,  even  in  summer.  If 
the  inflammation  is  at  first  deeply  seated  in  the  can- 
cellous tissue,  no  change  in  the  overlying  soft  parts, 
either  in  thickness  or  in  color,  will  be  observed  for  a 
number  of  days,  even  in  the  graver  cases,  though 
there  is  from  the  first  sensitiveness  to  pressure  over 
the  aff"ected  area,  and  frequently  the  superficial  veins 
are  abnormally  distinct.  Before  long,  however,  the 
external  layers  of  the  bone  and  periosteum  become 
involved,  and  swelling  of  the  soft  parts  and  redness  of  the  skin  occur,  with 
quickly-following  fluctuation,  indicating  the  presence  of  pus.  When  the  disease 
originates  near  the  surface,  these  latter  symptoms  will  be  noticed  early,  the 
rapidly-forming  and  widely-spreading  pus  lifting  the  periosteum  off"  the  shaft 
for  a  variable  distance,  in  the  graver  cases  from  end  to  end  and  around  the 


Arrest  of  Development  of  the 
Ulna  following  Osteitis  near 
Epiphysis ;  continued  Growth 
and  Deformity  of  the  Radius 
(Poneet). 


2»i.S  A\    AMKUK'Ay    TKXT-JiOOK    OF  SURGERY. 

uhole  circumference  of  the  bone.  The  tenqierature  continuts  liigh,  with  daily 
fluctuations  of  two,  three,  or  more  degrees,  and  the  pain  is  excessive  until  ten- 
sion is  relieved  by  the  spontaneous  opening  of  the  abscess  or  by  operation. 
As  soon  as  there  is  such  an  opening,  probing  will  almost  certainly  reveal  the 
presence  of  dead  bone.  The  neighboring  joint  generally  soon  ])ecomes  inflamed, 
■with  resulting  eff'usion  into  its  capsule,  the  fluid  often  becoming  purulent  after 
a  time,  either  from  direct  communication  with  the  suppurating  area  in  the  bone 
or  from  transmission  of  the  pyogenic  cocci  through  the  blood-vessels  or  the 
lymphatics. 

In  young  children  the  acute  epiphysitis  that  at  times  occurs  is  very  apt  to 
cause  separation  of  the  epiphysis,  followed  by  suddenly  produced  displacement, 
resulting  in  shortening  and  deformity  (Fig.  58).  This  variety  of  bone-inflam- 
mation is  usually  located  at  the  hip,   knee,  or  shoulder. 

At  times,  though  not  often,  the  pyogenic  organisms  are  carried  from  one 
ind  of  the  bone  to  the  other  without  involvement  of  the  intervening  shaft,  two 
entirely  distinct  areas  of  inflammation  being  produced  in  the  same  bone. 

The  intensity  of  all  the  symptoms  will  vary  according  to  the  character  and 
number  of  the  infecting  organisms.  In  the  most  severe  cases,  fortunately  very 
rare,  only  pain  and  the  temperature  and  typhoid  state  of  an  acute  septicemia 
are  observed,  death  occurring  quickly.  Generally,  swelling  and  abscess-forma- 
tion are  added.  These  abscesses  are  extensive  and  developed  early  in  the  graver 
cases,  but  are  limited  and  appear  more  slowly  in  the  milder  ones,  the  latter 
being  those  more  commonly  met  with.  In  certain  cases  the  attack  may  be  so 
mild  that  pus  is  not  formed,  but  a  synovia-like  fluid,  chiefly  subperiosteal,  the 
nature  of  which  is  not  discovered  until  after  its  evacuation  ;  or  perhaps  pus  is 
formed  and  undergoes  a  later  mucoid  degeneration.  This  periostitis  albuvii- 
nosa  has  been  observed  only  a  very  few  times. 

The  diagnosis  in  the  earlier  hours  or  days  may  be  uncertain,  the  affection 
being  often  regarded  as  a  typhoid  fever  or  an  acute  rheumatism,  or,  in  the 
periosteal  variety,  because  of  the  redness  of  the  skin,  as  an  erysipelas.  But  if 
due  regard  be  had  to  the  age  of  the  patient,  the  location  of  the  pain  close  to 
but  not  in  the  joint  (commonly  the  knee,  the  ankle,  or  the  hip),  its  peculiar 
gnawing,  boring  character  so  indicative  of  bone-inflammation,  and  the  sud- 
denness of  appearance  and  severity  from  the  start  of  the  constitutional  symp- 
toms, with  the  absence  of  the  progressive  daily  rise  of  temperature  that  belongs 
to  typhoid  fever  in  its  first  week,  there  will  seldom  be  any  doubt  as  to  the 
nature  of  the  disease. 

The  prognosis  as  respects  both  part  and  life  is  grave.  Death  from  sep- 
ticemia in  a  few  intensely  infective  cases  takes  place  so  soon  (within  one,  two, 
or  three  days)  that  its  osteo-myelitic  origin  is  not  recognized.  When  it  origi- 
nates superficially,  the  disease  is  less  dangerous  than  when  of  central  origin, 
as  the  pus  more  readily  and  rapidly  reaches  the  surface  and  is  more  quickly 
evacuated. 

Though  the  prognosis  is  much  affected  by  the  intensity  of  the  inflammation, 
it  is  more  influenced  by  treatment.  This  to  be  effective  must  be  operative, 
and  the  sooner  the  diseased  area  is  cut  down  upon  and  the  bone  drilled  or 
trephined,  the  greater  the  likelihood  of  arresting  the  inflammation  and  lessen- 
ing the  local  destruction.  The  application  of  heat,  pressure,  tincture  of  iodine, 
etc.  will  not  stop  the  disease;  tension  must  be  relieved,  pus  evacuated,  the 
bone  trephined  and  the  bone  cavity  scraped,  and  the  parts  irrigated  with  a 
sublimate  solution  in  order  to  kill  the  staphvlococci. 

When  the  medulla  is  extensively  involved,  much  benefit  will  follow  tre- 
phining at  two  different  levels  or  at  many  points,  scraping  out  the  intervening 


SURGERY   OF    TlIK    OSSEOUS  SYSTEM. 


269 


Fig.  ()0. 


Fig.  59. 


m 


M 


infected  tissue,  even  to  tlie  removal  of  the  whole  medulla  of  a  long  bone,  such 
as  the  tibia,  and  thoroughly  irrigating  with  antiseptic  solutions.  In  the  super- 
ficial variety  (even  in  the  so-called  acute  piilegmonous  periostitis),  when  the 
periosteum  has  been  extensively  separated,  it  may  regain  attachment  to  the 
bone  to  a  large  extent  after  early  free  incision  and  irrigation  and  the  vitality 
of  the  shaft  in  the  main  be  preserved. 

If,  as  is  generally  the  case,  from  neglect  of  treatment  or  in  spite  of  it, 
necrosis  has  resulted,  the  dead  bone  should  be  removed  as  soon  as  it  has 
become  detached ;  but  often  in  the  more  severe 
cases,  in  order  that  the  profuse  discharge  and  pro- 
gressive exhaustion  may  be  stopped,  an  early  opera- 
tion will  be  required  at  the  end  of  four,  five,  or  six 
weeks,  even  at  the  risk  of  taking  away  too  much 
or  too  little  of  the  shaft  and  having  little  or  no 
regeneration  of  bone  follow. 

Sequestra — The  dead  piece  of  bone,  whether 
large  or  small,  is  called  a  sequestrum  ;  when 
upon  the  exterior  it  is  superficial  (Fig.  59) ;  in  the 
interior  it  is  central;  when  of  limited  thickness, 
but  involving  the  entire  circumference,  as  after 
amputation,  it  is  tuhidar-  (Fig.  60)  or  ring-shaped 
according  as  it  extends  for  a  considerable  distance 
up  the  bone  or  is  confined  to  the  sawn  end ;  when 
it  embraces  the  whole  shaft,  with  or  without  the 
epiphysis,  it  is  complete.  For  a  long  time  the  frag- 
ments in  a  compound  fracture  have  been  spoken  of 
as  sequestra — primary  when  completely  separated  at 
the  time  of  the  injury,  secondary  when  for  a  time 
held  by  periosteal  or  muscular  attachments,  and 
tertiary  when  later  destroyed  by  inflammation  ;  but 
the  term  should  be  restricted  to  the  latter,  since  the 
others  are  not  at  first  dead  nor  in  a  large  proportion 
of  cases  will  they  die  if  suppuration  be  prevented. 

AVhen  not  exposed  to  the  air,  sequestra  are 
almost  always  of  a  dull-white  color ;  when  so  exposed,  they  are  generally  black. 
When  struck  by  a  probe,  the  note  is  clear  and  high-pitched,  altogether  different 
from  that  given  out  by  healthy  or  by  carious  bone.  The  orifice  of  a  sinus 
communicating  with  the  sequestrum  is  more  or  less  open,  the  granulations  are 
pouting,  and  the  bony  rim  is  firm  to  the  touch. 

When  the  periosteum  with  its  deeper  layer  is  not  destroyed,  and  especially 
when  the  external  layers  of  the  bone  are  living,  if  sufficient  time  is  afforded  for 
the  production  of  new  bone  an  osseous  envelope  is  formed,  called  the  invo- 
lucrum.  This  more  or  less  completely  shuts  in  the  sequestrum.  Avhose  outer 
surface  is  either  smooth  if  the  new  formation  is  of  periosteal  origin,  or  rough 
and  worm-eaten  if  the  separation  has  been  produced  by  a  rarefying  osteitis. 

Where  there  has  been  ulceration  through  the  periosteum  and  bone-layers 
outside  the  sequestrum,  no  such  re-formation  occurs  at  these  points,  and  the 
involucrum  is  pierced  by  openings  of  a  size  corresponding  to  the  parts 
destroyed  ;  these  openings  are  called  cloacae.  Plate  X  shows  on  the  exterior 
the  involucrum  pierced  by  numerous  cloacae  and  on  the  interior  the  sequestrum 
of  the  entire  shaft  of  the  femur,  the  result  of  an  acute  osteo-myelitis. 

When  the  necrosed  piece  is  central,  the  living  bone  about  it  often  becomes 
so  sclerosed  that  it  can   be  cut  through  only  with   difficulty.     Occasionally, 


[♦i  ^V' 


Superficial 

Sequestrum 

(original). 


Tubular 

Sequestrum 

(original) 


270  AN   AMF.incAX    TEXT-IIOOK    OF   sruCKUY. 

though  rarrly.  tliis   coinh-iised  l)one  is  not   perforated  ))y  even  a  single   .sinus 
and  the  se([iiestriini  is  eoniph'tely  enclosed.  (PI.  XI.  Fig.  1.) 

The  separation  of  the  dead  hone  from  the  living  is  a  comparatively  slow 
process,  occupying  two,  three,  or  more  months,  hut  it  should  nearly  always  he 
waited  for  when  removal  by  operation  is  to  be  effected,  so  that  only  the 
dead  bone  may  be  taken  away  and  time  be  afforded  for  the  formation  of  a  firm 
involucrum :  the  only  exception  to  this  rule  is  found  in  those  more  severe  cases 
of  acute  osteo-myelitis  in  whicli  an  early  removal  is  demanded  in  order  that 
fatal  exhaustion  from  profuse  suppuration  may  he  ])revented.  That  such 
separation  has  taken  place  may  generally  be  recognized  by  the  mobility  of  the 
sequestrum  when  pressed  upon  through  one  or  more  of  the  cloacae,  though 
occasionally  movement  is  prevented  by  the  firm  hold  of  the  granulations  upon 
the  dead  ])iece.  Detachment  from  the  living  bone  must  then  be  inferred  from 
the  length  of  time  that  has  elapsed.  Though  a  non-infected  sequestrum  may 
in  very  rare  instances  be  absorbed  or  remain  shut  in  and  innocuous  for  a  long 
time,  dead  bone,  as  commonly  met  with,  is  an  irritating  foreign  body,  which 
must  be  got  rid  of  either  by  spontaneous  extrusion,  by  chemical  solvents,  or 
by  operative  removal  before  a  healthy  condition  of  the  affected  region  can  be 
secured.  Small  sequestra,  especially  superficial  ones,  may  make  their  way  to 
the  surface  and  be  thrown  oft",  but  the  process  is  a  very  slow  one. 

Treatment  by  the  application  of  a  dissolving  fluid,  such  as  dilute  nitric  or 
hydrochloric  acid,  is  uncertain,  tedious,  and  to  be  advised  only  in  those  rare 
cases  in  which  the  sequestrum  is  so  placed  that  it  cannot  readily  and  safely  be 
got  at  ])y  operation.  In  the  great  majority  of  cases  the  removal  of  the  seques- 
trum will  be  by  operation — sequestrotomy. 

Sequestrotomy. — When  practicable,  the  parts  should  be  rendered  blood- 
less by  the  Esmarch  bandage,  or,  better,  when  tlie  disease  involves  an  extremity, 
by  elevation  for  four  or  five  minutes,  followed  by  the  a))])lication  of  the  rub- 
ber band.  If  there  is  a  cloaca  large  enough  to  permit  of  the  introduction  of  a 
forceps,  the  dead  bone  is  seized  through  it,  and  if  of  small  size  is  dragged 
away.  When  necessary  the  opening  should  be  enlarged  and  the  sequestrum 
divided  before  removal.  When  the  necrosed  piece  is  a  large  one  it  will 
generally  be  necessary  to  cut  away  with  chisel  or  gouge  a  portion  of  the 
involucrum,  it  may  be  for  nearly  the  entire  length  of  the  bone.  The  dead 
bone  having  been  lifted  out,  the  granulations  in  which  it  has  rested  are  to  be 
thoroughly  scraped  away,  the  parts  Avell  irrigated,  the  cavity  stuffed  with  iodo- 
form or  other  antiseptic  gauze,  an  antiseptic  dressing  applied,  and  the  limb 
immobilized.  When  the  involucrum  is  quite  thin  or  im|)erfectly  developed,  it 
may  be  broken  in  the  removal  of  the  sequestrum,  but  repair,  as  a  rule,  readily 
and  rapidly  takes  place  after  immobilization.  Usually  the  progress  of  the 
case  is  very  satisfactory :  the  cavity  more  or  less  completely  fills  up  by  the 
formation  of  new  bone,  and  after  a  few  weeks  the  patient  can  begin  to  use  the 
part  if,  as  is  generally  the  case,  the  operation  has  been  done  on  one  of  the 
extremities.  Only  rarely,  and  when  there  has  been  great  general  weakness  or 
when  the  wound  becomes  infected,  is  the  result  a  fatal  one.  If  the  gap  in  the 
bone  is  long  and  deep,  much  of  the  involucrum  having  been  cut  away,  an 
effort  should  l)e  made  to  fill  it  up,  either  by  an  organizable  blood-clot,  by  bone- 
<:hips,  by  breaking  down  and  bending  in  the  edges  of  the  involucrum,  or  by 
skin-flaps  turned  in  and  attached  at  the  bottom  ;  preferably  the  first  or  second. 
The  decalcified  bone-chips,  originally  employed  by  Senn,  generally  serve  the 
purpose  of  a  framework  or  scaffolding  on  which  new  bone  is  built  up,  the 
chips  themselves  undergoing  absorption.  In  Liicke's  "  Osteoplastic  Necrot- 
omy," in  the  shafts  of  the  long  bones  a  longitudinal  incision  is  made  through 


INFLAMMATION  OF  BONE. 


Plate  X. 


.  ■  1 

i 

i 

I^^L 

'^^■«  -« 

' 

j 
.     -    'i 

Sequestrum  of  entire  shaft  of  femur,  involucrum  riddled  with  cloacae ;  the  result  of  acute 

osteo-myelitis. 


iSURGKHV    or    THE    OSSEOUS  SYSTEM.  271 

the  skill  and  periosteum,  as  nearly  as  possible  in  the  line  of  the  cloacae,  and 
a  section  of  involiicrmn  chiseled  out  corresj)on(lin<;  with  this  incision.  At 
either  end  where  the  sequestrum-cavity  terminates  tiie  soft  parts  are  divided 
transversely  and  the  bone  correspondingly  chiseled  through.  With  a  small 
chisel  the  base  of  the  skin-periosteum-bone-flap,  thus  obtained,  is  divided 
from  within  the  se((uestrum-cavity  so  that  the  entire  Haji  may  be  turned  back 
out  of  the  Avay.  Such  a  lla|)  may  be  made  on  one  or  both  sides  of  the  cavity. 
After  cleaning  out  the  bone  the  flaps  are  bent  inward  so  as  to  fill  the  cavity 
as  far  as  possible.  In  order  that  success  may  follow  the  adoption  of  any  of 
these  methods  the  wound  must  be  made  aseptic  and  kept  so. 

THE   CHRONIC   INFLAMMATIONS  OF   BONE. 

The  chronic  inflammations  of  bone  are  generally  such  from  the  begin- 
ning. They  are  of  much  more  frefjuent  occurrence  than  the  acute,  and,  like 
them,  are  of  pyogenic,  syphilitic,  malignant,  or  tubercular  origin.  They  are 
very  rarely  traumatic  and  unassociated  with  pyogenic  infection,  though,  as  is 
seen  in  the  vertebnie  pressed  upon  by  an  aneurysm,  ulceration  from  prolonged, 
frequently-repeated  injuries  may  take  place. 

The  prevailing  tyjie  is  the  rarefying.  Molecular  death  occurs  to  some 
degree  in  all  cases ;  death  in  mass  results  chiefly  in  those  due  to  syphilitic  or  pyo- 
genic infection ;  often  extensive  new  formation,  both  in  length  and  thickness, 
takes  place  in  the  syphilitic,  and,  to  a  certain  extent,  in  the  pyogenic. 

The  diseases  induced  by  the  different  causes  are  located  by  preference  in 
diff'erent  parts  of  the  skeleton :  thus,  syphilis  infects  chiefly  the  long  bones  and 
those  of  the  head  and  fixce ;  sarcoma  and  carcinoma,  the  long  bones,  the  pelvis, 
and  the  jaws;  pus  infection,  the  long  bones;  tuberculosis,  the  bones  of  the 
hands  and  feet  and  the  spongy  tissue  in  close  relation  w^itli  the  hip-,  knee-,  and 
elbow-joints. 

Children  and  adolescents  are  the  ordinary  subjects  of  osteo-myelitis,  tuber- 
culosis, and  inherited  syphilis  ;  young  adults,  of  sarcoma,  acquired  syphilis,  and 
the  relapses  of  the  inflammjftions  of  youth  ;  persons  of  middle  and  advanced 
life,  of  syphilis  and  cancer. 

Symptoms. — Pain  is  the  most  common  symptom,  its  intensity,  however, 
being  very  variable  even  in  cases  having  a  like  origin.  As  a  rule,  it  is  worse 
at  night,  the  increased  fulness  of  the  veins  and  capillaries  due  to  the  more 
sluggish  circulation  making  greater  the  tension-pressure  upon  the  nerve-fibers. 
It  is  aching,  gnawing,  boring,  or,  in  tubercular  cases  in  which  there  is  inflam- 
mation of  the  subarticular  layer  of  osseous  tissue,  starting. 

With  or  without  the  development  of  an  abscess  a  sinus  may  form,  through 
which  more  or  less  discharge  may  take  place,  the  discharge  being  often  gritty 
or  having  in  it  small  yet  readily  detected  spicules  of  bone,  show'ing,  as  does  the 
bone  itself,  that  the  aff"ection  is  truly  a  caries  or  decay  of  the  osseous  tissue. 

When  the  inflammation  is  located  upon  the  surface,  examination  by  the 
eye,  the  finger,  or  the  probe,  or  of  the  cleaned  and  dried  specimen,  shows  that 
the  process  is  an  ulcerative  one,  producing  an  ulcer  with  all  the  characteristics 
of  an  ulcer  of  the  soft  parts ;  and  the  same  is  true,  certainly  as  respects  the 
process,  when  it  is  centrally  developed.  The  granulations  may  be  numerous 
and  moist,  as  is  commonly  the  case,  or  large  and  abundant  with  little  fluid 
(fungous  caries),  or  very  feebly  developed  with  no  discoverable  fluid  (dry 
caries),  as  in  a  few  cases  of  syphilitic  or  tubercular  origin. 

This  caries  sicca  is  frequently  observed  upon  the  skull  and  in  the 
upper  ends  of  the  humerus  (Fig.  61)  and  femur.     The  bone-destruction  is 


272 


AN  A}fi':iii<'.\x  Ti:xr-ii<)<)K  of  srnarjiv. 


Fig.  61. 


Caries 


iltuiK  in 


Absorption  aiifl  Deform- 
ity of  the  Head  of  the 
Humerus  (Duplay  and 
Reclus). 


often  extensive,  ami  in  the  loiij;  Ixjiics  is  due  in  :i  measure  to  tlie  wearing 
effect  of"  the  pressure  of  contiguous  parts.  Not  sehlom  its  existence  is  indi- 
cated only  by  impairment  of  function  and  by  severe 
pain,  very  persistent,  and  irremediable  except  by  re- 
moval of  the  diseased  part. 

This  form  of  osteitis,  if  left  to  itself,  (1)  may  termi- 
nate in  arrest  of  formation  of  the  granulations,  absorp- 
tion or  elimination  of  the  dead  tissue,  and  sclerosis  of 
the  new  layers  and  of  the  ])arts  aro  md.  with  or  without 
l^^-^^^^^S^B^k  overgrowth  of  the  affected  bone,  which  when  it  occurs 
(? ■'  «tf:" ' '.^S^^mM  causes  permanent  alteration  even  to  the  extent,  it  may 
be,  of  marked  deformity ;  or  (2)  ma}  continue  for  a  long 
time  without  material  local  change  or  the  development 
of  visceral  lesions  ;  or  (3)  may  often  lowly  but  steadily 
advance,  destroying  more  and  more  widely  the  bone, 
involving  otlier  portions  of  the  skeletoi  causing  marked 
general  debility,  and  inducing  grave  lisease  of  inter- 
nal organs,  especially  the  lungs,  the  kidney,  and  the 
intestine. 

The  treatment,  in  general,  is  made  up  of  measures 
calculated  to  relieve  irritation  and  to  hasten  the  elimi- 
nation of  dead  tissue — measures  therapeutic  and  opera- 
tive, considered  in  detail  under  the  separate  heads  of  the  various  classes  of 
bone-inflammations,  septic,  specific,  malignant,  and  tubercular. 

Tubercular  Inflammation  of  Bone. — The  most  frequent  and  most 
typical  of  these  inflammations  is  the  tnhereular,  and  is  often  secondary  to  some 
distant  primary  focus  of  the  disease.  Infected  granulation-tissue  forms  more 
or  less  rapidly,  vshowing,  as  a  rule,  comparatively  few  bacilli,  and  these  chiefly 
in  the  new  growths  farthest  from  the  point  or  points  of  original  deposition ;  such 
tissue,  by  its  pressure  and  after-caseation  with  its  associated  fluid,  produces  wast- 
ing of  the  osseous  trabeculge. 

Caseation  and  liquefaction  so  affect  the  cells  of  the  growth  that,  together 
with  the  altered  layers  of  bone,  they  may  be  scraped  away  as  grayish-yellow 
masses  saturated  with  fluid.  At  times  little  or  no  fluid  is  to  be  seen,  though  the 
bone  has  become  so  soft  as  to  be  easily  cut  with  a  knife.  Cavities,  larger  or 
smaller,  few  or  many,  filled  with  fluid  degenerated  cells  and  bone  detritus,  are 
of  frequent  formation  (PI.  XI,  Fig.  2).  In  the  long  bones  infiltration  of  the 
medulla  of  the  central  canal  may  occur  throughout  its  length  or  be  limited  to  a 
few  distinct  areas.  Usually,  hoAvever,  the  new  growth  is  in  the  cancellous  spaces 
of  the  extremities  and  in  the  Haversian  canals,  pushing  toward  the  exterior  of 
the  bone.  After  the  bone  itself  is  involved,  there  is  subperiosteal  new  forma- 
tion, which,  if  caseation  has  not  occurred,  may  remain  for  a  considerable  time 
as  a  semi-solid  mass,  the  adjacent  bone  and  periosteum  undergoing  thickening 
and  hardening.  Sooner  or  later,  and  quite  rapidly  as  a  rule  when  caseation 
has  taken  place,  the  periosteum  is  infected  and  destroyed,  the  adjacent  soft 
parts  become  tubercular,  and  by  one  or  several  tortuous  channels  following  the 
lines  of  least  resistance  the  disease  reaches  the  skin,  the  piercing  of  which  com- 
pletes the  formation  of  the  sinus  or  sinuses.  The  walls  of  such  sinus,  from  its 
mode  of  formation,  are  necessarily  tubercular,  and  its  outlet  is  filled  with  granu- 
lations more  or  less  exuberant,  more  or  less  dark-colored,  readily  bleeding  when 
torn,  and  at  times  quite  sensitive.  A  probe  being  introduced,  often  with  much 
difficulty  because  of  the  flexures  of  the  canal,  softened,  easily-penetrated  bone 
may  be  felt,  but  its  presence  may  escape  detection  because  of  the  heavy  granula- 


INFLAMMATION   OF   BONE. 


Plate  XI. 


F 


SURGERY    OF    THE    OSSEOUS  SYSTEM.  273 

tioii-Iayer  covering  it.  The  dificrencc  in  the  ai)j)ejir:ince  of  the  external  granu- 
lations, in  the  resistance  to  the  probe  offered  by  the  bony  walls,  and  in  the 
percussion  note  elicited  by  the  probe  (which  is  here  flat),  enables  one  readily  to 
distinguish  caries  from  necrosis. 

When  a  circumscribed  area  of  bone  has  broken  down  and  litjuefaction  of 
the  caseated  granulation-tissue  in  it  has  taken  place,  such  a  collection  of  fluid 
has  long  been  spoken  of  as  an  abscess ;  and  the  same  is  true  of  the  similar 
collections  between  the  periosteum  and  bone  and  in  the  overlying  soft  parts. 
But,  though  accumulations  of  a  fluid  in  appearance  much  like  pus,  they  are  not, 
properly  speaking,  abscesses,  since  true  pus  is  not  present  (unless  it  be  a  fact 
that  at  times  the  bacillus  is  a  pyogenic  organism)  except  when  a  double  or 
mixed  infection  has  taken  place.  This  is  not  often  the  case  until  a  communica- 
tion with  the  external  air  has  been  established  by  the  spontaneous  or  operative 
opening  of  the  sinus.  When  such  an  opening  has  been  made,  the  previously 
pent-up  liquid,  with  its  associated  characteristic  cheesy,  curdy  material,  escapes, 
and  the  continuous  development  of  similar  fluid,  now  probably  become  puru- 
lent, keeps  up  the  discharge.  This  varies  in  amount  from  a  few  drops  to 
many  ounces  a  day,  and  lasts  indefinitely,  with  occasional  temporary  stoppages 
from  blocking  up  of  the  canal  at  one  point  or  another.  Its  complete  arrest 
can  be  secured  only  by  destruction  of  the  infected  area.  This  prolonged  sup- 
puration, by  the  exhaustion  and  amyloid  visceral  changes  which  it  induces, 
often  has  much  to  do  with  the  production  of  a  fatal  termination. 

In  consequence  of  plugging  of  the  vessels  necrosis  may  take  place,  the  pro- 
duced sequestrum. being  often  of  considerable  size.  If  centrally  located  in  the 
cancellous  tissue,  it  is  surrounded  by  the  infected  granulations,  and  remains  until 
removed  by  art  or  until,  after  a  long  time,  it  has  broken  down,  Avhen  it  may 
be  discharged  piecemeal.  Often  in  the  extremity  of  a  long  bone,  because  of 
the  arrangen»ent  of  the  vessels  which  have  been  plugged  by  a  tubercular  embo- 
lus or  by  a  thrombus  resulting  from  the  mural  implantation  of  tubercle  bacilli, 
it  is  conical  in  shape,  its  base  directed  toward  the  articulation ;  and  to  its 
presence  may  be  due  rapid  involvement  of  the  articulation  in  the  morbid  action. 

In  its  earlier  stages  the  progress  of  tubercular  osteitis  is  ordinarily  insidi- 
ous, often  the  only  symptoms  of  its  existence  being  impaired  function  of  the 
part,  rigidity  of  the  muscles  about  the  neighboring  joint,  and  pain  in  the 
affected  area.  Muscular  rigidity,  which  is  a  reflex  condition  and  protective 
in  its  action  (or  intended  to  be  such),  is  of  great  diagnostic  value.  It  is  often 
the  only  symptom  present,  and  when  observed  is  deserving  of  careful  con- 
sideration, for  if  no  other  cause  for  its  existence  is  apparent,  it  may  be  safely 
assumed  that  there  is  something  abnormal  in  the  neighboring  joint.  The 
pain  may  be  spontaneous  or  exist  only  as  tenderness  on  pressure  over  the 
diseased  spot,  but  it  can  always  be  developed  by  such  pressure.  By  the  ther- 
mometer slight  increase  in  the  heat  of  the  region  may  at  times,  or  possibly 
always,  be  detected ;  but  a  long-recognized  peculiarity  of  this  form  of  inflam- 
mation is  the  absence  of  any  decided  elevation  of  temperature. 

The  appearance  of  the  overlying  skin  is  generally  unchanged,  even  after 
infection  of  the  superficial  soft  parts ;  though,  because  of  interference  with  the 
circulation  by  pressure,  there  may  be  some  general  discoloration  or  certain  of 
the  veins  may  become  unduly  prominent. 

Even  up  to  the  time  of  the  establishment  of  a  communication  with  the  exte- 
rior the  symptoms  are  far  from  severe,  pain,  swelling,  and  impairment  of  func- 
tion being  present,  but  no  decided  constitutional  symptoms,  and  the  patient 
may  go  about  as  if  in  health.     But  when  septic  infection  has  taken  place  all 

the  local  symptoms  are  aggravated  and  the  constitutional  ones  become  decided., 
18    " 


274  AN   A}fi:i^'I<A.\    TEXT- HOOK    OF   SVROERY. 

The  only  disease  with  wliicli  tlie  affection  is  tli<ii  liktly  to  Ije  confounded  is 
protracted  osteo-myelitis  of  pyogenic  orijrin  ;  and  this,  thou;,'h  more  common 
than  is  often  su])posed,  is  far  less  fn.Mjucutly  met  with  than  tubercular  osteitis, 
and  seldom  if  ever  attacks  the  parts  of  the  skelctun  which  ai-e  so  often  the 
seat  of  the  latter  disease — the  vertebrie,  the  tarsus  and  carpus,  the  upper  end  of 
the  femur,  and  the  bones  of  the  elbow.  It  is  largely  to  the  prevention  of  sec- 
ondary pyogenic  disturbances  that  the  present  favorable  course  and  prognosis, 
as  compared  with  tliose  of  but  a  few  years  ago,  are  to  be  attributed.  Under  any 
treatment,  and  especially  under  inefficient  or  no  treatment,  the  course  of  the 
affection  is  ordinarily  slow,  occupying  many  weeks,  it  may  be  months.  At  any 
stage  it  may  be  arrested  sj)()ntaneously  (1)  by  removal  of  the  diseased  tissue, 
which  is  followed  by  condensation  of  the  surrounding  bone  with  or  without 
cicatricial  obliteration  of  the  cavity ;  or  (2)  by  encapsulation  of  the  infected 
tissue,  which  permanently  or  temporarily  protects  the  part.  Very  often  it  is 
temporary,  since  recurrence  fre(iuently  takes  place. 

The  treatment  is  mechanical,  therapeutic,  or  operative — more  frequ<'ntly 
the  first  and  second,  but  often  all  three  methods,  are  employed  either  simultane- 
ously or  successively. 

Mechanical  treatment  may  be  held  to  include  all  measures  adapted  to  ensure 
rest  of  the  diseased  part,  whether  by  position,  immobilization,  or  the  applica- 
tion of  fixation  apparatus  of  one  sort  or  another.  Rest  is  of  prime  importance 
at  any  stage  of  the  affection,  and  is  especially  valual)le  in  the  earliest,  when  it 
may  be  sufficient  to  bring  about  arrest  of  morbid  action  and  more  or  less 
complete  restoration  to  health.  Simple  confinement  to  bed  .may  be  all  that  is 
needed,  or  an  immobilizing  dressing — e.  g.  the  plaster-of-Paris  or  a  properly 
constructed  and  applied  splint — may  be  required.  Under  such  treatment, 
even  when  there  has  been  much  destruction  of  bone  and  "cold  abscess"  has 
formed,  the  symptoms  may  subside.  This  will  be  because  of  absorption  and 
contraction,  it  may  be  calcification,  of  the  tubercular  masses,  condensation 
taking  place  in  and  around  the  carious  area,  and  functional  action  being 
resumed;  though,  as  a  rule,  there  will  be  more  or  less  impairment,  more  or 
less  deformity,  and  an  ever-existing  danger  of  a  recurrence  of  the  disease. 

The  therapeutic  treatment  is  geneial  and  local.  The  former  consists  in  the 
administration  of  remedies  serving  to  improve  nutrition  and  increase  the  general 
strength  ;  and  of  these  cod-liver  oil  has  lon<»;  been  regarded  as  the  most  valu- 
able.  The  local  treatment  consists  in  the  injection  into  and  around  the  dis- 
eased center  of  agents  calculated  to  destroy  the  infecting  germs  and  produce 
condensation  of  the  surrounding  bone  and  of  the  uninfected  new-formation 
layers,  thus  bringino;  about  cicatrization.  The  remedies  of  this  class  that  have 
proved  of  decided  value  are  the  acid  phosphate  of  lime,  the  chloride  of  zinc, 
and  iodoform  ;  the  latter  of  which  in  ethereal  solution,  or,  better,  suspended 
in  glycerin  (10  per  cent.)  or  in  oil  (5  to  25  per  cent.),  has  been  found  of  great 
value  as  a  substitute  for  the  operative  removal  of  the  morbid  tissue,  or  em- 
ployed after  it.  These  solutions  are  carried  down  by  means  of  a  syringe  to 
and  into  the  diseased  area,  and  injected  in  small  quantity,  the  injections  being 
repeated   every  three,   seven,  or  ten  days  according  to   circumstances. 

Operative  treatment  consists  in  the  removal  of  the  diseased  area  by  scrap- 
ing or  excision.  Amputation  is  rarely  demanded,  at  least  in  properly  treated 
cases.  Scraping,  to  be  effective,  must  be  thorough,  and  special  care  must  be 
taken  to  clean  away  the  walls  of  sinuses,  to  remove  infected  deposits  in  the 
medullary  canal  of  a  long  bone,  and  in  the  foot  and  hand  to  leave  no  part  of 
a  softened  bone  (unless  it  be  perhaps  the  shell  of  the  os  calcis,  and  this,  as  a 
rule,  should  be  taken  away).     No  associated  tubercular  growth  in  the  tendon 


,si'ii(ij:in'  OF  'nil-:  osseous  system.  275 

sheaths,  the  synovial  pouches,  or  the  superficial  fascia  or  skin  should  in  any 
case  be  allowed  to  remain. 

Ignipunc-ture  by  means  of  the  thermo-cautery  has  been  practised  by  a  few 
surgeons  \\\x\\  good  efiect. 

Cases  of  visceral  tuberculosis  are  generally  much  benefited,  and  not  seldom 
cured,  by  change  of  climate  and  altitude,  and  strumous  children  often  rapidly 
imj)rove  at  the  seaside.  Much  good  would  unquestionably  be  effected,  in  the 
earliest  stages  especially,  by  sending  patients  with  chronic  bone  disease  to  the 
coast,  the  highlands,  or  the  ))ine  woods. 

Chronic  pyogenic  osteitis  is  almost  always  the  sequel  of  an  acute  osteo- 
myelitis that  occnn-ed,  it  may  be,  many  years  before,  and  is  the  cause  of  two 
very  different  conditions — abscess  and  overgrowth.  It  is  usually  circumscribed, 
and  may  be  located  in  the  medullary  canal,  or,  much  more  often,  in  the  can- 
cellous extremity  of  a  long  bone,  especially  in  the  head  of  the  tibia  or  the  lower 
end  of  the  femur.  It  pro))ably  is  due  ordinarily  to  the  newly-aroused  activity 
of  long-latent  pyogenic  organisms  leftover  from  an  osteo-myelitis  of  childhood; 
but  at  times  it  may  be  consequent  upon  a  new  infection  attacking  parts  less 
resistant  than  others  because  of  their  having  previously  been  the  seat  of  a 
septic  inflammation. 

Rarefaction  of  the  bone  takes  place  in  a  limited  area ;  condensation  goes 
on  around  it,  though  rarely  to  the  extent  of  producing  necrosis,  except,  it 
may  be,  of  very  limited  amount ;  pus  may  be  almost  altogether  absent  or  may 
be  present  in  considerable  quantity  and  form  a  chi'onic  abscess  in  the  interior 
of  the  hone  (PI.  XII,  Fig.  1).  This  is  especially  frequent  in  the  cancellated 
tissue  in  the  lower  end  of  the  femur  or  in  either  end  of  the  tibia.  The  most 
characteristic  symptom  is  pain,  severe,  often  intense,  gnawing  or  boring, 
decidedly  worse  at  night,  limited  to  a  small  space,  pressure  over  which  is  usually 
painful,  sometimes  because  of  associated  periostitis,  at  times  disappearing  for 
weeks  or  months  to  reappear  again,  often  Avithout  any  apparent  cause.  The 
bone  is  frequently  decidedly  enlarged  as  the  result  of  its  early  inflammation  or 
of  the  hypertrophying  effect  of  the  long-continued  secondary  osteitis. 

No  treatment  is  of  value  except  drilling  or  trephining,  by  which  exit  is 
afforded  the  pent-up  pus,  thus  taking  off  the  tension.  Careful  exploration  with 
a  long  pin  or  fine  drill,  carried  in  various  directions  through  different  openings 
or  from  the  sides  of  the  trephine-well,  should  be  made  before  deciding  that  pus 
is  not  present.  Even  if  no  pus  can  be  found,  relief  is  afforded  and  the  so- 
called  neuralgic  condition  is  removed.  Not  seldom  the  pierced  bone  is  abnor- 
mally dense.  When  pus  is  found  it  is  wise  not  to  be  content  with  simple 
evacuation  of  the  matter,  but  to  scrape  away  the  softened  bone,  letting  the 
resulting  cavity  fill  up  or  contract  as  it  may,  or,  better,  endeavoring  to  secure 
its  rapid  and  complete  closure  by  means  of  a  blood-clot  or  bone-chips,  for  the 
success  of  which  attempt  complete  asepsis  is  required. 

The  overgrowth  from  irritation  resulting  from  this  form  of  osteitis  may 
affect  a  part  or  the  whole  of  a  bone.  At  times  it  is  very  great,  producing 
marked  deformity.  Although  a  chronic  process,  it  is  very  generally  the  result 
of  the  early  osteo-myelitis,  and  the  process  never  having  been  altogether 
arrested,  it  can  hardly  be  considered  a  part  of  the  phenomena  of  chronic  pyo- 
genic osteitis  unless  there  is  joined  with  it  the  limited  suppuration  already  con- 
sidered. Overgrowth  in  length  consequent  upon  the  irritative  action  of  a 
tubercular  osteitis  is  at  times  observed,  and  has  occurred  after  excision,  par- 
ticularly of  the  lower  articulating  extremity  of  the  femur,  the  region  of  the 
epiphyseal  line  not  having  been  removed. 

Much  more  often  after  both  tubercular  and  septic  inflammations,  whether 


27G 


AN  AMERICAN    TKXT-liOOK    OF  SURGERY 


an  operation  has  been  done  or  not,  there  is  arrest  of  development.  :iiid  as  a 
result  shortening,  which  in  children  is  apt  to  be  progressive  up  to  the  time  of 
full  maturity. 

Atrophi/,  evidenced  by  lessened  solidity,  thickness,  or  lenjith,  or  by  all  of 
these  conditions,  is  the  necessary  result  of  long-continued  defective  nutrition 
due  to  feebleness  of  the  general  circulation  or  to  disturbed  innervation  of  the 
part.  It  is  a  common  phenomenon  of  chronic  osteitis.  It  may  be  temporary, 
as  after  fracture,  or  permanent,  as  in  infantile  paralysis  and  in  old  age.  It 
causes  more  or  less  impairment  of  the  functional  value  of  the  bone  and  strongly 
predisposes  to  fracture.  No  special  treatment  is  of  value,  unless  it  be  the 
production  of  hyperemia,  as  by  frequent  applications  for  a  limited  time  of  the 
Esmarch  bandajxc  or  bv  drillino;  the  bone. 


EHACHITIS.     (See  Chapter  xv.,  p.  85.) 
OSTEO-MALACIA    (mOLLITIES    OSSIUM,  MALACOSTEON). 

This  is  a  disease  of  adult  life,  and  is  very  rarely  met  with  in  children  or  old 
persons.  In  the  great  majority  of  cases  it  affects  Avomen,  chiefly  those  who  are 
pregnant  or  Avho  have  borne  children.  It  is  characterized  by  progressive  soft- 
ening of  the  various  parts  of  the  skeleton,  with  resulting  deformities  (Fig.  62), 
usually  goes  on  from  bad  to  worse,  and  after  it  may  be  a  number  of  years  causes 
death,  chiefly  from  exhaustion  or  disease  of  the  lungs.     It  has  been  attributed 

to  the  action  of  many  causes,  such 
^^"  ^"'  as  defective  nutrition,  excess  of 

lactic  acid,  disease  of  the  trophic 
nerves,  ovarian  and  uterine 
changes,  etc.,  but  the  real  excit- 
ing cause  is  uncertain. 

The  bone  lesions  are  great 
increase  of  vascularity  with  re- 
sulting hemorrhages,  degenera- 
tion of  the  medulla  and  its  ulti- 
mate conversion  into  a  pulp  re- 
sembling splenic  tissue,  absorp- 
tion of  the  lime  salts,  destruction 
of  the  trabeculre,  formation  of 
cavities  or  more  rarely  tumor-like 
enlargements,  and  absorption  of 
the  cortical  layers.  The  perios- 
teum is  ordinarily  thicker  and  more  vascular  than  normal,  and  serves  as  a  pro- 
tective envelope  to  the  broken-down  bone.  Fracture  from  muscular  action  or 
from  slight  movement  is  of  frequent  occurrence,  and  deformity  to  a  greater  or 
lesser  extent  is  sure  to  be  produced  in  other  than  the  mildest  cases,  the  distor- 
tion at  times  becoming  excessive  and  most  peculiar. 

Until  such  deformity  has  occurred,  or  until  at  least  the  softening  has 
advanced  so  far  as  to  permit  of  bending  of  the  bone,  the  diagnosis  is  difficult 
and  uncertain,  since  the  progress  of  the  disease  is  for  a  considerable  time  an 
insidious  one.  The  early-developed  and  persistent  pain  ordinarily  causes  the 
affection  to  be  regarded  as  rheumatic;  but  the  multiplicity  of  the  painful  areas, 
the  sex  of  the  patient,  the  existence  of  pregnancy,  and  the  presence  of  large 
quantities  of  the  lime  salts  in  the  urine,  should  direct  attention  to  the  probable 
existence  of  osteo-malacia. 


Deformed  I'elvis  fn.m  » tbtLu-malacia  (Oilier) 


INFLAMMATION    OF  BONE.  Plate  XII. 


1.  Abscess  in  the  great  trochanter.       2.  Impacted  fracture  of  neck  of  femur. 


SURGERY   or    THE    OSSEOUS  SYSTEM.  277 

Thoufih  commonly  for  a  time  not  exerting  any  unfavorable  influence  upon 
life,  and  occasionally  ceasing  to  advance,  even  being  recovered  from,  though 
very  rarely,  its  prognosis  is  grave,  the  disease  usually  ending  fatally.  Medi- 
cal treatment  by  the  use  of  phosphorus  and  the  phosphates,  the  lime  salts,  cod- 
liver  oil,  etc.  has  proved  of  little  or  no  value.  The  best  possible  hygienic 
surroundings  should  be  secured  and  the  patient  kept  quiet  and  free  from  pain. 
Proper  retentive  dressing  should  be  api)lied  to  prevent  fracture  and  lessen 
deformity.  Of  late  in  a  few  cases  the  ovaries  and  uterus  have  been  removed 
with  reported  decided  benefit.  When  this  operation  is  not  done,  pregnancy 
should  be  prevented,  as  childbearing  exerts  a  powerful  and  deleterious  influence 
upon  the  progress  of  the  disease. 

FRAGILITAS  OSSIUM. 

Abnormal  brittleness  due  to  rarefaction  and  predisposing  to  the  occurrence 
of  fracture  upon  the  infliction  of  slight  violence  is  sometimes  observed  in  cases 
of  syphilis,  of  malignant  tumors,  and  of  trophic  disturbances  after  injuries  of 
bones  and  joints  necessitating  long  confinement.  It  is  also  seen  in  the  earlier 
stages  of  rickets,  in  general  paralysis,  and  in  tabes.  But,  besides  this  condition, 
which  is  a  sequel  of  disease,  there  is  at  times  seen  a  pure  and  simple  fragility, 
accompanied,  so  far  as  can  be  discovered,  by  no  pathological  changes,  general 
or  local.  This  fragilitas  ossium  is,  as  a  rule,  an  inherited  peculiarity  manifest- 
ing itself  in  infants  (even  in  the  fetus  in  utero),  in  children,  and  in  adolescents, 
and  ceasing  to  exist  when  full  maturity  is  reached.  Fracture  after  fracture  in 
one  or  in  several  bones  or  in  many  parts  of  the  skeleton  occurs,  presenting 
the  usual  symptoms  and  followed  by  rapid  recovery.  As  the  cause  is  un- 
known, nothing  can  be  done  further  than  to  protect  the  individual  from  injury 
as  much  as  possible,  and  to  treat  the  fractures  in  the  usual  way. 

SYPHILIS  OF  BONE.    (See  Syphilis.) 

TUMORS   OF   BONE. 

Bone  tumors,  like  tumors  of  other  parts,  are  benign  or  malignant ;  the 
former  being  commonly  exostoses,  fibromata,  or  chondromata,  the  latter  sar- 
comata or  carcinomata. 

Exostoses  are  homologous  outgrowths  differing  from  hypertrophies  in 
that  but  a  limited  part  of  the  circumference  of  the  bones  is  involved.  They 
are  either  spontaneous,  and  appear  first  during  the  period  of  development,  or 
are  symptomatic  of  osteitis,  traumatic  or  non-traumatic,  usually  syphilitic. 
They  are  located  chiefly  upon  the  long  bones,  the  skull,  or  the  maxillae,  and 
are  generally  cancellous  in  structure,  but  at  times  compact,  even  of  ivory 
hardness ;  this  is  particularly  true  of  the  syphilitic  exostoses  of  the  skull. 
When  developmental,  originating  in  childhood,  though  the  outgrowths  may 
be  found  upon  any  part  of  the  skeleton,  even  upon  many  and  generally  sym- 
metrical parts  at  the  same  time  (Fig.  63),  they  are  commonly  in  connection 
with  a  long  bone  near  its  epiphyseal  line.  If  primarily  upon  the  diaphyseal 
side  of  the  cartilage  of  conjunction,  they  may  apparently  be  carried  upward 
as  the  shaft  elongates,  so  as  ultimately  to  occupy  a  level  much  above  the 
articular  exti-emity.  They  may  be  either  broad-based  or  pedunculated,  and 
not  seldom  the  free  extremity  is  covered  by  a  bursa  resulting  from  friction  or 
the  separation  of  a  part  of  the  synovial  sac  in  the  outgrowth  of  an  originally 
subsynovial  spur.  Their  growth  ceases,  as  a  rule  having  few  exceptions,  at 
or  before  the  twenty-fifth  vear. 


27S 


I^V  AMERICAN    TEXT- HOOK    OF  sriiCEUY. 


The  diagnosis  is  coniiiiMiily  cusy,  tlie  tumor  ht'iii;^  hard  and  fixed  and 
readily  felt  or  seen.     Pain  is  seldom  present,  and  whatever  local  damage 

results  is  from  pressure  causinf^  atrophy  or 
ulceration  of  the  overlyin;^  soft  parts  (and 
this  is  not  of  coiiiinon  occurrence)  or  from 
position  interfering  with  the  free  use,  espe- 
cially with  flexion,  of  the  limh,  as  in  sitting 
or  riding.  In  a  large  proportion  of  cases 
no  serious  inconvenience  is  experienced. 
When  the  mass  is  upon  the  inner  side  of 
the  skull  (of  di))loic  origin,  as  a  rule),  a 
resulting  compression  of  the  brain  may 
give  rise  to  serious  cerebral  disturbances, 
but  often  no  appreciable  effect  is  produced, 
and  the  existence  of  the  tumor  is  not  dis- 
covered until  after  death. 

The  only  effective  treatment  is  opera- 
tive, removal  of  tlie  growtii,  or  the  break- 
ing of  it  off,  the  former  being  preferable, 
the  latter  practicable  only  when  the  attach- 
ment is  by  a  pedicle.  In  many  cases  no 
treatment  is  required. 

Fibromata. — Springing  from  the  peri- 
osteum or,  much  less  freijuently,  central  in 
origin,  the  fibrous  tumors  of  bone  are  found 
generally  in  connection  with  the  maxillse 
and  the  base  of  the  skull,  though  they  are 
occasionally  located  upon  the  vertebne,  the 
pelvis,  or  the  long  bones.  When  of  long 
standing  they  are  likely  to  undergo  degen- 
eration, fatty,  cystic,  or,  particularly,  cal- 
careous, rarely  becoming  ossified.  Not  sel- 
dom they  are  either  primarily  or  secondarily 
mixed  in  character — fibro-sarcomata,  fibro- 
chondromata.  Their  development  is  slow, 
and  they  often  cease  to  enlarge  about  the 
time  when  the  skeleton  has  reached  full 
maturity,  after  which  they  may  atrophy, 
or  even  completely  disappear. 

If  superficially  placed,  they  can  gen- 
erally be  readily  diagnosticated  by  their 
more  or  less  irreijular  contour,  tiieir  firm- 
ness  but  not  bony  hardness,  their  evident 
close  connection  with  bone,  and  their  grad- 
ual enlargement.  The  most  common  of 
these  growths  are  the  ndso-pharjiuiieal polyp 
and  epulis,  both  of  which  are  often  decidedly 
sarcomatous.  The  former  is  a  disease  of 
adolescence.  It  originates  from  the  under  surface  of  the  sphenoid,  fills  up 
the  naso-pharynx,  pushes  into  the  nasal  fossae  and  the  antrum  on  one  or  both 
sides,  and,  it  may  be,  outwardly  through  the  spheno-palatine  foramen,  causing 
extensive  destruction  of  the  bones  of  the  face  by  pressure.  It  is  dangerous 
because  of  the  attending  hemorrhages,  which,  as  a  rule,  are  profuse  and  fre- 


Exostoses  of  Various  Dimensions  (Pierret). 


SURGERY    OF    Till:    OSSEOUS  SYSTEM.  271) 

(|iu'iitly  recurring.  Tlie  character  of  the  central  tumors,  which  are  often 
cystic,  will  not  be  recoirnizcd  .so  long  as  they  are  surrounded  by  a  bony 
envelope,  and  usually   is  not  determined  until  after  their  removal. 

Treatment. — Extirpation,  preferably  by  enucleation  or,  when  this  is  not 
practicable,  by  excision  of  the  portion  of  the  bone  to  which  the  growth  is 
attached,  is  the  proper  treatment,  though,  as  has  been  stated,  nature  some- 
times affords  relief  through  atrophy. 

The  naso-])haryngeal  polyp,  if  not  rapidly  growing  or  often  bleeding,  may 
be  let  alone  in  the  hope  of  s])ontaneous  disappearance  when  the  patient  shall 
have  reached  the  age  of  twenty-  F  •  rj 

five  years  or  a  little  more ;  but 
in  the  majority  of  cases  the  risk 
of  death  from  exhaustion  conse- 
quent upon  repeated  hemorrhage 
will  forbid  such  delay.  (See 
Diseases  of  the  Nose.) 

Choxdromata. — As  might 
be  expected,  the  cartilaginous  are 
the  most  common  of  the  benign 
osseous  tumors,  their  chief  places  ,     ^     , 

„     ,        .         ,     .  1       ,  \  Multiple  Chondromata  of  the  Hand  (Leo). 

Oi  election  being  the  long  bones 

(in  their  extremities)  and  those  of  the  hands  and  feet  (Fig.  64).  They  may 
be  either  peripheral  or  central,  and  are  not  seldom  mixed  in  character,  the 
addition  of  sarcomatous  elements  being  particularly  frequent.  Even  when 
microscopical  examination  has  apparently  shown  them  to  be  pure  chondromata 
they  have  at  times  the  characteristics  of  malignant  growths,  in  so  far  as  they 
recur  after  removal  and  by  transference  of  their  cell-elements  develop  visceral 
disease  in  the  lungs,  the  liver,  or  the  spleen,  especially  the  first.  It  is  possible, 
however,  that  these  are  examples  of  mixed  tumors,  all  portions  of  which  had 
not  been  subjected  to  examination.  The  more  nearly  their  histological  struct- 
ure approaches  that  of  embryonic  cartilage,  the  greater  is  the  liability  to  sec- 
ondary manifestations.  Traumatism  is  often  an  exciting  cause.  Their  grow^th 
is  generally  slow  ;  they  frequently  become  cystic,  and  always  tend  toward 
destructive  changes  both  in  their  own  tissues  and  in  the  part  in  which  they  are 
developed.  The  overlying  skin  may  be  unaff'ected  for  a  long  time,  but  ulti- 
mately becomes  ulcerated,  and  a  sinus  is  established  communicating  with  the 
breaking-down  tumor-mass. 

As  a  rule,  they  are  not  painful  except  when  there  is  involvement  of  or 
pressure  upon  adjacent  nerves,  either  of  which  is  comparatively  rare;  but  by 
their  presence  they  may  interfere  with  free  muscular  or  articular  movements. 

If  externallv  located,  as  upon  the  hands  or  feet,  their  diagnosis  is  easy: 
when  upon  the  long  bones  it  can  be  made  as  a  strong  probability  if  regard  is 
had  to  their  position,  their  slow  growth,  their  elastic  firmness,  which  though 
decided  is  not  that  of  bone,  and  their  irregular  contour.  When  softened  or 
cystic  their  nature  may  be  misunderstood  until  after  incision  or  puncture.  When 
of  mixed  sarcomatous  character,  because  of  rapid  growth  and  associated  consti- 
tutional weakness  they  may  be  readily  mistaken  for  osteo-sarcomata — a  mistake, 
however,  of  no  practical  importance,  since  the  treatment  of  the  two  aifections  is 
the  same.  The  central  growths  cannot  be  recognized  until  they  have  reached 
considei'able  size,  and  even  then  their  character  will  not  generally  be  deter- 
mined before  removal. 

The  only  treatment  of  value  is  operative,  the  growth  being  removed  either 
by  itself  when  it  is  external  and  pedunculated,  or  with  a  part  or  the  whole  of 


280  .Lv  .\}ri:i:f(AX  TKxr-iiooK  of  svuckiiy. 

the  bone  in  which  it  rests  ;  in  other  words,  hy  taking  it  out  and  scraj»in<:  away 
the  tissue  immediately  about  it,  by  excision  of  the  diseased  portion  of  the 
bone,  or  by  amputation. 

Kk..  I!'). 


Osteo-sarconm  of  the  Femur  (original). 

Malignant  Tumors. — The  malicrnant  bone-tumors  are  either  carcinoma- 
tous or  sarcomatous.  The  former  are  comparatively  rare  and  always  secondary  ; 
the  latter  are  of  frequent  occurrence  and  primary^  except  when  following  upon 
like  disease  of  tne  adjacent  soft  parts  or  upon  melanotic  .sarcoma.  Unlike  osteo- 
carcinoma,  osteo-sarcoma  is  a  disease  of  early  life,  even  of  infancy  and  childhood, 
only  a  very  small  proportion  of  the  cases  observed  occurring  in  individuals 
over  forty  years  of  age.  Histologically,  it  is  of  three  varieties — round-celled, 
epindle-c'elled,  and  giant-celled ;  locally,  there  are  two  varieties — central  and  peri- 
osteal. Its  malignancy  structurally  is  in  inverse  proportion  to  the  size  of  the 
cells,  being  greatest  in  those  tumors  made  up  of  small  round  and  spindle  cells, 
least  in  those  composed  chiefly  of  giant  cells.  As  respects  location,  when 
orif'inally  external  it  progresses  more  rapidly,  has  earlier  and  more  frequently 
secondary  visceral  manifestations,  and  is  more  certainly  fatal  than  when  inter- 
nal. It  especially  affects  the  maxilh\i  and  the  long  bones:  of  the  latter,  those 
of  the  lower  extremities  much  oftener  than  those  of  the  upper.  The  adjacent 
ends  of  the  femur  and  tibia  are  the  most  common  sites  (Fig.  65).  Local  injury 
is  a  strongly  predisposing  cause. 

Osteo-sarcoma  affects  a  neighboring  joint  comparatively  seldom,  even  at 
times  passing  outside  the  articulation  from  one  1)one  to  anotlier.  Often  the 
bone  in  which  it  is  situated  is  so  weakened  by  it  that  spontaneous  fracture 
occurs,  and  this  is  occasionally  the  first  indication  of  its  existence.  Its  rate 
of  growth  is  variable,  though  with  rare  exceptions  it  is  rapid  as  compared 
with  that  of  the  benign  tumors.  The  size  which  it  may  attain  is  usually 
not  great,  but  is  occasionally  enormous.  The  central  growths,  which,  speaking 
generally,  are  giant-celled  at  the  extremities  of  the  long  bones,  and  round-  or 
spindle-celled  in  their  shafts,  have  for  a  time  an  osseous  envelope,  so  thin  in 
some  cases  as  to  yield  and  crepitate  on  pressure,  and  later  a  complete  or  partial 
osteo-peri osteal  capsule.  This  is  not  the  case  with  the  external  growths,  the  lim- 
iting wall  of  which  is  periosteum  until  that  membrane  has  become  involved  and 
the  disease  has  pushed  through  it  into  the  adjacent  soft  parts.  The  vascularity 
of  the  internal  tumors  may  be  so  great  as  to  render  them  pulsatile,  apparently 
aneurysmal.  Without  doubt  nearly  all  the  reported  cases  of  aneurysm  of 
bone  have  been  sarcomata  of  this  character.  Hemorrhage  into  the  substance 
of  the  tumor  is  of  frequent  occurrence,  and  degenerations,  fatty,  cystic,  and, 
especially  in  the  periosteal  growths,  calcareous  or  to  a  greater  or  lesser  extent 
bony,  commonly  take  place.  Dissemination,  with  resulting  disease  of  remote 
parts,  bony  or  visceral,  is  chiefly  by  way  of  the  blood-vessels,  affections  of  the 


SURGERY    OF    THE    OSSEOUS  SYSTEM.  281 

lymphatic  glands  being  infrequently  observed.     When  present  it  is  in  large 
measure  only  irritative  in  character. 

The  cliief  symptoms  are  pain,  wjiich  is  seldom  absent,  and  at  times  is 
intense;  swelling,  recognized  early  in  the  external,  ))Ut  much  later  in  the 
internal,  variety,  in  shaj)e  globubir,  pear-shaped,  or  conical  near  the  end  of  a 
long  bone,  spindle-shaped  upon  the  shaft;  and  increased  heat,  as  determined 
by  the  hand  or  the  surface  thermometer.  There  is  little  or  no  impairment  oi 
the  joint  motions  for  a  consideralde  time. 

The  diseases  with  whicli  it  is  most  likely  to  be  confounded  are  rheumatism, 
because  the  pain  is  usually  in  the  neigliborhood  of  a  joint,  and  tul^ercular  dis- 
ease, because  of  the  location  of  the  swelling.  But,  taking  into  consideration 
the  age  of  the  patient,  the  non-existence  of  other  evidences  of  any  diathetic 
affection,  the  absence  of  joint  disease,  the  firmness  of  the  growth,  especially 
in  its  earlier  stage,  the  rapidity  of  its  enlargement,  and  the  local  temperature- 
changes,  a  strongly  probable,  if  not  absolute,  diagnosis  can  usually  be  readily 
established.  Puncture  or  exploratory  incision  may  be  made  if  necessary.  It 
may  also  be  mistaken  for  an  abscess. 

The  treatment  to  be  effective  must  be  radical,  the  affected  bone  being 
removed,  or  in  an  extremity  amputation  being  done  at  or  above  the  nearest 
joint  rather  than  in  the  continuity  of  the  bone,  except  in  cases  of  central  giant- 
celled  growths  in  the  lower  end  of  the  bones  of  the  leg  or  of  the  femur.  When 
necessity  seems  to  demand  disarticulation  at  the  hip,  it  is  very  questionable  if 
any  operative  interference  should  be  resorted  to,  in  view  of  the  risks  of  the 
amputation  and  the  almost  absolute  certainty  of  an  early  recurrence  of  the 
disease  in  the  stump  or  viscerally.  After  amputation  other  than  at  the  hip  the 
probability  of  reappearance  is  strong:  even  in  the  least  malignant  variety,  the 
central  giant-celled,  it  occurs  in  about  one  patient  out  of  five. 

ACTINOMYCOSIS.     (See  p.  137.) 
ACROMEGALY. 

Enlargement  of  many  of  the  bones  of  the  skeleton,  especially  of  the  face 
and  head,  the  thorax,  the  pelvis,  and  the  foot  and  hand,  is  a  very  constant 
symptom  of  the  peculiar  and  rare  nervous  affection  first  described  by  Marie 
in  1886,  and  by  him  named  acromegaly.  Such  enlargement  is  a  true  hyper- 
trophy, new  growth  taking  place  under  the  periosteum  and  at  the  cancellous 
extremities.  The  bones  of  the  hands  and  feet  and  the  lower  jaw  are  early 
and  markedly  affected.  The  cause  of  the  disease  has  not  been  determined. 
By  some  it  has  been  assumed  to  arise  from  an  abnormal  vascular  development; 
by  others,  from  changes  in  the  central  and  peripheral  nervous  systems  ;  by  yet 
others,  from  a  special  affection  of  the  pituitary  body.  In  a  large  proportion 
of  cases  examined  post  mortem  the  pituitary  body  has  been  found  diseased, 
but  certainly  not  in  all ;  and  further,  in  some  cases  similar  changes  in  the 
pituitary  body  have  been  discovered  when  there  was  no  acromegaly. 

The  more  common  surgical  diseases  with  which  it  is  likely  to  be  con- 
founded are  osteitis  deformans  and  arthritis  deformans.  From  the  former  it 
may  be  differentiated  by  the  earlier  age  at  which  it  appears,  by  the  almost 
constant  affection  of  the  feet  and  hands,  by  the  absence  of  curvature  of  the 
long  bones,  by  its  being  generally  symmetrical,  and  by  the  ordinarily  much 
greater  disease  of  the  face  than  of  the  head ;  from  the  latter,  by  the  great 
overgrowth  of  the  hands  and  feet,  and  by  the  absence  of  the  pain,  the 
deformity,  and  the  later  ankylosis  that  are  symptomatic  of  the  joint  affection. 

The  disease  is  of  long  duration  and  incurable,  and  no  treatment  has  any 
special  influence  upon  the  progressive  hypertrophy. 


2.S2 


AN  A.vi'jncAX  'rExr-iiooK  OF  srii(n:HY 


CHAPTER    III. 


FRACTURES. 


Definition. — The  sudden,  forcible  destruction  of  the  continuity  of  a  bone,, 
in  whole  or  in  part,  except  when  done  Avith  a  cutting  instrument,  is  called  a 
fracture.  A  simple  fracture,  in  the  common  use  of  the  term,  is  one  that  is  not 
compound  (see  below) ;  a  spontaneous  fracture  is  one  produced  by  very  slight 
violence  ;  a  patholoqical  fracture  is  one  made  easy  by  partiiil  destruction  of  the 
bone  by  disease;  an  ununited  fracture  is  one  in  which  bony  union  has  not  yet 
taken  place  after  the  lapse  of  a  period  of  time  that  is  usually  sufficient  for  repair. 

The  injury  is  a  common  one ;  it  occurs  about  three  times  as  frequently  in 
males  as  in  females,  but  the  proportion  varies  at  different  ages :  in  infants- 
and  between  the  ages  of  fifty  and  seventy  years  both  sexes  are  about  equally 
affected  ;  in  middle  life  fractures  are  ten  times  as  fre({uerit  in  men  as  in  women  ; 
and  after  the  age  of  seventy  women  are  much  more  frequently  affected  than 
men,  the  commonest  fracture  then  being  that  of  the  neck  of  the  femur.  The 
majority  of  fractures  occur  in  the  first  and  third  decades  of  life,  but  if  the 
number  of  people  living  at  the  diff"erent  ages  be  considered,  the  greatest  rela- 
tive frequency  will  be  found  at  about  the  age  of  sixty  years. 

The  following  table  shows  the  relative  frequency  of  fractures  of  the  dif- 
ferent bones.     The  italics  mark  bones  with  more  than  10  per  cent. : 


Fractures  Treated  in  the  London  Hospital,  1842-77. 


Skull  .  . 
Face  .  . 
Spine 
Pelvis  . 
Coccyx  . 
Rihi  .  . 
Sternum 
Scapula 
Clavicle  . 
Arm  .  . 
Forearm 
Hand 
Thigh  . 
Patella  . 
Leg  .  . 
Foot  .    . 


Hospital. 

Out- 
patients. 

Total. 

730 

27 

757 

732 

513 

1245 

169 

3 

172 

139 

3 

142 

5 

10 

15 

4784 

3477 

8261 

45 

7 

52 

135 

290 

425 

382 

7458 

7840 

1064 

3020 

4084 

709 

8731 

9440  ; 

856 

4899 

5755  , 

3072 

171 

3243 

649 

15 

664 

8067 

256 

8323 

965 

555 

1520 
51,938  1 

22.503 

29.435 

Per  cent. 


1.4.57 
2  397 
0.331 
0.273 
0.028 

15.905 
0.100 
0.818 

15.094 
7.863 

18.175 

11.080 
6.243 
1.278 

16.024 
2.926 


Number  by  Regions. 


)  Head, 
I  t'     2,002. 

Il 

t  I  Trunk, 
I      1^,067. 
I 

J 
1 


I  Upper  extremity, 


27,119. 


Per  cent. 


3.854 


17.457 


52.214 


1  Lower  extremity, )  i  oft  179 
r     13,750.  '    j  I  ^^-"^^^ 


Varieties. — The  varieties  of  fracture  are  numerous,  the  differences  depend- 
ing upon  the  extent,  direction,  and  seat  of  the  fracture,  the  number  of  bones 
involved,  the  associated  injury  of  the  .soft  parts,  and  the  character  or  mode  of 
action  of  the  cau.sative  violence.     They  may  be  grouped  as  follows : 
1.   Incomplete  fractures. 
(a)  Fis.su re. 

(6)  True  incomplete  fracture,  "green-stick"  fracture. 
{<;)  Depressions. 
(cl)  Separation  of  a  splinter  or  of  an  apophysis. 


FRACTURES. 


283 


Fig 


2.  Complete  fractures,  subdivided,  accordiiij^  to — 

{(i)  Direction  of  the  line  of  fracture,  into  transverse,  oblique,  longi- 
tudinal, toothed,  V-slia))ed,  T-shaped  ; 

(/))  Seat  of  the  fracture,  into  fracture  of  the  shaft,  neck,  condyle,  etc., 
separation  of  the  epiphysis  ; 

((*)  Ixelatiiinti  to  nci(/hhori)ig  joints,  into  intra-articular,  extra-capsu- 
lar,  intra-capsular ; 

((/)  3Iode  of  production,  into  fractures  by  direct  violence,  by  indirect 
violence,  by  muscular  action  ; 

{e)  Number  of  fractures  or  of  bones  fractured,  or  the  extent  and 
character  of  the  crushing,  into  multiple,  comminuted,  impacted, 
and  fractures  with  crushing. 

3.  Compound  fractures,  including,  as  a  special  class. 

Gunshot  fractures. 

1.  Incomplete  Fractures. — This  class  includes  fractures  of  long  bones 
in  which  the  continuity  of  the  bone  has  not  been  entirely  lost,  and  fractures  of 
the  flat  bones  in  which  the  line  of  fracture  does  not  extend  completely  across 
the  bone  or  through  its  entire  thickness. 

Fissure,  or  fissured  fi'acture,  is  a  split  or  crack  of  limited  extent;  the  most 
frequent  examples  are  in  the  bones  of  the  cranium  and  in  connection  with 
complete  fractures  of  other  bones. 

True  incomplete,  or  ^^ gree7i-stick,"  fracture  is  one  involving  part  of  the 
thickness  of  a  long  bone,  and  accompanied  by  some  longitudinal  splitting  and 
by  a  permanent  bending  of  the  unbroken  portion.  Possibly 
in  some  cases  there  is  only  permanent  bending  without  visible 
fracture.  It  occurs  in  the  young,  and  especially  in  the  clavicle 
and  forearm  (Fig.  66).  In  correcting  the  deformity,  which  is 
best  done  by  bending  the  bone  in  the  opposite  direction,  the 
fracture  is  frequently  made  complete. 

Depression  is  the  crushing  of  a  portion  of  the  thickness  of 
a  bone;  it  perhaps  belongs  more  properly  among  "wounds  of 
bone"  than  among  fractures.  The  class  also  includes  certain 
rare  "fractures  by  depression,"  in  w^iich  by  the  forcible  bend- 
ing of  a  flat  bone  a  frag-ment  is  broken  from  the  side  toward 
which  the  bone  is  bent,  as  in  isolated  fracture  of  the  inner 
table  of  the  skull :  it  does  not  include  "  depressed  fractures 
of  the  skull,"  in  which  the  entire  thickness  of  the  bone  is 
broken. 

Separation  of  a  Spli7iter  or  of  an  Apophysis. — Direct 
violence,  as  by  a  bullet  or  a  sword,  may  break  off"  a  piece 
without  completely  fracturing  the  bone,  or  the  violent  con- 
traction of  a  muscle  or  a  strain  exerted  through  a  ligament 
may  tear  off  a  scale  of  bone  or  an  apophysis  to  which  the 
tendon  or  ligament  is  attached. 

2.  Complete  Fractures. — {a)  Subdivided  according  to  the  Direction  of 
the  Line  of  Fracture. — The  fracture  is  termed  transverse  (Fig.  67)  if  its  line 
is  exactly  or  nearly  transverse  to  the  long  axis  of  the  bone  and  regular ; 
longitudinal  (Fig.  68)  if  it  runs  for  a  considerable  distance  more  or  less 
exactly  parallel  to  the  long  axis ;  oblique  (Fig.  69)  if  its  direction  is  inter- 
mediate between  the  two  preceding.  The  division  is  of  course  somewhat 
arbitrary.  The  fracture  is  termed  toothed  or  dentate  (Fig.  70)  if  its  line  is 
broken  by  sharp  points  and  depressions,  which  may  constitute  a  serious 
obstacle  to  complete  reduction.      V-shaped  fracture  of  the  tibia  (Fig.  71)  is 


Partial  or  Green- 
stick  Fracture 
of  the  Radius 
(Stimson). 


284 


AN  AMERICAN   TEXT- HOOK    OF  SURGERY. 


Fig.  07. 


fig. 


characterized  by  a  prominent  triangular   j)rojc'ction  at  the  lower  v\n\  of   tlie 

U])j)er  fragment  on  its  inner  aspect;  its 
L'S]»i'cial  importance,  otliei'  than  the  (occa- 
sional (litliculty  of  reduction,  is  due  to 
a  fissure  \vhich  may  extend  from  the 
corresponding  re-entrant  angle  on  the 
lower  fragment  down  to  the  ankle-joint. 
T-xhaped  fractures  are  found  at  the 
lower  end  of  the  humerus  and  femur, 
and  are  sometimes  termed  mtercondy- 
loid  (Fig.  72):  there  is  a  transverse  line 
of  fracture  above  the  condyles,  and  a 
longitudinal  one  running  from  the  trans- 
verse line  downward  between  the  con- 
dyles. 

(^b)  Subdivided  accordinfi  to  the  Seat 
of  the  Fracture. — The  fracture  receives 
a  name  indicative  of  the  portion  of  the 
bone  involved  in  it :  thus,  fracture  of 
the  shaft,  of  the  neck,  of  a  condyle,  or 
of  a  specific  process,  as  the  malleo- 
lus, greater  tuberosity  of  the  humerus, 
olecranon.  The  term  separation  of  an 
eptpki/sis  also  indicates  that  the  frac- 
ture lies  wholly  or  mainly  at  the  carti- 
laginous junction  between  the  epiphysis 
and  the  shaft ;  this  variety  is  found, 
of  course,  only  in  persons  whose  growth  is  not  yet  complete ;  that  is,  as  a 
rule,  only  in  those  who  have  not  yet  reached  the  age  of  twenty-four  or 


Transverse  Frac- 
ture of  the  Fe- 
mur (Gurlt). 


Longitudimil  Fracture  of 
the  Tibia  (Stimson). 


Fig.  69. 


Oblique  Fracture  of  the  Clavicle  (Stimson). 


twenty-five  years ;  the  date  of  consolidation  of  the  epiphysis  with  the  shaft 
varying  with  the  sex,  the  individual,  and  the  different  bones.  Separation  of 
the  epiphysis  is  more  easily  effected  than  a  fracture  of  the  same  bone  by  cross- 
strain  :  the  periosteum  is  usually  stripped  up  from  the  shaft  for  a  considerable 
distance,  varying  with  the  displacement,  and  remains  attached  to  the  ej)iphysis. 
The  injury  is  of  especial  importance  because  of  frequent  difficulty  of  reduction, 
and  because  the  irritation  of  the  traumatism  may  lead  to  premature  ossification 
of  the  cartilage,  with  consequent  local  arrest  of  growth.  This  consideration  is 
of  most  importance  at  the  knee,  the  upper  end  of  the  humerus,  aufl  the  lower 
end  of  the  radius  and  of  the  ulna,  where  the  princijoal  growth  in  length  of 
the  respective  bones  occurs. 

(c)  Subdivided  aecordinjj  to  the  Ilelations  to  Neighboring  Joints. — The 
term  intra-articular  indicates  that  the  line  of  fracture  extends  into  a  joint — a 
complication  that  is  important  because  of  the  possible  inflammation  of  the  joint 


FRA  CTURES. 


285 


an.l  of  possible  change  in  the  relations  of  the  fragment,  either  of  whbh  may 
permanently  restrict  the  mobility  of  the  joint.     Intracapsular  and  extra- 


FiG.  71. 


Intercondyloid  Fractun-  of  the 
Humerus  (Stimson). 

Fig.  73. 


Toothed  Fracture  of  the 
Femur  (Stimson). 


V-shaped  Frac- 
ture (Stimson). 


Comminuted  Gunshot  Fracture  of  the 
Head  of  the  Humerus,  with  Impacted 
Ball  (Army  Med.  Mus.). 


capsular  are  terms  used  almost  solely  in  ^^onnection  with  fractures  of  the  ned^^ 
of  the  femur  to  indicate  the  position  of  the  line  of  fracture  within  oi  .Mthout 
the  attachment  of  the  capsule  to  the  femur.  . 

(d)  Subdivided  according  to  the  Mode  of  Products  on. -l<r.ctnves  by  d^;ect 

violence  are  those  in  which  the  fracture  takes  place  at  the  point  where  the  blow 

Lr  ceTved ;  fractures  by  indirect  violence  are  those  in  which  it  takes  p  ace  at  a 

distance  from  that  point;  fractures  by  muscular  action  ^ve  those  m  which  the 

fracture  is  produced  by  the  action  of  the  patient  s  muscles.  ^      ,      ^ 

%  Subdivided  according  to  the  Number  of  Fractures  or  of  Bones  Fractured 

or  to  the  Extent  and  Character  of  the  Crushing  .-'^\^e  term  muliiple  "^^hcates  t^  o 

or  more  separate  fractures  of  a  bone,  or  the  fracture  of  two  or  more  bones  other 

than  the  tibia  and  fibula  or  the  radius  and  ulna  of  the  same  limb.     A  -...uj  .cZ 

fracture  (Figs.  73  to  76)  is  one  accompanied  by  considerable  splintenng  of  the 

boTe   which  is  broken  into  several  small  fragments.     K^mmcted  fracture 

is  one  in  which  one  main  fragment  is  driven  into   and  firmly  fixed  in  the 

other    "hi^h  is  commonly  the  expanded  spongy  end  of  the  bone:  the  spongy 

porticJn  into  which  the  other  fragment  is  driven  is  ^^cessardy  more  or  le  s 

cru  hed  thereby,  and  if  the  crushing  and  splintering  are  such  that  the  entei- 


*286 


Ay  A.u/:/i'/(A\  Ti: XT- HOOK  OF  sii:(;i:i!Y. 


ing  piece  is  not  firmly  impacted,  the  fracture  is  said  to  be  one  ivith  cruxhing. 
Both  conditions  are  more  common  in  advanced  life,  and,  as  the  crushing 
amounts  to  an  actual  loss  of  substance,  some  deformity  must  persist. 


Vu:.  74. 


Fm.  :.■). 


Comminuted  Perforating  Gun-  Comiiiinuled  Fracture  of  the    Comminuted  Fracture  of  the  Neck 

shot   Fracture  of  the   Head  Lower  End  of  the  Radius,               of  the  Femur  (Stimson). 

of  the  Huincrns  lArmy  Med.  palmar  aspect  (Stimson). 
Mus.K 

3.  Compound  Fractures. — A  compound  fracture  is  one  which  com- 
municates with  the  exterior  tlirough  a  wound  of  the  overlying  soft  parts. 
The  latter  wound  may  be  directly  caused  by  the  same  violence  that  pro- 
duces the  fracture,  as  in  the  passage  of  a  wheel  of  a  wagon  across  the 
leg,  or  it  may  be  made  from  within  outward  by  the  forcible  projection 
of  the  end  of  one  of  the  fragments  through  the  skin  ;  or  a  simple  frac- 
ture may  become  compound  through  sloughing  of  the  soft  parts  occa- 
sioned either  by  bruising  inflicted  at  the  time  of  the  accident,  or  by 
the  pre.'jsure  of  a  di.^jjlaced  fragment,  or  tlirough  careless  handling,  or  by  the 
movements  of  the  patient  while  delirious.  The  injury  is  much  more  serious 
than  a  simple  fracture,  because  of  the  possibility  of  infection  of  the  wound,  with  its 
train  of  consequences — suppuration,  necrosis,  failure  of  union,  septicemia,  and 
loss  of  limb  or  life.  Excluding  the  hand  and  foot,  compound  fractures,  accord- 
ing to  Gurlt,  are  most  frequent  in  the  leg,  being  17.96  per  cent,  of  all  com- 
pound fractures;  those  of  the  forearm  form  11.68  per  cent.;  those  of  the 
femur,  7.0.5  per  cent.  :  those  of  the  humerus,  Cy.QQ  per  cent.  The  prognosis  is 
serious  in  compound  fractures  by  direct  violence,  because  the  soft  parts  are  usu- 
ally so  bruised  and  lacerated  that  primary  union  cannot  be  obtained  ;  whereas 
in  fractures  by  indirect  violence  in  which  the  wound  of  the  skin  is  made  by  the 
end  of  a  fragment  the  prognosis  is  much  better,  for  the  wound  is  generally  small 
and  clean,  and  if  properly  treated  will  usually  unite  promptly,  and  the  fracture 
will  thus  be  transformed  into  a  sinii>le  one.  Tlie  diagnosis  of  the  compound 
character  of  a  fracture,  when  in  any  doubt,  may  be  made  in  case  of  necessity 
bv  careful  exploration  of  the  wound  with  the  purified  finger,  but  usually,  and 
especiallv  whenever  the  wound  is  small  and  bruising  or  laceration  is  abi>ent  or 
slight,  it  is  better  to  abstain  from  completing  the  diagnosis  by  any  measures 
that  niav  increase  the  chance  of  infection,  and  to  direct  all  efforts  to  obtaining 
the  prompt  disinfection  and  closure  of  the  wound. 


FRA  CTURES. 


287 


Gunshot  fractures(Figs.  73,  74,  77)  constitute  an  especially  seven- form  of 
ooiiij)()iiii(l  tVactiiros  Itocause  of"  the  usually  extensive  comniinution  and  lissui-in<^ 
of"  the  bone,  the  bruising  of"  the  soft  parts  along  the  track  of  the  bullet,  and  the 
greater  frequency  of  associated  injury  of  important  blood-ves- 
sels and  nerves.  A  small  bullet  may  make  a  clean  perforation  Fio.  77. 
with  but  little  splintering ;  a  large  one  literally  smashes  the  l)one 
at  the  point  of  contact  and  produces  fissures  that  may  exteml 
to  a  great  distance ;  the  bullet  may  pass  completely  througli 
the  bone  or  may  lodge  in  it.  In  fractures  produced  by  a 
charge  of  shot  the  associated  laceration  of  the  soft  parts  is 
usually  the  dominant  feature  of  the  case.  Amputation  and 
excision  have  been  the  rule  in  the  past,  and  discussion  has 
turned  mainly  on  the  respective  merits  of  primary  and  second- 
ary operations.  Antise})tic  surgery  has  not  yet  been  put  to  a 
sufficient  test  in  Avar  to  determine  fully  the  extent  to  which  it 
will  modify  previous  rules  of  treatment,  but  it  will  undoubted- 
ly avail  to  save  a  much  larger  proportion  of  limbs  and  lives. 
In  civil  practice  it  has  been  clearly  shown  that  suppuration 
and  infection  can  be  prevented  in  a  large  proportion  of  bullet 
wounds,  and  that  the  removal  of  the  bullet  is  not  a  necessary 
preliminary  to  successful  treatment.  The  guiding  principle  is 
to  abstain  as  far  as  possible  from  exploration  of  the  wound 
with  probe  or  fingei%  to  disinfect  it  thoroughly  by  antiseptic 
washing,  and  to  seek  its  prompt  healing  under  a  single  dress- 
ing combined  with  measures  to  immobilize  the  fracture :  this 
failing,  counter-openings,  drainage,  and  irrigation  to  meet  the 
needs  created  by  suppuration. 

Displacements. — The  following  six  classes  comprise  the 
common  changes  in  the  relations  of  the  principal  fragments, — 
the  name  indicating,  in  all  but  the  fifth,  the  direction  in  which 
the  change  has  taken  place :  1,  transverse  displacement ;  2, 
angular  ;  3,  rotary  ;  4,  overriding  ;  5,  impaction  or  crushing  ;  Gunshot  Fracture  of 
6,  direct  longitudinal  separation.  Commonly  two  or  more  are  Med.  muso"^  ^^^ 
associated  in  any  given  case. 

Transverse  or  lateral  displacement  may  take  place  in  any  direction  at  right 
angles  to  the  long  axis  of  the  bone,  and  may  be  complete  or  partial.  In  angular 
displacement  one  fragment  deviates  obliquely  from  the  line  that  represents  the 
normal  relation  of  its  long  axis  to  that  of  the  other  fragment.  In  rotary  displace- 
ment one  fragment  has  been  separately  turned  about  its  long  axis.  In  overriding, 
the  upper  and  lower  ends  of  the  bone  are  brought  nearer  to  each  other  by  the 
passage  of  the  broken  surfaces  past  each  other :  it  is  common  in  oblique  frac- 
tures, and  is  necessarily  associated  Avith  some  transverse  displacement,  and  usu- 
ally with  angular  displacement.  In  impaction  or  crushing  the  bone  is 
shortened  by  the  forcing  of  one  fragment  into  the  other,  or  in  spongy  bones 
an  angular  displacement  is  effected  by  the  crushing  of  the  bone  at  the  angle 
on  the  side  toward  which  it  is  bent.  Direct  longitudinal  separation  is  most 
commonly  seen  after  fracture  of  the  patella  and  olecranon,  and  is  then  due 
to  the  contraction  of  the  attached  muscle;  but  it  may  be  produced  after  frac- 
ture of  the  humerus  by  the  unsupported  weight  of  the  lower  part  of  the  arm 
and  the  forearm. 

Displacement  may  be  caused  at  the  time  of  the  accident  by  the  force 
which  produces  the  fracture,  or  subsequently  by  the  action  of  gravity  or  of 
the  attached  muscles  upon  the  fragments.     The  tonicity  of  the  muscles  and 


288  AN  AMERK'AX    TEXT-llOOK    OF  SURGERY. 

their  contraction  when  excited  by  pain  habitually  tend  to  produce  angular 
displacement,  and  overriding  when  the  character  of  the  displacement  per- 
mits it.     (See  Figs.  07  and  09.) 

Etiolocjy. — 1.  Predisposing  Causes. — These  are  of  two  kinds,  normal 
and  pathological.  Nonual  predisposing  causes  are  found  in  the  shape,  struc- 
ture, and  functions  of  the  different  bones,  with  such  modifications  as  are  pro- 
duced by  advancing  years.  A  long  bone  is  exposed  by  its  very  length,  as  well 
as  by  the  uses  which  that  length  subserves,  to  fracture  by  indirect  violence,  by 
cross-strain,  or  by  torsion ;  length  is  to  that  extent  a  predisposing  cause.  A 
short  bone  or  the  spongy  end  of  a  long  one  is  fitted  by  its  texture  and  its 
breadth  to  receive  and  transmit  violence  w^ith  the  minimum  of  damage  to  the 
bone  with  which  it  is  in  contact,  but  the  same  texture  and  breadth  expose  it  to 
easy  crushing  and  splintering  when  the  violence  is  unusually  great  or  is  abnor- 
mally directed.  To  that  extent  its  spongy  texture  is  a  predisposing  cause. 
The  normal  curves  found  in  so  many  long  bones,  and  the  transformation  of 
the  segments  of  a  limb  into  the  equivalent  of  a  single  sharply-bent  bone  by 
the  rigidity  of  the  strongly-contracted  muscles,  tend  to  diminish  the  risk  of 
dangerous  violence  to  the  trunk  and  viscera  in  a  fall,  but  in  thus  protecting 
vital  organs  they  become  themselves  more  exposed  to  fracture. 

As  age  advances  the  bones  become  more  fracrile  by  rarefaction  of  their 
spongy  and  compact  tissue:  the  change  is  an  actual  diminution  of  the  amount 
of  bone-tissue  in  the  bone,  not  an  alteration  in  the  proportions  of  the  diff'erent 
elements  that  compose  that  tissue  ;  there  appears  to  be  no  increase  in  the  amount 
of  the  earthy  matter,  either  actually  or  relatively.  As  an  habitual  incident 
of  advanced  age  this  senile  atrophy  may  be  deemed  a  normal  predisposing 
cause,  but  when  it  appears  prematurely  or  in  an  excessive  degree  it  is  patho- 
logical. Such  premature  and  excessive  fragility,  dependent  upon  causes  that 
are  not  always  understood,  may  be  inherited  or  acquired.  Cases  have  been 
reported  in  which  successive  generations  have  shoAvn  remarkable  liability 
to  fracture  from  infancy ;  in  one  instance  a  child  received  fourteen  fractures 
before  he  was  thirteen  years  old.  In  other  cases  some  or  all  of  the  childi-en 
of  a  family  have  shown  it,  the  parents  being  free  from  it ;  thus,  a  girl  suf- 
fered thirty-one  fractures  between  tlie  ages  of  three  and  fourteen  years,  and 
her  sister  nine  between  the  ages  of  eight  months  and  six  years,  while  two 
brothers  and  a  third  sister  showed  no  such  predisposition.  The  cases  are 
much  more  numerous  in  which  a  similar  liability  to  fracture  has  developed  later 
in  life,  the  bones  breaking  under  the  slightest  violence  or  muscular  effort. 
Such  fractures  commonly  unite  within  the  usual  time.  Post-mortem  examina- 
tion has  shown  great  thinning  and  rarefaction  of  the  bone.  Fragility  may  be 
developed  by  disuse,  as  in  limbs  that  have  remained  dislocated,  and  in  conjunc- 
tion with  certain  diseases  of  the  nerve-centers.  Ilhachitis  is  a  predisposing 
cause  in  childhood,  through  the  incomplete  development  of  the  bone-tissue 
to  which  it  leads,  the  bone  remaining  spongy  instead  of  developing  a  firm,  com- 
pact, cylindrical  formation.  Syphilis,  cancer  and  other  tumors,  and  caries  may 
predispose  to  fracture  by  destroying  a  portion  of  the  bone.  Kheumatism  has 
been  alleged  to  be  a  predisposing  cause,  because  some  patients  have  suff"ered 
aching  pain  in  certain  bones  for  some  time  before  they  have  broken  under  slight 
violence  or,  more  commonly,  by  muscular  action.  The  widespread  disposition  to 
call  such  pains  "  rheumatic  "  accounts  for  the  supposed  connection.  Fracture 
of  the  patella  is  not  infrequently  preceded  by  such  pain,  which  seems  possibly 
to  be  evidence  of  previous  slight  injury  or  partial  fracture. 

2.  Immediate  or  Determining  Causes  of  Fracture. — The  immediate 
cause  of  a  fracture  mav  be  violence  received  at  some  point  upon  the  surfi;ice  of  the 


FliACTURES.  289 

body,  or  exerted  upon  the  bone  that  is  broken  by  the  muscles  that  are  attached 
directly  or  indirectly  to  it.  The  former  are  termed  fractures  hy  extertial  vio- 
lence, the  \'A.iXov  fractures  hy  muscular  action.  The  latter  class  does  not  include 
cases  in  whieli,  -while  tlic  causative  force  ori<rinates  in  the  contraction  of  the 
patient's  nmsclos,  an  additional  and  essential  factor  is  created  by  external  resist- 
ance, as  in  the  breaking  of  the  leg  by  a  sudden  turn  or  forward  movement  of 
the  body  Avhile  the  foot  is  held  fast,  or  of  the  arm  by  striking  it  against  some 
object. 

Fractures  by  external  violence  are  divided  into  two  classes  which  have 
important  clinical  diffcrwiccs — those  by  direct  and  those  by  indirect  violence. 
Fractures  by  direct  violence  are  those  in  which  the  bone  is  broken  at  a  point 
corresponding  to  that  upon  the  surface  where  the  blow  is  received ;  fractures  by 
indirect  violence  are  those  in  which  the  bone  is  broken  at  a  distance  from  the 
point  where  the  blow  is  received.  An  important  clinical  difference  is  that  in 
the  former  the  overlying  soft  parts  are  contused,  and  often  to  such  an  extent 
that  the  fracture  is  or  soon  becomes  compound,  and  primary  union  of  the 
wound  is  difficult  or  impossible;  in  fractures  by  indirect  violence  the  injury  to 
the  soft  parts  is  habitually  less,  and  if  the  fracture  is  compound  the  edges  of  the 
wound  in  the  skin  are  not  so  contused  that  primary  union  is  difficult  to  obtain. 

Fractures  by  muscular  action  are  most  common  at  the  patella,  the 
bone  being  broken  by  the  powerful  contraction  of  the  quadriceps ;  in  other 
cases  the  muscles  produce  the  fracture  by  exaggerating  the  normal  curve  of  the 
bone,  as  the  humerus  or  femur  in  spasmodic  or  voluntary  contraction,  or  the 
ribs  in  coughing,  or  the  sternum  in  straining  during  labor ;  or  by  tearing  off 
an  apophysis  to  which  the  muscle  is  attached,  as  the  coracoid  process  or  the  pos- 
terior end  of  the  calcaneum  ;  and  in  others  by  creating  in  portions  of  the  body 
conditions  of  momentum  which  act  in  the  same  manner  as  external  violence,  as 
in  fracture  of  the  humerus  by  throwing  a  stone,  of  the  femur  by  kicking  at, 
but  not  striking,  an  object,  of  the  neck  in  throwing  the  head  back. 

Symptoms  and  Diagnosis. — Before  proceeding  to  the  examination  of  the 
injured  region  inquiry  should  be  made  into  the  circumstances  connected  with 
the  injury,  and  the  question  should  always  be  asked  if  the  part  has  been  pre- 
viously injured,  in  order  that  an  old  deformity  may  not  be  mistaken  for  a 
recent  one. 

1.  Objective  Symptoms. — Deformity.— Under  this  term  are  included 
changes  in  the  appearance  of  the  injured  region,  in  the  dimensions  of  the 
limb,  and  in  the  relations  of  different  bones  or  parts  of  bones  to  one  another. 
Swelling  occurs  promptly,  and  is  often  associated  with  heat  and  redness. 
Ecchymoses  appear  rather  tardily  in  fractures  by  indirect  violence,  and  usually  at 
some  distance  from  the  seat  of  fracture.  Large  blebs,  containing  a  liquid  that 
is  at  first  yellow  and  later  bloody,  sometimes  appear  during  the  first  or  second 
day,  especially  in  fractures- of  the  leg  and  forearm.  Most  of  the  various  displace- 
ments that  have  been  above  described  may  be  readily  recognized  by  the  eye 
or  finger  when  the  bone  is  not  thickly  covered  by  soft  parts ;  angular  displace- 
ment is  often  shoAvn  by  a  change  in  the  direction  of  the  segments  of  the  limb  ; 
and  overriding  or  impaction  is  demonstrated  by  measurement  of  the  length  of 
the  bone  or  of  the  limb.  When  the  two  ends  of  a  bone  can  be  readily  recog- 
nized, as  those  of  the  forearm  or  leg,  its  length  can  be  directly  measured,  but 
in  fractures  of  the  femur  or  the  humerus  it  is  necessary  to  measure  from  points 
on  other  bones,  the  ilium  and  the  acromion  respectively ;  and  then  it  is  essential 
to  accuracy  that  the  injured  limb  and  its  fellow  Avith  which  the  comparison  is 
made  should  be  symmetricall}''  placed  with  reference  to  the  bone  on  which  one 
of  the  fixed  points  is  taken.     Two  other  possible  sources  of  error  in  measuring 

19 


290  AN  AMERICAN   TEXT-BOOK    OF  .sriiGEIi'V. 

should  always  be  borne  in  mind  :  one  is  previous  injury  or  disease  that  may 
have  affected  the  lent^th  of  either  limb  ;  the  other  is  the  normal  inequality  in 
the  len^'tli  of  the  limbs  which  exists  in  many  people;  this  rarely  amounts  to 
more  than  a  ([uarter  of  an  inch,  although  it  may  reach  an  inch  or  more,  and 
its  existence  is  usually  unknown  to  the  individual  until  revealed  by  meaisure- 
ment. 

By  abnormal  mobility  after  fracture  is  meant  the  independent  mobility 
of  the  fragments  of  a  fractured  bone  which  is  normally  one  unbroken  structure, 
or  the  mobility  of  a  joint  in  an  abnormal  direction  or  to  an  abnormal  extent 
in  consequence  of  the  fracture  of  a  portion  of  the  end  of  one  of  the  bones  that 
constitute  it.  It  is  usually  present  and  recognizable  with  great  ease  when  the 
fracture  occupies  the  shaft  of  a  long  bone,  but  it  may  be  absent  or  unrecog- 
nizable when  the  fracture  is  close  to  the  end  of  the  bone.  It  is  habitually 
accompanied  bv  a  sensation  of  grating  which  may  be  heard  or  felt,  and  which  is 
technically  known  as  crepitus.  This  is  produced  by  the  rubbing  of  the  broken 
surfaces  upon  each  other.  Abnormal  mobility  and  crepitus  are  pathognomonic 
of  fracture,  but  it  must  be  remembered  that  in  not  a  few  fractures  either  or  both 
are  absent  or  unrecognizable,  and  that  failure  to  obtain  them  is  not  a  proof 
of  the  non-existence  of  a  fracture.  Furthermore,  the  manipulations  necessary 
to  recognize  them  are,  in  some  cases,  actually  harmful,  and  the  diagnosis  must 
be  made  on  other  symptoms. 

2.  Subjective  Symptoms. — These  are  chiefly  diminution  or  loss  of  func- 
tion, and  pain.  The  history  of  the  case  is  also  of  much  value.  The  extent  of 
the  interference  with  function  depends  upon  the  importance  of  the  broken 
bone  to  that  function,  the  relations  of  the  fragments  to  each  other,  and  pain 
or  fear  of  pain.  After  fracture  of  the  thigh  or  leg  the  patient  is,  as  a  rule, 
entirely  unable  to  walk  or  to  lift  the  limb  from  the  bed  when  he  is  recumbent, 
but,  on  the  one  hand,  the  disability  may  be  much  less,  and,  on  the  other,  equal 
disability  may  be  caused  by  a  simple  contusion.  Pain,  either  spontaneous  or 
aroused  by  pressure  or  movement,  is  a  constant  accompaniment  of  fracture,  and 
when  limited  to  a  small  area  and  invariably  aroused  by  pressure  with  the  end 
of  the  finger  or  by  slight  movements  communicated  to  the  limb,  is  a  valuable 
sign  of  fracture — one  upon  Avhich  a  diagnosis  of  fracture  in  certain  regions  can 
be  safely  made  when  the  history  of  the  accident  indicates  that  such  a  fracture 
may  have  been  produced. 

"^ The  examination  should  be  made  quietly  and  systematically;  movements 
communicated  to  the  bone  in  the  search  for  abnormal  mobility  and  crepitus 
should  be  slight  and  gentle,  and  if  the  muscles  are  spasmodically  contracted, 
or  the  patient  timid,  or  the  injury  obscure  and  of  doubtful  character  in  the 
neighborhood  of  a  joint,  an  anesthetic  should  be  employed. 

Repair  of  Fracture. — In  simple  fractures  there  is  at  first  some  rise  of 
temperature,  the  limb  swells  promptly,  blebs  sometimes  appear  on  the  surface, 
ecchymoses  and  yellow  discoloration  of  the  skin  extend  to  a  considerable  dis- 
tance :  then  the  swelling  subsides,  and  a  firm  ovoid  mass,  which  is  tender  on 
pressure,  can  be  felt  about  the  seat  of  fracture.  This  gradually  grows  smaller 
and  harder  and  the  abnormal  mobility  diminishes.  After  a  lapse  of  time,  the 
length  of  which  varies  with  many  conditions,  abnormal  mobility  entirely  disap- 
pears and  the  fracture  is  said  to'be  united.  The  length  of  time  requisite  for 
such  union  is  greatest,  as  a  rule,  when  the  fracture  is  of  the  shaft  of  the  femur 
in  an  adult,  in  which  case  it  is  usually  from  six  to  eight  Avecks ;  it  is  least  at 
the  spongy  ends  of  the  bones,  less  in  children  than  in  adults,  and  greater  when 
there  is  much  permanent  displacement.  After  final  healing  the  limb  slowly 
regains  its  usefulness,  the  muscles  fill  out,  and  the  skin  becomes  soft,  but  for 


FRACTURES.  291 

many  weeks  the  limb  may  show  a  tendency  to  venous  conf^estion  and  oedema 
and  the  movements  of  its  joints  be  restricted.  In  compound  fractures  that  do 
not  promptly  become  simple,  if  left  to  itself  the  wound  suppurates,  the  pus  bur- 
rows, neighboring  abscesses  form,  union  of  the  fracture  is  delayed,  and  even 
after  it  has  taken  place  the  wound  may  be  kept  open  for  weeks  or  months  by 
8upj)uration  about  a  loose  or  attached  necrotic  fragment. 

The  lesions  of  a  fracture  comprise  the  breaking  of  the  bone  into  two  or 
more  fragments,  the  tearing  of  the  periosteum,  and  the  laceration  of  the  soft 
parts.  A  portion  of  the  periosteum  habitually  remains  untom,  although 
stripped  up  for  a  greater  or  less  distance  from  one  or  both  fragments,  and  con- 
stitutes a  remaining  bond,  a  "periosteal  bridge,"  between  the  fragments.  This 
plays  an  important  part  in  the  repair  of  the  fracture.  The  periosteum  thickens, 
and  on  its  under  surface  ajjpears  a  layer,  at  first  soft,  then  cartilaginous,  which 
extends  along  the  periosteal  bridge  from  one  fragment  to  the  other,  as  well  as 
under  the  periosteum  that  remains  adherent ;  the  portion  belonging  to  the 
periosteal  bridge  thickens  and  spreads  between  the  fragments,  and  ultimately 
becomes  bony  and  continuous  with  the  granulations  coming  from  the  bone 
itself.  This  is  the  only  portion  of  the  callus  which  passes  through  a  carti- 
laginous stage.  The  bone  becomes  rarefied  by  enlargement  of  its  Haversian 
canals,  and  at  its  broken  edge  and  on  the  adjoining  surface  of  the  medullary 
canal  granulations  appear  which  increase  until  they  meet  those  coming  from 
the  periosteal  bridge  and  from  the  other  fragments,  and  fill  the  space  between 
them,  and  also   usually  the  medullary  canal  at  the  seat  of  fracture. 

These  granulations  become  fibrous  and  finally  bony,  and  thus  is  formed  the 
callus,  Avhich,  when  complete,  fills  the  gap  between  the  fragments,  occupies 
the  medullary  canal  for  some  distance,  and  forms  a  layer  on  the  outside  of  the 
bone  for  a  greater  or  less  distance  above  and  below  the  fracture.  As  time 
passes  this  callus  becomes  smaller,  and  the  portion  that  forms  the  medullary 
plug  may  entirely  disappear,  and  thus  the  continuity  of  this  canal  may  be 
restored.  If  there  is  much  permanent  displacement,  or  if  the  fragments  are 
not  effectually  immobilized  during  repair,  the  callus  will  be  larger  than  under 
other  circumstances,  and  tendons  and  fibrous  tissue  attached  to  the  bone  near 
the  fracture  may  be  included  in  the  area  of  irritation  and  become  ossified. 
Such  ossification  at  a  distance  may  be  destructive  to  the  functions  of  the  limb, 
as  when  a  fracture  is  in  the  neighborhood  of  a  joint,  or  in  the  case  of  the 
radius  and  ulna,  which  may  become  united  to  each  other  with  consequent  loss 
of  rotation  of  the  forearm.  Sometimes  a  neighboring  joint  becomes  entirely 
obliterated  by  bony  union  of  its  opposing  articular  surfaces. 

Fragments  that  are  entirelv  detached,  even  from  the  periosteum,  mav  regain 
their  vital  connection  with  the  body,  apparently  by  the  growth  of  new  vessels 
into  their  Haversian  canals,  and  again  form  an  integral  part  of  the  bone. 
Others  may  remain  imbedded  in  the  callus,  but  without  vascular  connection, 
and  be  tolerated  for  years :  under  the  influence  of  various  causes  they  may 
ultimately  lead  to  suppuration. 

Occasionally  the  evolution  of  the  callus  is  arrested  at  the  fibrous  stage,  and 
union  is  then  said  to  have  failed  or  to  be  fibrous.  Fibrous  union  may  be  so 
close  and  firm  or  so  well  supplemented  by  the  interlocking  of  the  different 
parts  of  the  callus  that  have  ossified  that  the  limb  is  \er\  useful.  The  common 
causes  of  fibrous  union  are  separation  of  the  fragments  and  insufficient 
immobilization. 

Complications  and  Late  Consequences. — With  the  healing  of  the 
fracture  the  limb  is  not  immediately  restored  to  a  normal  condition ;    it  is 


292  AN  AMERICAN    TEXT-DOOK    OF  SrUGERY. 

shrunken,  the  skin  is  dry  and  rough,  the  limb  swells  on  use,  and  its  joints  are 
more  or  less  stiff. 

Most  of  these  abnormal  conditions  gradually  disappear,  but  in  the  aged 
the  limb  may  long  remain  sensitive  to  free  use  and  to  changes  in  the  weather, 
and  the  stiffness  of  the  joints  may  persist.  The  latter  is  due  in 
great  part  to  the  inflammatory  conditions  that  have  existed  in  and  about  the 
joint  as  a  direct  consequence  of  the  fracture,  or  to  the  implication  of  neigh- 
boring tendons  ;  but  in  the  joints  of  the  fingers  it  may  be  due  to  the  immobili- 
zation, and  is  much  more  likely  to  arise  when  the  fingers  have  Ijcen  kept 
extended.  It  has  been  clearly  shown  that  prolonged  immobilization  of  the 
large  joints,  per  se,  is  not  a  cause  of  permanent  stiffness,  and  that  passive 
motion  of  the  joint  is  not  necessary,  or  even  desirable,  during  treatment  of 
the  fracture,  to  prevent  it.  If  the  joint  is  inflamed,  the  best  means  of  reducing 
the  inflammation  and  restricting  its  results  is  to  keep  the  joint  at  rest.  Per- 
sistent swelling  of  the  limb,  especially  of  the  leg,  is  apparently  the  result  of 
interference  with  the  venous  floAv,  and  may  be  the  cause  of  or  be  associated 
with  much  trouble  and  annoyance,  especially  if  the  callus  is  large  and  adherent 
to  the  skin.  The  nutrition  of  the  limb  is  interfered  with,  persistent  ulcers 
form,   and  eczema  torments  the  patient. 

Persistent  paralysis  of  one  or  more  groups  of  muscles  may  appear  as  a 
consequence  of  injury  of  a  nerve-trunk  at  the  time  of  the  accident,  or  of  its 
later  inclusion  in  the  callus  ;  the  latter  has  been  observed  only  in  the  musculo- 
spinal nerve  after  fracture  of  the  shaft  of  the  humerus. 

Exuberant  and  Painful  Callus — Excessive  size  of  the  callus  may 
cause  trouble  by  interference  with  the  circulation,  or  by  stretching  the  skin, 
or  by  pressure  on  a  nerve.  The  second  cause  is  not  uncommon  in  the  leg,  and 
may  call  for  relief  by  chiselling  away  the  bone.  Pressure  upon  a  nerve  may 
occur  at  any  point  where  a  nerve  lies  in  close  proximity  to  the  bone,  as  in  the 
case  of  the  ulnar  nerve  at  the  back  of  the  elbow.  Persistent  pain  in  the  callus 
may  be  due  to  an  inflammatory  process,  as  suppuration  about  a  sequestrum,  or 
to  a  non-inflammatory  condition  of  unknown  character  which  has  been  termed 
osteo-neuralgia  ;  occasionally  it  has  been  traced  to  inclusion  of  a  nerve-filament 
in  cicatricial  tissue. 

The  other  complications  to  be  described  are  those  that  arise  during  the 
earlier  period  of  the  case  and  put  the  patient's  life  in  danger.  Most  of  them 
are  extremely  rare. 

Embolism, — The  thrombus  of  the  small  veins  that  have  been  torn  may 
extend  to  the  large  ones,  and  a  portion  may  be  detached  and  lodge  in  the  heart 
or  in  the  pulmonary  artery.  For  the  symptoms  and  course  the  reader  is 
referred  to  the  section  on  Thrombus  and  Embolism  (p.  58).  Fat  embolism 
(see  p.  96)  has  been  recently  recognized  as  an  occasional  cause  of  death  in 
the  first  few  days  after  the  receipt  of  a  fracture.  Liquid  fat  set  free  by  the 
crushing  of  the  marrow  passes  into  the  open  veins  and  lodges  in  the  pulmonary 
capillaries.  The  symptoms  are  not  constant  or  characteristic ;  there  may  be 
sudden  dyspnea  with  subsequent  oedema  of  the  lungs,  or  there  may  be  only 
prostration  without  dyspnea,  but  with  cyanosis,  quick,  feeble  pulse,  and  coarse 
rdles.  In  some  cases  the  symptoms  resemble  those  of  shock,  from  which  the 
affection  is  to  be  distinguished  by  its  antecedent  period  of  comparative  well- 
being. 

Rupture  of  a  large  artery  may  be  caused  by  stretching  or  by  perfora- 
tion ;  the  blood  escapes  freely  until  the  resistance  of  the  soft  parts  checks  it, 
and  then  a  traumatic  aneurysm  forms.  The  general  })ractice  is  to  postpone 
active  treatment  of  the  injury  of  the  artery,  if  possible,  until  repair  of  the 


FRACTURES.  293 

fracture  has  taken  place.     The  l)rnisiii;f  of  an  artery  nuiy  l>o  followed  within  a 
few  linins  l)y  tlie  formation  of  an  obstruetiiif^  thrombus  witliin  it. 

Gangrene  may  be  the  result  of  direct  bruising  of  the  soft  ])arts  or  of 
interference  with  the  circulation  in  the  large  vessels  arising  from  their  injury 
or  compression  by  a  displaced  fragment  or  from  the  pressure  of  a  bandage.  It 
may  be  partial  or  may  involve  the  limb  as  far  up  as  the  seat  of  the  fracture. 

Septicemia  and  pyemia  occur,  as  a  rule,  only  after  compound  fracture, 
and,  it"  the  fracture  is  treated  antiseptically,  are  very  rare. 

Tetanus  is  a  rare  complication,  and  is  seen  most  frequently  after  com- 
poun-d  fracture. 

Delirium  tremens  is  a  frequent  complication  of  fracture  in  adults  addicted 
to  the  use  of  alcohol.  It  is,  as  a  rule,  milder  than  the  delirium  tremens  that 
develops  without  an  injury.  Warning  of  its  approach  is  given  by  agitation 
and  in.somnia,  and  it  can  often  be  aborted  or  arrested  by  the  vigorous  use  of 
sedatives.  The  outbreak  seems  generally  to  be  due  to  the  cutting  off  of  the 
daily  ration  of  alcohol,  which  is  usually  the  result  of  the  accident  and  the 
admission  to  a  hospital;  and  this  indicates  the  advisability  of  continuing  mode- 
rate stimulation  for  the  first  week  or  two  in  patients  Avho  are  habitual  drinkers. 

Treatment. — By  the  reduction  or  setting  of  a  fracture  is  meant  the  res- 
toration of  the  displaced  fragments  to  their  normal  position,  or  at  least  to  that 
in  which  it  is  desired  that  reunion  shall  take  place.  The  manipulations  com- 
monly employed  are  traction  upon  the  lower  fragment  to  correct  overriding  or 
angular  displacement,  and  direct  pressure  to  correct  lateral  displacement  or 
longitudinal  separation.  Reduction  should  be  made  as  completely  and  as 
promptly  as  circumstances  will  permit,  having  regard  to  the  condition  of  the 
patient  and  of  the  limb.  If  there  are  severe  associated  injuries  and  the  shock 
is  great,  it  is  Avell  to  wait  for  reaction,  and  meanwhile  to  immobilize  the  parts 
in  partial  reduction  with  simple  dressings ;  if  the  limb  is  greatly  swollen  it 
may  be  impossible  to  restore  it  to  its  full  length  without  causing  dangerous 
pressure.  An  anesthetic  may  be  required  to  overcome  the  opposition  of  the 
muscles;  and  in  the  case  of  a  fracture  near  to  or  involving  a  joint  anesthesia 
is  doubly  valuable,  both  to  recognize  the  details  of  the  fracture  and  to  facili- 
tate the  complete  and  accurate  readjustment  of  the  parts. 

Usually  no  greater  force  is  required  to  effect  reduction  than  that  which  can 
be  exerted  by  the  hands  of  the  surgeon  or  of  an  assistant,  but  in  some  impacted 
fractures  the  fragments  are  so  firmly  wedged  together  or  one  is  so  small  or  inac- 
cessible that  reduction  cannot  be  made.  Traction  is  made  by  grasping  the 
lower  segment  of  the  limb  and  pulling  firmly  and  steadily  upon  it ;  coaptation 
is  made  by  the  direct  pressure  of  the  fingers  and  thumbs  upon  the  fragments 
close  to  the  fracture;  angular  displacement  in  "green-stick  "  fracture,  and  in 
others  where  it  is  not  combined  with  overriding,  is  corrected  without  traction 
by  forcibly  bending  the  bone  back  into  line.  If  there  is  so  much  crushing  of 
the  spongy  end  of  a  bone  that  the  restoration  of  the  fragments  to  their  normal 
position  would  leave  an  important  gap  between  them,  the  restoration  should 
not  be  made,  but  the  fragments  should  be  left  in  contact. 

Permanent  dressings  have  for  their  main  object  the  prevention  of  dis- 
placement of  the  fragments  by  the  action  of  the  muscles  or  by  external  forces, 
especially  gravity.  The  means  by  which  this  object  is  to  be  attained  vary 
greatly  in  the  different  fractures,  but  in  most  cases  they  consist  of  some  form 
of  lateral  support,  often  combined  with  permanent  traction  upon  the  lower  seg- 
ment of  the  limb.  Dressings  applied  circularly  about  a  limb  expose  it  to  the 
danger  of  constriction,  and  consequent  gangrene,  if  swelling  should  occur  after 
the  dressing  has  been  applied,  and  therefore,  as  a  general  rule,  such  should  not 


294 


,LV    A.VEEICAX    TKXT-noOk'    OF   SURGERY. 


Fig.  78. 


be  used  during  the  first  few  days,  or  if  used  should  be  frequently  inspected. 
If  applied  while  the  limb  is  swollen,  they  are  lialde  to  be  made  too  loose  by  the 
subsidence  of  the  swelling  and  to  need  renewal  or  readjustment.  As  a  general 
rule,  a  roller  bandage  should  not  be  applied  to  the  limb  under  the  splints ;  it 
will  rarely  do  good,  and  may  do  great  harm.  Another  rule  is  to  include  in  the 
dressings  the  joints  at  either  end  of  the  broken  bone. 

The  simplest  form  of  lateral  support  is  that  furnished  by  wooden  splints : 
they  should  be  longer  than  the  broken  bone,  of  such  breadth  and  tliickness 
that  they  will  not  yield  under  the  weight  of  the  limb,  and  siiould  be  thickh' 
padded  with  cotton  to  fit  the  contour  of  the  limb  or  placed  over  detached  cush- 
ions made  for  the  purpose ;  they  are  made  fast,  one  on  each  side,  with  strips 
of  adhesive  plaster,  straps,  or  a  roller  bandage ;  they  should  be  so  wide  that 
the  enveloping  bands  will  not  circularly  constrict  the  limb.  Projecting  bony 
points  should  be  protected  by  thick  padding  about  them,  not  on  them.  Carved 
wooden  splints  made  to  fit  average  limbs  rarely  have  advantages 
commensurate  with  their  cost.  Gooch's  flexi])le  Avooden  splints 
(Fig.  78)  made  of  thin  strips  of  wood  fastened  close  together  on  a 
muslin  backing  are  convenient  in  some  cases.  They  can  be  easily 
made  by  fastening  the  strips  upon  a  sheet  of  adhesive  plaster. 

Fracture-boxes  are  essentially  a  combination  of  lateral  and  pos- 
terior splints,  and  are  used  only  for  fractures  of  the  leg.  They 
consist  of  a  long  rectangular  piece  of  Avood  with  two  hinged  sides 
and  a  movable  foot-piece.  The  central  posterior  piece  is  first  well 
covered  with  cotton,  oakum,  or  bran ;  the  limb  is  laid  upon  it  and 
the  foot  bound  to  the  foot-piece ;  then  the  sides  are  turned  up,  Avith 
interposed  padding,  and  bound  to  each  other  across  the  front  of  the 
leg  by  cords  or  bands  running  through  holes  made  for  the  purpose. 
To  avoid  troublesome  pressure  upon  the  heel  the  foot  may  be  sus- 
pended by  a  long  and  not  too  narrow  strip  of  adhesive  plaster  run- 
ning from  the  middle  of  the  calf  along  the  back  of  the  leg  to  the 
Gooch's        heel,  and  up  past  the  sole  of  the  foot  to  the  top  of  the  foot-piece. 

Flexible  .     ^  .  ^  . 

Wooden        After  application  of  a  fracture-box  or  any  equivalent  apparatus 

(Stimson).      suspension  from  a  horizontal  bar  held  up  by  tAvo  vertical  side-pieces 

is  often  of  great  advantage. 

Volkmann  s  splint  is  a  convenient  substitute  for  a  fracture-box,  and  very 

useful  as  a  temporary  dressing  for  fractures  of  the  leg.     It  is  a  shalloAv  gutter 

of  tin  with  a  foot-piece  and  a  movable  support  by  AA'hich  the  loAver  end  is  held 

at  a  convenient  height  above  the  bed. 

Wire  gauze  is  a  convenient  dressing  for  fractures,  since  it  is  flexible  enough 
to  adapt  itself  to  the  varying  dimensions  of  the  limb  under  the  pressure  of  a 
roller  bandage,  and  ca.n  be  bent  to  fit  the  elboAV  or  ankle  by  cutting  it  partly 
through  on  the  sides. 

Moulded  splints  can  be  made  of  any  material  that  can  be  temporarily  soft- 
ened so  as  to  be  fitted  to  the  limb  and  Avill  then  harden  and  retain  the  shape 
that  has  been  given  to  it.  For  the  lighter  splints  plaster  of  Paris,  pasteboar(l. 
leather,  felt,  and  gutta-percha  are  used  ;  for  the  heavier  ones  plaster  of  Paris  is 
the  most  convenient.  To  make  a,  plaster-of-Paris  splint  (Fig.  79)  the  surgeon 
cuts  strips  of  gauze,  coarse  muslin,  or  thin  blanketing  of  the  desired  length 
and  width,  and  soaks  them  Avith  freshly-prepared  plaster  of  the  consistency  of 
thick  cream  ;  he  then  squeezes  out  the  superfluous  Avater,  covers  the  limb  tliickly 
with  vaseline,  applies  the  splint,  and  secures  and  at  the  same  time  moulds  it  to 
the  limb  Avith  a  roller  bandage  ;  after  it  has  hardened  he  removes  the  roller  and 
secures  the  splint  by  circular  turns  at  two  or  three  points.     If  sharp  angles  are 


FBA  CTURES. 


295 


made,  as  at  the  elbow  or  ankle,  the  fit  can  be  improved  by  notching  the  splint 
while  it  is  still  soft  and  slipping  one  edge  of  the  cut  under  the  other.     Such 


Fig. 79. 


Fig.  80. 


Posterior  Plasterof-Faris  Splint  or  Gutter 
(Stimson). 


Plaster-of-Paris  Dressing,  made  of  coarse  saclicloth 
(Esmarch). 


splints  are  very  useful  in  the  treatment  of  fractures  of  the  leg,  but  are  not 
strong  enough  for  those  of  the  femur;  they  may  be  applied  Avhile  the  injury  is 
still  recent,  and  permit  inspection  without  having  to  be  removed. 

The  plaster-of -Paris  bandage  for  complete  encasement  of  the  limb  is  most 
conveniently  made  by  using  gauze  rollers  that  have  been  prepared  by  thorough 
filling  with  dry  plaster.  The  limb  is  enveloped  in  cotton  or  other  soft  material, 
and  then  the  prepared  roller  bandages,  after  having  been  thoroughly  wet,  are 
applied  in  the  usual  manner.  Or  strips  of  some  coarse  material  soaked  m  pias- 
ter cream  may  be  applied,  as  shown  in  Fig.  80.  They  can  be  fenestrated  at 
any  point  by 'cutting  out  a  piece  after  the  plaster  has  hardened,  or  may  be 
"interrupted,"  the  two  segments  being  attached  to  each  other  by  iron  bands 
n  set  into  the  dressing.'    Similar  dressings  can  be  made  with  sili- 

cate of  soda,  dextrin,  starch,  or  glue. 

In  order  that  such  a  dressing  shall  prevent  shortening  of  the  limb  within 
it,  it  is  essential  that  it  should  have  a  bearing  against  bony  prominences  or  a 
flexed  secrment  of  the  limb  above  and  below  the  fracture  :  such  points  ot  counter- 
pressure  "are  easily  found  in  the  leg  and  forearm,  but  with  difficulty  m  fractures 
of  the  arm  and  thigh.  i        r  ^■  a 

If  any  splint,  or  still  more  any  circular  encasement,  has  been  applied 
shortly  after  the  receipt  of  the  injury,  it  should  be  inspected  at  intervals  of 
a  few  hours  for  the  first  day  or  two,  with  the  view  of  loosening  it  at  once  it 
it  should  prove  to  have  been  too  tightly  applied  or  if  it  should 'have  beconie 
too  tight  in  conse(iuence  of  the  subsequent  inflammatory  swelling  of  the  limb. 
The  patient  and  his  friends  should  be  warned  of  the  possibility  of  strangula- 


296 


AN  AMERICAN   TEXT- HOOK    OF  SURGERY. 


tion  of  the  limb,  and  instructed  to  watch  the  color  and  temperature  of  its 
distal  portion,  which,  for  this  reason,  should  always  be  left  uncovered  by  the 
dressing.  It  is  almost  always  advisable  to  use  during  the  first  few  days  splints 
that  can  be  easily  loosened  or  which  will  permit  swelling  to  take  place  without 
causing  dangerous  constriction  ;  and  then  after  the  swelling  has  notably 
diminished  to  readjust  the  splints  or  apply  a  permanent  immovable  dressing. 

Ambulant  Treatment. — In  fijicture  of  the  leg  a  i)lasterspliiit  can  be  made 
so  that  the  patient  can  walk  about  on  it  after  the  first  week.  Alaverof  cotton  two 
inches  thick  is  bound  under  the  sole  by  a  few  turns  of  the  bandage,  and  then  a 
plaster  sole,  made  of  eight  or  ten  layers  of  gauze,  added  and  firmly  included  in  the 
dressing.  The  foot  is  to  be  in  moderate  flexion,  so  that  the  patient  is  made  to  walk 
ujion  his  heel.  Theleg  portion  ofthes))lint  should  be  applied  directly  to  the  skin, 
or  with  only  a  thin  layer  of  cotton  interposed,  and  should  be  snugly  moulded 
to  fit  the  expanded  upper  portion  of  the  tibia  and  fibula.  If  the  fracture  is 
above  the  lower  third,  the  dressing  should  be  carried  up  above  the  knee. 
Patients  with  fracture  of  the  thigh  can  also  be  enabled  to  walk  about  by 
supplying  them  with  a  plaster  dressing  and  adding  an  apparatus  like  the 
splints  used  in  cases  of  hip  disease.  The  advantages  claimed  for  this  "  ambu- 
latory method  "  are  the  avoidance  of  the  risks  of  confinement  to  bed,  less 
atrophy  of  the  muscles  and  stiffness  of  joints,  and  shorter  convalescence. 

The  methods  for  applying  continuous  traction  to  the  lower  segment 
of  the  broken  limb  include  the  double  inclined  plane,  suspension,  Buck's  exten- 
sion, and  india-rubber  bands  in  combination  with  side-splints. 

The  double  inclined  plane  (Fig.  81)  is  sometimes  used  in  fractures  of  the 


Fig.  81 


Jismarch"s  Double  Inclined  Plane  (^Esmarch  and  Kowalzig). 

thigh ;  it  is  made  of  a  short  thigh-  and  a  long  leg-piece  hinged  together  at  tne 
knee,  and  hinged  at  the  upper  end  of  the  thigh-piece  to  a  long  underlying  third 
piece,  as  shown  in  the  figure.  Traction  is  made  by  the  weight  of  the  pelvis  as 
it  sinks  in  the  bed. 

In  Buck's  extension,  a  very  popular  method  of  treating  fractures  of  the 
femur,  the  traction  is  effected  by  a  weight  attached  to  the  leg  by  a  cord  which 
runs  over  a  pulley  at  the  foot  of  the  bed.  This  attachment  is  made  by  adhesive 
plaster,  the  introduction  of  which  constituted  an  immense  improvement  in  the 
treatment  of  these  fractures.  It  is  applied  as  follows :  A  strip  of  stout  adhe- 
sive plaster,  four  or  five  inches  wide  and  long  enough  to  reach  from  well  above 
the  knee  loosely  around  the  sole  of  the  foot  and  back  to  the  same  height  above 

Fig.  82. 


Adhesive  Plaster  cut  for  Buck's  Extension  (Stimson). 

the  knee,  is  cut  as  shown  in  Fig.  82 ;  a  piece  of  wood  five  by  three  inches  and 
perforated  at  its  center  is  placed  at  the  middle  of  the  strip,  the  edges  of 


FRA  CTUBE8. 


297 


A\  bicli  are  turned  down  ovtjr  it  and  over  each  other,  as  shown  in  Fig.  83 ;  a 
stout  cord  is  then  passed  through  the  hole  in  the  piece  of  wood  and  its  end 


Fio.  83. 


Adhesive  Plaster  folded  for  Buck's  Extension  (Stimson). 

is  tied  in  a  knot.  A  roller  bandage  is  applied  to  the  foot  and  the  lower  third 
of  the  leg ;  the  adhesive  plaster  is  then  applied  to  the  sides  of  the  leg  and 
thigh  above  it,  and  secured  by  continuing  the  bandage  upward  (Fig.  84). 
The  cord  is  then  carried  over  a  pulley  at  the  foot  of  the  bed  and  attached  to 
the  weight,  ten  to  twenty  pounds  according  to  circumstances.  The  foot  of 
the  bed  must  be  raised,  to  obtain  the  counter-extension  by  the  weight  of 
the  body.      Outward  rotation  is  prevented  by  securing  the   limb  to  a  long 


Adhesive  Plaster  applied  for  Extension  (Stimson). 


side-splint   having  a  cross-piece    at   its   lower    end    that   rests    on    the    bed, 
or,  better,  by  placing  the  leg  on  a  Volkmann's  sliding  rest  (Fig.  85)  which 


Fig.  85. 


Buck's  Apparatus  with  Volkmann's  Sliding  Rest  for  Fractures  of  the  Thigh. 

is  composed  of  two  side-pieces  about  two  feet  long  and  eight  inches  apart,  on 
which  rest  by  two  cross-pieces  a  posterior  splint  and  foot-piece,  to  which  the 


298 


AN  AMERICAN    TEXT- HOOK    OF  srilGKllY. 


foot  and  leg  are  attached  in  the  usual  manner.  Instead  of  the  weight  and  jiul- 
li'V  an  india-rubber  cord  may  be  used,  ^riu'  attachment  to  tlio  limb  is  made  by 
adhesive  plaster.     Fig.  8G  shows  such  an  a})i)aratus  in  use  for  fractures  of  the 


Double  pulley. 


!3KS!?ra^ 


3^ 


3: 


Ind.  Rubber  Aecumulalor. 


Cripps'  Splint. 


thigh.  Vertical  suspension  of  the  limb  by  a  rubber  cord  attached  to  the  limb 
by  adhesive  plaster  is  sometimes  useful  in  fractures  of  the  humerus  close  to 
the  elbow,  and  is  common  in  the  treatment  of  fractures  of  the  thigh  in  young 
children. 

Nathan  R.  Smith's  anterior  splint  (Fig.  87)  acts  like  the  double  inclined 


Fig.  87. 


Nathan  K.  Smith's  Autcmu-  .■'jilinl. 

plane  when  the  suspension  is  vertical,  and  like  Buck's  extension  when  it  is 
oblique. 

Hodgens  splint  (Fig.  88)  acts  on  the  princijde  of  Buck's  extension,  and 
has  the  additional  advantages  of  slight  flexion  of  the  knee  and  of  greater  facil- 
ity in  moving  the  patient  in  bed.  It  consists  of  two  lateral  iron  rods  con- 
nected by  a  straight  cross-piece  at  the  lower  end  and  a  curved  one  at  the 
upper  end.  Lateral  strips  of  adhesive  plaster  are  applied  to  the  limb,  as  in 
Buck's  extension,  and  their  projecting  ends  made  fast  to  the  foot-piece.  Five 
or  six  narrow  compresses  or  pieces  of  bandage  are  run  across  from  one  rod  to 
the  other  beneath  the  limb,  and  so  adjusted  as  to  give  uniform  support  to  it 
Avhen  the  apparatus  is  raised  from  the  bed.  The  point  of  attachment  of  the 
supporting  cord  should  be  at  least  four  feet  above  the  bed,  and  the  cord  should 
be  inclined  about  ten  degrees  from  the  vertical  (toward  the  foot  of  the  bed, 
of  course).     The  greater  the  inclination  the  greater  the  traction. 

Treatment  of  Compound  Fractures. — Oneof  the  chief  advances  made 
possible  by  antiseptic  surgery  is  in  the  results  now  achieved  in  the  treatment 
of  compound  fractures.  Formerly  they  were  excessively  dangerous  accidents 
from  septic  infection ;  now  this  danger  has  been  almost  entirely  eliminated. 
But  all  depends  on  the  proper  and  thoroughly  anti.septic  character  of  the  first 
dressing. 

This  dressing  of  a  compound  fracture  is  often  ecjuivalent  to  a  major 


FBA  CTURES. 


29i> 


surgical  operation,  re([uiring  the  aid  of  anesthesia,  the  use  of  instruments,  and  the 
protection  of  antiseptic  measures.   After  anesthetization,  the  surface  of  the  limb 


Fig. 


Hodgen's  Splint  (original). 

all  about  the  wound  is  thoroughly  washed,  shaved,  and  purified.  By  "  purifying  " 
is  meant  securing  the  most  thorough  antiseptic  cleansing  of  the  entire  interior 
as  well  as  exterior  of  the  wound  in  every  nook  and  corner  of  possible  infec- 
tion. This  is  a  sine  qud  non.  If  covered  with  machinery  grease,  etc.,  thorough 
rubbing  with  sweet  oil  or  with  turpentine  and  alcohol  before  scrubbing  with 
soap  and  water  greatly  facilitates  the  proper  cleansing.  Blood-clots  and  loose 
splinters  are  removed,  wounded  vessels  tied,  divided  nerves  and  tendons  sutured, 
the  ends  of  the  fragments  sparingly  trimmed  if  necessary,  contused  tissues  cut 
away,  counter-openings  made  for  drainage,  and  the  cutaneous  wound  sutured. 
A  thick  antiseptic  dressing  is  applied,  and  over  all  is  placed  such  retentive 
apparatus  as  is  suitable.  The  main  indication  is  to  secure  early  union  of  the 
cutaneous  Avound :  while  this  is  taking  place  it  is  desirable  that  the  fragments 
should  remain  properly  reduced  ;  but  this  is,  in  a  measure,  of  secondary  import- 
ance, for  a  final  readjustment  can  usually  be  made  in  the  second  or  even  the 
third  week.  But  if  the  wound  in  the  skin  is  small  and  clean,  it  is  advisable 
to  limit  interference  to  its  irrigation,  to  the  setting  of  the  fracture  as  if  it  were 
simple,  and  to  the  application  of  an  antiseptic  dressing,  and  then  after  the  lapse 
of  a  week,  when  the  wound  will  probably  have  healed,  to  remove  the  dressing 
and  make  permanent  reduction  and  retention  if  it  has  been  impossible  to  effect 
this  at  the  primary  dressing. 

The  use  of  metallic  sutures  and  similar  devices  to  maintain  the  fragments 
in  contact  with  each  other  is  rarely  advisable,  since  sufiicient  support  can 
usually  be  given  by  an  external  apparatus,  and  the  presence  of  the  foreign 
body  appears  somewhat  to  retard  bony  union. 

If  siqrpuration  follow  from  prior  infection,  the  limb  must  be  placed  in  a 
splint  that  will  permit  the  removal  of  the  dressings  with  the  minimum  of  dis- 


:i()0  AX  AMERICAN   TEXT-llOOK    OF  SURGERY. 

turbance  of  the  fra<i;ments.      Somo  form  of  int('rni|)tcMl  piaster  or  suspended 
splint  may  be  applied,  and  later  indications  mot  as  they  arise. 

Concerning  the  propriety  of  in-'unarij  atiiputation  or  excision  of  a  joint 
definite  rules  cannot  be  laid  down ;  each  case  must  be  judged  according  to  the 
extent  of  the  injury,  the  probable  usefulness  of  the  limb  if  saved,  and  the 
ability  to  protect  against  suppuration  and  septic  infection.  The  protection 
afforded  by  attention  to  the  modern  principles  of  treatment  of  wounds  is  such 
that  in  doubtful  cases  the  patient  may  safely  take  the  l)enefit  of  the  doubt  and 
be  given  an  opportunity  to  shoAv  whether  or  not  the  limb  can  be  saved. 

After-treatment. — After  union  of  a  broken  bone  has  been  obtained 
the  surgeon's  attention  may  be  directed  to  hastening  the  complete  return  of 
function,  the  disappearance  of  congestion  and  turgescence,  the  reduction  of 
the  stiffness  of  neighboring  joints,  and  the  strengthening  of  the  muscles. 
The  roughness  of  the  skin,  turgescence  of  the  limb,  and  weakness  of  the 
muscles  can  be  relieved  by  massage  and  electricity,  and  in  the  case  of  the  leg 
comfort  Avill  often  be  promoted  by  snug  bandaging  during  the  day.  Stiffness 
of  joints  at  a  distance  from  the  fracture  will  usually  disappear  under  ordinary 
use,  but  special  attention  may  be  needed  at  the  ankle  to  obtain  dorsal  flexion 
within  a  right  angle.  Stiffness  of  the  fingers  in  the  old  and  rheumatic  is 
very  likely  to  folloAV  simple  immobilization  and  to  be  very  persistent.  It 
should  be  guarded  against  by  leaving  the  fingers  uncovered  during  treatment 
of  the  fracture  whenever  that  is  possible,  and  encouraging  the  patients  to  use 
them  ;  when  it  is  necessary  to  immobilize  them  during  treatment,  they  should 
be  kept  flexed,  since  stiffness  is  less  likely  to  take  place  in  that  than  in  the 
extended  position. 

When  the  fracture  is  in  the  immediate  neighborhood  of  a  joint,  nothing 
should  be  done  in  the  way  of  passive  or  voluntary  motion  until  after  union 
is  complete  or  at  least  nearly  so,  and  then  should  be  done  with  great  care. 
The  same  should  be  the  rule  also  Avhen  the  fracture  actually  involves  the 
joint,  as  at  the  elbow.  The  most  that  is  permissible  is  the  occasional  slight 
change  of  the  angle  at  which  the  joint  is  immobilized. 

As  regards  passive  motion,  it  is  rarely  re(iuired  or  even  useful,  and  as  so 
often  employed,  under  ether  or  with  production  of  pain,  it  is  actually  harm- 
ful. The  stiffness  of  a  joint  after  fracture  involving  it  or  in  its  immediate 
neighborhood  is  due  either  to  mechanical  changes  in  the  joint-surfaces  or  the 
relations  of  the  bones,  which  cannot  be  materially  changed  by  passive  motion, 
or  to  periarticular  thickening  the  result  of  the  traumatism,  which  will  disap- 
pear, if  its  disappearance  is  possible,  under  ordinary  (juiet  use,  and  will  only 
be  increased  and  prolonged  by  forcible  motion,  which  means  the  infliction  of 
further  injury. 

PsEUDARTHROSiS  AND  DELAYED  Union.* — When  abnormal  mobility  has 
not  ceased  after  the  usual  lapse  of  time,  the  condition  is  described  as  delayed 
union  ;  if  tliis  condition  persists  after  some  additional  weeks,  it  is  termed 
pseudarthrosis,  or  failure  of  union,  or  ununited  fracture.  Delayed 
union  is  not  very  uncommon,  but  failure  of  union  is  relatively  rare;  most  of  the 
sases  occur  in  middle  life,  and  most  frequently  in  the  humerus,  tibia,  and  femur 
in  the  order  mentioned.  In  proportion  to  the  number  of  fractures  of  the  respect- 
ive bones,  delayed  union  and  fiiilure  of  union  occur  more  frequently  after  frac- 
ture of  the  shaft  of  the  femur  than  after  that  of  the  tibia.  Anatomically,  two 
distinct  varieties  exist :  in  one  the  fragments  are  more  or  less  closely  bound 
together  by  solid  bands  of  fibrous  tissue,  sometimes  enclosing  nodules  of  bone; 

'  The  fibrous  union  witli  ])ersistent  mobility  wliich  is  the  rule  after  fracture  of  the  patella 
and  of  some  apophyses  will  not  be  here  considered. 


FBA  CTURES.  30i 

in  the  otlier  similar  fibrous  bands  enclose  a  central  cavity  containing  a  viscid 
synovia-like  licjuid,  into  which  tlie  ends  of  the  fragments  may  project;  and 
these  ends  may  be  smooth  and  eburnated  or  even  covered  by  hyaline  cartilage 
— a  complete  new  joint.  The  clinical  difference  between  the  two  varieties  is 
important,  as  will  appear  when  their  treatment  is  considered. 

The  reason  of  delay  or  of  failure  of  union,  in  the  great  majority  of  cases, 
lies  in  the  arrest  of  the  evolution  of  the  callus  before  it  has  entered  upon 
the  stage  of  ossification — /.  e.  its  persistence  as  fibrous  tissue ;  in  others  the 
separation  of  the  fragments  is  so  great  and  the  gap  so  broken  by  interposed 
muscle  that  a  continuous  callus,  formed  by  granulations  springing  from  the 
bones,  has  never  existed,  and  the  fibrous  bond  is  composed  solely  of  the  thick- 
ened surrounding  connective  tissue.  The  ends  of  the  fragments  are  variously 
affected  in  accordance  with  the  extent  of  the  rarefying  and  productive  pro- 
cesses which  follow  the  injury ;  according  as  one  or  the  other  predominates  the 
ends  are  diminished  in  size,  sometimes  to  slender  conical  points,  or  enlarged  by 
the  formation  of  irregular  masses  of  bone  upon  them.  In  a  very  few  cases 
the  rarefying  process  has  gone  so  far  that  a  large  portion,  or  even  the  whole,  of 
the  shaft  has  gradually  disappeared.  This  tendency  to  excessive  rarefaction, 
when  present,  is  a  serious  obstacle  to  the  success  of  operations  undertaken  to 
secure  union,  and  it  has  seemed  to  some  writers  to  be  increased  by  the  presence 
of  metallic  sutures  binding  the  fragments  together.  Occasionally  the  fragments 
are  in  close  apposition  by  their  broad  surfaces,  the  fibrous  bond  is  short  and 
complete,  and  the  fragments  are  enlarged  by  peripheral  productions  of  bone, 
and  yet  ossification  of  the  short  fibrous  bond  fails. 

The  resultant  disability  varies  with  the  amount  of  abnormal  mobility  and 
the  uses  to  which  the  limb  is  put :  thus,  failure  of  union  in  the  leg  or  thigh 
may  make  the  limb  wholly  useless,  while  in  the  arm  or  forearm  it  may  interfere 
but  slightly  with  its  usefulness. 

With  respect  to  the  cause,  certain  general  conditions  have  seemed  at  times 
to  delay  repair,  such  as  syphilis,  pregnancy,  and  acute  general  diseases,  but 
the  common  causes  are  local.  Advanced  age  is  not  a  cause.  The  local  causes 
are  separation  of  the  fragments  (by  displacement  or  by  loss  of  substance),  the 
interposition  of  a  foreign  body  or  of  a  portion  of  muscle,  disease  of  the  bone, 
defective  blood-supply,  defective  innervation,  inflammation  on  the  surface  of 
the  limb,  and  faulty  treatment. 

The  first  three  act  mechanically  by  creating  a  gap  that  cannot  be  filled  by 
the  granulations,  and,  in  addition,  in  the  third  the  surfaces  may  be  so  modified 
by  the  disease  (syphilis,  caries,  cancer,  etc.)  that  they  are  unfit  to  furnish 
the  necessary  granulations.  Defective  blood-supply,  the  result  of  injury  to 
the  nutrient  artery  of  the  bone  or  to  the  main  artery  of  the  limb,  has  often 
been  alleged  as  a  cause,  but  satisfactory  proof  is  lacking  and  theoretical  con- 
siderations do  not  furnish  much  support.  The  influence  of  defective  innerva- 
tion has  been  shown  in  some  fractures  of  the  lower  limb  combined  with  injury 
to  the  lower  part  of  the  spinal  column ;  it  appears  to  arise  not  from  the  same 
cause  that  produces  the  paralysis  of  motion,  for  such  delay  does  not  occur  in 
paraplegia  due  to  injury  at  the  upper  part  of  the  spinal  column,  but  from  injury 
to  trophic  centers  in  the  lower  part  of  the  cord.  The  influence  of  surface 
inflammation  has  been  occasionally  shown  in  the  delay  of  repair  or  in  the  soften- 
ing of  a  firm  callus  coincidently  with  the  appearance  of  an  erysipelas  or  a 
phlegmon  of  a  limb. 

Excluding  incomplete  reduction,  the  fault  in  treatment  which  is  most  likely 
to  delay  or   prevent   repair  is  insufiicient  immobilization.     Its  influence  is 


302  AN  AMERI(A.\    TKXT-nOOK   OF  SURGERY, 

unquestionable,  altliough  of  course  it  is  knoAvn  that  union  may  take  place 
in  spite  of  it.  It  is  tii()ut:;ht  that  the  relative  frequency  of  lailure  of  union 
after  fracture  of  the  humerus  is  largely  due  to  this  cause.  The  local  applica- 
tion of  cold  is  also  thought  to  retard  union.  It  has  been  asserted  also  that 
treatment  by  couq)lete  encasement  of  the  limb  in  a  plaster-of-Paris  bandage  is 
followed  by  a  larger  proportion  of  delays  and  failures  than  is  the  case  where 
other  methods  are  enqjloyed,  and  that  the  increase  is  due  to  the  shutting  out 
of  air  and  light  from  the  limb  :  a  more  probable  explanation  of  the  frecjuency, 
if  it  actually  exists,  is  defective  immobilization.  Piemature  use  of  the  limb 
may  be  followed  by  a  gradual  return  of  the  abnormal  mobility,  as  well  as  by 
distinct  refracture ;  and  a  similar  occurrence  has  been  observed  under  the 
influence  of  intercurrent  diseases  weeks  or  even  months  after  union  appeared 
to  be  complete. 

Treatment. — If  a  general  cause  exists,  such  as  syphilis  or  malnutrition, 
measures  should  be  taken  to  remove  it,  whether  the  case  is  one  of  delayed 
union  or  of  failure  of  union.  In  delayed  union  of  short  duration,  and  with 
only  slight  mobility  and  displacement,  much  is  to  be  hoped  from  time,  aided  by 
accurate  immobilization  by  splints  that  will  permit  the  patient  to  leave  his  bed. 

A  gratifvino;  number  of  successes  in  fractures  of  the  letj  and  thigh  have 
been  obtained  by  the  use  of  orthopedic  splints.  In  a  number  of  cases  of 
delayed  union  of  the  leg  union  has  gradually  become  complete  while  the  patient 
was  using  the  limb  under  the  protection  of  a  suitable  splint :  it  is  thought  that 
the  slight  irritation  caused  by  bearing  the  weight  upon  the  limb  favors  ossifica- 
tion. On  the  same  theory  percussion  of  the  bone  at  the  fracture  has  been  used. 
If  the  case  is  of  longer  standing  and  the  mobility  greater,  a  more  decided  local 
irritation  is  required — one  that  will  bring  the  parts  more  nearly  to  the  condi- 
tion of  a  recent  fracture  and  start  the  process  of  repair  afresh.  Under  anesthe- 
sia the  limb  is  forcibly  bent  at  the  seat  of  fracture,  care  being  taken  not  to 
injure  main  vessels  and  nerves.  The  bending  should  be  nearly  or  quite  to  a 
right  angle,  and  the  laceration  should  be  sufficient  to  permit  a  jfiiirly  complete 
reduction  if  there  has  been  previous  displacement.  The  fracture  is  then  treated 
as  a  recent  one. 

Direct  irritation  of  the  ends  of  tlie  bones  can  be  produced  by  subcutaneous 
drilling,  but  it  seems  better,  and,  if  antiseptically  done,  is  equally  safe,  to  expose 
the  bone  by  incision  and  apply  the  drill  under  the  guidance  of  the  eye  and 
finger :  it  should  be  forced  into  the  end  of  each  fragment  at  several  points. 
This  plan  is,  in  the  writer's  judgment,  more  efficient  than  the  permanent  intro- 
duction of  metallic,  bone,  or  ivory  pins. 

Excision  of  the  fibrous  tissue  and  of  the  end  of  each  fragment  is  the  only 
means  that  will  cure  old  cases  and  those  in  which  a  joint-cavity  has  formed 
between  the  fragments.  Under  the  protection  of  antiseptic  treatment  of  the 
wound  it  has  become  a  popular  method,  and  has  proved  safe  and  efficient.  The 
bones  should  be  freely  exposed,  and  their  surfaces  freshened  and  fitted  to  each 
other — preferably  by  a  transverse  section,  if  that  does  not  recjuire  the  removal 
of  too  much  tissue — and  the  periosteum  should  be  stitched  together  as  exten- 
sively as  is  practicable.  Buried  or  temporary  sutures  of  silver  wire  or  of  strong 
silk  are  sometimes  used  to  bind  the  fragments  together  and  prevent  displace- 
ment ;  as  are  also  long,  narrow  metal  plates  on  each  side  of  the  bone,  crossing 
the  line  of  fracture  and  secured  to  the  fragments  by  long  pins  that  are  left  pro- 
jecting beyond  the  skin  and  are  removed  after  two  or  three  weeks,  the  plates 
being  left  to  heal  in. 

The  attempt  has  been  successfully  made  in  a  few  instances  to  obtain  union, 
when  there  was  a  considerable  gap  between  the  fragments  due  to  loss  of  substance, 


FRA  CrURES. 


303 


by  aiUnq  the  gap  with  small  pieces  of  sterilized  decalcified  bone  or  of  fresh  bone 
taken  from  aiiimals:  tlie  intermediate  fibrous  tissue  is  removed,  the  ends  of  the 
fragments  freshened,  and  the 
skin  closed  over  the  inserted 
pieces ;  perfect  asepsis  is  neces- 
sary to  success. 

Finally,  amputation  may  be 
required  to  rid  the  patient  of  a 
useless  and  troublesome  limb. 

Faulty  Union. — An  opera- 
tion may  be  required  to  relieve 
a  disability  due  to  union  -with 
deformity  or  to  exuberant  cal- 
lus :  thus,  the  femur  may  have 
united  with  an  angular  displace- 
ment that  causes  effective  short- 
ening of  the  leg  in  such  man- 
ner that  the  foot  does  not  rest 
squarely  on  the  ground  or  is 
outside  the  line  of  support ;  or 
the  bones  of  the  forearm  may 
unite  with  a  callus  that  prevents 
rotation  ;  or  an  exuberant  callus 
may  compress  a  nerve.  Fig. 
89,  from  a  photograph,  is  an 
example  of  union  with  extreme 
deformity.  The  measures  employed  are  subcutaneous  refracture,  osteotomy, 
and  chiselling  away  of  exuberant  bone.    (See  Operations  on  Bones.) 


Faulty  Union  after  Fracture  (original). 


SPECIAL  FRACTUKES. 
FEACTUEES  OF  THE  SUPEEIOE  MAXILLA   AND  MALAE  BONES. 

These  are  caused  only  by  direct  violence,  are  generally  comminuted,  and 
unite  with  great  rapidity.  Displacements  may  often  be  corrected  by  direct 
pressure,  and,  except  in  *^the  case  of  the  alveolar  border,  require  no  retentive 
apparatus.  If  the  anterior  wall  of  the  antrum  has  been  driven  in.  an  incis- 
ion is  made  at  the  junction  of  the  lip  and  gum,  and  the  seat  of  fracture  is 
exposed.  The  depressed  portion  of  bone  is  drawn  into  place  with  a  blunt 
hook  or  a  gimlet,  and  the  incision  is  sutured.  When  a  portion  of  the  alveo- 
lar border,  with  more  or  less  of  the  adjoining  bone,  is  loosened,  it  may  need 
to  be  retained  by  wiring  its  teeth  to  the  neighboring  ones  or  by  keeping  the 
lower  jaw  pressed  against  it. 


FEACTUEE  OF  THE  NASAL  BONES. 

This  is  produced  by  direct  violence,  and  is  often  compound,  either  through 
the  skin  or  through  the  mucosa.  The  fracture  may  extend  to  the  superior 
maxilla  or  to  the  cribriform  plate  of  the  ethmoid;  the  latter  is  a  dangerous 
complication  because  of  the  possibility  of  septic  meningitis.  Cellular  emphysema 
of  the  face  and  evelids,  due  to  the  forcing  of  air  through  the  lacerated  mucosa 
by  efforts  to  clear  the  nostrils,  may  appear.  Repair  takes  place  so  rapidlv  that 
it  is  necessary  to  recognize  and  reduce  displacements  promptly.     Reduction  is 


304 


AN  AMERICAN    TEXT- HOOK    OF  SURGERY. 


best  made  by  pressure  with  a  small  stiff  metal  rod,  like:  a  director,  |)iissc'd  into 
the  nostril.  Ordinarily  there  is  but  little  tendency  to  recurrence  of  the  dis- 
placement, but  it  may  sometimes  be  necessary  to  oppose  it.  A  plan  that  has 
yielded  good  results  is  to  transfix  the  nose  close  beneath  the  fragments  -with  a 
stout  pin,  and  steady  them  ^vitil  a  piece  of  Iiidia-nililier  or  adiiesive  j)Lastcr 
crossing  the  bridge  of  the  nose  and  caught  uiion  the  ends  of  the  pin.  The 
pin  may  be  removed  in  a  week  or  ten  days. 

Suppuration  may  be  followed  by  necrosis  of  the  fragments.  Possibly  it 
could  be  prevented  by  irrigating  the  nostrils  Avith  an  antiseptic  solution  and 
plugging  the  passage  with  iodoform  gauze.  This  should  always  be  done  very 
carefully  if  injury  to  the  cribriform  jdate  is  suspected.  (See  Fractures  of 
the  Base  of  the  Skull  in  the  section  on  Injuries  of  the  Head.) 


FEACTUEE  OF  THE  LOWEE  JAW. 

This  may  be  single  or  double :  single  fractures  are  most  common  at  or  near 
the  median  line ;  those  of  the  ramus  and  condyloid  process  are  much  rarer. 
Double  fractures  may  occupy  one  or  both  sides,  or  one  of  the  fractures  may  be 
in  the  median  line.  They  are  quite  common.  Fractures  of  the  body  of  the 
bone  are  usually  compound ;  those  of  the  coronoid  process  are  extremely  rare, 
and  have  been  found  only  in  connection  with  fractures  of  the  condyle,  zygoma, 
and  malar  bone. 

The  displacement  in  fractures  of  the  body  is  almost  invariably  such  that  the 
level  of  the  teeth  on  one  side  of  the  fracture  is  lower  than  on  the  other,  and 
with  this  is  often  associated  an  antero-posterior  or  lateral  displacement  accord- 
ing to  the  position  of  the  fracture  ;  sometimes  there  is  overriding.  In  fracture 
of  the  ramus  there  is  usually  little  or  no  displacement. 

The  common  cause  is  violence  received  upon  the  chin  or  cheek. 
The  diagnosis  is  readily  made  in  fractures  of  the  body  by  recognition  of 
the  change  in  the  relations  of  the  teeth,  of  abnornuil  mobility  and  crepitus,  and 

usually  of  looseness  of  the  adjoining  teeth  and 
bleeding  from  the  gums.  In  fracture  of  the 
ramus  the  only  symptom  may  be  pain  on  pres- 
sure or  on  tightly  closing  the  jaws.  The  pain 
should  be  sought  for  by  making  pressure  with 
the  finger  within  the  mouth  as  well  as  on  the 
cheek. 

The  course  is  marked  by  swelling  of  the 
face  and  gums,  and  often  by  sujipuration  at 
the  seat  of  fracture,  the  pus  escaping  into  the 
mouth  alongside  the  teeth,  and  also  often  open- 
ing through  the  skin  near  the  lower  border  of 
the  jaw.  Suppuration  may  be  maintained  for 
a  long  time  by  necrosis,  and  may  lead  to  a 
considerable  loss  of  bone  with  consequent  fail- 
ure of  union  and  great  disability. 

Reduction  can  almost  always  be  readily 
eflecte<l  l)y  direct  ])ressure,  but  the  prevention 
of  recurrence  may  be  very  difficult.  In  sim- 
ple cases  treatment  consists  in  the  application 
of  a  "four-tailed  bandage"  (Fig.  iMj),  -which 
should  be  worn  for  four  weeks ;  in  the  more  difficult  cases  recourse  has  been 
had  to  a  great  variety  of  interdental  splints  and  methods  of  wiring  the  bones 


'  Four-tailed  Randape  "  for  Fracture  of 
the  Jaw  (Stimson). 


FRACTURES. 


305 


or  tho  teeth  t(),!iether.      For  the  eoiistruetion  of  most  of  these  the  surgeon  will 
re([iiire  the  services  of  a  dentist. 

FRACTURE    OF    THK    UVUID    l50Ni;. 

This  is  exceedingly  rare,  and  in  the  few  recorded  cases  has  been  caused  by 
direct  violence  and  has  almost  always  involved  one  of  the  greater  cornua. 
The  svmptoms  are  sharp  pain,  swelling,  marked  dysphagia,  and  sometimes 
bleedin.-  from  the  mouth  due  to  perforation  of  the  mucous  membrane  by  the 
fragments.  Death  from  ccdema  of  the  glottis  may  occur.  In  these  cases 
intubation  or  tracheotomy  may  be  demanded. 

The  patient  is  placed  semirecumbent  in  a  bed-rest,  and  wears  tor  tour 
weeks  a  pasteboard  collar  and  a  ban<lage  around  the  head,  neck,  and  slioulders. 

FRACTURE  OF  THE  STERNUM.    (See  also  Dislocations.) 

This  fracture  is  rare ;  it  may  be  incomplete,  multiple,  transverse,  longitu- 
dinal or  oblique,  but  the  common  form  is  transverse  and  situated  at  or  near 
the  junction  of  the  manubrium  and  bodv  of  the  bone.  As  a  complete  joint 
sometimes  exists  between  the  manubrium  and  body,  it  may  be  impossible  to 
say  whether  a  separation  exactly  following  the  line  of  their  junction  is  a  frac- 
ture or  a  dislocation.  Displacement  may  be  absent,  or  may  be  angular  or 
transverse  with  or  without  overriding,  either  piece  lying  in  front  of  the  other. 
The  periosteum  on  the  posterior  surface  appears  habitually  to  remain  untorn. 
When  the  fracture  takes  place  at  the  junction  of  the  first  and  second  pieces, 
the  second  rib  usually  remains  in  contact  with  the  manubrium.  Fractures  of 
the  bodv  are  most  common  in  its  upper  half;  those  of  the  ensiform  process, 
including  its  separation  from  the  body,  are  extremely  rare. 

The  fracture  has  been  caused  in  several  cases  by  straining  during  labor 
and  by  lifting  heavy  objects ;  external  violence  may  cause  fracture  directly,  as 
in  a  blow  upSn  the  breast,  or  indirectly  by  bending  the  trunk  backward. 

The  diagnosis  is  made  by  recognition  of  the  displacement  when  it  is 
present,  localized  pain,  and  the  history  of  the  case.  There  is  sometimes  irreg- 
ularity of  the  heart  with  dyspnoea.  -^    -i    -c    \. 

The  treatment  consists  in  reduction  by  direct  pressure,  aided,  it  there  is 
overridincr,  by  extension  of  the  trunk  and  by  deep  inspiration  by  the  patient, 
and  in  relention  by  a  broad  band  of  adhesive  plaster  around  the  chest.  The 
patient  should  be  kept  in  bed  in  the  semi-erect  position  for  four  weeks,  but 
the  plaster  should  be  left  for  a  week  longer. 

FRACTURE  OF  THE  RIBS. 

This  fracture  is  of  frequent  occurrence ;  it  may  be  partial  or  complete, 
sintrle  or  multiple.  Incomplete  fractures  are  rare,  whether  by  bending  or  by 
fraSure  of  a  piece  from  one  border  of  the  bone.  Complete  fracture  may 
involve  one  or  several  ribs,  or  one  or  more  ribs  at  two  points  each ;  the  ribs 
most  frequently  broken  are  the  fifth  to  the  ninth  ;  fracture  of  the  floating  ribs 
is  almost  unknown,  and  that  of  the  upper  ribs  apparentlv  very  rare,  although 
there  is  some  reason  to  think  that  fracture  of  the  first  rib  is  not  infrequent, 
but  usually  passes  unrecognized.  ,     ,      i        .-.         •    v^^i 

Unless  two  or  more  adjoining  ribs  are  simultaneously  broken,  there  is  little 
or  no  displacement ;  if  thev  are  thus  broken,  the  displacement  may  be  angu- 
lar with  the  apex  directed  inward  or  outward,  and  overriding  may  be  produced 
by 'the  sinkincr  in  of  the  chest-wall.  If  a  rib  has  been  broken  at  two  places,  the 
intermediate  piece  mav  move  in  and  out  as  the  patient  breathes.     Associated 


20 


306  ^i.v  AMKL'HA.x   'riixi'- ii(j( )K  OF  Si  i^(n:i:y. 

injurij  to  tJir  hill;/  ]>\  the  point  of"  a  tV;i;^MiK'iit  is  coniiiioii,  as  sliowii  l)_v  ciiipliv- 
sema  or  bloody  expectoration  ;  and  extensive  laceration  of  the  lun<;,s  or  heart 
may  be  produced  when  the  violence  is  great.  Serious  hemorrhage  from  a 
wounded  intercostal  artery  is  rare. 

The  common  cause  of  the  fracture  is  external  violence,  but  it  mav  also  be 
caused  by  muscular  action,  especially  in  coughing.  External  violence  may 
produce  the  fracture  directly,  or  indirectly  by  exaggerating  the  curve  of  the 
bone. 

The  symptoms  in  the  less  extensive  cases  are  pain  on  deep  inspiration  or 
coughing  and  when  pressure  is  made  upon  the  broken  rib  ;  abnormal  mobility 
can  often  be  recognized  by  placing  a  finger  on  the  rib  on  each  side  of  the 
fracture  and  noticing  that  movement  communicated  to  one  fragment  is  not 
transmitted  to  the  other:  during  this  manipulation  crepitus  may  be  perceived, 
or  it  may  sometimes  be  heard  by  listening  with  the  ear  upon  the  chest  while 
the  patient  breathes  deeply.  Bloody  expectoration  is  frequent.  The  presence 
of  cellular  emphysema,  in  the  absence  of  a  wound  or  other  sufficient  cause,  is 
pathognomonic.  In  the  severer  cases,  in  which  several  adjoining  ribs  are 
broken,  the  fracture  is  readil}^  recognized  by  the  deformity;  associated  symp- 
toms due  to  laceration  of  the  lung  may  be  very  urgent. 

The  treatment  is  habitually  limited  to  immobilization  of  the  chest  by 
means  of  a  broad  band  of  adhesive  plaster  placed  about  it  at  the  end  of  expi- 
ration and  worn  for  four  weeks.  Angular  displacement  outward  can  be  cor- 
rected by  direct  pressure  upon  the  projection  ;  it  has  been  propose<l  to  raise 
a  depressed  rib  by  cutting  down  upon  it  or  by  passing  a  sharp  hook  uiuler 
it,  but  this  is  very  rarely  necessary.  For  the  treatment  of  associated  injuries 
of  the  thoracic  viscera,  pneumothorax,  and  hemothorax,  the  reader  is  referred 
to  the  chapter  on  Injuries  of  the  Thorax. 

FRACTURE  OF   THE   COSTAL  CARTILAGES. 

This  may  be  caused  by  direct  or  indirect  violence  or  by  muscular  action ; 
it  appears  to  occur  more  frequently  near  the  junction  with  the  rib  than  at  other 
points,  and  to  involve  the  seventh  and  eighth  cartilages  more  freiiuently  than 
others.  Marked  symptoms,  when  present,  are  due  to  associated  lesions,  injury 
of  the  heart  or  lungs,  or  other  effects  of  the  crushing  violence  that  has  caused 
the  fracture.  The  diagnosis  is  made  on  the  local  pain  and  the  deformity.  The 
treatment  is  the  same  as  that  of  fracture  of  the  ribs. 

FRACTURES  OF  THE   CLAVICLE. 

The  clavicle  is  broken  more  frequently  than  any  other  one  bone,  with  the 
possible  exception  of  the  radius,  and  the  injury  is  very  much  more  common  in 
the  young  than  in  adults,  about  half  the  cases  occurring  in  children  under  five 
years  of  age.  The  fracture  may  be  partial  (green-stick)  or  complete,  simple 
or  compound,  single  or  multiple.  The  partial  (in  the  very  young)  and  simple 
complete  (in  the  adult)  of  the  middle  third  of  the  bone  are  the  common  forms; 
fracture  of  the  outer  third  is  second  in  order  of  frequency  ;  that  of  the  inner 
third  is  infrequent.  The  division  of  fractures  into  those  of  the  inner,  middle, 
and  outer  thirds  is  justified  by  important  anatomical  and  resultant  clinical 
differences,  the  chief  of  which  arise  from  the  firm  ligamentary  attachments  of 
the  outer  third  to  the  coracoid  process  of  the  scapula. 

Fracture  of  the  middle  third  (Fig.  69,),  the  most  common  variety,  may 
be  oblique  or  transverse,  the  latter  form  being  found  mainly  in  children  ;  the 
line  of  oblique  fracture  runs  from  above  downward  and  inward,  so  that  the 
point  of  the  outer  fragment  underlies  that  of  the  inner  one — an  important  element 


fltACTURES.  307 


in  ,1,0  prclnotion  of  tl,e  usual  .lisplaceuionl;  the  scat  of  f™'^'' ™  ^  "!"f '^  ^3 
rt,o  outc'i-  lu.lf  of  this  tliinl.  Tlu.  loss  of  support  occas.oncd  bv  lie  "»<•'"  '^'^ 
Vn.  ,  1  bv  tbofalli..!;  of  tl,cshoul.lc.-  dmnnvard,  forward,  and  ""':'"-<^'jl''^l' 
1  ,  n  o  ,„r  f,-,Tn,R.i,t  uiukT  the  inner  one,  and  thus  .-a.ses  the  bvokcn 
ir^oV  tt  la"^'-am«v"nu.nt  .hi.*  is  son.etin,es  aided  by  the  contvae.ton  of 
the  cleirmastoid.  If  the  line  of  fraeture  is  so  nearly  transverse  that  over- 
ridinTctrt  oeeur,  the  displacement  is  transverse  or  angular  «,tl,  the  apex 

^'■it::Ctft  rt^M:tr^::th  is  n,ueb  ,„.  ^eq-t  'ha„  «he  P. 
ccdino,  the  line  of  fracture  is  more  often  transverse  than  oblique,  and  tic  dis- 
placement is  usually  angular  Nvith  the  ape.  directed  backward,  but  it  may 

""  irLTm"  t  innT'thlrd,  which  is  ,uite  rare,  the  line  is  commonly 

SE-^dt'ri^^i^^i^^---^^^^^ 

SimuuVneous  fracture  of  both  clavicles  has  been  caused  by  direct  v  o- 
lence  a    the  k  ck  of  a  horse,  each  hoof  striking  one  bone,  or,  more  frequently 
bvmlirec  violence,  the  force  acting  upon  both  shoulders  to  press  them  t«gethci. 
Ked  dyspnea,  attributed  to  the  weight  of  the  shoulders  resting  on  the  tho- 
rnT   T.nd  relieved  by  dorsal  decubitus,  was  observed  in  some. 

C  causes  of  fracture  of  the  clavicle  are  in.lirect  violence,  as  in  a  fa 
upon'be  hand  or  shoulder;  muscular  action,  as  in  lifting  or  striking;  and  direct 

Tircourse  is  uneventful,  and  union  is  usually  complete  .vithm  a  mon  li  in 

^^^-rtsrnitrriiitinTr^^^^^^^^^^ 

ufJ:Xf^.^ara,  ana  oat.ard  to  its  -rmal  position  a«l«l  -1-  ncces-  y  bj 

f=,rtotaSni^  sh.^M:^rtlr■prt^,r  s  ..'-^-i- 

un™^^^       ^vei..ht  of  the  shoulder  is  the  cause  of  the  displacement.      Ihis 
rt!ide,::!:^t"hf  fore^rttog  on  the  chest,  meets  the  indication  by  remov- 


308 


.l.V   AMERICA  X    TEXr-liOOK    <>!'   Si' lid  K  I:  Y 


ing  the  ciiiise,  but  the  conJineiMrnt  is  too  irksome  to   be  endured  except  when 
the  importance  of  avoiding  any  irreguhirity  in  the  bone  is  great. 

Sat/re's  (lnKsin(/  (Figs.  91, '92)  is  in  very  general  use  ;  it  requires  two  strips 
of  adhesive  phister,  each  three  indies  wide  and  long  enough  to  go  once  and  a 
half  around  the  chest.  The  end  of  one  strip  is  fixed  loosely  about  the  arm  of 
the  injured  side  just  below  the  axilla,  and  the  strip  is  carried  around  the  back 
and  the  opposite  side  to  the  chest  in  front,  so  as  to  hold  the  elbow  a  little  behind 
the  axillary  line  ;  the  second  strip  is  then  carried  from  the  top  of  the  shoulder 
on  the  uninjured  side,  across  the  back,  to  the  opposite  elbow,  and  up  along 
the  flexed  forearm  to  the  place  of  beginning,  meanwhile  pressing  the  elbow 


Fig.  91. 


Fig.  92. 


Sayre's  Adhesive  Plaster  Dressing  for  Fracture  of  the 
Clavicle  (Stimson). 


Velpcau's  Dressing  for  Fracture  of  tne 
Clavicle  (Stimson). 


forward,  inward,  and  upAvard.  It  is  well  to  leave  the  hand  uncovered  by  the 
second  strip.  A  few  turns  of  a  roller  bandage  about  the  arm  and  chest  will 
give  additional  support.  In  this  and  all  similar  cases  care  must  be  taken 
not  to  allow  the  bare  skin  of  the  forearm  to  rest  on  that  of  the  chest,  in  order 
to  prevent  retention  of  moisture,  maceration  of  the  epidermis,  and  even  ulcer- 
ation. Cotton  wadding,  linen,  or  other  similar  material  should  always  be 
interposed  between  the  two  cutaneous  surfaces. 

Velpeaiis  dressmg  (Fig.  93)  is  made  with  a  roller  bandage ;  the  hand  is 
placed  on  the  opposite  shoulder,  the  elbow  pressed  upward,  and  a  series  of 
turns  with  the  roller  applied,  which,  beginning  at  the  opposite  axilla,  pass 
upward  across  the  back,  over  the  injured  shoulder,  downward  in  front  of  the 
arm,  and  under  the  elbow  to  the  point  of  beginning :  after  several  turns  have 
been  thus  made  the  bandage  is  carried  circularly  about  the  body,  covering  in 
the  arm  from  below  upward. 

A  Jigure-of-8  bandar/e  of  plaster  of  Paris,  passing  in  front  of  each  shoulder 
and  crossing  at  the  back,  meets  the  indication  very  well,  but  is  liable  to  inter- 
fere with  the  circulation  in  the  arms.  Short  crutches  fastened  to  the  chest 
by  adhesive  plaster  or  bandages  have  been  in  occasional  use  for  many  years 
to  maintain  the  shoulder  in  the  desired  position. 

When  the  fracture  is  at  the  extreme  acromial  end,  and  the  dis])lacement 
is  like  that  of  dislocation  of  the  acromial  end  upward,  the  method  of  treat- 
ment of  the  latter  injury  by  a  strip  of  adhesive  plaster  passing  under  the 
elbow  and  crossing  on  top  of  the  shoulder  is  equally  efficient.  In  some  cases 
of  fracture  of  the  clavicle  it  is  impo.ssible  to  reduce  the  deformity  by  ordi- 
nary methods.      Such  persistent  deformity  may  be  due  to  the  interposition  of 


FRA  CTURES.  309 

inusclo  or  fascia  between  the  {Va^nneiits.      Tlie  proper  treatment  for  cases  of 
tliis  description  is  to  make  an  incision,  hrinjr  tlie  fragments  into  position  and 
wire  them  together  or  suture  them  with  kan;4aroo  tendon. 
The  dressings  shoiihl  he  worn  for  three  or  four  weeks. 

FRACTURES  OF  THE  SCAPULA. 

These  fractures  may  be  grouped  as— 1,  of  the  body  ;  2,  of  the  inferior  angle  ; 
3,  of  the  upper  angle ;  4,  of  the  spine ;  5,  of  the  acromion  ;  6,  of  the  coracoid 
process ;   T,  of  the^'neck  ;  8,  of  the  glenoid  fossa. 

Fractures  of  the  body  are  caused  by  direct  violence,  and  may  be  partial, 
complete,  or  comminuted ;  when  there  is  a  single  line  of  fracture  crossing  the 
body  directly  or  obliquely,  either  fragment  may  project  outwardly  and  over- 
ride the  other.  ^    i     j-     i  .  v. 

The  diaqnosis  can  usually  be  made  by  recognition  of  tlie  displacement  by 
touch,  es})eeially  along  the  vertebral  border  of  the  bone  ;  by  independent 
mobility,  recognized  by  grasping  and  moving  the  lower  angle  ;  and  by  c-repitus. 
The  treatment  consists  in  immobilization  of  the  shoulder  and  arm  for  four 
weeks.  If  suppuration  ensues  in  consequence  of  bruising  of  the  soft  parts, 
early  opening  of  the  abscess  is  required,  with  especial  attention  to  the  dram- 
age  of  the  portion  which  lies  on  the  costal  surface  of  the  bone. 

Fracture  of  the  inferior  angle  is  caused  by  direct  violence  or  by  muscu- 
lar action ;  the  small  lower  fragment  is  displaced  forward  and  upward  by  the 
attached  muscles,  and  even  if  it  can  be  restored  to  its  place  it  cannot  be  main- 
tained there. 

Fracture  of  the  upper  angle  is  very  rare,  is  caused  by  direct  violence,  is 
followed  by  but  little  displacement,  and  is  to  be  treated  by  immobilization  of 

the  arm.  i,    v  j 

The  entire  spine,  including  the  acromion,  may  be  separated  from  the  body 
of  the  bone,  or  a  portion  may  be  broken  off,  leaving  the  acromion  attached  to 
the  body.  The  cause  is  direct  violence ;  the  displacement  is  slight ;  the  treat- 
ment is*  immobilization,  as  in  fracture  of  the  body. 

Fracture  of  the  acromion  process  may  be  caused  by  external  violence 

acting  either  directly  or  through  the  humerus ;  or  by  muscular  action  (contraction 

of  the  deltoid).     The  line  of  fracture  is  in  most  cases  in  front  of  the  articulation 

with  the  clavicle,  less  frequently  at  the  root  of  the  process.     The  spjijjtoins 

are  localized  tenderness,  abnormal  mobility,  and  crepitus.     Non-union  of  the 

epiphysis  at  the  external  extremity  of  the  spine,  which  is  not  very  uncommon, 

may,  'if  combined  with  a  contusion,  be  mistaken  for  a  fracture.     Bony  union 

is  apparently  the  exception,  but  the  failure  to  secure  it  creates  no  disability. 

The  treatment  consists  in  immobilization  of  the  arm  at  the  side  of  the  body, 

with  the  elbow  a  little  forward,  and  the  humerus  pressed  well  upward  against 

the  acromion  (the  Velpeau  position).      Dressings  to  be  worn  for  four  weeks. 

Fracture  of  the  coracoid  process  may  be  caused  by  external  violence  or 

by  muscular  action,  and  has  been  observed  both  alone  and  in  combination  with 

other  injuries.     The  symptoms  are  abnormal  mobility,  with  or  without  crepitus, 

obtained,  where  present,  by  pressure  with  the  finger  against  the  tip  of  the  process. 

Displacement  downward  by  the  action  of  the  attached  muscles  is  the  rule,  as  is 

also  fibrous  union.    The  treatment  consists  in  immobilization  of  the  arm  upon  the 

side  of  the  chest  with  the  elbow  directed  a  little  backward  for  four  or  five  weeks. 

Fracture  of  the  surgical  neck  includes  all  cases  in  which  the  detached 

fragment  comprises  the  attachment  of  the  long  head  of  the  triceps.     The  upper 

portion  of  the  line  of  fracture  may  end  in  the  suprascapular  notch,  or  in  front 

of  the  coracoid,  or  in  the  glenoid  fossa.     The  symptoms  are  flattening  of  the 


310 


AX  AMERICA X    TEXT-P.dOK    OF  SURGERY 


shoulder,  duo  to  the  sinking  of  the  liuinenis  in  consequence  of  tlie  h)ss  of 
support  by  tlie  triceps  (this  is  k'ss  Avheii  the  fnicture  passes  tliroii;^rli  the  siipra- 
scapuhir  notch,  because  the  fragment  is  then  supporte<l  by  the  coraco-chivicuhir 
ligament) ;  its  prompt  disappearance  when  the  arm  is  pressed  upward,  and  its 
immediate  return  when  the  pressure  is  removed ;  the  presence  of  a  movable 
hard  lump  deep  in  the  axilla,  felt  by  following  with  the  finger  the  axillary 
border  of  the  scapula  u})\vard  ;  and  crepitus,  obtained  by  pressing  it  upward 
and  backward.  Bony  union  with  some  displacement  appears  to  be  the  rule. 
The  indication  for  treatment  is  to  prevent  the  sinking  of  the  humerus.  This 
can  be  efi'ected  by  bandages  or  a  strip  of  adhesive  plaster  passing  under  the 
flexed  elbow  and  over  the  top  of  the  shoulder,  to  be  worn  for  five  weeks. 

Fracture  of  the  rim  of  the  glenoid  fossa  is  a  complication  of  dislocation 
of  the  shoulder.  ISome  authors  speak  of  stellate  fractures  of  the  fossa,  appar- 
ently the  result  of  crushing  violence  acting  through  the  head  of  the  humerus. 

FRACTURES  OF  THE  HUMERUS. 

These,  which  constitute  about  8  per  cent,  of  all  fractures,  may  be  con- 
veniently grouped  clinically  as  fractures  of  the  upper  end,  of  the  shaft,  and  of 
the  lower  end. 

Fractures  of  the  upper  end  include  those  of  the  head;  of  the  anatomical 
neck,  with  or  without  part  of  the  tuberosities ;  of  the  tuberosities ;  separation 
of  the  epiphysis;  and  fracture  of  the  surgical  neck. 

Fracture  of  the  head  is  very  rare,  if  from  the  group  are  excluded  those 
indentations  which  are  sometimes  associated  with  dislocation  {q.  v.).  It  cannot 
be  recognized  clinically. 

Fracture  of  the  anatomical  neck  is  rare:  the  majority  of  cases  probably 
occur  in  connection  with  anterior  dislocation,  the  head  being  split  off  by  the 

inner  lip  of  the  glenoid  fossa  acting  as  a 
wedge  along  the  line  of  the  neck.  In 
other  cases  it  appears  to  have  been  caused 
by  external  violence  acting  upon  the 
elbow  to  press  the  humerus  against  the 
scapula,  or  by  a  fall  upon  the  shoulder. 
When  associated  with  dislocation  the 
diagnosis  can  be  made  by  recognizing 
the  independent  mobility  of  the  head, 
but  when  not  so  associated  it  cannot  be 
grasped  by  the  fingers  so  as  to  permit 
the  recognition  of  this  fact,  and  the 
diagnosis  cannot  be  made  with  certainty. 
Symptoms  that  may  be  present  are 
crepitus  on  rotation  of  the  arm,  with 
preservation  of  the  continuity  of  the 
greater  tuberosity  with  the  shaft,  and 
pain  on  pressing  the  elbow  upward,  but 
in  a  case  reported  by  Stimson  there  was 
entire  absence  of  objective  symptoms. 
Hutchinson's  supposition  that  the  toni- 
city of  the  scapulo-humeral  muscles,  by 
drawing  the  shaft  upv.ard,  tended  to 
force  the  head  out  of  the  socket  has  not 
been  confirmed.  The  treatment  is  im- 
mobilization of  the  arm  by  binding  it  to  the  chest  for  about  four  weeks;  a 


Fk;.  ni. 


Impacted  Fracture  of  the  iluiin,rii>  u 
Tuberosities  (K.  W.  Smith). 


lUgii  the 


FRA  CTURES. 


ill 


Fig.  95. 


thin  compress  or  a  layer  of  absorbent  cotton  placed  between  the  arm  and  the 
chest  to  absorb  the  perspiration  will  add  to  the  patient's  comfort. 

Fracture  through  the  tuberosities  (Fi<i^.  94),  the  line  of  fracture 
running  partly  along  the  anatomical  neck,  and  usually  through  the  greater 
tuberosity,  is  apparently  less  rare  than  j)ure  fracture  along  the  anatomical 
neck :  the  fragments  are  commonly  impacted  with  comminution,  and  in  some 
cases  the  upper  one  has  been  turned  completely  over. 

The  treatment  is  immobilization  of  the  limb,  aided  possibly  by  permanent 
traction  downward. 

Fracture  of  the  greater  tuberosity,  complete  or  partial,  is  rarely  seen 
except  in  connection  with  anterior  dislocation ;  it  may  be  caused  by  direct 
violence  or  by  the  forcible  contraction  of  the  attached  muscles.  The  line  of 
fracture  runs  along  the  anatomical  neck  adjoining  the  tuberosity,  down  the 
bicipital  groove,  and  through  or  below  the  tuberosity;  the  fragment  may  remain 
partly  attached  by  untorn  periosteum  or  may  be  entirely  separated  and  drawn 
backward.  Tlie  symptoms  are  loss  of  voluntary  outward  rotation,  pain,  crepitus, 
and  swelling. 

Of  fracture  of  the  lesser  tuberosity  only  three  examples  have  been 
reported,  two  of  them  in  connection  with  the  very  rare  dislocation  of  the 
shoulder  upward,   the  third  without    history. 

Separation  of  the  epiphysis  (Fig.  95)  is  caused  by  external  violence, 
and  quite  frequently  in  the  new-born  by  traction  upon  the  arm  or  in  the  axilla 
during  delivery.  The  displacement 
when  not  complete  is  transverse  and 
angular,  the  apex  of  the  angle  directed 
forward  and  upward ;  when  the  dis- 
placement is  complete  the  lower  frag- 
ment lies  on  the  inner  side  of  the  upper. 
The  epiphysis  includes  the  tuberosities, 
and  is  so  shaped  that  the  upper  end 
of  the  shaft  has  the  form  of  a  low 
cone  or  wedge.  The  symptoms  are 
commonly  very  characteristic  in  this 
respect,  that  a  distinct  prominence 
can  be  seen  and  felt  on  the  front  of 
the  shoulder  about  an  inch  below  the 
acromion,  and  that  a  false  point  of 
motion  can  be  recognized  by  grasp- 
ing the  head  and  gently  rotating  the 
shaft ;  when  the  displacement  is  in- 
ward this  prominence  is  found  beneath 
the  coracoid.  Reduction  is  difficult 
because  of  the  smallness  of  the  upper 
fragment,  but  may  be  effected  by  carrying  the  elbow  forward  and  upward,  as 
the  posterior  portion  of  the  capsule  attached  to  the  upper  fragment  prevents  it 
from  sharing  in  the  movement.  In  a  few  cases  recourse  has  been  had  to  open 
incision.  Occasionally  the  growth  of  the  limb  at  this  point  is  arrested  in 
consequence  of  the  injury,  either  because  the  displacement  persists  or  because 
the  epiphyseal  cartilage  ossifies  prematurely. 

Fracture  of  the  Surgical  Neck  (Fig.  96). — The  surgical  neck  of  this  bone 
is  the  part  between  the  upper  expanded  end  and  the  insertion  of  the  pectoralis 
major  and  latissimus  dorsi.  This  is  by  far  the  most  frequent  fracture  at  the 
upper  end ;  it  is  commonly  caused  by  a  blow  upon  the  upper  part  of  the»  arm 


Separation  of  the  Upper  Epiphysis  of  the  Humerus  ; 
Displacement  Forward  of  the  Lower  Fragment 
(Moore). 


312 


AN  A^fKRl(\\N    TEXT-HOOK    OF  SURGERY. 


Fjg 


or  by  a  fall  on  tlie  hand  or  elbow.  The  line  of  fracture  may  be  irregular  or 
obli(|ue.  In  the  latter  case  the  lower  fra;riiient  lies  oftenest  on  the  inner  side 
of  the  upper  one,  drawn  tliither  l)y  the  latissinius  dorsi  and  pectoralis  major. 
Sj/>7i}tt<>vif(. — Abnormal  moltility  and  (•re])itns  are  recognized  l^y  grasping 
the  head  of  the  humerus  with  the  tiiunil)  and  fingers  of  one  hand  and  gently 
rotating  the  elbow  with  the  other.  Pain  is  caused  by  pressing  the  ellxiw  u])- 
ward  and  by  local  ])ressure  at  the  seat  of  fracture. 

Treatment. — Reduction  is  made  by  traction  and  coaptation  and  slowly 
bringing  the  lower  fragment  into  line  with  the  uj>|>er  one,  and,  if  the  deform- 
ity obstinately  returns,  may  be  maintained  by  ])ermanent  traction  with  weight 
and  ])ulley  combined  with  the  supj)ort  of  a  plaster-of-Paris  gutter  on  the  back 
and  sides  of  the  shoulder  and  arm.  If  the  line  of  fracture  is  such  that  the 
tendency  to  displacement  is  slight,  or  if  confinement  to  bed  is  very  undesir- 
able, s})lints  or  encasement  in  plaster  of  Paris  may  be  used.  In  such  a  case 
the  forearm  should  be  Hexed,  and  supported  only  at  the  wrist  by  a  sling,  in 
order  that  the  weight  of  the  limb  may  make  traction  while  the  patient  is 
erect,  or  occasionally  an  additional  weight  of  not  more  than  five  pounds  ma}^ 
be  hung  from  the  elbow.  A  dressing  consisting  of  a  folded 
towel  placed  against  the  side  of  the  chest  and  extending  into 
the  axilla  and  a  little  above  its  borders,  a  shoulder  cap,  and 
a  slinsc  at  the  wrist,  gives  most  excellent  results.  The  arm 
should  be  bound  to  the  side  by  circular  turns  of  a  bandage, 
and  the  shoulder  cap  should  be  held  in  place  by  a  spica.  A 
splint  may  be  used  on  the  outer  side,  resting  against  the 
acromion  and  the  elbow,  the  lower  fragment  being  secured  to 
the  splint  by  a  bandage:  it  opposes  the  displacement  of  the 
latter  inward  by  its  counter-pressure  against  the  acromion, 
but  does  little  or  nothing  to  prevent  shortening.  The  scap- 
ular muscles  attached  to  the  upper  fragment  tend  to  tilt  its 
lower  end  forward  and  outward,  and  when  this  tendency  is 
manifested  it  must  be  met  by  keeping  the  lower  fragment 
in  a  corresponding  position,  either  by  traction  in  bed  with 
the  arm  abducted  or  by  a  triangular  splint  or  cushion  placed 
between  the  arm  and  the  side  and  maintaining  the  arm  in  the  desired  posi- 
tion. If,  as  is  usual,  union  is  quite  firm  after  the  expiration  of  a  month, 
the  splint  may  be  removed  and  the  forearm  supported  in  a  sling  for  a  week 
or  two  longer. 

When  the  fracture  is  cornpUcated  Inj  simultaneous  dislocation  of  the  head, 
the  latter  may  sometimes  be  reduced  by  direct  manipulation  under  an  anes- 
thetic, or,  as  recently  done  by  McBurney,  cutting  down  through  the 
deltoid  to  the  lower  part  of  the  upper  fragment,  drilling  a  hole  in  it,  and 
inserting  in  this  hole  a  strong  right-angled  hook,  by  means  of  which  ibrcible 
traction  and  rotation  can  be  made  upon  the  fragment.  If  these  fail,  the  sur- 
geon has  his  choice  betAveen  securing  union  of  the  fracture  and  making  a 
subsecjuent  attempt  to  reduce  the  dislocation  and  the  establishment  of  a  false 
joint. 

Fracture  of  the  shaft  may  be  caused  by  direct  or  indirect  violence,  or 
by  musodar  action  :  all  the  varieties  of  fracture  and  displacement  seen  in  the 
shafts  of  other  long  bones  have  been  seen  here.  Among  observed  complica- 
tions: are  rupture,  throm1)osis,  and  aneurysm  of  the  brachial  artery  and  injury 
of  a  main  nerve,  especially  the  musculo-s])iral.  either  at  the  time  of  the  accident 
or  subsequently  by  inclusion  in  the  callus.  The  diagnosis  is  readily  made  by 
attention  to  the  common  signs  of  fracture,  all  of  which  are  usually  present. 


Fracture  of  the 
Surgical  Neck 
of  the  Humerus 
(Stimson). 


FRACTUREH.  313 

Union  takes  place  in  from  four  to  six  weeks,  but  it  is  to  be  remembered  tliat 
failure  of  iinion  is  more  frequent  after  fracture  of  the  shaft  of  the  humerus 
than  after  that  of  any  other  long  bone.  The  trcatmerif  is  by  an  internal  anjrular 
splint,  a  shoulder  cap,  and  a  sliiif^  at  the  wrist;  by  moulded  splints;  or  by 
encasement  in  jdaster  of  Paris,  which  should  include  the  forearm  (flexed  at  a 
right  angle)  and  the  shoulder.  Unless  measures  are  taken  to  prevent  it,  this 
latter  dressing  will  show  after  a  few  days  a  distinct  gap  above  the  shoulder,  due 
to  the  shortening  of  the  arm — a  gap  that  will  admit  one  or  two  fingers :  this 
may  sometimes  be  prevented  by  adding  a  spica  aljout  the  chest,  but  more  surely 
and  conveniently  by  a  weight  attached  to  the  ell)ow.  If  the  skin  is  so  bruised 
that  a  permanent  dressing  cannot  be  applied,  the  limb  nnist  be  supported  on 
cushions  in  a  suitable  position  or  bound  to  the  side  of  the  chest.  The  dressing 
should  be  worn  from  three  weeks  in  the  young  to  five  or  six  weeks  in  the  adult. 

Fractures  of  the  Lower  End  of  the  Humerus. — In  this  group  are 
included  fracture  close  above  the  condyles  ;  al)ove  and  between  the  condyles  ; 
of  either  condyle;  of  either  epicondyle;  and  se{)aration  of  the  epiphysis. 

In  fracture  above  the  condyles,  or  supracondyloid  fracture,  the 
line  of  fracture  passes  through  the  expanded  lower  end  of  the  humerus,  and 
may  open  into  the  joint  through  the  olecranon  and  coronoid  fossae;  the  line 
may  be  transverse  or  oblique,  either  laterally  or  antero-posteriorly,  and  in  a  few 
cases  has  been  almost  vertical  and  transverse — L  e.  parallel  to  the  anterior  sur- 
face, crossing  the  bone  close  behind  the  trochlea  and  capitellum. 

Symptoms. — The  usual  displacement  is  of  the  lower  fragment  backward,  and 
the  injury  is  often  compound  because  of  perforation  of  the  skin  by  the  sharp  end 
of  either  fragment,  especially  the  upper.  The  brachial  artery  or  median  nerve 
may  be  dangerously  stretched  across  the  end  of  the  upper  fragment.  When 
the  usual  displacement  is  present  the  general  appearance  of  the  region  resembles 
that  of  dislocation  backward  of  the  elbow.  The  diagnosis  is  then  made  by 
attention  to  the  relations  of  the  olecranon  and  head  of  the  radius  to  the 
epicondyles. 

Treatment. — Reduction,  which  is  sometimes  very  difficult,  is  made  by  trac- 
tion and  coaptation  with  the  elbow  flexed  at  a  right  angle  or  fully  extended, 
and  is  maintained  by  posterior  and  anterior  rectangular  splints  or  by  a  moulded 
posterior  splint  or  trough  that  extends  well  around  to  the  front  on  both  sides. 
The  dressing  is  to  be  worn  for  four  or  five  weeks.  Passive  motion  is  begun 
in  the  third  or  fourth  week.  Occasionally  vertical  suspension  for  a  fortnight 
with  the  elbow  extended  is  best,  especially  if  the  fracture  is  compound;  and  this 
attitude  has  the  advantage  of  being  followed  by  less  primary  stillness  of  the  joint 
than  is  usual  after  treatment  in  flexion.  In  compound  fractures  excision  of  the 
end  of  one  or  both  fragments  may  be  needed  to  secure  permanent  reduction. 

Intercondyloid  fracture,  sometimes  called  T-  or  Y-fracture,  differs  from 
the  preceding  by  the  addition  of  a  line  of  fracture  running  from  the  transverse 
one  downward  through  or  between  the  condyles ;  it  is  usually  caused  by  direct 
violence,  a  blow  or  fall  upon  the  elbow,  and  is  often  comminuted  or  compound. 

Syynptoms. — It  may  closely  resemble  a  supracondylar  fracture,  the  condyles 
preserving  their  relations  with  each  other,  or  the  latter  may  be  widely  sepa- 
rated, with  the  lower  end  of  the  upper  fragment  and  the  olecranon  interposed 
between  them. 

Treatment. — Complete  reduction,  in  attempting  which  the  aid  of  anesthesia 
should  always  be  had,  is  very  difficult,  as  is  also  its  maintenance.  It  is  to 
be  expected  that  the  movements  of  the  joint  after  recovery  will  be  seriously 
restricted,  and  it  is  well,  therefore,  to  keep  the  limb  during  treatment,  or  at 
least  during  the  later  weeks  of  treatment,  in  the  attitude  which  will  be  the 


;n4 


A^^  AMi.nicAy  text- hook  of  siiiarjiv. 


most  useful  if  ankylosis  ensues.  A  broad,  heavy,  posterior  moulded  splint 
reat'liintr  fn>ni  the  shoulder  to  the  wrist,  with  the  elhow  flexed  at  a  rif.'ht  an»rle, 
extendiniT  well  around  to  the  front  of  the  linil),  and  allowed  to  harden  while 
anesthesia  is  maintained,  is  ))rohably  the  best.  It  may  be  aided  by  permanent 
traction  at  the  elbow  in  the  direction  of  the  long  axis  of  the  arm.  Full  exten- 
sion during  the  first  two  weeks  with  the  arm  in  a  padded  anterior  splint  is 
thought  by  many  surgeons  to  prevent  the  displacement  upward  and  backward 
which  often  occurs.  Whatever  method  of  treatment  is  first  employ e<l,  after  ten 
days  or  two  weeks  it  is  desirable  to  flex  the  elbow  and  to  change  the  angle  of 
flexion  from  time  to  time,  in  the  hope  of  increasing  the  range  of  motion.  In 
compound  fractures  advantage  may  sometimes  be  taken  of  the  wound  to  pin 
the  fragments  together  with  steel  drills  passed  through  them  ;  in  other  cases 
excision  of  the  lower  end  of  the  humerus  is  advisable  with  the  object  of 
obtaining  a  movable,  though   weaker,  joint. 

Fracture  of  the  internal  epicondyle  may  be  caused  by  direct  violence 
or  bv  forced  abduction  of  the  extended  forearm  ;  in  the  latter  case  dislocation 
of  the  elbow  usually  follows  in  consequence  of  the  continuation  of  the  violence, 
and  the  fracture  becomes  a  complication  or  an  incident  of  the  more  important 
injury. 

The  diagnosis  in  the  pure  cases  is  made  by  recognition  of  the  mobility  of 
the  small  fragment,  possibly  with  crepitus :  in  those  in  which  it  complicates  a. 
dislocation  backward  the  diagnosis  is  made  in  the  same  manner ;  but  in  dis- 
locations outward  the  fragment  is  liable  to  be  drawn  down  below  the  trochlea, 
where  it  cannot  be  felt,  and  the  diagnosis  must  then  be  made  upon  its  absence. 
The  treatment  is  by  immobilization  of  the  joint  for  about  a  fortnight  in 
flexion  at  or  within  a  right  angle,  to  diminish  the  effect  of  the  attached  flexor 
muscles  upon  the  fragment. 

Fracture  of  the  external  epicondyle  is  very  rare;  the  diagnosis  must 
be  made  upon  tiie  recognition  of  a  small  movable  fragment  at  the  seat  of  the 
epicondyle. 

Fracture  of  the  Internal  Condyle  (Fig.  97). — The  line  of  fracture  ex- 
tends from  a  point  on  the  inner  side  of  the  humerus  above  the  epicondyle  down- 
ward and  outward  into  the  joint  at  the  center  of  the  trochlea 
or  between  the  center  and  the  capitellum.  The  usual  displace- 
ment is  of  the  fragment  upward  and  l)ackward,  and,  even  if 
it  is  but  slight,  the  persistence  produces  marked  deformity 
by  changing  the  relations  of  the  long  axis  of  the  arm  and 
making  the  external  condyle  unduly  prominent.  The  toni- 
city of  the  triceps  appears  to  favor  recurrence  of  this  dis- 
placement, as  does  also  pressure  upon  the  up]>er  part  of  the 
ulna  when  the  elbow  is  flexed.  This  undesirable  pressure 
may  be  readily  exerted  by  a  su])porting  sling,  with  or  with- 
out a  splint,  and  consequently  the  arm  should  be  su})ported 
only  at  the  wrist. 

Treatment. — If  care  be  taken  to  avoid  such  pressure 
and  to  make  complete  reduction  in  the  first  instance,  satis- 
factory results  can  usually  be  obtained  by  treatment  in  a 
posterior  rectangular  or  moulded  splint  or  trough,  or  even 
Fracture  of  the  Inter-    in  a  plaster-of-Paris  dressing,  worn  for  five  weeks ;  but  it 
H^um^rus^'dispia^e^    is  advisable  to  examine  the  joint  at  the  end  of  a  week  or 
mtiii  upward  and  in-    j^jj  davs,  and  to  corrcct  tile  (lisi)lacement  if  it  has  recurred. 

ward  (Uurlt).  ,,,  •/    '  .   ,      ,       .    .        •      ,.   ,,         ,         •  i  i 

Treatment  with  the  joint  in  lull  extension  enables  us  more 
surely  to  avoid  this  displacement  of  the   condyle   upward,  and   has   given 


Fig.  97. 


FRACTURES. 


315 


many  cxcclloiit  results;  but  the  attitude  is  not  so  convenient  to  the  patient  as 
that  of  flexion,  and  in  some  cases  there  is  a  tendency  to  displacement  for- 
ward or  tilting  of  the  fragment  in  the  extended  [)Osition.  If  it  is  employed 
at  all,  it  is  perhaps  sullicient  to  employ  it  during  the  first  fortnight,  and  tiien 
to  substitute  flexion.  The  ultimate  result  in  the  young  may  be  greatly  ini- 
paired  by  excessive  formation  of  callus. 

A  eompUcation  occasionally  seen  is  coincident  dislocation  of  the  radius 
backward ;  that  is,  both  bones  of  the  forearm  and  the  internal  condyle  are 
displaced  backward,  the  ulna  preserving  its  relations  with  the  latter  and  with 
the  radius.  Recurrence  after  reduction  is  best  avoided  by  keeping  the  elbow 
flexed   at   less  than   a   right   angle. 

Fracture  of  the  External  Condyle. — In  this  the  line  of  fracture  runs 
from  a  point  on  the  supinator  ridge  downward  and  inward  through  the  capitel- 
lum  or  the  outer  part  of  the  trochlea.  Ordinarily  the  displacement  is  .slight, 
but  it  may  be  considerable,  with  coincident  displacement  of  the  ulna  from  the 
internal  condyle  outward  or  backAvard,  the  head  of  the  radius  maintaining  its 
relations  with  the  capitellum  and  ulna.  The  treatment  is  immobilization  in  a 
posterior  rectangular  splint  or  immovable  dressing. 

Separation  of  the  epiphysis  is  not  a  frequent  accident,  and  there  have 
been  but  few  opportunities  for  direct  examination  of  specimens.  The  lower 
fragment  usually  comprises  the  entire  epiphysis,  which  is  composed  of  several 
distinct  pieces;  but  it  is  possible  that  either  or  both  epicondyles  may  remain 
attached  to  the  upper  fragment.  The  lower  fragment  tends  to  displacement 
backAvard  and  inward.  As  it  has  frequently  been  mistaken  for  dislocation, 
the  examination  should  always  be  made  under  an  anesthetic.  Treatment  is 
by  a  posterior  plaster  splint,  the  joint  flexed  to  or  within  a  right  ano-le. 

Diagnosis  and  Treatment  of  Fracture  at  or  near  the  Elbow. — In 
all  doubtful  cases  an  anesthetic  should  be 
used  to  make  the  diagnosis  complete  and 
to  facilitate  reduction.  Moulded  (plaster) 
splints  are,  as  a  rule,  to  be  preferred  be- 
cause of  their  more  accurate  fit,  and  great 
care  must  be  taken  in  supracondyloid  frac- 
ture and  fracture  of  the  internal  condyle 
that  the  sling  which  supports  the  arm  does 
not  press  the  flexed  elbow  upward,  for 
otherwise  the  direction  of  the  transverse 
axis  of  the  joint  is  changed  by  the  ascent 
of  the  internal  condyle,  and  the  forearm 
is  thereby  adducted  with  production  of  the 
"gunstock  "  deformity. 

Complete  extension  of  the  forearm  has 
been  recommended ;  but  this  requires  rest 
in  bed ;  and  if  anchylosis  occur,  the  arm 
is  useless.  Jones  of  Liverpool  has  recom- 
mended as  an  excellent  treatment,  after 
reduction,  complete  flexion  of  the  forearm, 
so  that  the  ball  of  the  thumb  rests  on  the 
neck.  Flexion  is  maintained  by  a  leather 
band  around  the  wrist  and  a  bandage 
around  the  neck,  the  bandage  passing 
through  a  rubber  tube  to  protect  the  neck  from  friction  and  pressure. 
Frazier   has   devised  a  jacket  (Fig.   98)  to   hold   the   arm  in  this   position. 


Fig.  98. 


Frazicr's  modificution  of  .Ioik'<'s   drrbsing 
for  injuries  of  the  elbow-joint. 


31  ti  AX   A.UKh'/CAX    TKXT-llOOK    OF  SURGERY. 

The  splints  or  other  apparatus  should  be  worn  from  tliroe  to  six  weeks, 
according  to  the  age  of  the  patient,  and  for  a  longer  time  in  sujtraeondylar 
fractures  than  in  condylar  fractures. 

After-treatment  of  Fracture  at  or  near  the  Elbow. — When  union 
after  iVaetiire  ahout  the  elbow  is  complete  and  tiie  sjdints  are  laitl  aside,  the 
elbow  is  usually  very  stiff,  and  much  anxiety  may  be  felt  concerning  its  future 
usefulness;  but  in  the  great  majority  of  cases  the  range  of  motion  will  rapidly 
increase  under  natural  use  of  the  limb,  and  the  surgeon  can  do  but  little  to 
hasten  it.  Daily  forcing  of  the  joint  is  more  likely  to  do  harm  than  good,  and 
the  best  results  are  obtained  by  simply  encouraging  the  patient  to  make  as 
much  use  as  possible  of  the  limb,  and  perhaps  aiding  him  by  elastic  traction 
from  the  wrist  to  the  shoulder  to  increase  flexion,  and  making  him  carry  a 
weight  in  the  hand  to  increase  extension. 


FRACTURES   OF  THE    RADIUS  AND   ULXA. 

Fracture  of  the  olecranon  may  be  caused  by  the  contraction  of  the 
triceps  or  by  external  violence  received  upon  the  olecranon  or  upon  the  ulna 
near  it,  the  commonest  cause  being  a  fall  or  blow  upon  the  elbow.  The  line 
of  fracture  may  be  at  right  angles  to  the  long  axis  of  the  bone  in  both  planes, 
or  oblique  in  either  plane,  or  irregular.  The  displacement  may  be  slight,  the 
periosteum  being  in  great  part  untorn,  or  the  fragment  may  be  drawn  one  or  two 
inches  upward  by  the  triceps.  The  symptoms  are  localized  pain,  independent 
mobility,  and-  crepitus  when  there  is  but  little  displacement,  and  the  absence 
of  the  olecranon  from  its  proper  place  and  its  presence  at  a  higher  point  when 
there  is  much  displacement. 

Treatment. — If  the  displacement  is  slight  and  the  olecranon  accompanies 
the  ulna  in  the  flexion  of  the  elbow,  no  other  treatment  is  required  than  immo- 
bilization of  the  limb  in  a  sling  or  an  immovable  dressing;  but  if  the  olecranon 
is  completely  detached  and  drawn  upward,  the  elbow  must  be  immobilized  for 
three  or  four  weeks  in  full  extension  by  a  long  anterior  splint,  and  the  frag- 
ment be  held  down  by  strips  of  adhesive  plaster,  or  india-rubber  traction,  or 
the  turns  of  a  roller  bandage.  After  the  limb  has  been  kept  extended  for 
three  weeks  the  patient  is  anesthetized,  the  forearm  is  bent  to  a  right  angle 
with  the  arm,  an  anterior  angular  splint  is  applied,  and  during  the  next  four 
weeks  passive  motion  is  employed  every  other  day.  Five  weeks  after  the 
accident  the  splint  may  be  discarded.  Of  the  various  methods,  one  of  the 
simplest  and  most  effective  is  a  U-shaped  strip  of  adhesive  plaster,  the  curve 
of  which  lies  on  the  back  of  the  arm  close  above  the  fragment,  and  the  sides 
are  carried  down  upon  the  forearm.  In  a  few  cases  the  fragments  have  been 
exposed  by  incision  and  wii-ed  together;  but,  except  in  old  cases  with  failure 
of  union  and  much  disability,  this  is  hardly  justifiable.  Union  may  be  bony  or 
fibrous;  and  even  when  union  fails  active  extension  is  not  always  entirely  lost. 

Fracture  of  the  coronoid  process  is  almost  unknown  except  as  a 
complication  of  dislocation  of  the  elbow  backward;  the  tendency  to  displace- 
ment is  not  great,  for  the  only  muscle  that  is  attached  to  the  process,  the 
brachialis  anticus,  is  also  broadly  attached  to  the  front  of  the  ulna  below  it, 
and  this  broad  attachment  must  be  broken  before  the  muscle  can  draw  the 
fragment  upward.  The  fragment  can  sometimes  be  felt  as  a  small  movable 
body  in  the  flexure  of  the  elbow.  The  treatment  is  by  immobilization  of  the 
joint  flexed  at  a  right  angle  for  four  weeks. 

Fracture  of  the  head  of  the  radius  has  been  observed  mainly  in  con- 
nection with  fracture  of  the  coronoid  process  of  the  ulna  as  a  complication  of 


FRACTl'RKS.  317 

dislocation  of  tlic  elbow  ;  it  is  j)jirtial,  the  fVa<^ment  beiii^  the  inner  or  ante- 
rior portion  of  the  head.  If  the  fra^rment  is  so  far  displaced  that  a  positive 
diagnosis  can  be  made,  it  should  be  removed. 

Of  fracture  of  the  neck  of  the  radius  a  few  cases  have  been  recorded: 
it  may  be  followed  by  suj)piirati<)n  of  the  joint  or  by  bony  union.  The  clinical 
histories  arc  not  sufficient  to  permit  a  systematic  description  :  possibly  the 
di<((/>ioi</s  could  be  made  by  localized  pain  and  by  recognition  of  the  failure 
of  the  head  to  share  in  rotatory  movements  of  the  shaft  of  the  radius.  Re- 
moval of  the  head  of  the  bone  is  generally  necessary  to  prevent  anchylosis. 

Fracture  of  the  Shaft  of  One  or  of  Both  Bpnes  of  the  Forearm. 
— Fracture  of  both  bones  is  frequent  in  the  lower  and  middle  thirds,  rare  in 
the  upper  third.  Usually  the  radius  is  broken  at  a  somewhat  higher  point  than 
the  ulna.  They  may  be  broken  by  direct  or  indirect  violence,  and  rarely  by 
muscular  action.  Partial,  "green-stick,"'  fractures  are  not  uncommon  in  the 
young.  Fracture  of  the  ulna  alone  is  commonly  due  to  direct  violence,  a  blow 
upon  the  raised  arm,  but  it  may  be  caused  by  a  fall  upon  the  hand,  and  is  then 
occasionally  complicated  by  dislocation  of  the  head  of  the  radius  forward  and 
upward.  Fracture  of  the  radius  alone  is  less  frequent  than  that  of  the  ulna, 
and  may  be  caused  by  direct  or  indirect  violence. 

The  displaeement  may  be  angular  or  lateral  or  Avith  overriding,  and  is  of 
especial  importance  because  of  its  effect,  if  unreduced,  upon  the  function  of 
rotation  of  the  forearm.  Rotatory  displacement  of  the  upper  fragment  of  the 
radius  occurs  especially  when 

the  fracture  is  above  the  in-  ^^^-  ^^• 

sertion  of  the  pronator  radii  v^^^a 

teres;    the  unopposed  action  '^      '      > 

of  the  biceps  supinates  it,  and 
the  result,  if  uncorrected,  is 
to  limit  supination  of  the 
limb  :  a  study  made  by  Cal- 
lender  of  the  specimens  in 
the  London  museums  showed 

■1     T      1  ,  •        -I         Fracture  of  the  Forearm,  angular  displacement,  and  union  be- 

SUCh  displacement  varying  be-  tween  the  bones  (Stimson). 

tween  six  and  forty  degrees. 

The  action  of  the  biceps  may  also  produce  angular  displacement  by  flexing  the 
upper  fragment.  Rotation  of  the  forearm  may  be  lost  in  consequence  of 
excessive  formation  of  callus,  of  the  union  of  the  callus  on  the  two  bones  (Fig. 
99),  or  of  ossification  of  the  interosseous  ligament. 

The  diagnosis  of  fracture  of  both  bones  is  easy,  that  of  either  bone  alone 
may  be  more  difficult :  independent  mobility  in  the  radius  may  be  recognized 
by  observing  that  the  head  of  the  radius  does  not  share  in  slight  rotatory  move- 
ments communicated  to  the  lower  end ;  in  isolated  fracture  of  the  ulna  there  is 
localized  pain,  often  a  corresponding  irregularity  in  outline  that  is  easily  rec- 
ognizable, and  sometimes  independent  mobility  can  be  obtained.  The  position 
of  the  head  of  the  radius  should  always  be  verified  in  case  of  fracture  of  the 
ulna  alone,  for  its  dislocation  forward  and  upward  is  a  not  infrequent  compli- 
cation. 

Treatment. — Reduction  is  made  by  traction,  with  or  without  pressure  upon 
the  projecting  angle  Avhen  one  exists,  pressure  being  necessary  in  "green- 
stick  "  fractures;  and  by  deep  pressure  with  the  fingers  in  front  and  behind  to 
press  the  bones  apart  if  they  have  been  approximated.  Anterior  and  posterior 
padded  splints,  long  enough  to  reach  from  below  the  palm  to  the  elbow  and 
■wide  enough  to  prevent  circular  constriction  of  the  limb  by  the  bandage  that 


318 


.l.V   AMERICAN    TEXT-llOOK    OF  SURGERY. 


secures  them  in  place,  are  usually  sufficient  to  maintain  reduction.  Tlie  fore- 
arm should  be  midway  Itetwoon  pronation  and  su)>ination.  P'requcnt  inspection 
is  necessary  at  first  to  detect  dan^jferous  constriction.  (langrene  has  occurred 
from  pressure  of  the  upper  end  of  the  palmar  splint  ajiainst  the  brachial  artery 
at  the  bend  of  the  elbow.  This  splint  may,  therefore,  with  advantage  be  made 
from  one  to  three  inches  shorter  than  the  posterior  one.  For  the  same  reason 
it  is  well  to  apply  the  splints  -while  the  forearm  is  flexed  upon  the  arm.  The 
supporting  sling  should  not  rest  against  the  ulna.  If  there  is  reason  to  guard 
against  supination  of  the  upper  fragment  by  the  bice])s,  the  wrist  must  be 
correspondingly  supinated ;  this  position  is  somewhat  irksome,  and  has  the 
disadvantage  of  bringinguhe  bones  nearer  together  at  the  center  than  they  are 
when  the  limb  is  in  the  midway  position.  After  two  or  three  weeks  a  moulded 
plaster-of-Paris  dressing  may  be  substituted  for  the  splints.  All  dressings  are 
discarded  after  four  or  five  weeks.  In  simple  fracture  of  the  radius  or  ulna 
alone  witliout  disphicement  moulded  plaster  of  Paris  may  be  safely  used  even 
earlier.  If  dislocation  of  the  head  of  the  radius  forward  and  upward  has 
occurred  in  connection  with  fracture  of  the  ulna  alone,  the  limb  should  be 
dressed  after  reduction,  Avith  the  elbow  flexed  at  less  than  a  right  angle. 

Fracture  of  the  lower  end  of  the  radius  (Colles's  Fracture) 
is  one  of  the  most  common  of  all  fractures;  it  is  seen  at  all  ages,  but  with 
the  greatest  frequency  in  the  old.  It  is  generally  produced  by  a  fall  upon 
the  palm  of  the  hand.  The  line  of  fracture  is  usually  situated  at  from  one- 
third  to  three-fourths  of  an  inch  above 


Fig.  100. 


Fig.  10 


the  articular  edge,  and  is  transverse, 
but  may  be  oblique  in  either  direc- 
tion, and  sometimes  the  lower  frag- 
ment is  comminuted.  In  the  young 
it  occasionally  follows  the  epiphyseal 
line.  The  commonest  di)<placeinent 
is  of  the  lower  fragment  backward 
(Figs.  100  and  101),  with  ascent  of 
the  styloitl  process  by  crushing,  and 
of  the  posterior  articular  border  by 
tilting  or  angular  displacement,  so 
that  the  articular  surface  looks  down- 
ward and  backward  instead  of  down- 
ward and  forward.  The  periosteum 
on  the  back  of  the  bone  remains 
untorn,  but  is  stripped  up  from  the 
upper  fragment  so  as  to  form  a  ''  ))eri- 
osteal  bridge:"  the  consequent  fonna- 
tion  of  bone  in  the  interval  gives  to 
specimens  of  old  unreduced  fractures 
the  appearance  of  deep  penetration 
of  the  lower  by  the  upper  frngment.  Exceptionally  the  styloid  process  of  the 
ulna  may  also  be  broken  off.  or  even  the  shaft  of  the  idna  l)roken  close  above 
its  lower  end. 

The  symptoms  are  a  characteristic  deformity,  consisting  in  a  prominence 
on  the  back  of  the  forearm  close  above  the  wrist  corresponding  to  tlie  lower 
fragment,  producing  what  is  often  called  the  '' silver- fork  "  deformity  (Fig. 
102),  and  a  fulness  on  the  palmar  surface  at  a  somewhat  higher  level,  cor- 
responding to  the  end  of  the  upper  fragment;  the  ascent  of  the  styloid  process 
of  the  radius  to  or  above  the  level  of  that  of -the  ulna;  pain  on  pressure  along 


Rerently-united  Fracture 
of  the  Lower  End  of  the 
Radius  (R.  W.  Smith). 


Fracture  of  the  Lower 
Knd  of  the  Radius, 
displaeemeiit  of  bro- 
ken fragment  back- 
ward (Stimson). 


FBA  CTUBES. 


31!) 


the  line  of  the  fracture  posteriorly  ;  and  swelling  of  the  front  of  the  wrist, 
with  deepening  of  the  transverse  lines  between  it  and  the  hand.  Crepitus 
and  abnormal  mobility  are  often  absent.  Because  of  the  swelling  of  the 
soft  parts  the  palmar  and  dorsal  prominences  are  more  marked  than  the 
displacement  of  the  fragment,  and  may  even  be  present  Avhen  there  is  no 
displacement. 

Fig.  102. 


"  Silver-fork  "  Deformity  of  CoHes's  Fracture,  photographed  half  an  hour  after  the  accident  (original). 

Treatment. — Eeduction,  which  at  times  is  very  difficult  and  even  impos- 
sible, should  be  first  attempted  by  traction  upon  the  hand  and.  direct  pressure 
upon  the  fragments  ;  if  that  fails,  the  wrist  should  be  placed  in  forced  extension 
and  the  fragment  pressed  downward  by  the  surgeon's  thumbs  while  his  fingers 
grasp  the  forearm  above  the  fracture.  If  this  also  fails,  an  anesthetic  should 
be  given,  and  the  fragment  mobilized  by  pressing  it  backward,  and  then  forced 
forward  into  place.  It  is  of  great  importance  to  the  appearance  of  the  limb 
that  the  posterior  displacement  should  be  fully  corrected :  that  which  is  due  to 
the  crushing  of  the  spongy  tissue  and  shortening  of  the  outer  border  of  the 
bone  cannot  be  corrected.  If  reduction  is  well  made,  there  is  but  little 
tendency  to  recurrence.  The  limb  is  then  placed  between  short  anterior  and 
posterior  splints,  the  former  padded  lightly  at  the  point  co^i-esponding  to  the 
end  of  the  upper  fragment,  and  the  latter  more  thickly  where  it  rests  against 
the  lower  fragment,  and  the  splints  fastened  by  a  circular  strip  of  adhesive 
plaster  near  each  end  and  at  the  middle,  or  held  in  place  by  a  roller  bandage. 
The  posterior  splint  should  end  at  the  wrist ;  the  anterior  one  may  end  at  the 
same  level,  or  may  be  carried  to  the  palm  with  a  pad  at  its  lower  end,  over 
which  the  fingers  may  partly  close.  Similar  anterior  and  posterior  moulded 
splints  of  plaster  of  Paris  are  very  convenient  and  equally  secure.  Many 
surgeons  prefer  after  reduction  to  place  the  hand  in  flexion  on  a  Levis's 
metallic  splint.  In  cases  where  there  is  little  tendency  to  displacement 
of  the  lower  fragment  a  Bond's  splint  with  the  wedge-shaped  compresses, 
as  above,  Avill  give  excellent  results.  The  dressing  of  Barton  is  that  pre- 
ferred by  some  surgeons,  and  varies  a  little  from  the  one  just  described. 
Two  wedge-shaped  compresses  and  two  light,  well-padded  splints,  long 
enough  to  reach  from  the  elbow  to  the  tips  of  the  fingers,  are  employed. 
The  compresses  are  placed  over  the  region  of  the  fracture,  one  on  the  dorsum 
of  the  wrist  with  its  base  upward  and  resting  on  the  upper  end  of  the  lower 
fragment,  the  other  on  the  front  of  the  wrist,  its  base  downward  and  correspond- 
ing to  the  lower  end  of  the  upper  fragment.  They  are  held  in  place  by  a  few 
turns  of  a  roller ;   the  anterior  splint  (the  shorter  of  the  two)  is  next  put  in 


320  AN  AMERICAN    TEXT-IiOOk'    OF  SURGERY. 

position,  ;iii(l  the  roller  is  carried  over  it  while  extension  is  kept  up  by 
an  assistant,  and  then  the  posterior  splint  is  applied.  The  arm  is  kept 
midway  between  pronation  and  supination  ;  the  thumb  is  left  free.  Pas- 
sive motion  of  the  finj^ers  should  be  constantly  made.  The  splint  is  to 
be  worn  for  three  weeks.  Passive  motion  of  the  wrist  is  to  be  commenced 
after  a  week.  In  the  young,  growth  of  the  bone  may  be  arrested  by  the 
traumatism,  with  a  resultant  deformity  resembling  that  of  a  fracture  with 
much  crushing  of  the  spongy  tissue.  As  there  is  sometimes  a  lateral 
spreading  of  the  lower  fragment  by  comminution,  especially  when  the 
causative  violence  has  been  great,  lateral  pressure  at  that  point  may  be 
advantageous,  as  by  a  circular  strip  of  adhesive  plaster,  as  recommended 
by  Pilcher,  or  by  making  the  palmar  plaster  splint  broad  enough  to  cover 
the  sides  of  the  wrist  and  pressing  it  against  them  with  moderate  force 
while  it  is  hardening.  The  <lressing  should  be  worn  about  three  weeks, 
and  the  patient  should  be  directed  to  use  the  fingers  freely  in  the  mean- 
time. 

Fracture  of  the  anterior  or  posterior  lip  of  the  lower  end  of  the 
radius  is  an  occasional  accompaniment  of  dislocation  of  the  carpus  forward  or 
backward  respectively;  the  latter  is  known  as  Barton  s  fracture. 

Fracture  of  a  metacarpal  bone  may  be  produced  by  direct  or  indirect 
violence ;  the  diagnosis  is  made  by  localized  pain  increased  by  pressing  the 
corresponding  finger  upward,  and  perhaps  by  abnormal  mobility  and  crepitus. 
The  tendency  to  displacement  is  slight,  and  no  special  treatment  is  required 
other  than  a  palmar  splint  padded  to  preserve  the  concavity  of  the  metacarpus. 

Fractures  of  the  phalanges  are  usually  the  result  of  direct  violence, 
and  are  often  compound.  In  fracture  of  the  proximal  phalanx  there  is  a 
marked  tendency  to  angular  displacement  with  the  apex  directed  forward, 
which  if  left  unreduced  is  the  source  of  considerable  disability.  A  convenient 
and  efficient  treatment  is  to  close  the  fingers  over  a  cylindrical  roller  bandage 
of  suitable  size,  and  bind  them  there  with  longitudinal  strips  of  adhesive 
plaster  or  another  roller  bandage  outside ;  or  a  padded  palmar  splint  may  be 
employed. 

FRACTURES  OF  THE   PELVIS. 

These  fractures  include  complete  fractures  at  one  or  more  points  of  either 
or  both  innominate  bones,  and  fractures  of  any  of  the  three  bones  constituting 
the  innominate. 

Fracture  of  the  ring  of  the  pelvis  is  caused  by  great  external  vio- 
lence, such  as  the  passage  of  the  wheel  of  a  wagon  across  the  bone,  the  fall  of 
a  heavy  object,  the  caving  in  of  an  embankment,  the  kick  of  a  horse,  or  a  fall 
from  a  height.  It  may  be  single,  double,  or  multiple.  The  most  frequent 
seat  is  in  the  pubic  bone,  the  line  of  fracture  passing  through  the  upper  ramus 
just  internally  to  the  ilio-pectineal  eminence,  and  through  the  lower  ramus  near 
its  junction  with  the  ischium.  With  the  anterior  fracture  may  be  associated 
a  posterior  one  (double  vertical  fracture  of  the  pelvis),  either  in  the  ilium  behind 
the  acetabulum  or  in  the  sacrum,  or  partly  in  either  bone  and  partly  along  the 
sacro-iliac  synchondrosis,  or  another  anterior  one  through  the  opposite  pubic 
bone.  Sejjaration  of  either  symphysis  is  the  practical  equivalent  of  a  fracture, 
but  separation  of  the  pubic  symphysis  alone  may  be  occasioned  by  much 
slighter  violence  than  that  which  is  rerjuired  for  a  fracture ;  separation  of  both 
symphyses  is  caused  only  by  great  violence,  and  is  usually  described  as  disloca- 
tion of  the  OS  innominatum.  The  pubes  is  sometimes  broken  in  two  places  or 
comminuted.     An  exceptional  form  of  fracture  of  the  lateral  portion  of  the  ring 


FRACTURES.  321 

is  that  in  wliicli  the  violence  is  exerted  through  the  femur  and  produces  a 
radiating  fracture  of  the  acetabuhnn. 

Associated  injuries  are  common  and  severe :  the  most  freijuent  in  the  male 
is  rupture  of  the  membranous  portion  of  the  urethra  (see  Injuries  of  the 
Urethra),  the  laceration  extending  in  severe  cases  through  the  perineum  and 
around  the  rectum  and  anus  ;  rujiture  of  the  bladder  is  next  in  frequency,  and 
then  injuries  of  other  abdominal  viscera. 

The  displacement  is  sometimes  very  marked,  so  that  it  is  easily  recognized 
by  the  finger  and  eye ;  in  other  cases  the  diagnosis  must  be  made  by  localized 
pain  caused  by  direct  pressure  or  by  pressure  inward  or  backward  upon  the 
wing  of  the  ilium.  The  patient  is  unable  to  raise  the  leg  from  the  bed.  Rup- 
ture of  the  urethra  is  indicated  by  bleeding  from  the  meatus. 

The  treatment  of  the  fracture  consists  in  immobilization  of  the  pelvis  by  a 
girdle,  aided  in  donlde  vertical  fracture  by  traction  upon  tlie  limb,  us  after 
fracture  of  the  thigli.  Immobilization  is  maintained  for  six  weeks.  If  the 
fracture  is  compound,  ample  drainage  must  be  provided ;  and  if  the  urethra 
is  injured,  perineal  section  must  be  made. 

Transverse  fracture  of  the  sacrum  is  very  rare,  and  has  always 
been  caused  by  direct  violence.  It  is  fretjuently  associated  with  paralysis  of 
the  bladder,  rectum,  and  lower  limbs.  The  displacement  is  angular,  with  the 
apex  directed  backward,  and  can  be  corrected  by  pressing  the  coccyx  forward. 

Fracture  of  the  coccyx,  which  is  very  rare,  resembles  in  symptoms  and 
treatment  dislocation  of  the  same  bone. 

Fractures  of  the  wing  and  processes  of  the  ilium  are  compara- 
tively frequent.  The  crest  of  the  ilium  may  be  broken  ofl"  by  direct  violence, 
the  size  of  the  fragment  varying  greatly  in  the  different  cases.  The  anterior 
superior  spinous  process  has  been  broken  off  by  direct  violence  and  by  muscular 
action;  the  posterior  inferior  and  the  anterior  inferior,  by  direct  violence. 
The  diagnosis  is  made  by  recognition  of  a  movable  fragment  with  crepitus. 
No  special  treatment  other  than  rest  in  bed  is  required. 

The  ischium  has  been  broken  in  a  few  cases  by  direct  violence,  as  a  fall 
upon  the  buttocks  ;  the  fragment  in  some  cases  has  included  almost  the  entire 
bone,  in  others  only  the  tuberosity. 

Fracture  of  the  pubes  not  extending  across  both  rami  is  rare :  we  have 
seen  one  case  in  which  the  upper  half  of  the  body  and  the  adjoining  part  of 
the  horizontal  ramus  W'ere  broken  off;  the  fracture  w'as  compound,  and  the 
fragment  was  removed. 

Fracture  of  the  rim  of  the  acetabulum  is  a  complication  of  disloca- 
tion of  the  hip. 

FRACTUEES  OF  THE   FEMUR. 

Fracture  of  the  Neck  of  the  Femur. — This  is  far  more  common  in 
elderly  people,  especially  in  women,  than  in  the  young  or  middle-aged,  and  is 
generally  caused  in  them  by  comparatively  slight  violence,  as  a  fall  while 
walking,  a  misstep,  or  even  the  effort  to  avoid  a  fall.  The  old  classification 
as  intra-  and  extra-capsular  fractures,  which  was  always  unsatisfactory 
and  took  no  account  of  the  large  group  of  "mixed"  fractures  in  which  the 
line  lay  partly  within  and  partly  without  the  capsule,  has  now  in  great  part 
given  place  to  a  division  into  fractures  at  the  base  of  the  neck  and  fractures 
at  the  small  part  of  the  neck. 

In  fractures  at  the  small  part  of  the  neck  (Fig.  103)  the  line  of 
fracture  crosses  the  neck  transversely  or  obliquely,  and  is  rarely  impacted ; 
a  portion  of  the  periosteum,  usually  on  the  anterior  and  inferior  surface, 

21 


322 


^i^v  A  mi: UK  AX  text-book  of  suroeuy 


conimonly  remains  untorn  and  aids  in  supplying  blood  to  the  head.  ])oiiv 
union  is  possible,  but  unlikely.  Separation  of  tlie  epiphysis,  \\liich  is  consti- 
tuted by  the  head  alone,  oeeasionally  ha]i|)cns,  ami  belongs  in  this  group. 

In  fracture  at  the  base  of  the   neck  (Fig.  104).  the  more  common 
variety,  the  line  of  fracture  follows  more  or  less  closely  the  junction  of  the 


Fio.  103. 


Fk;.  104. 


Fig.  lOo. 


Fracture  at  the  Small  Fart  of  the 
Neck  of  the  Femur  (Stimson). 


Fracture  at  the  Base  of  the  Neck 
of  the  Femur,  with  splitting  of 
the  great  trochanter  (Stimson). 


Impacted  Fracture  at  the  Base  of 
the  Cervix  Femoris,  with  heud- 
inp  of  the  head  backward  (Bige- 
low). 


shaft  and  neck ;  the  fragments  are  often  impacted  (PI.  XII,  Fig.  2),  and  the 
great  trochanter  split ;  the  crushing  or  impaction  appears  commonly  to  be 
greater  at  the  back  than  at  the  front,  so  that  the  neck  is  inclined  backward 
from  its  normal  position  Avith  reference  to  the  shaft,  or,  in  other  words,  the 
shaft  is  in  outward  rotation  upon  the  neck  (Fig.  105).  Bony  union  is  the 
rule,  and  often  with  excessive  production  of  bone  about  the  fracture  and  the 
trochanter. 

The  srimptoms  of  both  varieties  are  inability,  often  complete,  to  use  or 
move  the  limb ;  but  occasionally  the  patient  has  been  able  to  raise  the  limb 
from  the  bed  or  even  to  walk  a  short  distance.  As  a  rule,  however,  the 
limb  lies  straight  and  helpless  on  the  bed,  the  foot  is  everted,  the  upper  part 
of  the  thigh  is  fuller  and  rounder  than  usual.  Complaint  is  made  of  pain 
at  the  hip,  and  often  in  the  anterior  and  inner  part  of  the  middle  of  the 
thigh.  Pain  is  caused  by  pressure  in  front  of  or  behind  the  neck,  against 
the  trochanter,  or  upward  at  the  knee  or  ankle ;  but  sometimes  the  limb  can 
be  pressed  quite  forcibly  upward  without  causing  pain.  If  eversion  of  the 
foot  is  absent,  it  will  nevertheless  be  found  that  passive  inversion  is  less 
complete  than  normal.  Occasionally  the  foot  is  fixed  in  inversion.  Pres- 
sure over  the  front  of  the  neck  shows  that  the  tissues  are  less  depressible 
than  on  the  other  side — a  valuable  si<<;n  in  obscure  cases.  On  jxentle  rota- 
tion  of  the  limb  the  trochanter  is  found  to  share  in  the  movement,  and  occa- 
sionally crepitus  is  felt. 

Measurement  (in  making  which  care  must  be  taken  to  place  the  limbs  sym- 
metrically Avith  reference  to  the  pelvis,  as  mentioned  on  page  289)  shows  the 
injured  limb  to  be  shorter  than  its  fellow,  the  diiferenee  varying  between  a 
small  fraction  of  an  inch  and  two  inches.  This  is  best  done  l)y  marking  the 
site  of  the  spines  with  an  aniline  pencil,  and  then  measuring  from  the  fixed 


FRA  CTURES.  323 

niiilleolns  to  the  mark  over  spine  \vitlioiit  touching  the  skin  at  the  latter 
point.  Similarly,  the  trochanter  is  found  to  occupy 
a  higher  position  than  its  fellow  with  reference  to  a 
line'^lrawn  across  it  from  the  anterior  superior  spi- 
nous process  of  the  ilium  to  the  tuberosity  of  the 
ischium  (Nelaton's  line)  (Fig.  106).  If  a  line  be 
drawn  through  the  two  anterior  superior  spines,  and 
the  distancefrom  the  summits  of  the  trochanters  to 
this  line  be  measured,  it  will  be  found  shorter  on 

the  injured  sule  (Bryant's  line)  (Fig.  106).  ^  ^  ^  ^^^^^^^^^^^^ 

The  diagnosis  between  the  two  vaiieties  can-       Triangle;  a B.Neiaton's  Line 
not   always    be   made    with    certainty:    a   positive       '-Owen). 
sign  of  fracture  at  the  base  of  the  neck  is  enlarge-  ,      ,       •     r 

ment  of  the  trochanter,  due  to  its  splitting ;  and  it  is  thought  that  in  frac- 
ture of  the  small  part  of  the  neck  the  shortening  is  more  likely  to  be  slight 
at  first  and  to  increase  suddenly  and  rapidly  during  the  first  few  days  from 
separation  of  the  interlocked  fragments.  The  opinion  once  very  widely  held, 
and  even  now  occasionally  encountered,  that  the  differential  diagnosis  can  be 
made  bv  consideration  of  the  age  of  the  patient  (intracapsular  fractures  in 
those  more  than  sixty  years  old)  or  of  the  way  in  which  the  violence  was 
received  (intracapsular  by  a  fall  on  the  knee  or  foot,  extracapsular  by  a  fall 
upon  the  trochanter)  has  proved  to  be  wholly  untrustworthy. 

It  may  even  be  impossible  to  say  with  certainty  that  a  fracture  is  present, 
but  in  anv  case  in  which  an  elderhj  person,  especially  a  woman,  has  fallen  and 
complains  of  imin  at  the  hip,  with  inahility  to  use  the  limb,  a  fracture  is  prob- 
able, and  the  case  should  be  treated  as  such  for  at  least  three  weeks  and  until 
all  pain  and  soreness  have  ceased.  It  has  happened,  often  enough  to  justify 
great  caution  in  giving  an  opinion,  that  the  positive  signs  of  fracture  have  not 
appeared  until  after  a  number  of  days,  perhaps  after  the  patient  has  been 
assured  that  he  has  suffered  no  serious  injury  and  has  been  encouraged  to  use 
the  limb.  In  not  a  few  cases  the  patient  has  remained  disabled  long  after  the 
surgeon  has  ceased  his  attendance,  and  has  sued  the  latter  for  malpractice. 

The  indications  for  treatment  are,  in  the  order  of  their  importance,  m  the 
case  of  the  old  and  feeble,  to  guard  against  the  danger  to  the  life  of  the  patient 
arisincr  from  the  traumatism  and  the  necessary  confinement,  to   secure  firm 
union?  and  to  have  the  minimum  of  deformity.     The  vital  indication  requires 
that  the  patient's  strength  should  not  be  further  taxed  by  dressings  that  cause 
pain  or  by  prolonged  confinement  to  bed  if  its  ill  eff'ects  become  manifest  and 
threaten  to  become  serious.     In  the  latter  case,  if  necessary,  union  of  the  frac- 
ture must  be  sacrificed  to  the  preservation  of  life.     Special  attention  must  be 
given  to  securing  comfort  and  good  nourishment  and  to  the  avoidance  of  bed- 
sores.    Local  treatment   is  limited  to  making  only  so  much  reduction  of  the 
shortening  as  can  be  efi"ected  bv  moderate  traction,  and  to  immobilization  by 
traction  arid  cushions  or  by  a  fixed  dressing.      Complete  removal  of  the  short- 
enincr  is  liable  to  break  up  an  impaction  that  would  be  valuable  m  securing 
union.     Traction  bv  Buck's  extension  (Fig.  84)  with  a  weight  of  five,  or  at 
most  ten,  pounds  prevents  further  shortening  and  promotes  comfort,  and  small 
firm  cushions  or  sand-bags  placed  behind  the  trochanter  and  along  the  outer  side 
of  the  thigh  aid  the  immobilization.  Hodgen's  suspended  splint  (Fig.  88)  is  even 
better  than  Buck's.     For  immobilization  without  permanent  traction  either  a 
lono-  side-splint,  extending  from  the  side  of  the  chest  to  the  foot,  or  a  plaster- 
of-Paris  dressing,  including  the  entire  limb  and  the  pelvis,  may  be  employed. 
Lateral  pressure  in  non-impacted  fractures  is  of  great  importance  m  securing 


324  AX   AMERICAN    TEXT- HOOK    OF  SriKiKRY. 

bony  union,  and  on  this  account  Senn  recommends  with  the  latter  dressing  the 
use  of  direct  pressure  inward  against  the  trochanter,  made  through  a  fenestra  by 
a  pad  at  the  end  of  a  screw  that  passes  through  an  iron  supjwrt  iiiihedck'd  in  the 
plaster.  A  well-applied  plaster  dressing  apjjcars  to  meet  the  indication  suffi- 
ciently well.  The  dressing  should  be  worn  for  about  two  months  if  tlic  patient's 
condition  permits. 

It  is  to  be  expected  that  some  shortening  and  outward  rotation  of  the  limb 
will  persist ;  and  the  range  of  motion  of  the  joint  may  be  considerably  restricted 
by  the  consequences  of  the  arthritis  or  by  an  exuberant  callus.  Even  if  union 
fails  or  is  fibrous,  the  patient  may  still  be  able  to  make  fair  use  of  the  limb, 
the  support  being  given  by  the  Y-ligament,  which  secures  a  bearing  against  the 
ilium  in  the  ascent  of  the  shaft.  In  a  few  cases  in  which  union  has  failed  and 
the  disability  has  been  great  and  the  condition  painful,  operations  have  been 
done  to  obtain  union  by  freshening  the  surfaces  and  suturing  or  pinning  the 
fragments  toorether,  or  to  remove  the  detached  head. 

Fracture  of  the  great  trochanter  has  been  occasionally  caused  by 
direct  external  violence.  The  patients  have  usually  been  able  to  walk  not- 
withstanding the  injury.  In  the  specimens  obtained  after  death  the  fracture 
has  always  been  found  to  be  entirely  outside  the  joint.  The  fragment  may 
be  large  or  small,  and  in  the  young  may  comprise  the  entire  trochanteric 
epiphysis,  separated  along  the  conjugal  cartilage.  The  diayni>><iH  must  be 
made  on  the  independent  mobility  of  the  fragment  and  localized  ])ain.  The 
treatment  is  rest,  aided  perhaps  by  a  bandage  to  oppose  the  retraction  of  the 
fragment  upward  and  backward  by  muscular  action. 

Fracture  of  the  shaft  may  be  caused  by  direct  or  indirect  violence  or 
by  muscular  action.  All  the  varieties  of  fracture  of  the  shafts  of  long  bones  are 
found  here,  but  the  commonest  is  oblique  fracture,  often  with  the  splitting  oflF 
of  a  lateral  piece,  and  Avith  either  or  both  main  fragments  ending  in  a  long 
sharp  point :  transverse  fracture  appears  to  be  quite  common  in  children. 

Symptoms. — Angular  displacement  and  overriding  are  greatly  favored  by 
the  contraction  of  the  muscles,  both  those  connecting  the  lower  fragment  with 
the  pelvis  and  those  that  flex  and  abduct  the  upper  one.  Outward  rotation  of 
the  lower  fragment  may  be  produced  by  the  unsupported  weight  of  the  foot, 
which  turns  to  tlie  outer  side  ;  outward  rotation  of  tlie  up])er  fragment  may  be 
caused  in  like  manner  by  the  unsupported  weight  of  the  upper  and  outer  por- 
tion of  the  thigh,  the  foot  being  meanwhile  held  upright.  The  latter  displace- 
ment is  equivalent  to  inward  rotation  of  the  lower  fragment,  and  when  the 
patient  begins  to  walk  he  finds  that  the  toes  turn  in.  Compound  fracture  and 
associated  injury  to  the  large  vessels  are  infrequent.  Distention  of  the  knee- 
joint  by  an  effusion  immediately  after  the  injury  is  the  rule,  and  is  probably 
due  to  a  concomitant  sprain. 

The  diagnosis  is  made  by  pain,  loss  of  function,  shortening,  abnormal 
mobility,  and  crepitus.  Measurement  is  made,  as  in  fracture  of  the  neck  of 
the  femur,  from  either  the  malleolus  or  the  knee  to  the  anterior  superior  spine 
of  the  ilium,  and  the  same  precautions  are  needed  to  ensure  symmetry  of  posi- 
tion. The  fact  that  the  shortening  has  occurred  in  the  shaft,  and  not  in  the 
neck,  is  shown  by  the  normal  relation  of  the  trochanter  to  N(?laton's  line. 
Abnormal  mobility  can  be  recognized  by  passing  the  hand  under  the  limb  at 
the  suspected  point  and  gently  raising  it,  or  by  grasping  the  upper  ])art  of  the 
thigh  firmly  and  moving  the  foot  inward  and  outward,  or  by  observing  that  the 
trochanter  does  not  share  in  gentle  rotatory  movements  communicated  to  the 
lower  portion  of  the  limb.  Steady  traction  overcomes  or  diminishes  the  short- 
ening.    The  thickness  of  the  overlying  muscles  usually  prevents  recognition 


FRA  ( 'TUBES.  325 

ot"  till'  details  of  the  fViieture  aiid  displaeeiiieiit.  Sometimes  the  sharp  cud  of 
one  fragment  perforates  the  muscles  and  the  slcin,  commonly  the  upper  frag- 
ment in  front;  the  penetration  can  be  relieved  by  flexing  the  thigh  upon  the 
pelvis  and  the  leg  upon  the  thigh,  the  movement  drawing  the  nmscle  down 
past  the  fragment. 

Treatment  is  commoidy  by  one  of  the  methods  of  continuous  traction, 
Buck's  extension  by  weight  and  pulley  (Fig.  ''^4)  or  suspension  by  Ilodgcn's 
(Fig.  88)  or  N.  R.  Smith's  anterior  splint  (Fig.  87)  in  adults,  or  vertical  sus- 
pension in  infants  and  young  children.  Ilodgen's  splint  is  especially  useful  in 
compound  fractures,  because  of  the  facility  with  which  it  permits  the  dressings 
of  tlie  wouiul  to  be  changed.  The  methods  of  a{)plying  Buck's  extension  and 
the  suspended  splints  have  been  already  described.  The  plaster-of-Paris  dress- 
ing, including  the  pelvis,  is  still  in  use,  but  its  results  are  not  so  satisfactory 
as  those  obtained  by  the  other  methods.  Vertical  suspension  in  young  children 
is  very  usefid,  because  of  the  ease  Avith  wdiich  the  position  can  be  maintained 
and  the  child  kept  clean.  The  suspension  is  made  by  two  india-rubber  cords 
attached  to  a  cross-bar  above  the  bed  and  one  to  each  leg  by  adhesive  plaster, 
as  in  Buck's  extension;  the  limbs  are  kept  parallel  by  attaching  the  feet  to  a 
short  foot-})iecc.  The  traction  should  be  just  sufficient  to  raise  the  buttocks 
slightly  from  the  bed. 

Union  is  complete  in  the  adult  in  from  six  to  eight  weeks ;  in  young  children, 
in  three  or  four.  It  is  advisable  to  keep  the  patient  in  bed  for  a  week  after 
the  dressings  have  been  removed,  and  to  insist  upon  the  use  of  crutches  for  a 
week  or  two  thereafter.      Usually  some  shortening  persists. 

Fractures  at  the  Lower  End  of  the  Femur. — In  this  group  are 
included  the  supracondylar,  intercondyloid,  fracture  of  either  condyle,  and 
separation  of  the  epiphysis. 

Supracondyloid  fracture  is  commonly  produced  by  indirect  violence,  as 
a  fall  upon  the  feet ;  the  line  of  fracture  is  oblique  or  transverse ;  and  the  usual 
displacement  is  of  the  lower  fragment  backward.  Flexion  of  the  lower  frag- 
ment upon  the  tibia  by  the  action  of  the  gastrocnemii,  by  which  its  fractured 
surface  is  directed  somewhat  backw'ard,  occasionally  occurs,  but  is  by  no  means 
so  frequent  as  has  been  alleged.  A  dangerous  complication 
is  sometimes  found  in  rupture  or  stretching  of  the  popliteal  ^^-  ■^^^• 

vessels.  The  diagnosis  is  easily  made  by  recognition  of  the 
common  signs  of  fracture.  Treatment  is  by  the  plaster-of- 
Paris  dressing  or  by  suspension  in  Ilodgen's  or  Smith's  an- 
terior splint. 

Separation  of  the  epiphysis  is  commonly  caused 
by  torsion  or  hyperextension  of  the  leg.  The  treatment  is 
the  same  as  in  the  preceding  variety. 

In  intercondyloid  fracture  (Fig.  107)  the  condyles 
are  separated  from  the  shaft  and  from  each  other.  It  is 
caused  by  great  violence,  as  in  a  fall  from  a  height,  and  is 

consequently  often  compound  and  accompanied  with  much         

displacement.     It  is  always  a  serious  injury,  and  if  com-  intercondyloid  Fracture 
pound,  a  grave  one.      Continuous  traction  by  Buck's  exten-       of  Femur  (Bryant). 
sion  or  a  suspended  splint  is  advisable  for  the  first  two  or  three  weeks,  after 
which,  if  all  is  going  well,  the  limb  can  be  put  in  plaster.     If  compound,  it  is,  of 
course,  to  be  treated  antiseptically. 

Fracture  of  either  condyle  may  be  caused  by  direct  violence,  as  in  a 
fall  upon  the  flexed  knee,  or  by  lateral  flexion  of  the  leg:  the  line  of  frac- 
ture runs  from  the  intercondyloid  notch  more  or  less  obliquely  upward.     The 


326  ^lA^  AMERICAN    TF.XT-liOOK    OF  SVIiaKli  V. 

fragment  remains  attached  to  the  tihia  hy  its  latonil  linaincnt,  an<l  the  «lis- 
|)lacement  is  therefore  usually  sli^^iit,  alt'hou<^h  the  fra;,rujent  is  soiuftiiues 
carried  forward  or  l)ackward  by  rotation  of  tlie  leg.  The  courmc  is  usually 
simple  and  the  result  good,  but  in  a  few  cases  suppuration  of  llie  joint  or 
necrosis  of  the  fragment  lias  followed.  The  dicujuoaia  is  made  by  the  recogni- 
tion of  abnormal  mobility  and  crepitus ;  sometimes  the  only  sign  is  localized 
pain  on  pressure,  or  on  lateral  flexion  of  the  leg  toward  the  injure<l  side.  The 
treatment  is  reduction  of  the  displacement,  if  any,  by  bringing  the  leg  to  its 
proj)er  position   in   full   extension,  and  immobilization,  preferably  in  plaster. 

Fracture  of  the  patella  is  an  injury  of  frequent  occurrence  between 
the  ages  of  twenty  and  fifty  years,  especially  in  males.  It  is  usually  the 
result  of  muscular  action,  but  sometimes  of  direct  violence,  and  sometimes  of 
forcible  flexion  of  the  partially  stiff"  knee  when  the  descent  of  the  patella  is 
prevented  by  adhesions;  the  latter  is  the  common  method  of  production  of 
refracture.  Dull  pain  is  occasionally  felt  in  the  patella  for  some  days  before 
it  breaks.  Simultaneous  fracture  of  both  patellae  has  been  reported  a  num- 
ber of  times. 

The  line  of  fracture  is  almost  always  transverse,  and,  while  generally  near 
the  middle  of  the  bone,  may  be  close  to  either  end;  exceptionally  it  may  be 
oblique.  In  fractures  by  direct  violence  it  is  more  or  less  comminuted,  and  is 
likely  to  be  compound,  or  to  become  so  by  the  sloughing  of  the  bruised  skin 
The  upper  fragment  is  drawn  upward  by  the  quadriceps  to  a  greater  or  Icsst^r 
distance,  but  in  some  cases,  and  especially  in  fractures  by  direct  violence,  so 
much  of  the  periosteum  remains  untorn  that  the  separation  is  very  slight.  As 
a  rule,  the  periosteum  ruptures  at  a  different  level  from  that  of  the  fracture, 
and  thus  is  produced  a  narrow  fringe  which  lies  between  the  fragments 
when  they  are  approximated,  and  to  which  much  importance  has  been  attributed 
as  a  cause  of  failure  of  bony  union.  The  capsule  is  torn  transversely  on  each 
side  to  a  distance  that  varies  with  the  separation,  and  the  cavity  of  the  joint 
promptly  fills  with  blood  and  synovia,  which  still  further  increase  the  separa- 
tion by  distention. 

The  symptoyns  are  loss  of  the  power  of  active  extension  of  the  leg,  inde- 
pendent lateral  mobility  of  the  fragments,  and  usually  a  distinct  transverse  gap 
between  them  which  can  be  closed  by  pressing  them  together. 

The  treatment  is  immobilization  of  the  extended  knee  for  about  two  months, 
usually  combined  with  dressings  arranged  to  keep  the  fragments  in  contact  with 
each  other.  When  the  periosteal  covering  is  not  torn  and  the  separation  is 
slight,  a  plaster-of-Paris  dressing,  extending  from  the  ankle  to  the  upper 
third  of  the  thigh,  is  sufficient,  but  in  other  cases  special  dressings  are 
needed.  Of  these  the  variety  is  great.  The  simplest  form  consists  of  turns 
of  a  roller  bandage,  with  a  long  iKJSterior  splint,  applied  obliijucly  above 
and  below  the  fragments,  so  as  to  press  and  hold  them  together  (Fig.  108) ; 
the  patient  should  be  kept  in  bed  with  the  foot  raised.  Agnew's  splint 
(Fig.  109)  consists  of  a  piece  of  pine  board  thirty  inches  long,  five  inches 
wide  at  the  top,  and  four  at  the  lower  end,  with  four  lateral  pegs.  Fig. 
110  shows  the  manner  of  its  application,  the  fragments  of  the  fractmx'd 
patella  being  drawn  together  by  the  adhesive  ])laster  stri))s.  Another 
method  is  by  elastic  traction  applied  to  the  upper  fragment:  a  ])iece  of 
rubber  tubing  is  made  fast  to  each  end  of  a  strip  of  adhesive  plaster 
about  eight  inches  long  and  two  inches  wide;  the  adhesive  plaster  is  then 
placed  transversely  close  above  the  upper  fragment,  and  the  ruljber  cords 
are  stretched  down  on  each  side  of  the  leg  and  made  fast  to  the  posterior 
si)lint.       After    eight    weeks    the    patient    is    permitted    to    walk    with    the 


FBA  CTUBES. 


327 


aid  of  a  crutch  or  cane,  with  light  side-splints  of  pasteboard  to  the  knee. 
Mal.'aicrno's  hooks  (Fig.  Ill)  are  used  by  forcing  one  through  the  skin  into 
the  ui)Jer  border  of  the  upper  fragment,  the  other  into  the  lower  border 
of  the  lower  fragment,  and  then  bringing  them  together  by  means  ol  the 

Fig.  108. 


Hamilton's  Dressing  for  Fracture  of  the  Patella.    The  final  turns  of  the  roller  in  front  of  the  knee  are 

not  shown  in  the  cut. 

screw.  Treves  employs  them  after  a  preliminary  exposure  and  freshen- 
ing of  the  fragments,  as  in  the  operation  of  suturing,  over  which  he  thinks 
this  procedure"  has  some  advantages.  In  any  of  these  methods  the  effu- 
sion in  the  joint  may  often  be  promptly  removed  by  the  use  of  a  rubber 


Fig.  109. 


Fig.  110. 


Agnew's  Splint  for  Fractured  Patella. 


Agnew's  Splint  Applied. 


bandage,    or   the  joint   may    be    primarily    emptied   by    aspiration    of    its 

contents.  m,     /> 

Operative  measures  include  various  forms  of  suture.     The  first  to  be  em- 
ployed was  an  open  arthrotomy  wuth  direct  suturing  of  the  fragments  with 


Fig. 111. 


Malgaigne's  Hooks. 

silver  wire :  it  has  given  many  brilliant  successes,  but  also  cases  of  suppuration 
of  the  joint,  some  with  loss  of  the  limb  or  loss  of  life — a  risk  which,  in  the 
opinion  of  some  surgeons,  the  nature  of  the  injury  rarely  justifies.  The  ope- 
ration should  only  be  done  under  strict  antisepsis  and  in  healthy  subjects.    In 


328  AiX    AMERICAA    TEXT-IK >< >!<    O/     sri!(; EL' Y. 

coinpouiiil  t'nictures  it  is  not  «jnly  pcriui.ssible,  but  is  otteu  clotirly  indicated. 
The  operation  is  done  by  exposing  the  fragments,  freshening  the  fractured  sur- 
faces if  the  fracture  is  an  ohl  one,  or  dissecting  away  the  fibrous  tissue  and 
fragments  of  periosteum  or  synovial  meniltrane  often  found  interposed,  and 
drilling  the  bones  in  the  median  line,  the  diill-holcs  ruTiuing  (jbliijuely  from  the 
anterior  surface  of  the  attached  border  of  each  fragment  toward  the  posterior 
edges  of  the  fractured  surfaces.  Silver  wire  is  then  introduced  and  the 
fragments  are  approximated,  the  wire  being  cut  short  and  the  ends  ham- 
mered into  the  bone,  or  else  left  to  protrude  from  the  wound  to  be  with- 
drawn later. 

The  substitution  of  a  silk  ligature  through  the  tendon  of  the  quadriceps 
and  the  ligamentum  patelhx^  for  the  wire  suture  through  the  bone  is  {^referred 
by  some.  The  joint  must  not  be  invaded  by  the  ligature.  An  antiseptic 
dressing  is  applied,  and  the  limb  kept  on  a  posterior  splint  for  a  week.  If 
all  has  then  gone  well,  a  plaster-of-Paris  dressing  is  applied  and  Avorn  for  a 
month  ;  after  that,  for  another  month  it  is  worn  only  in  the  daytime  and 
removed  at  night.  The  silk  should  be  boiled  and  all  antiseptic  rules  should 
be  most  rigidly  followed;  if  suppuration  occurs,  free  exit  should  be  promptly 
given  to  the  pus,  to  diminish  the  risk  of  invasion  of  the  joint.  The  ligature 
may  be  employed  subcutaneously  by  means  of  a  long,  slightly-curved  needle 
introduced  and  brought  out  in  turn  through  four  small  incisions,  two  above 
and  two  below  the  patella,  or,  better  (Stimsou),  through  a  longitudinal  median 
incision  four  or  five  inches  long,  fully  exposing  the  bone,  and  the  tendons. 
After  the  joint  has  been  emptied  and  the  fringe,  if  present,  raised  from  the 
broken  surface,  the  silk  ligature  is  passed  by  means  of  a  curved  needle  trans- 
versely through  the  tendon  of  the  quadriceps  and  the  ligamentum  patella 
close  to  the  bone,  drawn  tightlv  to  brincr  the  broken  surfaces  into  contact, 
tied  and  cut  short.  The  fibrous  layers  between  it  and  the  patella  should  be 
smoothed  out,  and,  Avhen  necessary,  catgut  sutures  applied  to  close  the 
lateral  rents  in  the  capsule.  Recent  experience  has  sIiOAvn  that  catgut 
sutures  in  the  fibro-periosteal  layer  give  all  the  support  needed.  In  this 
form  the  operation  is  the  simplest  and  safest,  and  is  as  efficient  as  any 
other. 

Among  other  methods  that  have  been  recommended  may  be  mentioned 
subcutaneous  longitudinal  drillin(T  of  the  fragments  and  the  use  of  a  silver 
suture  ;  transverse  drilling  of  each  fragment,  the  drills  being  left  in  place  and 
tied  together  on  each  side.  Barker's  operation  (Figs.  112, 118),  which  hasfound 
much  favor  with  many  surgeons,  is  done  as  follows:  The  lower  fragment  of  the 
patella  is  steadied  by  the  finger  and  thumb,  and  a  narrow-bladed  knife  thrust 
into  the  joint,  edge  upward,  in  the  middle  line  of  the  ligamentum  patelh\?  at 
its  attachment  to  the  lower  fragment.  Through  the  wound  thus  made  a  stout- 
handled  pedicle  needle  is  thrust  into  the  joint  behind  the  lower  fragment,  and 
pushed  up  behind  the  upper  fragment  and  through  the  quadriceps  tendon  in 
the  middle  line  as  close  to  the  border  of  the  bone  as  possible,  the  upper  frag- 
ment at  this  time  being  forced  down  and  steadied.  When  the  point  of  the 
needle  becomes  apparent  beneath  the  skin,  the  latter  is  drawn  upward  and 
an  incision  made  upon  the  needle,  the  eye  of  which  is  then  threaded  with 
sterilized  silk  and  the  needle  Avithdrawn,  carrying  the  thread  behind  the  frag- 
ments. The  needle  is  next  unthreaded  and  passed  through  the  same  skin 
wound  below  and  out  of  the  upper  wound,  but  this  time  in  front  of  and  close 
to  both  fragments.     Here  it  is  threaded  with  the  upper  end  of  the  suture  and 

withdrawn.     The  two  fragments  are  then  brought  together,  friction  is  made 

.  .  . 

to  displace  clots  or  other  foreign  material,  and  the  ligature  tied  tightly  over 


FRAC'TriiES. 


329 


the  lower  border  of  the  patella.  Tlie  two  ends  of  the  li^xatnre  are  cut  short 
and  the  wounds  closed.  Union  of  the  skin-wound  is  by  first  intention. 
Passive  motion  is  begun  on  the  tenth  day. 

Union  /.v  almoat  inrnridhli/  fi/iroux  in  cases  treated  without  the  suture,  and 
the  bond  of  union  habitually  leuirtlicns  somewhat  under  use,  but  this  does  not 
materially  affect  the  usefulness  of  the  limb.  In  cases  treated  by  the  suture  the 
union  is  closer,  and  may  occasionally  be  bony. 

Rupture  of  the  bond  or  rcfraeture  of  the  bone  at  another  point  occasion- 
ally liaj)})ens :  the  common  cause  is  forcible  flexion  of  the  knee,  in  which  the 
upper  fragment  is  prevented  from  moving  by  adhesions  that  unite  it  to  the 
femur  or  by  shortening  of  the  capsule  on  each  side,  which  does  not  allow  it  to 
pass  below  the  condyles.  The  injury  may  become  compound  by  rupture  of  the 
adherent  skin  along  the  line  of  fracture. 

In  old  cases,  in  which  the  disability  is  great  because  of  the  wide  separation 


Fig.  112. 


Fj(;.  118. 


Barker's  Operation  for  Transverse  Fracture 
of  the  Patella  (first  stage). 


Barker's  Operation  for  Transverse  Fracture  of 
the  Patella  (second  stage). 


of  the  fragments,  open  arthrotomy  with  suture  has  been  done  many  times. 
Since  modern  aseptic  methods  have  come  into  use,  the  proportion  of  success- 
ful cases  has  been  much  larger  than  formerly. 


FRACTUEES  OF  THE  LEG. 

Fractures  at  the  Upper  End. — The  tibia  may  be  broken  at  its  upper 
end  by  direct  or  indirect  violence,  and  the  fibula  may  be  simultaneously  broken 
or  its  upper  end  dislocated,  or  it  may  be  uninjured.  The  fracture  may  be 
transverse,  oblique,  or  comminuted  and  impacted,  or  the  line  may  run  from  the 
side  of  the  head  into  the  joint,  separating  only  one  condyle,  or  it  may  follow  the 
epiphyseal  line  (separation  of  the  epiphysis).  In  fractures  by  direct  violence, 
usually  by  a  heavy  blow  upon  the  front  of  the  bone,  there  may  be  marked  angu- 
lar displaceinent,  the  apex  directed  backward,  or  backward  displacement  of  the 
lower  fragment,  with  the  possibility  of  serious  injury  to  the  main  vessels.  In 
fracture  by  a  fall  upon  the  feet  the  lower  fragment  is  driven  into  the  upper  one, 
splitting  it  and  opening  the  joint.     When  the  fibula  is  neither  broken  nor  dis- 


330  .l.V    AMUncAX    TEXT- HOOK    OF    Si  IlCKRY. 

located,  disphu-einent  of  the  tibia  is  slight.  The  jirogiiosis  is  serious  heciiuse- 
of  the  probability  of  implication  of  the  joint  in  the  inflammatory  reaction,  and 
it  has  been  noted  that  repair  of  the  fracture  takes  an  exceptionally  long  time. 
After  separation,  of  the  epiphysis  the  growth  of  the  bone  may  be  arrested. 

The  treatDwnt  consists  in  the  reduction  of  the  displacement,  and  in  exten- 
sion by  continuous  traction,  or  by  splints,  according  to  circumstances.  Manv 
of  these  cases  can  be  well  treated  ujion  a  double  inclined  plane,  which  is 
used  for  six  weeks. 

Fracture  of  the  Upper  End  of  the  Fibula  may  be  caused  by  muscular 
action  (vigorous  contraction  of  the  biceps),  by  forced  adduction  of  the  leg,  or 
by  direct  violence.  The  fragment  may  remain  in  place  or  may  be  drawn 
upward  by  the  biceps.  In  several  cases  the  external  popliteal  nerve  has  been 
injured,  either  in  the  accident  or  in  the  process  of  repair,  with  consequent 
paralysis  of  the  anterior  and  peroneal  groups  of  muscles.  The  treatment  is 
immobilization,  with  the  knee  flexed  to  relax  the  biceps.  This  is  maintained 
for  five  weeks. 

Fracture  of  the  Shaft  may  be  caused  by  direct  or  indirect  violence, 
and  in  the  latter  case  is  more  frequently  situated  at  or  near  the  junction  of  the 
middle  and  lower  thirds.  It  may  be  transverse,  oblique,  V-shaped,  or  commi- 
nuted, and  is  frequently  compound,  either  by  the  direct  action  of  the  violence 
upon  the  overlying  soft  parts  or  by  perforation  of  the  skin  by  the  sharp  end  of 
one  of  the  fragments,  especially  the  upper  one.  When  both  bones  are  broken 
the  fracture  of  the  tibia  is  commonly  at  a  lower  level  than  that  of  the  fibula. 
The  common  displacement  is  angular  with  overriding,  the  lower  end  of  the 
upper  fragment  being  displaced  forward.  The  injury  can  be  readily  recognized 
by  palpation  of  the  subcutaneous  surface  of  the  tibia ;  abnormal  mobility, 
■which  is  greater  when  both  bones  are  broken ;  and  crepitus.  Fracture  of 
the  fibula  alone  is  shown  by  localized  pain,  and  sometimes  by  abnormal 
mobility. 

Treatment. — After  reduction  by  traction  and  coaptation  the  limb  may  be 
secured  by  lateral  splints  or  in  a  Yolkmann  splint  or  fracture-box  for  a  few 
days  until  the  swelling  shall  have  subsided,  and  then  in  a  plaster-of-Paris 
dressing,  or  it  may  be  secured  at  once  in  moulded  plaster-of-Paris  splints, 
posterior  and  lateral.  Care  must  be  taken  to  prevent  angular  displacement 
by  the  sinking  of  the  foot,  and  it  is  always  advisable  to  remove  the  dressings 
and  inspect  the  fracture  after  the  first  fortnight,  when  it  is  still  possible  to 
correct  angular  displacement.  Union  commonly  takes  place  in  about  six 
weeks,  but  sometimes  is  long  delayed. 

Compound  fractures  should  be  dressed  in  accordance  with  general  ])rin- 
ciples,  and  the  limb  placed  in  a  fracture-box  or  Volkmann  splint ;  if  the 
fracture  has  not  become  simple  by  the  end  of  the  first  fortnight,  interrupted 
plaster  splints  arranged  for  suspension  will  be  found  convenient.  Delayed 
union  and  failure  of  union  are  not  uncommon  if  there  has  been  mucli  loss  of 
substance  of  the  tibia  by  splintering ;  and  if  the  fibula  has  maintained  its 
length  a  piece  should  be  cut  from  it  in  order  that  the  fragments  of  the  tibia 
mav  be  broujrht  toirether. 

Fractures  at  the  Lower  End. — Of  these  the  most  common  and  import- 
ant is  the  one  known  as  Pott's  fracture  at  the  ankle,  which  is  caused  by 
forcible  eversion  and  abduction  of  the  foot :  rarely  by  inversion  and  adduc- 
tion of  the  foot.  Fig.  114  shows  the  mechanism  of  both  varieties.  In  a 
typical  case  there  are  three  separate  lines  of  fracture  (Fig.  115):  one  of  the 
fibula  about  three  inches  above  the  tip  of  the  malleolus,  and  commonly 
extending  oblifjuely  downward  for  an  inch  or  more ;  one  of  the  internal  mal- 


FRA  CTURES. 


331 


leolus;  and  one  of  the  outer  lower  edge  of  the  tibia;  but  in  the  place  of  the 
last  two  there  is  often  rupture  of  the  internal  lateral  ligament  of  the  ankle 
and  also  rujjtureof  the  lower  tibio-fibular  ligaments,  or  possibly  their  avulsion 
from  the  tibia  with  a  small  scale  of  bone.  In  place  of  the  fracture  of  the 
internal  malleolus  there  is  often  rupture  of  tlie  internal  lateral  ligament.  The 
essential  feature  of  the  injury  is  the  sei)aration  of  the  external  malleolus  from 


Fig.  114. 


Fig.  11- 


Diagrams  to  Illustrate  the  Mechanism  involved  in  Fracture  of  the  Lower  End  of  the  Fibula:  .1,  parts  in 
normal  position:  a,  tibio-fibular  ligament;  b,  external  lateral  ligament;  c,  internal  lateral  liganient , 
B,  fracture  of  fibula  due  to  eversion  of  foot ;  C,  fracture  of  fibula  due  to  inversion  of  foot  (original). 

the  tibia  and  its  displacement  outward  in  company  with  the  foot.  "When  the 
injury  is  caused  by  pure  eversion  of  the  sole  the  fibula  is  broken  less  obliquely 
and  the  internal  malleolus  is  broken  square  across ;  when  abduction  of  the 
front  of  the  foot  is  associated  with  eversion,  the  fracture  of  the  fibula  is  more 
obli(iue  and  rupture  of  the  internal  lateral  ligament  is 
much  more  frequent  than  fracture  of  the  internal  mal- 
leolus ;  if  the  latter  occurs,  it  is  oblique,  the  anterior 
portion  only  being  broken  off. 

The  symptoms  are  the  characteristic  deformity  (Figs. 
116,  117),  Consisting  in  outward  displacement  of  the  foot 
and  prominence  of  the  internal  malleolus,  the  existence 
of  three  points  of  localized  pain  on  pressure  correspond- 
ing to  the  three  lines  of  fracture  or  the  equivalent  in- 
juries, and  the  possibility  of  moving  the  foot  from  side 
to  side  within  the  widened  tibio-fibular  mortise.  Occa- 
sionally the  (broken)  internal  malleolus  is  forced  through 
the  skm  and  the  joint  thus  opened,  or  if  the  displace- 
ment remains  unreduced  the  .skin  overlying  the  malle- 
olus may  slough  in  consequence  of  the  pressure.  The 
foot  has\  decided  tendency  to  slip  backward,  sometimes 
so  far  that  the  body  of  the  astragalus  lies  entirely  behind  the  tibia ;  and  this 
displacement  is  frequently  overlooked. 

The  essential  point  in  treatment  is  to  reduce  the  displacement  completely 
and  prevent  its  recurrence ;  the  former  is  easy,  and  so  too  is  the  latter  if  suit- 
able dressings  are  used,  but  each  requires  close  attention  and  full  appreciation 
of  the  needs.  Reduction  is  made  bv  grasping  the  leg  firmly  with  one  hand 
and  the  foot  with  the  other,  and  then,  after  lifting  the  latter  forward,  press- 
ing it  forcibly  inward  until  the  external  malleolus  is  felt  to  rest  against  the 
tibia.     An  efficient  dressing  is  made  of  moulded  plaster-of-Paris  splints,  one 


L  sual  Three  Lines  of  Frac- 
ture in  Pott's  Fracture 
at  the  Ankle  (Stimson). 


332 


A^'   AMERICAN    TEXT-JiOOK    OF  SURGE HY. 


of  wliich  is  placed  posteriorly  from  just  below  tlie  kiieo,  alon^'  the  calf,  the 
heel,  and  the  sole,  to  and  beyond  the  toes ;  the  other  begins  on  the  dorsum 
of  the  foot,  crosses  the  outer  border  and  the  sole,  and  is  carried  up  the  inner 
side  of  the  leg:  circular  turns  are  placed  above  the  ankle  and  at  the  uj)j»(t 
ends  of  the  splints.  It  is  advisable  to  invert  the  sole  of  the  foot,  in  order  to 
make  sure  that  the  lateral  reduction  is  complete.  While  the  splints  are  hard- 
ening the  foot  must  be  held  in  place  by  the  surgeon  or  by  an  assistant  who 
appreciates  the  necessity  and  the  means  of  maintaining  the  reduction,  both 
inward  and  forward.  This  dressing  is  to  be  preferred  to  complete  encase- 
ment in  plaster,  because  it  permits  inspection  of  the  region.  Good  results 
can  also  be  obtained,  though  with  less  security,  bv  the  use  of  an  internal 
lateral  splint  (Dupuytren's  splint)  projecting  below  the  foot.  A  wedge- 
shaped  pad  is  placed  between  this  splint  and  the  leg,  the  base  of  the  wedge 
being  just  above  the  internal  malleolus.     The  foot  is  then  secured  to  this 


Fig.  116. 


Fig.  117. 


Potts  Fracture,  showing  Outward  Displacement 
ioriginal). 


Pott's  Fracture,  showing  also  Backward  Displacement 
(original). 


internal  splint  in  adduction.  Great  care  must  bo  taken  to  protect  the  skin 
from  too  great  pressure.     The  apparatus  should  be  Avorn  for  five  weeks. 

Fracture  by  Inversion. — Forcible  inversion  of  the  foot,  aided  by  the 
weight  of  the  body,  breaks  the  external  malleolus  (or  the  lower  part  of 
the  fibula)  and  the  tibia  obliquely  above  the  base  of  the  internal  malleolus, 
and  displaces  the  latter  fragment  upward  and  inward. 

The  Hj/mptomH  are  pain  on  pressure  along  the  lines  of  fracture  and  the 
recognizable  displacement  of  the  tibial  fragment.  The  treatment  is  reduction 
by  traction  upon  and  abduction  of  the  foot  and  direct  pressure  on  the  frag- 
ment, and  immobilization  in  splints,  preferably  plaster  The  injury  is  likely 
to  bo  followod  by  niarkc(l  limitation  of  motion  in  the  ankle-joint. 

Fracture  of  the  External  Malleolus  is  caused  by  an  inward  twist  of 
the  foot,  by  wliich  the  astragalus  is  so  turned  in  its  mortice  as  to  force  the 
malleolus  outward  and  break  it.  The  line  of  fracture  is  lower  than  in  Pott's 
fracture,  and  lies  within  the  lowest  inch  or  inch  and  a  half;  sometimes  separation 
of  the  fibula  from  the  tibia  at  the  lower  tibio-fibular  articulation  is  produced 
instead  of  fracture,  as  .shown  by  pain  on  pressure  over  the  front  of  the  joint ; 
and.  much  more  rarely,  the  tip  of  the  internal  malleolus  is  sometimes  broken  off 
by  the  pressure  of  the  astragalus  against  it  in  the  .same  twist  of  the  foot.  The 
diagnosis  of  the  fracture  of  the  fibida  is  made  by  local  tenderness  on  pressure 
at  its  seat  and  on  twisting  the  foot  inward,  and  possibly  by  abnormal  mobility 


DISEASES   AND   INJURIES    OF    THE  MUSCLES,  ETC.       333 

recognized  by  pressure  inward  against  the  tip  of  the  malleolus ;  it  is  supported 
by  the  history  of  the  accident  and  the  appearance  by  the  second  or  third  day  of 
an  ecchymosis  below  the  malleolus.  No  treatment  is  needed  except  rest  and  the 
support  of  a  dressing  to  prevent  the  occurrence  of  another  twist  of  the  foot. 

FRACTURES  OF  THE  BONES  OF  THE  FOOT. 

The  astragalus  may  be  broken  by  a  fall  upon  the  foot,  the  line  of  fracture 
passing  through  the  body  or  the  neck,  and  the  injury  is  frequently  associated 
with  dislocation  of  one  of  the  fragments.  An  exact  diagnosis  may  be  difficult 
or  impossible  except  when  dislocation  is  present.  The  choice  of  treatment  lies 
between  immobilization  and  removal  of  one  or  both  fragments;  the  latter  is 
obligatory  when  the  fracture  is  compound  or  when  the  associated  dislocation 
is  such  that  the  skin  will  slough  or  that  the  subsequent  disability  will  be 
great.     The  functional  results  after  removal  of  the  astragalus  are  very  good. 

The  calcaneum  may  be  broken  by  a  fall  upon  the  foot  or  by  forcible 
contraction  of  the  nniscles  attached  to  the  tendo  Achillis.  In  the  latter  case 
a  larger  or  smaller  posterior  fragment  is  torn  off  and  may  be  displaced  upward ; 
the  treatment  is  immobilization  Avith  the  knee  and  ankle  so  flexed  as  to  relax 
the  calf-muscles.  Fractures  due  to  a  fall  are  usually  comminuted,  with 
depression  of  the  central  part  of  the  bone ;  the  diagnosis  must  be  made  upon 
the  flattening  and  broadening  of  the  sole  and  heel  (which  can  be  best  seen  by 
making  the  patient  kneel  and  then  comparing  the  soles  of  the  two  feet),  and 
by  the  relaxation  of  the  tendo  Achillis.  The  treatment  is  by  massage  and 
immobilization,  but  the  patient  should  be  encouraged  to  use  the  limb  as  soon 
as  possible. 

Fracture  of  the  Metatarsal  Bones  is  commonly  caused  by  direct 
violence,  and  is  frequently  compound  ;  the  first  and  fifth  are  the  most  frequently 
broken.  The  diagnosis  is  made  by  pain  on  pressure  at  the  seat  of  fracture 
or  on  pressing  the  corresponding  toe  directly  backward,  and  by  abnormal 
mobility  in  the  case  of  the  first  and  fifth  or  when  several  toes  are  broken. 
In  simple  cases  no  treatment  is  required  except  rest,  with  the  foot  elevated,, 
and  massage. 


CHAPTER    IV. 

DISEASES  AND  INJURIES  OF  THE  MUSCLES,  TENDONS,   AND  BURSiE. 
SECTION   I.— DISEASES  AND   INJURIES  OF  THE   MUSCLES. 

The  muscles,  with  very  few  exceptions,  are  situated  beneath  the  external 
layer  of  the  deep  fascia.  By  virtue  of  their  contractility  they  bind  together  and 
move  the  parts  of  the  skeleton,  contract  and  compress  organs  to  which  they 
are  attached,  and  aid  in  the  protection  of  vessels  and  nerves,  and  of  the  viscera 
in  the  great  cavities.  Their  essential  sarcous  elements  are  held  in  place  and 
maintained  in  proper  relation  by  connective-tissue  investments ;  their  power  is 
transmitted  through  inelastic  fibrous  bands — the  tendons — in  part  inserted  into 
the  bones,  in  part  blending  with  the  periosteum  or  the  great  fascial  planes. 
Like  other  structures,  they  are  at  times  the  seat  of  disease  and  injury,  though 
much  less  frequently  than  might  be  thought  probable  from  their  number,  size^ 
and  location. 


;334  AX    AMlUncAN    TKXT-llOOK    OF   SURGERY. 

Myalgia. — Pain  located  in  a  imiscle,  and  to  a  jfrcatcr  or  loss  extent  pre- 
venting its  use,  is  of  very  frtMjuent  occurrence,  and  dcjx'iids  upon  the  action 
of  many  causes,  such  as  strain,  twist,  or  slight  laceration  of  the  fibres,  acute 
infectious  disease,  poisoning,  as  by  lead  or  syphilis,  etc.  Muscle-pain  is  the 
one  common  symptom.  In  the  majority  of  cases  it  is  neuralgic,  but  may  at 
times  be  intiammatory.  It  is  easily  diagnosticated,  and  usually  quickly  sub- 
sides, either  spontaneously  or  in  consequence  of  the  employment  of  heat,  elec- 
tricity, anodynes,  or  anesthetics ;  or  it  disaj)pears  with  the  removal  of  the 
exciting  cause. 

Rupture. — Blows  from  without  or  undue  and  sudden  unopposed  contrac- 
tion may  cause  laceration,  varying  in  degree  from  a  tear  so  slight  as  not  to  be 
distinguishable  from  simple  stretching  to  a  complete  pulpification ;  and  in 
result  from  speedy  and  perfect  recovery  to  destruction  of  the  part  or  even  to 
loss  of  life.  Spo;itaneous  rupture  of  liealthy  muscle  can  occur  only  when  the 
contraction  is  sudden,  unexpected,  or  of  unusual  character,  as  in  the  "  lawn- 
tennis  leg"  or  "arm"  of  those  unaccustomed  to  that  form  of  exercise.  But 
when,  in  consequence  of  disease,  especially  typhoid  fever,  and,  nmch  less 
frequently,  scarlet  fever,  yellow  fever,  or  other  acute  grave  pyrexia,  the  fibers 
have  undergone  granular  or  vitreous  degeneration,  their  extreme  brittleness 
makes  it  possible  for  rupture  to  follow  voluntary  movement  of  slight  extent. 
The  rectus  abdominis,  the  rectus  femoris,  the  adductors  of  the  thigh,  the  calf 
muscles,  the  psoas,  and  the  flexors  of  the  forearm  are  those  most  frequently 
affected,  and  in  the  order  given.  Except  in  cases  of  laceration  occurring  in 
the  progress  of  general  diseases,  the  occurrence  of  rupture  is  generally  indi- 
cated by  a  sudden  sharp  pain,  accompanied  with  the  sensation  of  snapping  or 
of  the  "giving  way"  of  something  in  the  injured  region,  by  a  well-marked 
depression  or  a  wide  gap  at  the  seat  of  injury,  and  by  extravasation  of  blood, 
with  the  subsequent  color-changes  in  the  skin.  The  ability  to  use  the  muscle  is 
either  wholly  or  in  great  measure  lost.  Complete  recovery  may  be  expected 
■when  the  laceration  is  but  slight,  and  even  when  quite  extensive  the  ultimate 
damage  may  not  be  great.  When  the  abdominal  muscles  are  the  ones  injured, 
intestinal  obstruction,  simulating  strangulated  hernia  or  peritonitis,  may  be 
developed. 

In  the  treatment  of  these  injuries  the  chief  reliance  must  generally  be 
placed  upon  rest  and  the  approximation  of  the  edges  of  the  laceration  by  posi- 
tion and  due  compression.  In  rupture  of  healthy  muscle  sutures  may  advanta- 
geously be  employed,  but  are  of  little  or  no  value  when  the  muscle  has  under- 
gone degenerative  changes,  since  the  stitches  Avill  ordinarily  quickly  tear  out. 

Hernia  of  Muscle. — Occasionally,  in  consocjuence  of  the  imperfect  heal- 
ing of  a  w^ound  of  the  overlying  deep  fascia,  limited  protrusion  of  the  muscle 
is  observed  to  take  place,  Avith  resulting  impairment  of  muscular  power.  Such 
a  hernia  is  readily  recognized  by  the  marked  fulness  in  the  region  at  the  time 
of  muscular  contraction,  disappearing  when  relaxation  occurs,  and  by  the 
detection  of  an  opening  in  the  aponeurosis,  the  rounded  edges  of  which  may 
readily  be  felt  through  the  skin.  In  recent  cases  rest  and  methodical  pressure 
will  generally  effect  a  cure.  When  the  hernia  has  long  existed  the  edges  of 
the  opening  should  be  freshened  and  united  by  stitches.  If.  as  is  often  the 
case,  the  inconvenience  resulting  from  the  presence  of  the  hernia  is  but  slight, 
the  w-earing  of  a  bandage  may  be  all  that  will  be  required. 

Myositis. — Muscle  inflammation  is  almost  always  due  to  traumatism,  to 
contiguous  inflammation,  to  diathetic  states,  or  to  the  presence  of  parasites. 
If  consefjuent  upon  injury,  it  is  usually  a  matter  of  but  little  im])ortance  in 
comparison  with  the  other  conditions  dependent  upon  the  traumatism.     Sup- 


DISEASES   AM)    IXJURIES    OF    THE   MUSCLES,   ETC.       335 


puration  rarely  takes  place  unless  the  injury  be  of  the  psoas  muscle,  and  when 
it  iloos  occur  is  usually  followed  by  recovery.  Occasioually,  and  especially 
in  badly-nourished  individuals,  there  occurs  a  diffused  iiilhiumiation  of  great 
severity,  aluiost  always  of  septic  oi'igin,  in  which  the  aft'ected  muscle  (juickly 
breaks  down,  the  patient  generally  dying  speedily  of  septicemia.  Only  rarely 
can  it  be  cut  short  by  early  free  incision. 

So-called  rheumatic  myositis  {myositis  a  frigore,  muscidar  rheumatism) 
often  affects  the  muscles  of  the  back,  the  chest,  or  the  neck,  and  is  generally 
attributed  to  sudden  chilling  of  an  exposed  part.  It  is  probably,  in  the  great 
majority  of  cases,  not  an  intlanniiation  at  all,  but  the  result  of  a  sprain  or  a 
twist  of  the  muscle,  the  symptoms  and  treatment  being  those  of  myalgia. 

During  the  course  of  a  gonorrhea  myositis  has  occasionally  been  observed, 
generally  in  the  muscles  in  relation  with  an  inflamed  elbow  or  knee,  such 
inflammation  differing  from  the  ordinary  one  only  in  its  cause,  which  is  proba- 
bly a  mild  sapremia. 

Unless  associated  with  joint  or  bone  disease,  a  slowly-developed  chronic 
myositis  is  almost  always  syphilitic  in  origin.  Generally  in  these  cases  the 
affected  part  is  so  much  indurated  that  the  hardness  has  been  characterized  as 
"woody."  An  exceedingly  annoying  myositis  of  the  sphincter  ani  has  been 
observed  in  syphilitics,  in  women  more  often  than  in  men. 

Contractures.  (See  also  Orthopedic  Surgery.) — Persistent  shortening  of 
a  muscle — that  is,  the  fixed  approximation,  more  or  less,  of  its  points  of  origin 
and  insertion,  with  resulting  change  in  the  position  of  the  parts  to  which  it  is 
attached — may  be  due  to  the  action  of  very  many  causes.  Among  these  may 
be  mentioned  loss  of  substance,  intra-  or  extra-muscular,  followed  by  cicatricial 
contraction ;  inflammation,  either  traumatic,  infective,  specific,  or  toxic ;  con- 
tiguous bone  or  joint  disease,  with  associated  deviation  from  pathological  causes 
01"  from  gravity ;  weakened  ac- 
tion of  its  proper  antagonist;  Fm,  118. 
paralysis,  with  resulting  con- 
nective-tissue sclerosis,  due  to 
a  central  lesion,  either  cerebral 
or  spinal :  reflex  irritation  from 
local  injury,  with  or  without 
retention  of  a  foreign  body  ;  or 
it  may  be  but  a  symptom  of  a 
general  nervous  affection,  hys- 
teria, chorea,  etc. 

As  ordinarily  met  with  in 
non-traumatic  cases,  it  is  asso- 
ciated with  disease  of  the  cord 
or  brain,  with  infantile  paral- 
ysis in  children,  or,  much  more 
rarely,  with  cerebral  paralysis 
and  intracranial  hemorrhage  in 
adults.  In  the  former  it  is  of 
late  appearance,  and  is  observed  most  commonly  in  the  legs,  chiefly  because 
of  diminished  resistance  by  opposing  groups  of  muscles.  In  adults  it  is  either 
early,  transitory,  variable,  increased  upon  voluntary  motion,  absent  or  greatly 
lessened  in  sleep,  and  irritative  in  character;  or  late,  degenerative,  increasing, 
permanent,  and  especially  affecting  the  upper  extremity.  The  face  and  neck, 
occasionally  also  the  lower  extremities,  may  be  contractured,  but  never  so  alone. 
It  produces,  as  a  rule,  abnormal  flexions  in  the  upper  extremity,  but  extension 


Anderson's  Method  of  Lengthening  a  Tendon. 


336  Ai\   AM  ERICA  y    TEXT- HOOK    OE   SUlid  FJiV. 

at  the  knee  and  ankle ;  ^vllen,  liowever,  the  contractions  occur  in  connection 
with  chronic  spinal  inflammation  there  is  strong  flexion  at  the  hip  and 
knee. 

When  it  is  due  to  or  indicative  of  an  inflammation  of  a  neighboring  joint 
and  is  developed  early,  it  is  protective  in  character,  producing  such  fixation  of 
the  articulation  as  is  likely  to  lessen  the  disease  in  it  by  afllbrding  rest.  Not 
seldom  ^hen  unassociated  "vvith  joint  disease  or  paralysis  a  contracture  "vvill  be 
found  to  be  of  syphilitic  origin ;  and  this  is  especially  true  of  that  affecting  the 
biceps  cubiti. 

Lately  Anderson  and  several  other  surgeons  have  simultaneously  proposed  to 
lengthen  tendons  by  a  definite  amount  in  cases  of  contracture.  Fig.  118  shows 
very  -well  how  this  is  accomplished  by  splitting  the  tendon,  sliding  one  end  up 
or  down,  and  then  suturing  the  ends,  thus  securing  a  definite  amount  of  length- 
ening of  the  tendon. 

Hypertrophy. — The  enlargement  of  a  muscle  may  be  real,  the  sarcous 
elements  being  increased  in  number  or  in  size ;  or  apparent,  due  to  change  in 
the  amount  of  fat  or  connective  tissue  or  to  an  overgrowth  of  the  lympliatics 
and  blood-vessels.  It  may  be  physiological  and  consequent  upon  increased 
action  of  the  affected  muscle,  as  in  certain  classes  of  workmen,  or  associated 
with  pathological  states,  when,  as  in  the  enlarged  heart  or  the  thickened  blad- 
der, it  may  be  compensatory,  and  therefore  to  some  extent  salutary.  Lessened 
use  of  the  part,  or  rest,  aided  by  compression,  may  effect  a  reduction  in 
size. 

In  adults  there  has  occasionally  been  observed  a  progressive  muscular 
hypertrophy  affecting  chiefly  the  upper  extremity,  as  a  rule  on  one  side  only, 
which  is  usually  attended  with  lessened  rather  than  increased  functional 
strength. 

Atrophy. — Diminished  size  of  muscles  is  of  frequent  occurrence,  and  may 
be  due  to  disuse,  to  diseases  of  joints,  to  nerve-injury,  to  disease  of  the  spine  or 
the  brain  (rarely  observed  except  when  the  pons  is  affected),  or  to  a  general 
depraved  or  poisoned  state  of  the  blood.  As  met  with  in  connection  with 
lesions  of  bones  or  joints,  it  is  in  great  measure,  if  not  wholly,  due  to  reflex 
disturbance  of  the  trophic  nerves,  and  not  to  the  enforced  quietude  of  the 
affected  part.  Very  often  it  is  associated  with  degeneration,  granular,  pigment- 
ary, fatty,  or  waxy,  the  latter  two  being  the  more  common  and  the  more  im- 
portant. 

In  the  fatty  degeneration  there  may  be  a  substitution  of  fat  for  the  true 
muscular  elements,  or.  still  oftener,  for  the  connective  tissue,  occurring  slowly 
and  of  limited  extent,  or,  as  in  cases  of  pliosphorus-poisoning,  rapidly  developed 
and  largely  generalized;  or,  as  is  much  oftener  the  case,  the  fat  may  be 
present  as  an  infiltration  or  accumulation  in  relation  with  the  connective-tissue 
framework  of  the  muscle.  In  the  former,  though  the  deposit  may  be  absorbed 
and  muscular  redevelopment  follow,  there  is  generally  permanent  destruction 
of  the  affected  fibers ;  while  in  the  second  either  no  effect  is  produced  upon  the 
contractile  substance  or  it  is  affected  only  through  pressure. 

In  certain  of  the  acute  infectious  fevers,  especially  yellow  fever  and  typhoid, 
in  not  a  few  cases  of  tetanus,  and  occasionally,  though  rarely,  after  nerve-inju- 
ries, the  muscular  elements  appear  as  a  transparent.  Avaxy,  very  brittle  mass 
which  breaks  up  into  cuboidal  blocks,  the  connective  tissue  at  the  same  time 
taking  on  increased  growth.  Pain,  weakness,  impaired  function,  and  liability 
to  rupture  are  the  effects  of  this  vitreous  degeneration.  It  is  always  destruc- 
tive to  the  affected  fibers, — which  may  be  few  in  number  or  may  constitute  the 
greater  part  or  the  whole  of  the  muscle.     In  three  diseases  (progressive  muscular 


DISEASES   A.\l>    /.X./r/i'/ES    OF    THE   MUSCLES,  EIC.       337 

atrophy,  pseiulo-hyj)ertrophic  paralysis,  and  infantile  paralysis)  muscle  atrophy 
is  a  strongly-niarked  symptom,  of  medical  rather  than  surgical  interest,  except 
so  far  as  resulting  weakness  and  deformity,  especially  in  infantile  paralysis, 
necessitate  the  use  of  supporting  and  correcting  mechanical  appliances  with  or 
without  operative  interference. 

Ossification'. — Inflammation  following  long-continued  irritation  may  result 
in  the  formation  of  bone  in  tlie  belly  of  a  nmscle,  or,  as  is  more  often  the  case, 
in  its  tendon,  such,  for  example,  as  the  bone-plates  in  muscles  close  to  exuberant 
callus  after  a  fracture,  or  as  the  so-called  exercise  or  rider's  bone,  the  latter 
being  of  not  infrequent  occurrence  in  the  upper  or  lower  tendon  of  the  adductor 
magnus  femoris.  At  times  the  ossification  is  of  syphilitic  origin.  If  it  is  in 
one  of  the  superficial  muscles,  the  bone-plate  can  readily  be  felt  when  near  the 
attached  end  of  the  tendon,  the  only  (question  being  whether  it  is  tendon, 
bone,  or  a  true  exostosis ;  but  if  deeply  placed  its  existence  remains  undetected 
during  life.  To  whatever  cause  it  is  due,  the  bony  growth  is  permanent  unless 
removed  by  operation.  This  may  occasionally  be  rendered  necessary  by  exist- 
ing pain  or  impairment  of  function,  which  at  times  is  consequent  upon  the  size 
or  location  of  the  osseous  mass. 

A  few  cases  have  been  observed  of  an  early-commencing,  slowly-advancing, 
general  muscle  inflammation,  starting  usually  in  the  neck  and  back,  in  which 
after  a  time  the  atrophied  parts  become  the  seat  of  bone-formation,  myositis 
ossificans,  the  cause  of  which  is  as  yet  undetermined.  Generally  very  pro- 
tracted in  its  course,  it  resists  all  treatment,  death  resulting  from  involvement 
of  the  respiratory  muscles  or  from  simple  exhaustion. 

Tumors. — These  may  be  either  benign  or  malignant,  located  in  the  belly 
of  the  muscle  or  in  its  tendon.  The  majority  of  those  which  are  not  sarco- 
matous or  carcinomatous  are  of  syphilitic  origin,  the  specific  disease  affecting 
any  muscle,  but  particularly  the  sterno-cleido-mastoid  and  the  biceps  cubiti. 
The  malignant  tumors  are  very  rarely  primary.  In  an  interesting,  though 
fortunately  seldom  observed,  class  the  developing  cause  is  parasitic — /.  e.  the 
presence  in  the  muscle  of  the  echinococcus,  the  cysticercus,  or  the  trichina. 
The  diagnosis  will  be  based  upon  the  history  of  the  case  and  the  recognition 
of  a  more  or  less  well-defined  swelling  intimately  connected  with  the  muscle  or 
the  tendon ;  in  the  parasitic  form  the  microscopic  examination  of  an  excised 
portion  of  the  tumor  will  establish  the  diagnosis.  The  treatment  will  depend 
upon  the  nature  of  the  growth,  which  will  either  be  left  untouched  or  taken  out 
of  the  muscle,  or  removed  Avith  the  part  in  which  it  has  grown. 

Wounds,' — These  may  be  either  subcutaneous  or  open  wounds.  The  former 
are  sometimes  accidental,  but  usually  operative ;  the  latter  are  most  frequently 
incised  or  lacerated.  Hemorrhage  and  separation  of  the  edges  are  the  chief 
symptoms,  the  latter,  of  course,  being  much  more  marked  in  complete  than  in 
partial  transverse  section.  If  protected  from  septic  infection,  their  gravity  is 
very  slight,  and  unless  there  has  been  extensive  loss  of  substance  the  repair 
functionally  is  very  good,  union  taking  place  ordinarily  through  the  medium  of 
a  connective-tissue  scar,  though  when  the  wound  is  small  and  its  edges  have 
been  early  and  closely  approximated  true  muscular  regeneration  may  occur. 

The  treatment  consists  in  securing  close  apposition  and  in  the  mainte- 
nance of  rest.  Incised  wounds  and  lacerated  and  contused  ones  in  which  the 
parts  can  be  brought  together,  after  trimming  of  the  torn  edges  if  necessary, 
should  be  united  with  catgut  or  silk  buried  sutures  rather  than  treated  simply 
by  strapping  and  bandaging,  since,  when  sepsis  is  prevented,  the  stitches  do 
not  readily  tear  out,  and  a  quicker,  closer  repair  is  secured. 


338 


AN  AMERICAN    TEXT-BOOK    OF  SIROERY. 


SECTION    II.— DISEASES   AND   INJURIES  UF   TENDONS. 

Teno-synovitis,  or  Thecitis,  and  Palmar  Abscess. — Inflammation  of 
a  tendon  sheath  may  be  either  acute  or  chronic.  The  acute  form  is  chiefly  due 
to  traumatism,  and  is  suppurative  or  non-suppurative  accordin";  to  the  presence 
or  the  absence  of  [)yogenic  microbes  ;  the  chronic  form  is  of  tubercuLir  origin. 
The  acute  form  may  follow  a  wound  or  a  slight  but  froipiently  repeated 
contusion,  as  in  certain  classes  of  workmen,  or  it  may  result  from  a  strain  or 
be  connected  with  rheumatism,  syphilis,  or  gonorrhea.  In  the  nun-suppurative 
variety  there  are  present  pain  and  swelling  along  the  course  of  the  tendon, with 
early-developed  crepitation,  due  to  the  rubbing  of  the  exudation-lined  surfaces. 
Such  crackling  disappears  as  the  .'^heath  becomes  distended  with  fluid,  to 
reappear  again  for  a  while  as  absorption  takes  place.  The  associated  constitu- 
tional symptoms  are  ordinarily  slight,  except  in  cases  of  the  special  diseases 
mentioned,  when  they  are  those  of  such  diseases.  The  duration  of  the  aff'ection 
varies,  according  to  its  severity  and  to  the  treatment,  from  a  few  days  to  three 
or  four  weeks,  terminating  commonly  in  complete  recovery,  though  at  times 
some  dry  crackling  remains  for  a  while.  Rest  and  pressure  by  sjjlint  and 
bandage  are  usually  all  that  is  required  in  the  way  of  treatment,  though  hot- 
or  cold-water  applications  are  often  of  service  at  first,  and  the  use  of  the 
tincture  of  iodine  is  thought  highly  of  by  many.  Opiates  may  be  needed  to 
relieve  pain. 

When  the  thecitis  is  suppurative  the  severity  of  the  inflammation  is  great  : 
unless  free  incision  is  promptly  made,  destruction  of  the  sheath  and  its  contained 
tendon  will  take  place,  often  with  wide  extension  of  the  disease  along  the  ten- 
don and  in  the  neighboring  connective  tissue,  foUoAved.  it  may  be,  by  general 
infection.  The  pain  is  intense  and  throbbing,  the  tenderness  excessive,  the 
swelling  marked  and  rapidly  developed,  the  overlying  skin  red,  the  constitu- 
tional symptoms  of  high  grade.  Elevation 
and  rest  of  th<3  part,  as  complete  as  possible, 
must  be  secured,  and  hot  applications  made ; 
but  the  first  and  most  imperative  demand  is 
for  free  opening  of  the  sheath,  curetting,  and 
thorough  antiseptic  drainage  and  dressing. 
If,  notwithstanding  these  measures,  the  sup- 
puration extends,  other  and  more  free  incis- 
ions must  be  made,  and  thus  destruction  be 
limited  as  far  as  possible. 

The  disease  often  affects  the  flexor  sheath 
of  a  finger,  and,  unless  promptly  arrested, 
palmar  abscess  is  very  likely  to  follow. 
This  danger  is  much  greater  if  the  disease 
attacks  the  thumb  or  the  little  finger  rather 
than  the  other  three  fingers,  since,  while  the 
proximal  closed  end  of  the  sheath  in  the 
index,  middle,  and  ring  fingers  (Fig.  lli>  h) 
is  separated  from  the  cavitv  of  the  general 

S>-novial  Sheaths  of  Flexor  Tendons  of     „...,„..•    ]    oVip^tli    nf    nil    tbp*   tpndons    in    the 
Fingers :  a.  general  sheath  common  to      S}  UOMai    SncaiU    01     311    lUt     leiiuuns     Jii     iiie 

the  tendons  in  the  palm  and  those  of    pj^|,jj  /^^\  about  half  an  inch,  the  shcaths  of 

the  thumb  and  little  finger ;  b,  separate     r  v    /  ,     i       t     i      r> 

sheaths  of  the  fore,  middle,  and  ring     the  thumb  and  the  little  finger  coiumunicate 
fingers  (original).  directly  with  it.      Whether  secondary  to  teno- 

synovitis of  the  finger,  or  primary  and  due  to  direct  infection  and  inflammation 
of  the  palmar  fascia  and  the  connective  tissue  under  it,  it  is  a  serious  matter. 


Fig 


DISEASES   AND   INJURIES    OF    TIIK   MUSCLES,  ETC.       339 


It  may  be  liinitod  or  general,  according  to  the  intensity  of  the  infection,  and 
is  indicated  by  the  presence  of  symptoms  similar  to  those  already  mentioned 
as  characteristic  of  thecitis — pain,  swelling,  restrained  at  first  by  the  firm  fascia, 
high  fever,  etc.  Freijuently  a  small  superficial  serous  or  purulent  effusion  early 
shows  itself  in  the  palm,  which  has  often  been  mistaken  for  the  real  affection, 
to  tlie  serious  injury  of  the  patient  because  of  the  resulting  delay  in  freely  lay- 
ing open  the  parts.  If  untreated,  or  it  may  be  in  spite  of  treatment,  the  pus 
may  pass  between  the  bones  to  the  dorsum  of  the  hand  or  under  the  anterior 
annular  ligament,  upward  beyond  the  palmar  pouch  into  the  connective  tissue  of 
the  forearm,  along  the  planes  of  which  it  may  be  carried  to  or  even  beyond  the 
elbow.  Here,  again,  free  incision  nmst  be  made  in  the  line  of  a  metacarpal  bone 
and  disinfection  and  drainage  secured.  The  incision  may  be  made  fearlessly  up 
to  a  line  transverse  to  the  web  of  the  thumb,  as  the  palmar  arches  both  lie  above 
this  line.  Beyond  that  the  vessels  should  be  avoided,  or  if  divided  botJi  ends 
must  be  tied.  At  the  best,  some  stiffness  of  the  fingers  and  impairment  of  the 
functional  value  of  the  part  not  seldom  results,  and  the  hand  is  often  "  griffed  " 
(claw-hand).  Necrosis  of  the  carpus  may  occur,  necessitating,  at  times,  ampu- 
tation ;  there  may  be  troublesome,  even  dangerous,  hemorrhage  from  the  vessels 
of  the  hand  or  forearm ;  and  in  a  small  proportion  of  cases  death  takes  place 
because  of  exhaustion  or  septic  infection. 

Chronic  teno-syrrovitis,  as  has  been  stated,  is  a  tubercular  disease,  pre- 
senting itself  either  as  a  firm  swelling  (Fig.  120)  conse([uent  upon  the  presence 
of  a  thick  mass  of  granulation-tissue  in  and  upon  the  sheath  ;  a  more  or  less  dis- 
tinctly fluctuating  swelling  in  wdiich  there  is  less  deposit  upon  the  walls,  but 

Fig.  120. 


Fig.  121. 


Chronic  (Tubercular)  Teno-synovitis  or  Thecitis  of  the  Sheaths  of  the  Extensor  Tendons  (original). 

fluid  in  considerable  quantity  in  the  cavity  of  the  sac  ;  or  a  similar  swelling  con- 
taining in  addition  small  bodies  resembling  rice-kernels  {riziform,  or  melon-seed 
bodies.  Fig.  121)  attached  to  the  walls  or  floating  free.  Tu- 
bercle bacilli  in  greater  or  less  number  are  almost  invariably 
present  in  each  form  of  the  affection.  It  is  observed  most  fre- 
quently, indeed  in  nearly  four-fifths  of  the  cases,  in  the  fore- 
arm. It  may  be  developed  in  connection  with  any  of  the 
tendons,  but  especially  those  of  the  fingers  and  those  in  the 
vicinit}^  of  the  knee  and  ankle.      Though  very  slow  in  its 

course,  particularly  in  the  cystic  varieties,  its  tendency  is  to 

extend  upward  and  downward  along  the  affected  tendon  mce-kernei  or  Meion- 
(which  in  the  fungous  variety  is  invaded  and  in  part  or  wholly     sarne^case^(Fig™  120I 
destroyed),  to  attack  other  tendons  in  close  proximity,  and  to     original), 
pass  into  underlying  joints.     Frequently  it  is  secondary  to  joint  tubercu- 
losis.    As  it  is  attended  by  little  or  no  pain,  for  a  long  time  it  may  cause 


340  .I.V    AMFJiKAX    TKXT-noOK    OF   SURGERY. 

no  material  functional  iiuijairniciit.  A  cry  rarely  it  spontaneously  disappears. 
The  contents  liavin;^  In-oken  down  the  sheath  and  escaped  externally  (and  this  is 
very  much  more  common  in  the  fungous  variety j,  an  ordinary  tubercular  abscess 
generally  follows,  the  spontaneous  or  non-aseptic  opening  of  which  permits  of 
infection  by  pyogenic  organisms  with  resulting  extensive  suppuration. 

The  locality  of  the  swelling,  its  more  or  less  spindle  shape,  its  slow  course, 
and  the  little  attendant  inconvenience  are  the  diagnostic  signs  of  the  dis- 
ease in  general ;  the  degree  of  resistance  to  touch  and  the  absence  or  presence 
of  fluctuation,  those  of  the  variety,  fungous  or  cystic ;  a  peculiar  crepitation 
elicited  by  pressure  or  upon  movement  indicates  the  presence  of  the  riziforn. 
bodies.  AVhen  located  in  the  palm  of  the  hand,  affecting  the  several  flexor 
tendons  and  extending  up  to  the  wrist,  the  swelling  of  this  so-called  "  compound 
ganglion  "  is  more  or  less  hour-glass  in  shape  because  of  the  constriction  made 
by  the  anterior  iininilar  ligament. 

The  treatment  to  be  effective  must  be  operative,  by  tapping  and  injec- 
tion, by  evacuation  and  scraping,  or  by  excision.  AVhen  there  is  but  little 
thickening  of  the  sheath  and  the  contents  of  the  sac  are  simply  fluid,  aspira- 
tion or  limited  incision,  with  injection  of  iodoform,  will  generally  bring  about 
a  cure ;  when  the  melon-seed  bodies  are  present  the  sheath  must  be  laid  open 
to  such  extent  as  to  permit  a  complete  evacuation  and  thorough  scraping  of 
the  walls  (in  the  palmar  ganglion  the  annular  ligament,  if  necessary,  being 
divided  and  later  reunited) ;  when  the  case  is  fungous,  relief  can  be  afforded 
only  by  complete  removal  of  all  the  infected  tissue  outside  the  sheath,  in  the 
sheath  itself,  and  in  the  tendon.  The  parts  should  be  rendered  bloodless  by 
the  Esmarch  l)andage,  so  as  to  permit  of  the  recognition  and  careful  dissection 
of  Avhat  must  be  taken  away,  and  great  care  should  be  exercised  to  do  as  little 
damage  as  possible  to  contiguous  healthy  structures.  If  it  becomes  necessary 
to  remove  any  considerable  part  of  the  tendon,  much  benefit  will  follow  sutur- 
ing to  the  upper  end  of  the  lower  fragment  a  piece  secured  by  splitting  from 
the  upper  fragment  and  turned  down.  Relapses  very  often  occur,  and  not 
seldom  the  patient  ultimately  dies  of  one  form  or  other  of  visceral  tuberculosis. 
In  all  operations  for  teno-synovitis  and  in  the  after-treatment  it  is  of  extreme 
importance  to  prevent  sepsis,  since  pyogenic  infection  is  very  dangerous  to  the 
part  and  to  life. 

Paroxyciiia,  Whitlow,  or  Felon  is  an  inflammation  of  a  finger,  rarely  of 
a  toe,  consequent  upon  traumatism,  usually  of  slight  character:  it  may  be  but  a 
scratch  or  prick  or  little  abrasion,  permitting  of  the  entrance  of  septic  germs. 
It  may  be  of  moderate  or  great  severity  according  to  the  virulence  of  the 
organism  and  the  general  state  and  resisting  power  of  the  individual  affected. 
It  is  more  common  upon  the  right  than  the  left  hand,  and  usualh'  commences 
upon  the  last  phalanx.  It  may  be  superficial  or  deep,  in  the  latter  case  begin- 
ning as  such  or  becoming  so  by  extension  from  the  under  surface  of  the  derm, 
favored  in  the  pulp  of  the  finger  by  the  fibrous  threads  that  tie  it  down  to  the 
bone. 

The  superficial  variety  is  the  more  common  and  the  least  troublesome,  affect- 
ing one  finger  or  several  in  succession  or  at  the  same  time,  as  is  often  the  case 
in  debilitated  subjects,  especially  children,  and  located  generally  around  and 
under  the  nail.  The  inflannnation  may  be  slight  and  subside  (luickly ;  or  some- 
vhat  more  severe,  causing  subepidermal  serous  or  purulent  eftusions.  The  former 
is  absorbed  in  a  few  hours  or  days  ;  the  latter  is  associated  with  ulceration,  but 
soon  heals,  though  often  leaving  a  scar  which  is  red  and  tender  for  some  time. 
In  much-enfeebled  individuals  the  inflammation  may  be  of  a  high  grade,  the  pain 
intense,  the  swelling  decided,  the  suppuration  abundant,  and  may  cause  loss  of 


DISEASES   AND    INJURIES    OF    THE   MUSCLES,  ETC.      341 

part  or  the  whole  of  the  nail  and  the  development  of  fungous  granulations,  the 
disease  often  in  nejilected  eases  lastin";  for  weeks  or  months  until  the  necrosed  nail 
is  thrown  oft".  The  treatment  varies  with  the  severity  of  the  inflammation. 
Rest  and  elevation  of  the  part  and  cold  applications  are  all  that  is  required  in 
the  milder  cases.  The  use  of  hot  fomentations,  simple  or  medicated,  together 
with  ])rompt  and  complete  evacuation  of  the  pus,  is  indicated  when  suppuration 
occurs.  In  the  graver  cases  early  incision  and  the  administration  of  tonics 
and  anodynes  are  necessary.  Change  of  residence,  if  it  can  be  eftected,  is  use- 
ful. The  nail  must  be  removed  as  soon  as  it  is  evident  that  it  must  be  lost,  and 
iodoform,  corrosive  sublimate,  carbolic  acid,  nitrate  of  lead,  or  other  similar 
agent  may  be  applied  to  the  ulcerated  surface. 

The  deep  whitlow  usually  commences  on  the  palmar  aspect  of  the  last 
phalanx,  though  it  may  originate  in  an  injury  of  the  second  or  first  phalanx, 
or,  more  rarely,  upon  the  dorsum.  In  a  few  hours  it  may  be,  or  more  commonly 
within  a  day  or  two,  after  the  receipt  of  the  injury,  the  finger  becomes  painful, 
tense,  hot,  and  throbbing,  with  accompanying  elevation  of  temperature  and 
acceleration  of  pulse.  These  symptoms  rapidly  increase  in  severity,  especially 
the  pain  and  tension,  and  are  both  aggravated  by  the  dependent  position. 
Resolution  rarely  occurs,  suppuration  usually  taking  place.  Associated  with 
the  deep  collection  of  pus  there  is  often  a  superficial  abscess  that  may  be 
mistaken  for  the  real  disease. 

Though  at  times  the  application  of  cold,  of  the  tincture  of  iodine,  of  car- 
bolic acid,  or  of  a  blister  has  aff'orded  relief,  in  the  great  majority  of  cases  such 
treatment  is  of  no  value.  Carbolic  acid  has  been  known  to  produce  gan- 
grene of  the  finger.  So  strong  is  the  probability  of  the  formation  of  pus,  that 
it  is  better  to  employ  hot  antiseptic  solutions  or  fomentations  from  the  begin- 
ning, and  if  within  two  or  at  most  three  days  decided  improvement  does  not 
take  place,  free  incision  should  be  made — to  the  bone  when  it  is  the  last  pha- 
lanx that  is  affected,  to  the  tendon  when  the  first  or  second,  since  in  the  former 
locality  the  disease  is  almost  certain  to  have  gone  down  to  the  periosteum, 
while  in  the  latter  it  very  probably  is  as  yet  only  a  teno-synovitis,  and  the 
integrity  of  the  tendon  may  be  preserved  by  opening  the  sheath.  The  after-treat- 
ment should  be  thoroughly  antiseptic.  Often  in  spite  of  early  incision  and 
proper  dressing  necrosis  of  the  last  phalanx  occurs.  When  it  does,  it  is  likely 
to  stop  at  the  epiphyseal  line,  and  the  dead  bone  can  be  removed  later  without 
opening  the  articulation.  Necrosis  of  the  second  or  first  phalanx  will  gene- 
rally necessitate  amputation,  though  a  tolerably  useful  finger  may  at  times  be 
secured  by  simple  removal  of  the  necrosed  bone. 

GrANGLioisr. — Closely  connected  with  a  tendon,  especially  upon  the  back  of 
the  hand,  there  is  often  found  a  small  round  swelling,  firm  to  the  touch,  at  times 
almost  as  hard  as  bone,  slowly  developed  as  a  rule,  and  causing  little  inconve- 
nience except  when  in  consequence  of  the  occupation  of  the  patient  the  tendon 
has  been  largely  exercised.  The  contents  of  this  swelling  are  a  viscid  honey- 
like fluid.  At  any  period  of  its  development  the  little  swelling  may  disappear 
or  cease  to  grow.  Formerly  regarded  as  a  dropsy  of  the  tendon  sheath  (hence  a 
common  name,  "  Aveeping  sinew  "),  it  is  probably  an  outgrowth  of  the  s^^novial 
follicles  of  these  sheaths,  more  rarely  of  the  synovial  pouches  or  the  subsynovial 
bodies  of  Henle,  or  perhaps  it  is  a  new  growth,  a  colloid  cyst,  having  nothing 
to  do  with  the  tendon  sheath  except  that  it  lies  in  close  apposition  with  it. 
It  is  diagnosticated  by  its  shape,  location,  and  feel,  and  is  to  be  treated  by 
subcutaneous  evacuation  or  by  excision.  Generally  the  former  method  is 
adopted,  though  refilling  of  the  sac  often  occurs.  By  pressure  of  the  thumb 
a  thin-walled  ganglion  may  be  readily  burst,  and  even  a  somewhat  thick-walled 


342  ^liV^   AMHUKAX    TEXT-I'.Oi >K    OF   SlUdEIlY. 

one,  by  a  smart  hlow.  J'ivfV'r;il)ly,  however,  tlie  sac  should  he  subcutaneously 
divided  hy  a  small  kiiite  or  spear-poiiiti^d  needle,  and  the  contents  pressed  out 
alon<^side  the  instrument  or  into  the  surroundin<f  tissue,  wiien  rapid  absorption 
ordinarily  takes  place.  When  tlic  tumor  is  very  hard  or  very  large,  or  there 
liave  been  several  recurrences,  excision  should  be  done,  the  sac  being  freely 
exposed  and  carefully  dissected  oft'  the  tendon.  Under  proper  antiseptic  dress- 
ing primary  union  may  be  expected. 

RuPTriiE  OF  A  Tendon. — Sudden  violent  efibrts  are  at  times  followed  by 
ru])ture  of  a  tendon,  indicated  by  a  snap  which  may  be  both  felt  and  heard,  by 
jiain,  by  cessation  of  the  action  of  the  associated  nmscle,  and  often  by  a  fall  Avhen 
the  tendon  is  in  the  lower  extremity.  A  gap  at  the  seat  of  injury,  increased 
upon  extension,  may  frequently  be  recognized  on  palpation,  and  a  depression 
may  be  seen.  At  the  knee  there  will  soon  In;  marked  effusion  into  the  joint,  and 
if  the  ligamentum  ])atell;e  is  ru})tured  the  ])atella  may  be  more  or  less  displaced 
upward.  The  rupture  may  be  complete  or  partial,  generally  the  former.  The 
tendon  of  the  rectus  femoris  above  or  below  the  patella,  or  the  tendo  Achillis 
in  the  lower  extremity,  and  those  of  the  triceps  or  biceps  in  the  arm,  are  the 
ones  usually  torn.  The  treatment  consists  sometimes  of  approximation  by 
position  of  the  separated  ends  as  much  as  jjossible,  and  maintenance  of  the  same 
by  splints,  bandages,  or  apparatus  until  reunion  takes  place,  which  commonly 
occurs  in  from  four  to  eight  weeks.  Generally,  however,  the  better  method  is 
by  suture,  especially  when  the  existing  gap  is  a  wide  one  or  the  tendon  is  that 
of  a  muscle  in  which  contraction  can  be  controlled  only  imperfectly  or  with 
great  difficulty.  In  the  leg  esj)ecially  operation  is  indicated  unless  great  age 
or  other  contraindication  exists.  The  old-time  objections  to  exposing  and 
operating  upon  a  tendon  no  longer  hold  good,  since  se[)tic  infection  can  very 
generally  be  prevented.  This  is  especially  important  at  the  knee,  as  the  joint 
may  be  opened  at  the  operation. 

Wounds  of  Tendons. — These  are  either  punctured,  subcutaneous,  or  open. 
The  former  are  of  no  importance  unless  accompanied  by  the  entrance  of  pyo- 
genic organisms,  when  they  may  be  very  destructive  from  the  inflannuation  of 
the  tendon,  its  sheath,  and  the  surrounding  parts.  Subcutaneous  wounds,  when 
complete,  as  in  the  operation  of  tenotomy,  are  attended  with  a  snap  and  sejiara- 
tion  of  the  ends,  causing  the  formation  of  a  depression  both  seen  and  felt ; 
they  are  accompanied  ordinarily  with  but  slight  hemorrhage  and  little  pain. 
Repair  takes  place  readily  without  any  decided  local  or  general  disturbance, 
the  connective-tissue  callus  being  shorter  or  longer  according  to  the  amount  of 
approximation  secured.  When  formal  tenotomy  is  done  a])position  of  the  ends 
is  not  Avanted,  and  by  position  considera])le  separation  is  maintained,  the  func- 
tional value  of  the  part  ultimately  becoming  nearly  or  quite  perfect.  Open 
wounds  are  dangerous  or  not  according  as  they  do  or  do  not  become  infected. 
If  aseptic,  they  arc  quickly  recovered  from,  and  modern  experience  has  so 
clearly  demonstrated  this  that  to-day,  l)y  preference,  most  such  operations  are 
performed  openly  in  cases  in  which  until  recently  the  greatest  care  was  exer- 
cised to  prevent  any  extensive  division  of  the  overlying  soft  parts.  After 
operative  tenotomy  the  treatment  is  by  position  and  pressure.  After  acci- 
dental division,  however,  the  treatment  should  invariably  be  by  suture,  the  stitch 
being  of  buried  catgut  or  silk.  At  the  wrist.  Avhere  several  tendons  may  be 
simultaneously  divided,  care  must  be  taken  that  the  two  ends  of  the  same 
tendon  are  united. 

Tendon-suture  may  be  done  also  in  old  cases  of  rupture  or  wound, 
even  when  extensive  dissection  is  required  to  find  and  free  the  w  idely-sej)arated 
ends  buried  it  may  be  in  a  mass  of  scar  tissue.     If  the  freshened  fragments 


DISEASES   AND    INJURIES    OF    THE   MUSCLES,  ETC.       343 


~      I  I "  nil  .11  ijiiTii^iiBifiril^iii^^ 


;^**-^ 


Czerny's  Method  of   Tendon-suture  when  the   Ends  cannot 
be  Approximated. 


can  \)v  applied  to  each  other,  t-itlior  end  to  end  or  overhippinj.',  tlie}'^  should  be 
stitched  together,  the  sutures  bein<i  drawn  only  sulHciently  ti;^ht  to  maintain 
the  apposition  without  making  undue  constriction  of  the  included  parts.  If 
there  has  been  too  great  loss  of  substance  to  permit  such  direct  attachment, 
but  the  sheath  ends  can  be  united,  this  should  be  done,  as  redevelopment  of  the 
tendon  will  occur  in  the  canal  thus  formed  ;  or  long  catgut  stitches  may  be  used 
which  will  serve  as  a  framework  \i\)on  which  the  new  formation  can  take  place; 
or  one  of  the  pieces  of  the  tendon  may  be  longitudinally  split  for  the  necessary 
distance  nearly  to  the  end,  and 

the  detached  half  turned  down  •  ^ig.  122. 

and  united  to  the  other  part  of 
the  tendon,  the  ultimate  result 
being  the  formation  of  a  tendon 
sufficiently  strong  fully  to  per- 
form its  physiological  function 
(Fig.  122).  Where  this  can- 
not be  done,  transplantation 
may  be  effected,  either  of  an- 
other tendon  from  the  same 
individual  when  there  has  been  extensive  injury  of  the  part,  or  of  one  taken 
from  a  lower  animal:  .in  the  latter  case  usually,  if  not  always,  the  graft  is 
absorbed  and  its  place  taken  by  a  new  formation.  When  only  one  end  can 
be  found  and  separated  from  the  surrounding  cicatricial  tissue,  it  may  with 
advantage  be  united  to  an  adjoining  uninjured  tendon  having  the  same  general 
anatomical  course ;  as,  for  example,  the  flexors  or  extensors  of  the  hand  and 
fingers  or  those  of  the  foot  and  toes.  In  all  cases  of  tendon-suture  much 
advantasje  will  be  derived  from  the  use  of  the  Esmarch  bandao-e  durino;  the 
operation,  which  will  prevent  the  blood  from  obscuring  the  field  of  operation. 
DiSPLACEMEXT  OF  Texdoxs. — Unassociated  with  fracture  or  dislocation, 
displacements  of  tendons  are  of  rare  occurrence.  Consequent  upon  sudden 
muscular  action  or  extreme  violence  the  tendon  is  forced  from  its  normal  posi- 
tion, is  quickly  and  spontaneously  replaced,  or  remains  luxated  until  returned 
by  manipulation.  The  tendons  of  the  peroneal  muscles  are  those  most  usually 
affected,  especially  that  of  the  brevis,  which  is  not  very  seldom  found  thrown 
out  of  its  bed  behind  the  external  malleolus  and  carried  forward  so  as  to  be 
readily  felt  and  easily  moved  upon  the  malleolus.  Slight  pressure  will  return 
it  to  its  proper  place,  but  it  is  held  there  with  much  difficulty  and  only  imper- 
fectly as  a  rule.  The  parts  should  be  immobilized  and  a  retentive  dressing 
kept  on  until  repair  of  the  torn  sheath  or  lateral  ligament  has  taken  place,  if 
this  can  be  secured.  An  aseptic  suture  or  two  may  assist  in  retaining  it  in 
place.  The  late  Dr.  James  R.  Wood  devised  and  carried  into  effect  an  opera- 
tion for  the  relief  of  dislocation  of  the  tendon  of  the  peroneus,  viz.,  tenotomy 
followed  by  fixation  with  plaster  of  Paris.  Dislocation  of  the  tendon  of  the 
long  head  of  the  biceps  flexor  cubiti  occurs  occasionally ;  AVhite  has  reported 
and  figured  a  case. 


SECTION   III.— AFFECTIONS   OF  BUES^. 


In  connection  with  some  tendons  and  in  close  relation  with  most  joints  there 
are  to  be  found  bursge,  which  are  either  normally  present  or  acquired.  The 
former  are  present  at  the  time  of  birth  or  soon  after ;  the  latter  are  devel- 
oped later  in  life  in  consequence  of  muscular  action  and  friction.  They 
may  be  superficial  or  deep-seated ;  many  of  the  latter  communicate  directly 


344  iiX  AMKRICAX    TEXT-liOOK    OF   Si'RGKRY. 

with  neighboring  artienhitions,  especially  in  adults.  As  the  result  of  injury 
and  of  diathetic  aft'eetions  these  bursii?  are  frecjuently  the  seat  of  disease, 
giving  rise  to  simple  excess  of  fluid ;  to  suppurations ;  to  deposits,  tuber- 
cular, syphilitic,  or  malignant;  to  thickenings;  and  to  fibrous  and  cal- 
careous degenerations. 

Bursitis. — The  inflammations  are  acute,  subacute,  and  chronic,  the  last 
at  times  succeeding  to  the  second,  but  generally  such  from  the  beginning. 
"When  it  is  one  of  the  superficial  pouches  that  is  aflected,  the  prognosis  is 
ordinarily  good,  though  at  times,  because  of  neglect  of  proper  treatment, 
extensive  and  destructive  cellulitis  results :  when  a  deep-seated  bursa  is 
affected  the  prognosis  is  much  more  grave,  since  there  is  danger  of  the  exten- 
sion of  the  inflammation  to  the  joint  as  the  result  of  the  affection  itself  or  of 
the  measures  adopted  for  its  relief. 

Acute  bursitis,  due  ordinarily  to  injury,  at  times  to  over-use,  when  super- 
ficially located,  is  indicated  by  pain  or  at  least  tenderness,  skin-redness  of  vary- 
ing intensity,  and,  particularly,  by  swelling,  coming  on  rapidly  and  consequent 
upon  excess  of  secretion,  and,  oftentimes,  blood  in  considerable  quantity.  The 
peculiar  location  in  relation  to  a  tendon  and  the  limited  extent  and  globular 
form  of  the  swelling  serve  to  distinguish  the  disease  from  an  ordinary  cellulitis. 
The  associated  general  symptoms  may  be  of  high  grade.  If  suppurative,  unless 
promptly  arrested  there  is  strong  probability  of  extension  to  the  connective 
tissue  outside  the  bursa,  with  resulting  increase  in  the  severity  of  symptoms 
local  and  general.  The  deep-seated  inflammations  will  often  be  mistaken  for 
those  of  the  joints  near  by  :  and,  indeed,  in  a  considerable  proportion  of  cases 
they  actually  become  articular  after  a  little  time,  the  bursa  and  the  synovial 
sac  either  directly  communicating  or  being  separated  by  a  thin  wall  that 
soon  breaks  down.  Many  of  the  extra-articular  inflammations  also  doubt- 
less originate  in  bursal  disease. 

The  local  treatment  is  at  first  by  rest,  elevation,  pressure,  and  cold  appli- 
cations ;  later,  if  the  eftusion  does  not  rapidly  diminish  and  the  inflammatory 
symptoms  do  not  subside,  the  sac  should  be  aspirated,  or,  if  pus  is  present,  freely 
laid  open,  disinfected  by  pure  carbolic  acid,  and  dressed  antiseptic-ally  until  oblit- 
eration of  the  cavity  has  been  secured.  If  the  patient  is  rheumatic,  gouty,  or 
syphilitic,  the  ordinary  general  treatment  of  the  particular  diathetic  state 
should  be  employed. 

Chronic  bursitis,  of  much  more  frequent  occurrence  than  the  acute  variety, 
generally  gives  rise  to  little  or  no  distress,  and  is  characterized  chiefly  by  swell- 
ing, due  to  sac  distention,  or  to  this  combined  with  much  thickening  of  the 
wall.  At  times  the  swelling  is  solid  and  of  fibrous  character,  it  mav  be.  though 
rarely,  bony.  A  very  common  locality  is  on  the  front  of  the  knee,  the  prepa- 
tellar bursa  being  the  one  usually  affected  (Fig.  123).  It  is  due  to  long-con- 
tinued pressure  and  irritation,  as  in  those  who  kneel  much,  and  is  known  as 
housemaid's  knee,  as  a  similar  affection  of  the  olecranon  bursa  is  spoken 
of  as  miner  s  eJboiv.  The  enlargement  of  the  prepatellar  bur.sa  is  median  in 
position,  is  globular,  usually  fluctuates,  and,  unless  it  has  become  acutely 
inflamed,  is  painless  or  nearly  so,  though  some  weakness  of  the  knee  is  often 
complained  of.  The  subligamentous  bursa  is  sometimes  diseased,  when  the 
swelling  shows  itself  on  the  sides  of  the  ligament,  the  tension  of  which  causes 
a  central  depression. 

The  treatment  of  the  prepatellar  enlargement  is  by  aspiration  or  free 
incision  ;  the  latter,  when  aseptically  done  and  when  the  resulting  wound  is 
aseptically  treated,  gives  the  best  result.  Instead  of  a  median  cut,  small  open- 
ings may  be  made  on  the  sides  and  a  drainage-tube  carried  through.     When 


DISEASES   AND    IXJURIES    OF    THE   MUSCLES,  ETC.       346 


Fig.  123. 


K-i^ 


suppuration  lias  occurred  lateral  incisions  low  down  are  to  be  preferred  to  a 
central  one,  as  they  much  more  certainly  secure  drainajfe  of  the  pockets  on  the 
sides  where  the  bursa  overlaps  the 
inner  and  outer  edges  of  the  pa- 
tella. If  the  sac  has  very  thick 
walls  or  the  mass  is  solid,  it  should 
be  dissected  out,  care  being  taken 
in  the  removal  to  keep  as  close  as 
possible  to  the  outer  surface  of  the 
swelling. 

The  deeper  subligamentous 
bursal  swelUny  will  ordinarily  be 
treated  by  rest,  together  with  pres- 
sure or  the  application  of  small 
blisters,  and  relief  may  be  ex- 
pected only  after  considerable 
time.  The  likelihood  of  existing 
communication  with  the  knee- 
joint  makes  aspiration  the  pref- 
erable form  of  operative  treat- 
ment. 

Occasionally  the  bursa  beneath 
the  semimembranosus  tendon  is 
diseased,  and  when  it  has  enlarged 
so  much  as  to  cause  marked  swelling,  not  only,  as  at  first,  near  the  inner  border 
of  the  knee,  but  well  out  to  or  beyond  the  median  line,  the  affection  may  easily 
be  mistaken  for  an  intra-articular  one  or  for  an  aneurysm.  The  very  general 
connection  of  this  pouch  with  the  synovial  cavity,  at  least  in  adults,  as  a  gen- 
eral rule  contraindicates  any  operation  other  than  aspiration. 

As  the  result  of  abnormal  pressure  combined  with  malposition  of  the  articu- 
lating surfaces  there  is  frequently  observed  a  bursal  tumor  over  the  metatarso- 
phalangeal articulation  of  the  great  toe,  much  less  frequently  over  that  of  the 
little  toe  or  over  one  of  the  other  toe-joints.  This  is  known  as  a  "  bunion  " 
(Fig.  139).  It  may  cause  but  little  inconvenience,  but  almost  always  there  is 
some  tenderness  in  the  part,  and  it  is  quite  likely  to  become  acutely  inflamed. 
Then  the  pain  is  decided — and  it  may  be  excessively  severe — the  skin  is  red- 
dened, the  fluid  in  the  sac  much  increased,  and  walking  becomes  difiicult,  and, 
it  may  be,  impossible.  When  suppuration  occurs  the  pus  may  break  through 
the  wall  and  cellulitis  be  developed,  or  a  joint  inflammation  be  excited  and 
cause  more  or  less  destruction  of  the  articulating  surfaces.  The  treatment  is 
that  of  acute  bursitis  in  general — rest,  cold,  discutient  lotions,  tapping,  or 
incision  and  prompt  evacuation  of  pus.  If  either  the  surrounding  connective 
tissue  or  the  underlying  joint  has  become  infected,  free  incision  should  be 
made  and  the  wound  dressed  antiseptically.  Should  the  bone  have  become 
diseased,  it  must  be  removed  by  the  sharp  spoon  or  the  gouge  forceps,  and  the 
previous  malposition  of  the  toe  corrected  during  the  period  of  healing. 


Double  Housemaid's  Knee  (original). 


346 


AX  AMERICAN    TEXT- HOOK    OF  SURGERY. 


CHAPTER    V. 


ORTHOPEDIC  SURGERY. 


Orthopedic  surgery  lias  to  do,  properly,  with  tlu-  treatment  oi  deformitieB 
and  contractions,  especially  by  some  form  or  other  of  mechanical  aj)pliance, 
though  of  late  its  field  has  been  somewhat  extended  so  as  to  include  the  con- 
sideration of  many  deformity-producing  joint  affections. 

Torticollis,  or  avky-xeck,  is  a  contracted  state  of  one  or  more  of  the  mus- 
cles of  the  neck,  producing  an  abnormal  position  of  the  head.  As  ordinarily 
observed  it  aftects,  either  wholly  or  chiefly,  the  sterno-cleido-mastoid  muscle 
(Fig.  124),  though  the  deep  muscles  are  at  times  at  fault,  and  in  long-standing 
cases  they  are  apt  to  be  in  greater  or  less  measure  involved.     It  is  occasionally 

acute,  and  is  then  commonly  due 
Fig.  124.  to  either  cold  or  trauma.     But 

it  is  more  commoidy  chronic, 
and  is  then  spastic  in  character 
and  dependent  upon  nerve-irri- 
tation. It  has  been  produced 
by  an  habitual  malposition  of 
the  head,  assumed  because  of 
existing  ocular  defect.  It  is 
noticed  coninionly  in  young 
children :  thougli  rarely,  it  may 
be  congenital  and  due  to  ver- 
tebral deformity  or  to  injuries 
received  at  time  of  birth.  If 
it  first  appears  in  adult  life,  as 
it  does  occasionally,  though  for- 
tunately not  often,  instead  of 
being  spastic  it  is  intermittent, 
spasmodic,  and  generally  affects 
one  or  more  of  the  muscles  in- 
nervated by  the  spinal  accessory  nerve.  When  acute  it  generally  passes  away 
under  the  influence  of  rest,  heat,  and  time,  or  it  may  become  chronic  and  per- 
manent. The  spasmodic  variety  may  disappear  without  treatment  or  after  the 
employment  of  baths,  friction,  and  massage,  electricity,  tonics,  quinine  (for  it 
may  be  of  malarial  origin),  change  of  locality,  etc.,  or  it  may  remain  until 
stretching,  section,  or  removal  of  a  portion  of  the  spinal  accessory  nerve  be 
done ;  and  even  these  operations  may  leave  the  patient  little  or  no  better  than 
before. 

The  diagnosis  of  the  commonly  observed  spastic  contraction  of  the  sterno- 
cleido-mastoid  nniscle  is  easy :  the  head  is  turned  to  the  opposite  side,  the  chin 
is  extended,  the  ear  of  the  affected  side  is  drawn  downward  toward  the  shoulder, 
and  the  muscle  is  in  strong  relief  and  abnormally  firm.  At  times  only  one  of 
the  divisions  of  the  nmscle,  and  that  more  commonly  the  sternal,  is  markedly 
contracted.  When  the  disease  has  been  of  long  duration  there  is  often  decided 
atrophy  of  the  corresponding  side  of  the  face.  The  posterior  rotator  muscles 
of  the  neck  are  probably  involved,  together  with  the  sterno-mastoid.  Pain  is 
not  usually  present.     Rectification  of  the  malposition  can  often  be  effected,  at 


Torticollis  (original) 


ORTHOPEDIC  SURGERY.  347 

least  to  a  considerable  extent,  voluntarily  or  by  manual  pressure,  but  at  once 
recurs  when  the  pressure  is  removed.  When  the  deeper  muscles  are  diseased 
there  may  be  a  question  as  to  the  existence  of  caries  of  the  cervical  spine,  but 
the  history  of  the  case,  the  absence  of  bilateral  rigidity,  and  the  character  of 
the  deformity  will  generally  suffice  to  indicate  the  nature  of  the  trouble. 

Having  no  tendency  to  get  well  of  itself,  the  sp  antic  form  should  always  be 
treated  either  mechanically  or  by  operation,  followed  l)y  the  apjdication  of 
proper  retentive  apparatus.  Collars  and  braces  of  various  kinds  have  been 
devised  with  the  intention  of  holding  the  head  in  the  improved  position  secured 
by  forcible  manipulation,  and  the  plaster-of-Paris  bandage  over  head,  neck, 
and  shoulders  has  been  used  for  the  same  purpose.  Often  in  the  milder  cases 
relief  of  the  deformity  may,  in  time,  be  secured  by  such  appliances,  but  Avhen- 
ever  the  muscular  contraction  is  well  marked  the  tendon  and  the  adjacent 
fascial  bands  should  be  cut,  either  subcutaneously  or  through  an  open  wound. 
Until  recently  the  former  method  was  almost  uniformly  employed,  being  much 
safer  and  leaving  but  a  very  slight  scar;  but,  aseptically  made,  the  open  wound 
is  attended  with  little  or  no  risk,  and  has  the  advantage  of  permitting  a  more 
complete  division  of  the  contracted  tissues.  The  subcutaneous  method  will, 
however,  often  be  preferred.  The  head  being  so  held  as  to  render  the  tendon 
tense,  a  small  incision  is  made  low  down  over  its  internal  border;  through 
this  a  blunt-pointed  tenotome  is  carried  to  and  along  the  under  surface  of 
the  sternal  portion,  its  cutting  edge  turned  forward,  and  section  made,  after 
which,  in  the  same  manner,  the  clavicular  portion  may  be  divided  if  necessary. 
At  times  the  sternal  tendon  can  be  cut  upon  the  bone,  thus  avoiding  the 
danger  of  wounding  the  anterior  jugular  vein  as  it  passes  behind  the  muscle 
a  short  distance  above  the  sterno-clavicular  articulation — an  accident,  how- 
ever, of  little  moment,  as  the  hemorrhage  can  be  easily  controlled  by  pressure 
and  the  clot  will  soon  be  absorbed.  The  internal  jugular  vein  has  been 
wounded,  the  knife  having:  been  carried  too  far  back  in  the  first  stasje  of  the 
operation. 

As  has  been  stated,  for  the  relief  of  spasmodic  lory-neck,  affecting  the 
sterno-cleido-mastoid  muscle,  the  spinal  accessory  nerve  may  be  stretched,  cut, 
or  in  part  removed,  the  latter  being  much  the  most  promising  procedure.  To 
expose  the  nerve  an  incision  may  be  made  along  the  posterior  edge  of  the 
sterno-cleido-mastoid  muscle  at  its  middle  or  along  the  anterior  edge,  begin- 
ning at  the  mastoid  process  and  carried  downward  for  about  three  inches :  the 
muscle  being  drawn  aside,  the  nerve  can  be  readily  lifted  and  a  piece  of  it 
cut  away.  Exsection  of  one  or  more  of  the  upper  cervical  nerves  when  the 
posterior  muscles  are  affected  necessitates  careful  dissection  and  somewhat  exten- 
sive division  of  the  trapezius  and  complexus  muscles,  and  will  not  often  be  per- 
formed. 

Contractures. — As  has  already  been  stated,  there  are  at  times  observed 
in  adults,  as  late  phenomena  of  hemiplegic  paralysis,  contractures  of  the  muscles 
of  the  arm,  forearm,  and  hand,  especially  of  the  flexors :  such  contractures 
increase  in  intensity  in  proportion  as  the  parts  to  which  the  muscles  are  sup- 
plied are  farther  removed  from  the  trunk.  As  commonly  seen,  the  arm  is 
adducted,  firmly  held  against  the  side  (though  occasionally  it  is  abducted),  the 
forearm  is  flexed  upon  the  arm,  the  hand  upon  the  forearm,  and  the  fingers 
upon  the  palm  ;  these  flexions  cannot  be  entirely  overcome  by  either  passive 
or  active  movements  in  extension.  The  deformity  produced  is  proportionate 
to  the  degree  of  contracture,  and  ordinarily  is  not  relieved  by  any  treatment. 
Traumatic  contractures  due  to  wounds,  not  seldom  to  burns,  and  those  conse- 
quent upon  extensive  cellulitis  with  loss  of  tissue  and  the  formation  of  strong 


348 


.I.V    A  mi: UK  AX    TEXT-IK K>K    OF   SURGERY. 


cicatricial  adhesions,  are  so  variable  in  locality,  extent,  and  force  that  each 
case  must  be  treated  accordin;^  to  its  special  indications,  mechanically  or  opera- 
tively,  by  the  use  of  apparatus  or  by  stretching,  rupturing,  dividing,  or  by  the 
plastic  insertion  of  healthy  tissue  taken  from  a  near  or  a  remote  part  of  the 
body  or  fmm  a  lower  animal.  At  times  the  disability  consequent  uj)on  the 
irremediable  deformity  is  so  great  that  amjiutation  is  done.  For  the  treatment 
of  contractures  by  lengthening  of  the  tendon,  see  p.  oSo  (Fig.  IIH). 

CoNTKACTlMX    OF    TlIK    PALMAK    FaSCIA  {T)u]>Uj/trc7l' h  rO)ltr(n'fi<>n)   (Figs. 
12")  and  126),  producing  permanent  Hexion  of  a  finger  or  fingers,  is  at  times 


Fi(i.  125. 


Fkj.  126. 


Dupuytren's  Contraction  of  the  Palmar  Fascia  (Keen). 


The  Same  Hand  afler  Opt' ration  (Keen). 


met  -with,  generally  in  individuals  beyond  the  middle  period  of  life,  much  more 
frequently  in  men  than  in  women.  It  affects  indifferently  either  hand,  some- 
times both.  The  ring  or  the  little  finger  or  both  are  most  frequently  flexed  ; 
next  the  middle  finger:  the  thumb  and  the  index  more  rarely.  The  ilegree  of 
flexion  varies  with  the  case  and  the  length  of  time  that  tlie  disease  has  existed. 
It  is  not  the  flexor  tendons  that  are  contracte(L  as  was  formerly  believed  to 
be  the  case,  but  the  palmar  fascia  and  its  digital  prolongations,  together  with 
the  fibrous  bundles  uniting  the  fascia  and  the  overlying  skin,  which  latter  is 
involved  only  late  and  secondarily  if  at  all.  Beginning  usually  a^  a  small  hard 
nodule  at  or  near  the  line  of  the  nietacarpo-phalangeal  articulation,  the  disease 
extends  more  or  less  slowly  both  downward  and  upward,  with  corresponding 
drawing  down  of  the  affected  finger  or  fingers,  until  in  very  severe  cases  the 
finger-tip  is  strongly  and  steadily  held  against  the  palm.     Its  occurrence  has 


ORTJKH'KDIC   SURGERY.  349 

been  attributed  to  the  action  of  various  causes, — slight  traumatisms  frequently 
repeatotl,  the  rheumatic  or  gouty  diatlicsis,  rcHex  nervous  irritation,  etc.  ;  but 
which  of  these  is  its  real  cause,  or  whether  it  depends  upon  any  single  cause, 
has  noi  been  determined.  It  certainly  seems  to  be  most  frequent  in  those  who 
are  rheumatic  or  gouty.  A  recently-reported  cure  by  hypnotic  suggestion,  as 
far  as  it  goes,  gives  support  to  the  nervous  theory. 

The  diagnosis  is  easily  made:  the  thickened  elevated  band  in  the  palm 
extending  to  the  sides  of  the  finger,  the  marked  flexion  resisting  strong  efforts 
at  extension,  the  absence  of  pain,  the  slow  development  of  the  condition,  the 
age  of  the  individual,  the  non-existence  of  cerebral  or  spinal  disease,  or  of 
injury  of  the  extremity  followed  by  loss  of  substance  and  resulting  scar-con- 
traction,— all  taken  together  render  it  impossible  to  mistake  the  nature  of  the 
affection. 

Treatment. — Left  to  itself,  the  palmar  contraction  always  gets  worse,  and 
it  can  be  relieved  oidy  by  operation.  The  skin  should  be  divided  by  a  linear 
wound  or  reflected  in  a  V-shaped  flap,  base  downward,  and  the  contracted 
tissue  dissected  out,  an  operation  which  of  late  years  has  been  freijuently 
done  with  success.  The  hand  and  forearm  are  placed  upon  a  palmar  splint 
for  a  few  days. 

Club-Haxd  (Fig.  127)  may  occur  congenitally  as  the  result  of  de- 
fective  osseous    development,   or   later    because   of  wounds   attended   with 

Fig.  127. 


Double  Club  Hand   original). 

much  loss  of  substance  in  the  soft  parts  or  the  bones  of  the  forearm 
or  carpus,  or  of  paralytic  contractions.  There  is  a  deviation,  lateral,  an- 
terior, or  posterior  (very  rarely  the  latter),  similar  to  that  in  the  lower 
extremity  constituting  club-foot,  and  hence  known  as  club-hand.  Gen- 
erally the  hand  is  drawn  over  in  flexion  and  toward  the  radial  side.  It  is 
often  present  at  birth,  or  has  followed  extensive  resection  of  the  lower  part 
of  the  radius  or  ulna  or  of  the  carpus.  Little  or  no  relief  can  usually  be  afforded, 
though  early  and  persistent  manipulation,  with  the  use  of  a  retentive  dressing, 
plaster  or  instrumental,  has  occasionally  been  followed  by  decided  improvement 
in  the  position  and  usefulness  of  the  hand.  Always  after  bone-removal,  espe- 
cially of  the  lower  end  of  the  radius,  care  must  be  taken  for  many  months  to 
prevent  the  deflection  of  the  hand,  otherwise  likely  to  occur,  by  passive  and 
active  movements,  and,  if  necessary,  by  the  employment  of  a  suitable  apparatus. 
Tenotomy  ordinarily  has  done  little  good,  and  at  times  has  done  harm. 

Webbed  Fixgers  (Syndactylism)  is  a  congenital  affection.  It  may  affect 
two  or  more  fingers  on  one  or  both  hands,  the  union  extending  to  any  point, 
even  to  the  tips.  There  may  be  a  wide  web  of  skin  with  but  little  connective 
tissue  within,  or  a  narrow  and  thick  one,  or  the  phalanges  of  the  two  fingers 
may  be  in  close  apposition.  Frequently  the  deformity  is  a  family  peculiarity, 
running  back  through  three,  four,  or  more  fjenerations.  If  onlv  two  fingers 
are  united,  they  are  usually  the  ring  and  middle  ones.     The  strength  and  use- 


350 


AX   AMKIilCAN    TKXT-liOOk'    OF   SURGERY. 


Fig.  128. 


fulness  oftlir  liaiul  art'  ot'tni  hut  little  im|iaire(l.  Siiii|ilc  division  of  the  web 
rarely  gives  other  than  teiniiorary  relief,  the  web  re-lbniiin^f  iVoiu  the  bottom 
as  the  wound  heals.  To  prevent  such  re-tbrmation  a  tlap  of  skin  may  be  fixed 
in  the  angle  between  the  sepa- 
rated fingers  (see  Fig.  128),  or 
a  small  hole  may  at  first  be 
made  at  the  level  of  the  edge 
of  the  normal  web,  in  which 
a  thread  or  a  button  may  be 
placed  and  retained  until  the 
edges  of  the  cut  have  healed, 
after  which  the  remainder  of 
the  web  may  be  cut  through. 
The  most  satisfactory  op- 
eration is  Didot's,  in  which  a 
flap  the  length  of  the  finger 
and  half  its  width,  with  the 
added  width  of  the  web,  is 
taken  from  the  dorsal  surface 


Agnew's  Operation  for  Webbed  Fingers 


of  one  finger  and  the  palmar  surface  of  the  other  (thus  splitting  the  web  and 
separating  the  fingers),  and  each  carefully  applied  over  the  denuded  portion 
of  the  finger  to  which  it  is  attached,  securing  a  normal  skin  covering  of  the 
surfaces  that  are  to  be  in  apposition  (Figs.  129,  130). 

Supernumerary  Digits  (Polydactylism)  are  also  congenital,  are   not 
infrequent,  and,  like  webbed  fingers,  in  many  cases  are  hereditary.     They 

are  generally  svmmet- 
FiG.  129.  Fig.  130.  j-jcal,  and  often   pres- 

ent on  both  hands  and 
feet.  Usually  there  is 
but  a  single  digit  in  ex- 
cess,  commonly  on  the 
side  of  the  little  finger 
or  little  toe ;  though 
not  rarely  the  thumb, 
much  less  often  the 
great  toe,  is  double. 
The  development  may 
be  complete,  even  to  an 
extra  sui)porting  meta- 
carpal or  metatarsal 
bone,  or  it  may  be  more  or  less  imperfect,  so  that  the  supernumerary  digit  is 
scarcely  more  than  a  rudimentary  nodule  connected  with  the  side  of  a  phalanx. 
When  perfect  it  is  most  often  attached  at  a  greater  or  less  angle  to  the  broad- 
ened end  of  the  metacarpal  or  metatarsal  bone  of  the  normal  finger  or  toe, 
though  at  times  the  normal  and  extra  digit  are  very  closely  apposed,  or  even 
fused,  and  held  in  a  common  envelope  of  skin.  At  times  the  connection  with 
the  hand  or  foot  is  by  a  fibrous  band  of  varying  length  and  firmness.  It  may 
be  amputated  at  any  time,  but  if  not  closely  fused  with  the  adjoining  digit  it 
is  best  to  remove  it  very  soon  after  birth  :  and  even  if  so  fused,  it  should  be 
taken  aAvay  while  the  child  is  still  quite  young,  to  lessen  the  resulting  deformity. 
If  there  is  a  completely  formed  hand  or  foot,  Avith  an  extra  metacarpal  or  meta- 
tarsal bone  and  corresponding  digit,  no  operation  need,  or  indeed  should,  be 
done. 


Didot's  Operation  for  W'ebbed  Fingers 
(Walter  Pye). 


Transverse   Section,  showing 
flaps  before  and  after  suture. 


< )  R  Til  OPE  Die  8  UR  GER  Y. 


351 


Fig.  181. 


Genu  Valgum,  or  Knock-Knee  (Bradford 
and  Lovett). 


Genu  Valgum,  oit  Kn(ick-Knee  (Fig.  181). — This  is  the  result  of  over- 
growth of  the  internal  condyle  and  curving  inward  of  the  shaft  of  the  femur 
in  its  lower  part,  with  associated  relaxation 
and  elongation  of  the  internal  lateral  liga- 
ments of  the  knee-joint.  These  changes  pro- 
duce an  abnormal  inclination  of  the  interar- 
ticular  line,  more  or  less  close  approximation 
of  the  knees,  and  more  or  less  Avide  separation 
of  the  feet,  the  individual  in  standing  being 
unable  to  bring  the  heels  together. 

It  usually  manifests  itself  in  early  childhood, 
soon  after  the  child  begins  to  walk,  but  may 
not  do  so  until  about  the  ])eriod  of  puberty, 
or  even,  though  rarely,  much  later  in  life. 
In  the  former  case  it  is  a  rhachitic  manifesta- 
tion ;  in  the  latter,  it  is  consequent  upon  an 
occupation  requiring  long-continued  standing 
by  a  person  of  feeble  muscular  and  ligament- 
ous development.  Often  there  is  associated 
flat-foot,  which,  indeed,  at  times  may  be  the 
primary  and  causative  lesion.  It  may  affect 
one  or  both  knees,  may  be  so  slight  as  to  escape  detection  except  upon  very 
careful  examination,  or  so  severe  as  to  cross  the  knees,  separate  the  feet  very 
widely,  and  render  locomotion  difficult  and  the  gait  wabbling.  In  children 
other  evidence  of  the  existence  of  rickets  will  commonly  be  found. 

The  diagnosis  is  made  on  sight,  except  in  the  mildest  cases. 

Left  to  itself,  when  not  severe  it  often  spontaneously  improves  as  the 
rhachitic  state  passes  away  and  the  general  strength  increases.  This  favorable 
termination  is  common  in  the  static  knock-knee  of  adolescents. 

The  earlier,  however,  that  treatment,  general  and  local,  is  begun, 
the  speedier  will  be  the  recovery  and  the  less  the  resulting  deformity.  The 
ordinary  medicinal  and  hygienic  treatment  of  weak  and  rhachitic  subjects  is 
the  appropriate  one  for  young  children.  The  local  treatment  is  mechanical, 
supplemented  by  baths,  frictions,  massage,  electricity,  and  preceded,  in  the 
severer  cases,  by  osteotomy. 

If  the  rickets  is  still  active  and  the  bones  are  soft  and  yielding,  standing 
and  walking  should  be  forbidden,  the  limb  should  be  straightened  as  much  as 
possible  by  manipulation,  and  maintenance  of  the  correct  position  should  be 
secured  by  an  outside  splint  and  bandage.  Later,  when  the  bones  have  become 
firmer,  great  benefit  often  follows  the  use  of  such  a  splint  with  a  counter-press- 
ing pad  on  the  inside,  the  resulting  change  in  the  relative  positions  of  the 
articular  surfaces  of  the  femur  and  tibia  permitting  the  increased  growth  of 
the  external  femoral  condyle  Avith  restriction  of  that  of  the  internal.  Plaster 
of  Paris  is  an  excellent  material  for  this  splint,  or  the  limb  may  be  completely 
enveloped  in  it. 

Immobilization  w^ith  the  leg  flexed  at  a  right  angle  wnth  the  thigh  is,  by 
many,  preferred  to  that  in  the  straight  position,  as  the  deformity  is  much  less- 
ened by  the  flexion.  Forcible  rectification  followed  by  immobilization  has  often 
been  followed  by  great  improvement,  there  being  produced  in  the  rapid  straight- 
ening an  epiphyseal  separation  of  greater  or  less  extent  or  a  laceration  of  the 
external  lateral  ligament.  But  if  sufficient  force  to  produce  such  condition  is 
required,  it  is  better  instrumentally  to  break  the  thigh  at  a  determined  level 
or  to  divide  the  bone  with  saw  or  chisel,  especially  as  severe  injury  to  the  soft 


:}52  Ay   AMK/i'lCAX    ThWr-JiOOk'    OF  .SURGERY. 

parts  and  the  joint  structures  has  at  times  been  produced  by  the  former  method. 
Braces  of  various  kinds  have  l)et'n  devised,  all  intended  to  correct  the  deformity 
and  allow  the  patient  to  go  about,  and  many  of  them  are  of  much  service  in 
very  young  children. 

If  the  knock-knee  is  great  and  the  bones  are  firm,  no  material  change  for  the 
better  can  be  ett'ected  without  operation,  either  fracture  (osteoclasis)  or  section 
(osteotomy),  of  which  the  latter  is  to  be  preferred,  fracture  requiring  the  use 
of  a  special  apj)aratus,  and  not  always  being  produced  at  the  desired  ])lace. 
Section  nuiy  be  so  done  as  to  separate  the  internal  condyle  or  divide  the  lower 
portion  of  the  femur,  which  latter  is  the  operation  ordinaril}"  performed.  A 
small  lontfitudinal  incision  beinff  made  down  to  the  bone,  half  an  inch  or  a  little 
more  above  the  adductor  tubercle,  the  osteotome  is  introduced,  turned  at  a  right 
angle,  and  by  successive  blows  of  the  hammer  driven  toward  the  outer  side, 
being  so  moved  uj)\vard  and  downward  as  to  secure  division  of  the  entire  thick- 
ness of  the  bone  for  three-quarters  or  four-fifths  of  its  transverse  diameter,  the 
uncut  portion  being  readily  broken  by  moderate  force.  The  limb  is  then  to  be 
straightened,  an  antiseptic  pad  applied,  a  layer  of  cotton  put  on,  and  immo- 
bilization made  by  plaster  of  Paris.  Little  or  no  reaction  ordinarily  follows: 
in  about  a  month  the  dressing  may  be  taken  off,  and  after  two  or  three  weeks' 
additional  rest  the  patient  is  allowed  to  walk.  Though  the  operation  is  not 
altogether  devoid  of  danger,  since  there  may  be  serious  hemorrhage  from  a 
divided  popliteal  or  anastomotica  magna  artery,  or  from  the  bone  itself,  or  a 
resulting  aneurysm  or  gangrene,  causing  death  or  necessitating  amputation,  or 
damage  inflicted  upon  the  external  popliteal  nerve,  yet  the  likelihood  of  these 
accidents  is  verj^  slight,  and  may  be  practically  disregarded  in  deciding  upon 
the  advisability  of  making  the  section.      (See  Osteotoni}''.) 

Genu  Varum,  or  Bow-Legs  (Fig.  132),  the  opposite  of  genu  valgum,  is  a 
deformity  usually  affecting  both  limbs,  in  which  the  knees  are  more  or  less  widely 

separated,  the  joint  surfaces  are  in  such  relation  to 
^'^-  ^^'■^-  each  other  that  the  angle  between  them  points  outward, 

and  the  chief  pressure  is  between  the  internal  con- 
dyles. Except  in  a  very  few  cases  there  is  outward 
curvature  of  the  femur  and  tibia,  or  of  the  tibia  alone, 
with  at  times  an  anterior  bend  of  the  latter  bone. 
The  curves  of  the  tAvo  legs  together  may  form 
an  almost  complete  circle.  A  line  drawn  from  the 
center  of  the  femoral  head  to  the  ankle  is  internal 
to  the  knee.  The  disease  l)egins  in  early  childhood 
and  is  of  rhachitic  origin,  and  the  deformity  is  the 
direct  result  of  the  weight  of  the  body  and  muscular 
action.  Inspection  at  once  reveals  its  existence, 
which  is  further  indicated  by  the  turning  in  of  the 
feet  and  the  rolling  walk.  In  elderly  persons  suffer- 
ing from  osteitis  deformans  there  may  be  a  bow- 
cienu  vurum.  or  Bow-Legs  lagged  condition  whicli  is  a  part  of  the  general  bone 
(Bradford  and  Lovett)  disease,  and  is  irremediable. 

Treatment. — Spontaneous  correction  sometimes  occurs,  much  more  fre- 
quently than  in  genu  valgum  ;  but  if  the  case  is  at  all  severe  and  the  child  so 
young  that  the  bones  have  not  become  firmly  set  in  the  abnormal  curves, 
mechanical  treatment  should  be  employed  to  bring  the  limbs  in  toward  the 
median  line.  This  may  be  by  plaster  or  braces,  according  to  circumstances. 
In  older  patients  the  bones  are  too  strong  to  yield  to  any  such  pressure,  and 
correction  of  the  deformity  can  be  made  only  after  fracture  or  section.     Though 


ORTHOPEDIC  SI ^RGKR Y. 


353 


osteoclasis  by  the  aid  of  one  or  other  of  the  instruments  now  employed  gives 
better  results  than  in  cases  of  genu  valgum,  yet  osteotomy  is  the  operation 
that  is  generally  done,  linear  division  being  effected  at  such  levels  as  the  con- 
dition of  the  individual  case  may  indicate.  The  method  of  operating  and  the 
after-treatment  are  the  same  as  in  knock-knee. 

Turning  in  or  turning  out  of  the  knee  conseciuent  upon  paralysis  or 
vicious  union  after  fracture  requires  no  special  consideration.  Each  case  must 
be  treated  according  to  its  cluiracter,  medically,  mechanically,  or  operatively. 

Antero-posterior  Curvature  of  the  Legs  is  another  of  the  deformities 
due  to  rickets  which  in  its  aggravated  form  can  be  relieved  only  by  operation. 
When  slight  and  detected  early,  it  may  be  expected  to  disap})ear,  either  with- 
out treatment  or  more  probably  under  rest  and  appropriate  fixation  dressing ; 
but  in  neglected  cases,  in  some  of  which  there  is  excessive  bowing,  linear  or 
often  cuneiform  osteotomy  must  be  done  on  one  or  both  bones  according  to 
circumstances.  In  the  performance  of  the  latter  the  summit  of  the  curve  in 
the  tibia  is  freely  exposed  by  a  longitudinal  incision  of  sufficient  length.  By 
a  saw  or  chisel  a  wedge,  with  its  base  anterior,  is  cut  out  of  tlie  tibia,  after 
which,  if  necessary  to  the  straightening  of  the  leg,  the  fibula  is  broken  or 
instrumentally  divided.  Tenotomy  of  the  tendo  Achillis  also  is  generally 
needed.  Proper  adjustment  having  been  made,  the  limb  is  immobilized  and 
quietude  maintained  until  repair  and  consolidation  are  completed.  The  ope- 
ration and  dressing  must  be  done  aseptically,  that  suppuration  may  not  take 
place,  Avhich  will  always  materially  lengthen  the  period  of  treatment.  There 
is  a  risk,  but  not  a  great  one,  of  wounding  the  anterior  tibial  vessels  or  nerve. 

Club-Foot,  or  Talipes,  is  a  non-traumatic  deviation  of  the  foot  in  the 
direction  of  one  or  other  of  the  four  lines  of  movement — extension  (T.  equmus, 
Fig.  133),  flexion  (T.  calcaneus,  Fig.  134),  adduction  (T.  varus),  and  abduc- 


FiG.  133. 


Fig.  134. 


Talipes  Calcaneus  (Albert). 


Talipes  Equimis  (Albert). 


tion  (T.  valgus), — or  of  two  of  these  combined,  as  in  equino-varus  (Fig.  135). 
It  is  due  either  to  under-  or  over-action  of  muscles  or  to  abnormal  position, 

2.3 


3o4 


AX  A.\fi:in('AX  TEXT-r.ooK  or  surgery. 


Double  Equino-varus  loriijiual  i. 


shape,  or  relations  of  one  or  more  parts  of  the  skeleton  of  tlu-  foot.  It  may 
be  either  congenital  or  accjuired,  in  tiie  latter  case  being  generally  devel- 
oped in  early  childhood  and  the  result  of  infantile  paralysis  (acute  anterior 
poliomyelitis). 

In  the  congenital  variety  the  displacement  is  almost  ahvays  one  of  adduc- 
tion, with   commonly  some  elevation  of  the  heel   (Talipes  Eqlino-vakus, 

Fig.    185).       Generally  affecting 
Fiu.  135.  t)oth  feet,   it  may  be  confined  to 

one,  the  right  oftener  than  the 
left.  The  inner  border  is  raised, 
the  sole  turned  toward  the  median 
line  of  the  body,  the  heel  more 
or  less  lifted,  the  distal  part  of 
the  foot  flexed  upon  the  ])ro.\imal 
part  at  tiie  mid-tarsal  articulation. 
The  degree  of  deformity  varies 
from  that  which  is  ])ut  little  in 
excess  of  the  natural  inclination 
of  the  foot  of  the  new-born  infant 
up  to  so  great  rotation  that  the 
weight  in  the  erect  posture  is  borne  upon  the  ujtper  and  outer  ])art  of  the 
dorsum.  At  the  time  of  birth  and  for  some  months  afterward  the  deformity 
can  usually  be  easily  corrected  by  manipulation,  but  later,  if  left  to  itself,  it 
becomes  in  greater  or  less  measure  fixed,  in  consequence  of  muscular  contraction 
and  developmental  clianges  in  the  shape  of  the  bones. 

As  to  its  cause,  there  has  been  much  question.  It  has  been  attri])uted  to 
uterine  pressure,  to  intra-uterine  disease  of  the  cerebro-spinal  axis  with  result- 
ing paralysis  and  arrests  of  development  (it  is  not  seldom  associated  with 
malformations  of  the  head,  the  face,  the  spine,  the  abdominal  wall,  or  the 
pelvis),  and  to  persistence  of  the  earlier  foetal  position  of  the  foot,  the  later 
normal  rotation  of  the  leg  and  foot,  or  at  least  of  the  latter,  not  having  taken 
place — an  explanation  that  seems,  at  present,  the  most  likely  to  be  correct. 
In  a  considerable  number  of  cases  it  is  a  family  peculiarity,  either  in  the 
ascending  line  or  affecting  several  children  of  the  same  parents. 

The  diagnosis  is  easy,  and  the  prognosis  good  if  proper  treatment  is 
promptly  adopted  and  steadily  maintained  for  a  sufficient  length  of  time,  though 
even  under  the  m.ost  favorable  circumstances  the  ultimate  development  of  the 
foot  is  not  what  it  would  have  been  had  the  deformity  not  existed. 

The  treatment  must  be  either  manipulative  or  mechanical,  or  l)oth.  In 
those  cases — and  they  are  the  majority — in  which  at  birth  and  soon  afterward 
the  foot  can  readily  be  brought  into  proper  position  by  hand-pressure,  such 
pressure,  could  it  be  steadily  maintained,  would  in  time  relieve  the 
deformity.  As  this  cannot  be  done,  some  substitute  for  it  must  be  found,  and 
that  is  best  which  most  nearly  apjiroaches  it  in  evenness  and  gentleness  of 
pressure.  Simple  bandaging  or  the  application  of  adhesive  straps  has  been 
used,  and,  at  times,  with  success,  but  immobilization  of  the  foot  and  leg  by 
plaster  of  Paris  or  gutta-percha  is  very  much  better,  the  parts  being  ju-otected 
by  cotton  and  the  dressing  carried  sufficiently  high  up  to  prevent  its  ready 
displacement.  Frequent  removals  and  reaj)])lications  of  the  plaster  will  be 
required'.  Very  rarely  in  these  young  subjects  is  there  such  tendon  contrac- 
tion as  to  necessitate  section.  The  earlier  the  deformity  is  corrected  and  the 
foot  held  in  right  position  the  better.  If  the  case  has  been  neglected  and 
nothing  done  until  the  child  has  begun  to  stand  and  walk,  the  malposition  may 


onriloPEDlC  SURGERY.  355 

still  be  coi-rected  by  iiKinipiibition  and  overcome  by  immobilization,  but  with 
much  more  difficulty.  Decided  retraction  of  the  heel  may  often  in  this  way 
be  relieved,  but  considera])le  time  will  be  required— time  which  may  be  saved 
bv  tenotomy.  The  tenotome  is  introduced  by  the  side  of  the  tendo  Achillis 
(rendered  as  tense  as  possible  by  flexion  of  the  foot),  carried  underneath  it,  its 
cutting  edge  turned  against  it,  and  division  made  by  pressure  and  a  slight  saw- 
in*^  motioii!  There  are  but  two  dangers  in  this  operation,  that  of  wounding 
tlie  posterior  tibial  artery,  and  that  of  freely  dividing  the  skin,  neither  of 
which  is  likely  to  occur  if  care  is  taken.  If  either  accident  does  happen,  it  la 
usually  a  matter  of  no  great  importance.  Pressure  will  stop  the  flow  of  blood, 
and  under  antiseptic  treatment  the  open  wound  will  (quickly  close  without 
inflammation.     Elastic  traction  has  been  employed  with  much  benefit. 

Upon  far  the  larger  number  of  these  patients  club-foot  shoes  are  applied. 
They  should  be  either  solid  or  jointed  opposite  the  middle  tarsal  articulation  to 
permit  of  any  re(iuired  lateral  movement  of  the  parts  in  front.  The  side-pieces 
should  be  carried  nearly  up  to  the  knee.  If  properly  made,  adjusted,  and  watched, 
if  it  overcomes  the  deformity  and  maintains  the  correction,  such  mechanical 
appliance  is  of  great  service.  But  as  very  often  used  it  is  of  little  or  no  bene- 
fit, frequently  a  positive  injury,  since  it  is  put  on  by  an  instrument-maker  or 
dealer  uninformed  in  anatomy  or  pathology,  and  makes  uneven  pressure, 
produces  callosities  and  ulceration,  fails  to  hold  the  foot  in  proper  position, 
frefjuently  breaks  and  gets  out  of  order,  thus  necessitating  expense  that  can 
be  ill  aff"o^i-ded,  and  is  often  worn  long  after  it  should  have  been  thrown  away 
and  a  new  one  applied.  Much  better  results  will  be  secured  by  the  average 
practitioner,  and  especially  among  the  poor,  by  plaster-of-Paris  immobilization 
than  bv  the  use  of  a  club-foot  apparatus. 

Before  a  proper  mechanical  appliance  can  be  put  on,  forcible  correction  under 
anesthesia  may  have  to  be  made,  together  wdth  tenotomy  of  the  tendo  Achillis, 
of  the  tibial  tendons,  anterior  or  posterior  or  both,  and  of  the  plantar  fascia. 
In  the  aggravated  long-standing  cases  in  which  there  has  taken  place  marked 
change  in°the  shape  of  the  bones,  in  the  length  and  position  of  the  ligaments, 
and  in  the  connective  tissues  of  the  foot,  rectification  cannot  be  effected  except 
after  operation  upon  the  bones  or  soft  parts  or  both.  A  wedge-shaped  piece 
may  be  taken  out  of  the  tarsus  (cuneiform  osteotomy),  or  the  cuboid,  the 
scaphoid,  or  the  astragalus  may  be  removed,  or  a  free  transverse  incision  may 
be  made  through  all  the  soft  parts  of  the  sole  of  the  foot,  which  has  been  done 
many  times  of^late  and  with  great  benefit  (A.  M.  Phelps).  Removal  of  the 
astragalus  gives  an  excellent  result,  preferable  to  that  secured  by  osteotomy. 
Always  after  operation  a  proper  retentive  apparatus  must  be  applied  and  its 
use  continued  for  a  long  time. 

Non-congenital  Talipes,  as  has  been  stated,  is  almost  always  of  paralytic 
origin.  It  mav  aff"ect  one  foot  or  both,  and  when  double,  unlike  what  is  true 
of  the  congenital  variety,  the  deviation  may  be  in  opposite  directions.  It  may 
be  noticed^as  soon  as  tlie  child  begins  to  walk,  or  may  appear  later,  according 
to  the  time  at  which  the  spinal  disease  occurs.  There  is  usually  decided  ele- 
vation of  the  heel,  with  less  lateral  deviation  than  in  the  congenital  cases,  or, 
it  may  be,  none  at  all,  and  passive  movements  at  the  ankle  and  middle  tarsal 
joints  are  readily  made  until  spastic  contractures  of  the  muscles  limit  or  pre- 
vent them.  This  freedom  of  movement,  together  with  the  coldness  of  the  parts 
and  marked  atrophy  of  the  leg  and  foot,  and  at  times  the  associated  paralytic 
or  paretic  state  of  the  upper  extremity,  serves  to  differentiate  the  affection  from 
the  congenital  form.  The  prognosis  is  less  favorable  than  in  the  latter,  because 
of  the  causative  muscular  paralysis. 


356 


AN  AMERICAN    TEXT- HOOK    OF  SURGERY. 


The  treatment  is  mucli  the  same :  rectification  of  the  lualpositiou  by 
manipuhition,  gentle,  forciljle,  or  after  tenotomy  according  to  circumstances; 
and  maintenance  of  tlie  proper  position  by  immobilization  or  by  apparatus. 
The  latter  has  the  advantage  of  permitting  the  employment  of  massage,  the 
douche,  electricity,  and  supplementary  elastic  traction  ;  all  of  \vliich  should 
be  combined  with  the  operative  and  mechanical  treatment. 

Talipes  VAL(iUS,  generally  non-congenital,  is  characterized  by  flatness  of 
the  foot,  abduction  of  its  anterior  part  and  more  or  less  elevation  of  its  outer 
border,  from  yielding  of  the  arch.  It  occurs  ordinarily  in  feebly-developed 
persons,  especially  children,  being  the  result  of  weight  coming  upon  a  foot 
unable  to  sustain  it,  and  may  be  associated  with  rickets,  spinal  curvature, 
knock-knee,  or  badly  united  fracture.  In  the  aggravated  cases  decided  displace- 
ment of  the  tarsal  bones  occurs,  especially  of  the  astragalus  and  the  scaphoid, 
toorether  with  changes  in  the  ligaments  unitinj;  the  os  calcis,  the  astragalus,  and 
the  scaphoid.  In  children  pain  is  commonly  absent,  but  in  adults  it  is  often 
complained  of  after  long  standing  or  walking,  and  upon  pres.sure  there  is 
generally  found  to  be  tenderness  in  front  of  the  inner  malleolus,  over  the  junc- 
tion of  the  astragalus  and  scaphoid,  and  over  the  proximal  ends  of  the  inner 
and  outer  metatarsals.  The  treatment  is  both  general  and  local,  consisting 
of  tonics,  gymnastics,  frictions,  massage,  and  the  douche,  and  especially  the  use 
of  a  supporting  steel  plate  as  a  substitute  for  the  normal  arch.  Under  such 
treatment  the  prognosis  is  good.  When  there  is  present  simply  a  weakness  of 
the  ankle,  support  should  be  given  either  by  a  leather  or  steel  anklet  or  a 
brace  shoe. 

Talipes  Calcaneus  (Fig.  134)  is  not  seldom  seen  as  the  result  of  infantile 
paralysis,  and  occasionally  at  the  time  of  birth.  It  consists  of  a  deviation  in 
the  direction  of  flexion,  the  patient  walking  upon  the  heel  with  the  anterior 
part  of  the  foot  raised,  with  or  without  some  associated  abduction.  Relief  may 
often  be  afforded  by  manipulation  alone,  and  generally  by  fixation  by  bandages, 

a  shoe,  or  a  shoe  and  brace. 
Tenotomy  Avill  seldom  be  re- 
quired. In  a  few  very  severe 
cases  a  portion  of  the  tendo 
Achillis  has  been  removed  and 
its  shortening  thus  secured. 

Pes  Cavus,  or  Hollow 
Foot. — As  the  result  of  contrac- 
tion of  the  peroneus  longus  or  of 
the  deep  muscles  of  the  foot,  or 
of  paralysis  of  the  calf  muscles, 
marked  exaggeration  of  the  arch, 
Avith  approximation  of  the  heel 
and  the  heads  of  the  metatarsals, 
is  occasionally  produced.  This 
is  known  as  pes  cavus  (Fig.  136) 
— a  condition  which  may  be  some- 
what relieved  by  a  steel  sole-plate 
with  counter-pressure  over  the 
dorsal  prominence.  In  the  com- 
paratively few  cases  in  which  the 
deformity  is  the  result  of  disease  or 
injury  w^ith  subsequent  contraction,  cicatricial  or  otherwise,  the  deviation 
varies  with  the  cause,  and  may  require  for  its  relief  the  use  of  some  mechanical 


Fig 


I'es  Cavus  (Albert). 


oirnioriihic  surgery: 


357 


appliance  or  operative  ti-eatiiicnt — tenotoiuy,  section  of  tlie  plantar  fascia,  free 
incision,  resection,  or  amputation. 

Pes  Planus,  or  Flat-Foot  is  due  to  an  obliteration  of  the  nornial  arch 
of  the  foot,  and  is  therefore  the  opposite  of  pes  cavus.  The  diagnosis  of 
these  two  conditions  is  fj;enerally  easily  made,  not  only  by  observing  the 
arch  of  the  foot,  but  also  by  wett"ing  the  foot-sole  with  a  colored  solution  and 
makino-  the  patient  step  once  squarely  on  a  piece  of  white  paper.  In  the  normal 
J"  foot-sole  (Fig.  137)  the  broad  impression  of 

^'•'-  ^•^'-  ^^'"-  '"*  •  the  ball  of  the  heel  and  that  of  the  balls  of 

^9  J&  A  *^^®  ^'^^"'^  ^^  connected  by  a  moderately  wide 

w       m  M^  ^/^  isthmus  along  the  outer  border  of  the  foot. 

In  pes  cavus  this  isthmus  disappears,  and  in 
pes  planus  (Fig.  138)  it  is  greatly  broader 
than  it  ought  to  be.  The  condition  is  often 
associated  with  talipes  valgus  and  lateral 
curvature  of  the  spine. 

The  cause  is  usually  general  weakness, 
combined,  as  a  rule,  with  long-continued 
standing,  as  in  mill-girls.  Walking,  unless 
very  excessive,  rarely  produces  it,  as  this 
tends  to  strengthen  the  foot.  The  chief 
symptom  is  pain,  which  is  produced  and 
is  aggravated  by  standing,  and  often  makes 
this  posture  impossible  for  any  length  of  time. 
The  best  treatment  is  a  general  constitu- 
tional tonic  treatment,  looking  to  greater 
vigor  of  frame,  less  by  drugs  than  by  hy- 
gienic means.  Locally,  a  steel  artificial  arch  under  the  sole,  with  an  internal 
lateral  offshoot,  will  generally  give  much  relief,  and  may  even  cure. 

Hysterical  Club-Foot  is  at  times  observed,  and  the  possibility  ot  its 
existence  should  be  kept  in  mind  when  the  age,  sex,  and  neurotic  temperament 
of  the  patient  are  such  as  to  favor  its  occurrence. 

A  moderate  degree  of  equinus,  the  pointed  toe,  is  frequently  met  witli 
just  after  recovery  from  a  fracture  of  the  lower  extremity, 
and  care  should  be  exercised  to  prevent  its  development  by 
keeping  the  foot  at  a  right  angle  with  the  leg  during  the 
period  of  treatment,  although  the  deviation  ordinarily  soon 
disappears   after  the  patient   begins   to  walk  about. 

Hallux  Varus,  or  Valgus. — Displacement  of  the  great 
toe  may  be  either  aAvay  from  or  toward  the  other  toes  {S. 
varus  or  ff.  valgus  (Fig.  139),  respectively),  most  frequently 
the  latter.  It  is  present  to  a  slight  degree  in  the  majority 
of  adults,  and  has  been  observed  at  times  even  m  young 
children ;  but  troublesome  hallux  valgus  is  met  with,  as  a 
rule,  only  in  persons  beyond  middle  age,  and  in  advanced 
life  is  often  associated  with  chronic  rheumatoid  arthritis. 
Because  of  the  wearing  of  a  too  narrow^,  too  short,  too 
pointed,  or  badly-fitting  shoe,  or  not  seldom  of  a  similarly 
faulty  stocking,  the  great  toe  is  crowded  over  upon  the  others 
and  inclined  at  a  more  or  less  obtuse  angle  with  the  inner  bor- 
der of  the  foot.  As  a  result,  the  normal  relations  of  the  bones 
of  the  metatarso-phalangeal  joint  are  disturbed,  and  the  pres- 
sure of  the  shoe  causes  bunion  and  periosteal  irritation,  and  may  even  give  rise 


I'liiit  of  a  Normal  Print  of  a  Flat 

Foot-sole.  Foot-sole. 

(Albert.) 


Fio.  139. 


Hallux  Valgus  and 
Bunion  (Bradford 
and  Lovett). 


358 


AX   J. 1/ /•;///( VI .V    TKXT-IiOOK    OF  SCRGERY. 


to  destructive  inflammation  nf  tlic  suit  parts  and  bono.      I'ain  ami  disturbed 
locomotion  arc  cnimnon   in   the  more  severe  cases. 

The  treatment  is  either  mechanical  or  operative.  In  the  first  case  an  ap- 
paratus is  applied  to  draw  the  toe  to  its  ])roper  plaee  and  hold  it  there,  and  at  the 
same  time  protect  the  bunion  from  pressure;  in  the  second  the  articular  extremi- 
ties of  one  or  both  bones  are  removed  with  the  saw  or  the  cutting  forceps — i.  e. 
complete  exsection  of  the  joint.  Another  plan  of  treatment  which  often  gives 
good  results  is  division  of  the  metatarsal  bone,  often  the  only  satisfactory 
method  of  treatment.  A  properly-shaped  and  well-fitting  slioe  should  always 
be  worn  afterward.  The  use  of  such  a  shoe  from  childhood  on  will  prevent 
the  production  of  the  deformity. 

Hammer-Toe. — There  is  observed  at  times  a  permanent  angular  flexion  of 
one  or  more  of  the  toes,  especially  the  little  and  second,  at  the  first  phalangeal 

articulation,  the  third  ])ha- 
FiG.  140.  lanx    being    either   in    line 

with  the  second  or  in  exten- 
sion or  flexion  on  it.  The 
first  phalanx  is  usually  ex- 
tended. Thickening  over  the 
phalangeal  joint  is  generally 
present,  bunion  may  be  de- 
veloped, and  partial  luxa- 
tion often  occurs  (Fig. 
140).  This  is  known  as 
hammer-toe,  and  is  the  re- 
sult of  contraction  of  the 
plantar  fibres  of  the  lateral 
ligaments  of  the  joint 
Beginning 


5  6 


Hammer-Toe  :  A,  a  diagram  of  the  position  of  lines  in  hammer-toe: 


ammer-ioe  :  a,  a  aiagram  oi  me  pusuiou  ui  iiiies  lu  utiuiiiici-njc:     ,^-,  -,  s 

1,  metatarsal  line  ;  2,  head  of  the  first  y)halanx;  slight  groove  cor-   (^onattUCKj 

responding  to  position  of  dorsal  border  of  second  phalanx  ;  3,  4,  „e,,„l1„  ;„  Ufpr  pbildbnnd 
5,  callosities  due  to  boot  pressure;  0,  bursa  over  contracted  joint;  "suaiiv  lu  laiei  uiuiuiiuuu, 
7.8,  shoe  (the  arrow  indicates  the  direction  in  which  the  pres-  ond  oftenpst  in  bovs  the 
sure  of  the  upper  leather  tends  to  force  downward  the  head  of  the  '*"^  uiieue&i  m  uu_).,  luc 
metatarsal  line  toward  the  sole);  B,  dissection  of  first  interpha-  deiormity  IS  the  CaUSC  01 
langealjoint  in  hammer-toe  ;  C,  the  same  preparation  after  section  ,     .    *'  .  -i      . 

of  plantar  fibres  of  lateral  ligaments  (Anderson).  mucn  inconvenience,  and  at 

times    of    actual   suff'ering. 

Relief  is  afforded  only  by  operation.     The  lateral  ligaments  have  been  divided, 

and  subcutaneous  and  open  division  of  the  soft  parts  on  the  under  surface  of  the 

first  phalanx  done,  but,  as  a  rule,  without  satisfactory  result.     Either  the  toe 

should  be  removed  or,  what  is  better,  the  joint  excised.     A  similar  disorder 

exists  in  the  hand,  known  as  hammer-finger. 


CONGENITAL   DEFORMITIES  BY   EXCESS  AND  DEFICIENCY. 

In  both  the  upper  and  the  lower  extremities  there  are  occasionally  observed 
errors  of  development  producing  abnormal  enlargement  of  a  part  or  the  whole 
of  a  limb,  or,  more  frequently,  deficiency,  due  either  to  arrested  growth  or 
absence  of  an  anatomical  segment,  or  both  combined,  the  result  being  a  mal- 
formation aff*ecting  the  functional  value  of  the  extremity  in  any  degree  from 
the  slightest  to  the  most  extreme.  The  hypertrophies  other  than  of  a  finger 
or  toe  are  not  amenable  to  treatment.  The  use,  if  necessary,  of  a  raised  shoe 
may  overcome  the  asymmetry  in  length  of  the  lower  extremities.  The  finger 
or  toe  of  excessive  size,  in  which  generally  not  only  the  bones  but  also  the  soft 
parts,  especially  the  blood-vessels  and  lymphatics,  are  aff'ected.  should  be  removed 
at  as  early  a  time  as  practicable.     Deformities  from  non-development,  interest- 


SURGERY   OF    THE   NERVES.  359 

ing  as  they  may  be  anatomically  and  teratologically,  arc  surgically  of  interest 
onlv  when  ('nuii<!;h  of  the  limb  has  been  developed  t(»  j)erniit  of  the  application 
of  some  form  of  prothetic  aj)paratiis,  or  when  one  of  the  two  bones  of  the  fore-' 
arm  or  leg  is  either  entirely  wanting  or  so  defective  as  to  permit  of  deviation  of 
the  hand  or  foot  from  muscular  action,  in  which  case  a  supporting  and  restrain- 
ing apparatus  is  of  much  value. 


CHAPTER  VL 

SURGERY  OF  THE  NERVES. 
•  SECTION   I— GENERAL   CONSIDERATIONS. 

The  larger  nerves,  like  the  blood-vessels,  as  a  rule,  lie  in  the  protected 
parts  of  the  body,  so  that  happily  they  often  escape  injury.  Thus  in  the  neck 
the  nerves  lie  deeply,  protected  in  front  by  the  collar-bone  and  laterally  by 
the  muscles  of  the  neck.  In  the  arm  they  lie  in  the  armpit,  on  the  inner  side 
of  the  upper  arm,  and  on  the  flexor  aspect  of  the  forearm.  In  the  trunk  and 
the  pelvis  they  lie  on  the  posterior  wall  of  these  cavities,  and  in  the  leg, 
chiefly  on  the  posterior  aspect  of  the  limb,  while  those  on  the  anterior  aspect 
are,  as  a  rule,  very  deeply  situated. 

If  we  examine  a  nerve  of  any  size,  we  find  that  it  has  on  its  exterior  a 
sheath,  called  the  perineurium,  between  which  and  the  nerve  proper  is  a  narrow 
lymph-space.  The  perineurium  sends  offshoots  into  the  interior  of  the  nerve, 
making  partitions  which  enclose  similar  bundles  of  primitive  nerve-tubules,  the 
partitions  themselves  constituting  the  endoneurium.  Nerves  are  also  supplied 
with  blood-vessels  and  with  7iervi  nervorum. 

It  will  be  seen,  therefore,  that,  however  small,  each  nerve  has  within  it  all 
the  elements  necessary  for  inflammatory  changes,  and  in  the  connective  tissue 
of  the  perineurium  and  endoneurium  all  the  possibilities  for  such  new  growths 
as  may  be  derived  from  this  tissue.  Waller  has  called  attention  to  the  degen- 
erative changes  which  follow  section  of  a  nerve,  and  which  constitute  the 
"Wallerian  degeneration."  It  follows  the  course  of  the  nerve-current.  Hence, 
if  a  sensory  nerve  be  cut,  the  Wallerian  degeneration  will  start  at  the  point  of 
of  section  and  travel  toward  the  spine ;  while  if  a  motor  nerve  be  cut,  the 
degeneration  will  extend  from  the  point  of  section  toward  the  periphery.  This 
process  begins  within  a  day  or  two  after  the  section  and  becomes  complete  in 
two  or  three  weeks.  It  consists  in  the  destruction  of  the  myeline,  and  even- 
tually of  the  axis-cylinder,  with  multiplication  of  the  nuclei  of  the  sheath.  In 
addition  to  this  there  is  more  or  less  atrophy  with  other  degenerative  changes, 
which  extend  not  only  toward  the  spinal  cord,  but  even  into  it ;  in  some  cases, 
for  instance  after  amputation,  such  changes  have  been  traced  all  the  w'ay  to  the 
brain.  The  muscles  supplied  by  such  a  divided  motor  nerve  soon  show  the 
"reaction  of  degeneration."  By  this  term  is  meant  a  peculiar  change  in  the 
response  of  the  muscles  to  the  galvanic  current.  In  the  normal  condition  it 
will  be  found  that  the  kathodic  closure  contraction  (KCC) — that  is.  the  contrac- 
tion which  follows  closure  of  the  electrical  circuit  by  the  application  of  the  nega- 
tive electrode  (kathode) — is  greater  than  the  anodic  closure  contraction  (ACC) — 
that  is,  the  contraction  following  the  similar  application  of  the  positive  electrode 


360  AK   AMKnrcAX    Ti:XT-]iOOK    OF  sri:(ii:L'Y. 

(anode) — a  condition  which  is  expressed  by  the  forniuhi  K€C>  ACC.  If  the 
muscle  have  its  motor  nerve  destroyed,  the  ACC  (juitklv  increases  until  KCC=* 
ACC,  and  finally  KCC<ACC. 

After  division  of  a  nerve,  even  in  cases  in  which  the  two  ends  have  not  been 
brought  into  apjxjsition,  reunion  with  true  regeneration  of  the  nerve-structure 
will  often  take  place,  the  axis-cylinder  iiaving  been  redevelojK-d  and  the  myeline 
also,  in  varying  amounts.  If,  however,  the  nerve-ends  are  united,  this  process 
is  not  only  hastened,  but  is  also  much  more  apt  to  be  permanent  than  where  no 
such  union  has  been  eft'ected. 

SECTIOX   II.— NEUKITIS,   OR   INFLAMMATION    OF   A    NERVE 

Causes. — A  neuritis  may  be  idiopathic ;  that  is.  arising  from  no  percepti- 
ble cause.  By  fiir  the  commonest  cause  is  exposure  to  wet  or  cold.  Gout, 
rheumatism,  syphilis,  typhoid  fever,  diphtheria,  and  the  exanthemata  may  also 
give  to  rise  such  an  inflammation.  Of  course  it  follows  wounds  and  injuries 
of  nerves.  Occasionally.  l»ut  rarely,  it  assumes  the  dangerous  fonn  known  as 
multiple  neuritis,  or,  better,  diffused  neuritis,  which  may  even  cause  death. 

Neuritis  may  be  either  acute  or  chronic.  In  acute  neuritis  there  will  be  a 
marked  increase  of  the  connective-tissue  elements  of  the  nerve,  with  oedema 
of  the  sheath  from  the  exudation.  The  nerve-tubules  become  softened  as  a 
result  of  granular  and  fatty  changes,  as  well  as  from  the  inflammatory  exudate, 
and  in  some  cases  even  pus  may  be  present.  Occasionally  there  will  be  hem- 
orrbase  into  the  nerve  substance. 

In  chronic  neuritis  there  is  apt  to  be  sclerosis  from  the  development  of 
the  connective  tissue  of  the  endoneurium  with  pressure  on  the  tubules,  which, 
as  a  nde.  results  in  their  atrophy.  In  such  a  nerve  the  fibrous  tissue  may  be 
so  developed  as  to  make  the  nerve  almost  as  tough  as  a  tendon.  In  spite, 
however,  of  such  complete  changes,  there  may  almost  always  be  seen  single 
nerve-tubules,  which  are  perfectly  normal,  associated  with  others  in  every  stage 
of  degeneration.  It  is  very  important  to  observe  that  a  neuritis  may  extend  in 
both  directions  along  the  trunk  of  the  nerve.  Such  a  progressive  neuritis  is 
called  either  an  ''ascending  "  or  a  "descending  neuritis."'  as  the  case  may  be. 
Its  commonest  pathway,  however,  is  upward  toward  the  spine,  and  hence  if,  for 
example,  the  ulnar  nerve  be  the  seat  of  the  neuritis,  the  inflammation  may  creep 
upward  till  it  reaches  the  brachial  plexus  and  there  involves  another  branch  of 
the  plexus  by  continuity  of  stnicture.  On  the  other  hand,  it  is  a  remarkable 
fact  that  a  nerve  may  lie  in  the  midst  of  inflamed  tissues,  and  even  be  surrounded 
bv  pus  for  a  long  time,  without  any  inflammatory  change  extending  to  the  nerve 
itself. 

Symptoms. — The  fii"st  symptom  of  neuritis,  as  a  rule,  is  an  aching  pain, 
which  follows  the  course  of  the  affected  nerve,  and  often  prevents  sleep.  This 
pain  is  apt  to  be  remittent,  is  markedly  worse  at  night,  and  is  increased  by 
motion  of  the  limb  or  by  pressure  or  friction  over  the  nerve.  Not  uncommonly 
it  will  extend,  it  is  thought  by  a  reflex  action,  to  neighboring  nerves  or  to 
corresponding  nerves  upon  the  other  side  of  the  body ;  for  instance,  we  are 
all  familiar  with  the  fact  that  a  carious  tooth  sometimes  causes  pain  in  the 
corresponding  tooth  on  the  opposite  side.  With  the  pain  there  are  apt  to  be 
headache  and  fever,  and  occasionally  even  rigors.  The  nerve  if  superficial 
can  be  traced  as  a  thick  cord  which  will  present  a  continuous  or  an  interrupted 
swelling,  and  its  course  is  .sometimes  marked  by  a  red  line,  as  in  phlebitis  or 
angioleucitis.  The  local  temperature  will  sometimes  rise.  There  may  be  sen- 
sations of  numbness  or  tingling  in  the  area  supplied  by  the  sensory  filaments. 


SURGERY    OF    THE   NERVES.  361 

This  will  very  likely  give  rise  to  a  mai-ked  hyperesthesia,  but  if  the  neuritis 
persists  and  is  followed  by  atro])hy  of  the  nerve,  hyperesthesia  will  give  place  to 
anesthesia.  The  motor  filaments  also  will  be  affected,  producing  twitching  and 
tremors  of  the  muscles,  very  soon  followed  by  j)aresis,  and  finally  by  complete 
paralysis,  and,  as  a  consequence  of  this,  by  muscular  wasting.  A  good  exam- 
ple of  these  symptoms  is  often  seen  following  inflammation  of  the  seventh  nerve 
as  it  ]):isscs  through  the  canal  of  Fallopius. 

Diagnosis. — From  rheumatism  a  neuritis  can  be  recognized  most  readily 
by  the  fact  that  the  pain  occurs  in  the  track  of  a  nerve,  and  later  it  can  also 
be  differentiated  by  the  sensory,  motor,  or  trophic  changes  which  set  in.  In 
ordinary  neuralgia  the  pain  is  of  a  very  different  order,  being  sharp  and  shoot- 
ing and  more  diff"used  over  the  affected  area.  There  is  no  rise  either  of  the 
general  or  of  the  local  temperature,  nor  is  there  apt  to  be  any  muscular  spasm, 
though  occasionally  this  is  seen  in  neuralgia  of  the  fifth  nerve. 

Treatment. — The  most  important  remedial  measure  is  absolute  rest — not 
by  putting  the  arm  in  a  sling  and  the  i)atient  on  a  lounge  or  in  bed,  and  enjoin- 
ing rest,  but  by  enforcing  rest  by  the  application  of  a  splint.  This  should  be  used 
in  all  cases  unless  absolutely  impossible.  With  this,  of  course,  there  should 
be  elevation  of  the  part,  with  the  application  of  heat  or  cold,  whichever  is  the 
more  grateful  to  the  patient.  Sometimes  blistering,  or  even  the  actual  cautery, 
over  the  course  of  the  nerve,  w^ill  be  found  of  value.  The  constant  galvanic  cur- 
rent is  an  excellent  remedy.  Deep  injections  of  morphine,  atropine,  cocaine,  or 
chloroform,  especially  in  cases  of  sciatic  neuritis,  have  proved  of  great  value, 
wdiile  morphine  by  the  mouth  may  be  exhibited  in  sufficient  quantities  to  give 
reasonable  sleep.  But  it  is  precisely  in  these  cases  of  chronic  neuritis  that  the 
greatest  care  must  be  exercised  lest  we  form  and  encourage  the  morphine  habit. 
If  anesthesia  sets  in  instead  of  hyperesthesia,  the  application  of  the  faradaic 
current  by  the  electric  brush  on  a  carefully  dried  and  dusted  skin  is  the  best 
treatment.  Of  course  the  general  health  must  be  looked  after,  with  attention  to 
diet,  the  state  of  the  bowels,  sleep,  habits,  and  exercise  when  this  latter  is 
permissible.  If  the  patient  is  of  a  rheumatic,  gouty,  or  syphilitic  constitution, 
appropriate  treatment  must  be  used  for  whichever  of  these  conditions  may  be 
found.  Meantime  the  muscles  must  be  kept  in  good  trophic  condition  until  the 
neuritis  subsides  and  the  nerve  resumes  its  normal  function  of  conveying  the 
stimulus  to  the  muscles.  This  is  best  eff"ected  by  hot  and  cold  douches,  massage, 
and  electricity,  continued  in  many  cases  for  weeks  or  even  months,  until  the 
nerves  resume  their  abandoned  work.  Sometimes,  especially  in  sciatic  neuritis, 
stretching  the  nerve  gives  good  results  when  all  other  means  have  failed. 

SECTION   III.— NEUEALGIA. 

Neuralgia  may  be  described  as  an  acute  paroxysm  of  pain  in  the  area  of 
distribution  of  a  nerve,  not  uncommonly  radiating  from  this  as  a  center  to 
neighboring  parts.  The  ordinary  forms  of  neuralgia  are  medical  rather  than 
surgical,  but  they  often  require  treatment  by  surgical  means. 

Cause. — The  disorder  is  apt  in  most  cases  to  follow  debility,  and  especially 
anemia  caused  by  conditions  that  aff"ect  the  constitution,  such  as  fever,  neuras- 
thenia, long-continued  lactation,  etc.  Hence  neuralgia  has  w^ell  been  called 
"the  prayer  of  the  nerves  for  blood."  Malaria,  gout,  rheumatism,  and  occa- 
sionally syphilis,  wnll  often  be  found  at  the  bottom  of  it.  Persons  of  neurotic 
temperament,  and  especially  those  coming  from  a  neurotic  family,  often  fall 
victims  to  it.  Not  uncommonly  in  such  patients  the  joints  suffer;  and  in 
young  women,  especially  if  the  menstrual  function  is  disordered  or  if  there  is 


;3(j2  AX  AMF.i^'fcAX  Tr.xr-nooK  of  smaERY. 

any  uterine  trouble,  there  may  be  a  serious  neuralgia  of  the  breast,  which  i& 
chiefly  annoying  by  reason  of  the  pain  and  the  freciuent  suggestion  of  malignant 
disease.  Local  conditions  also  may  occasion  it.  A  cari(nis  tooth  is  often  the 
cause  of  a  severe  neuralgia,  Avliich,  it  must  be  remembered,  will  manifest  itself 
not  uncommonly  in  the  corresponding  tooth  either  (jf  the  opposite  side  or  of 
the  other  jaw.  An  aneurysm  of  the  aorta  or  any  other  tumor  which  may  press 
upon  an  intercostal  or  other  nerve  will  cause  it,  and  disease  of  the  kidney  is 
often  attended  with  neuralgia  of  the  testicle.  The  variety  of  the  causes  which 
give  rise  to  neuralgia  will  suggest  to  us  that  a  most  careful  examination  should 
be  made  of  the  personal  and  family  history  in  order  to  determine  the  appro- 
priate treatment. 

The  neuralgias  Avhich  are  most  frequently  brought  to  the  attention  of  the 
surgeon  are  that  form  of  neuralgia  of  the  fifth  nerve  known  as  trifacial  neu- 
ralgia or  tic  douloureux,  sciatica,  and  the  neuralgia  of  stumps  and  scars. 

Tic  douloureux  is  so  called  to  distinguish  it  from  ''tic  convulsif,"  or 
spasm  of  the  facial  muscles,  which  is  sometimes  painless  and  sometimes  a 
symptom  of  tic  douloureux. 

Cause, — As  the  disease  manifests  itself  most  commonly  in  the  face  and 
teeth,  if  no  cause  is  found  in  the  face  it  is  apt  to  be  attributed  to  the  teeth. 
It  is  not  uncommon  for  patients  to  be  brought  to  the  surgeon  who  have  already 
lost  most  or  even  all  of  their  teeth  in  the  vain  hope  of  arresting  the 
relentless  pain.  As  a  rule,  as  soon  as  one  tooth  in  which  the  neuralgia  has 
seemed  to  be  worst  has  been  removed  another  immediately  assumes  the 
prime  importance,  and  so  tooth  after  tooth  is  needlessly  sacrificed.  The  cause 
must  be  sought  in  the  condition  of  the  nerve  or  its  blood-vessels.  Microscopical 
examination  will  often  show  a  neuritis  accompanied  even  with  hemorrhage  into 
the  substance  of  the  nerve,  but  more  commonly  it  Avill  reveal  a  marked  senile 
sclerosis  (Putnam,  de  Schweinitz,  and  Horsley).  This  is  in  accordance  with 
the  fact  that  the  disease  rarely  attacks  persons  before  middle  life,  when  the 
changes  incident  to  age  have  begun.  Dana  has  recently  published  some 
investigations  which  seem  to  indicate  that  the  cause  is  not  to  be  sought  so  much 
in  the  connective  tissue  of  the  nerve-trunk  as  in  its  vessels  which  have  been 
subject  to  obliterating  arteritis,  itself  the  result  of  advancing  years.  Carless 
has  called  attention  to  the  fact  that  the  foramen  ovale  differs  greatly  in 
size  from  nearly  a  circle  seven  or  eight  millimeters  in  diameter  to  a  mere 
slit  not  more  than  two  millimeters  broad.  This  narrowness  of  the  foramen  and 
a  similar  contraction  of  the  lumen  of  the  infraorbital  and  inferior  dental  canals 
may  easily  exert  increasing  pressure  as  the  patient  grows  older,  and  so  cause 
a  progressive  neuralgia.  In  view  of  the  influence  of  age  as  a  cause  of  tic 
douloureux,  it  is  not  surprising  that  very  frequently  after  an  operation  on  the 
nerve  has  given  relief  for  a  time,  the  disease,  whether  due  to  sclerosis  or  to 
obliterating  arteritis,  will  recur  in  the  nerve  stump  and  require  another  and 
more  radical  operation.  Similar  alterations  have  been  traced  in  some  cases 
even  to  the  Gasserian  ganglion.  Cold  and  dampness  are  also  factors  in  the 
production  of  the  disease. 

Symptoms. — Scarcely  any  disease,  except  possibly  tetanus,  is  more 
calculated  to  arouse  the  sympathies  of  the  attending  surgeon  than  severe  tic 
douloureux.  The  pain  is  usually  described  as  burning,  boring,  cutting,  or 
darting.  It  is  evoked  by  the  slightest  cause :  a  breath  of  air.  mastication  of 
the  simplest  food,  attempts  to  speak  or  to  laugh,  even  the  lightest  touch  or  a 
slight  noise,  will  produce  the  most  fearful  paroxysm  of  pain,  in  which  the 
patient  Avill  suddenly  protect  rather  than  grasp  his  face  with  his  hands,  and 
will  writhe  about,  moaning  or  crying  aloud  with  the  fierce  pain.     Each  meal 


SURGERY   OF    THE   NERVES.  363 

costs  him  frightful  suffering.  Only  liquid  food  can  be  taken,  for  the  slightest 
attempt  to  masticate  brings  on  a  paroxysm  of  pain ;  even  the  swallowing 
of  li<[ui(l  is  endured  only  because  of  the  imperious  demand  of  the  body  for 
food  and  drink.  While  his  days  are  days  of  misery,  his  nights  are  nights  of 
sleepless  agony.  Sometimes  he  Avill  be  free  from  the  pain,  it  may  be  for  days 
or  even  weeks,  but  it  is  sure  to  return,  at  longer  or  shorter  intervals,  until  life 
becomes  a  burden. 

The  diagnosis  is  easy,  for  there  is  nothing  with  which  such  a  terribly 
painful  disease  can  be  confounded. 

Sciatica,  or  neuralgia  of  the  sciatic  nerve,  often  from  a  true  neuritis,  is 
not  unusual.     Its  symptoms  are  obvious,  and  the  diagnosis,  as  a  rule,  is  easy. 

Neuralgia  of  StUiMPS  and  Scars. — Sometimes  after  an  amputation  or  an 
operation  the  stump  or  the  scar  will  become  the  seat  of  severe  neuralgic  pains. 
AVhile  not  so  severe  as  those  of  tic  douloureux,  they  are  sufficient  to  render  life 
miserable.  The  wearing  of  an  artificial  limb  is  sometimes  made  impossible,  as 
even  light  touching  of  the  stump  will  produce  severe  pain.  Gradually  increas- 
ing pressure  is  often  better  borne  than  light  pressure.  In  stumps  it  is  the 
general  rule  that  the  cut  ends  of  the  nerves  become  bulbous — that  is,  develop 
neuromata  (Fig.  141) — and  it  is  believed  that  these  are  probably  the  cause 
of  the  pain.  In  scars  the  entanglement  of  small  terminal  filaments  of  the 
nerves  is  thought  to  be  the  cause.  Occasionally  in  either  case  a  true  neuritis 
is  set  up. 

Treatment  of  Neuralgia. — The  first  thing  to  determine  is  the  cause,  if 
this  be  possible.  If  the  patient  be  the  subject  of  malaria,  quinine  in  full  doses, 
up  to  20  or  even  30  grains  a  day,  and  in  anemia  iron,  quinine,  and  cod-liver  oil 
generously  given  will  often  be  of  use.  If  these  fail,  arsenic  may  be  pushed  to 
its  physiological  effect,  while  strychnine  and  gelsemium  will  be  found  of  value. 
If  the  patient  be  subject  to  gout  or  rheumatism,  colchicum,  the  alkalies,  the  sali- 
cylates, or  the  iodide  of  potassium  will  be  indicated,  and  in  syphilis  the  iodide 
of  potassium,  and  sometimes  mercury,  will  give  relief.  Locally  much  can  be 
done  to  benefit  the  patient.  If  the  nerve  itself  be  tender,  sometimes  leeching 
will  bring  relief.  Heat  or  cold,  whichever  is  more  grateful  to  the  patient, 
even  the  application  of  freezing  mixtures  over  the  nerve,  especially  at  the 
tender  spots,  may  be  useful.  The  application  of  the  ointment  of  belladonna 
or  veratrine,  the  menthol  pencil,  the  application  of  croton  chloral,  and  occa- 
sionally the  Paquelin  cautery,  will  be  of  use.  The  long-continued  daily  use 
of  the  constant  galvanic  current  has  often  done  good.  Of  course  ihe  whole 
system  should  be  built  up  by  the  best  and  most  easily  digested  food,  with 
regulation  of  the  bowels  and  the  secretions  and  attention  to  the  habits  of  the 
patient.  In  women  the  menstrual  function  and  the  condition  of  the  uterus 
and  ovaries  should  be  ascertained  and  any  necessary  treatment  be  adopted. 
Occasionally,  however,  the  patient  may  be  more  benefited  by  a  change  of  climate, 
surroundings,  occupation,  etc.  than  by  treatment  with  drugs.  There  is  a  great 
temptation  in  rebellious  cases  to  resort  to  the  use  of  alcohol  or  morphine, 
either  by  the  mouth  or  hypodermatically,  but  these  remedies  are  dangerous, 
and  the  "latter  too  often  makes  the  patient  the  victim  of  the  morphine  habit, 
the  consequences  of  which  are  worse  than  the  disease  for  which  relief  is 
sought. 

In  neuralgia  of  the  joints,  absolute  rest  by  means  of  a  splint,  or  more 
commonly  exercise,  massage,  the  hot  and  cold  douche,  and  electricity  in  some 
of  its  forms,  are  the  best  remedies.  In  neuralgia  of  the  breast  it  is  very  im- 
portant to  calm  the  patient's  fears  as  to  malignant  disease.  Nervous  tonics 
and  sedatives,  such  as  valerian,  the  bromides,  asafetida,  strychnine,  iron,  arse- 


.■5()4  AiX   AM  ERIC  AX    TEXT- HOOK    OF   SIIHIERY. 

nic,  and  quinine,  will  ])e  found  usefid,  as  will  also  gentle  massage  with  any  of 
the  sinipli'V  oiiitmciits. 

I.  Surgical  Treatment  of  Tic  Douloureux. — Most  of  the  drugs  above 
mentioned  will  jjrobably  have  already  been  tried.  If  not,  they  should  be  used 
fearlessly,  eonibined,  as  a  rule,  with  heat  or  cold  and  the  constant  current  or 
other  form  of  electricity.  The  extraction  of  the  teeth,  as  a  rule,  is  to  be  con- 
demned. Ordinarily  all  that  is  left  f)r  the  surgeon  to  do  is  to  proceed  at  once 
to  operation. 

The  operation  for  the  removal  of  the  nerves  will  be  described  later. 
Though  sometimes  permanent,  the  relief  obtained  by  such  an  excision,  as  a  rule, 
will  be  only  temporary ;  yet  it  is  such  a  boon  to  the  exhausted  sufferer  that  it 
should  always  be  given  when  other  means  have  failed.  One,  two,  or  three  years 
after  the  operation  the  patient  will  return  with  his  neuralgia  almost  or  quite  as 
bad  as  before.  But  the  case  is  by  no  means  hopeless.  Sometimes  internal 
remedies  or  local  applications,  especially  of  the  constant  current,  will  again 
give  relief,  and  if  not,  a  second  operation  can  be  done  for  the  removal  of  the 
stump  of  the  nerve.  In  some  cases  where  there  is  no  stump  of  the  nerve  left, 
simply  the  seizing  of  the  fibrous  tissues  at  the  point  of  the  former  excision  and 
their  avulsion  will  bring  a  prolonged  freedom  from  pain.  This  may  be  repeated 
more  than  once.  If  the  entire  trunk  of  the  superior  maxillary  has  been  removed 
far  back  in  the  orbit,  the  second  operation  will  consist  in  the  removal  of  Meckel's 
ganglion.  Recently  Rose,  Hartley,  and  others  have  gone  even  farther  back 
and  removed  the  Gasserian  ganglion  itself.     (See  Operations  on  Nerves.) 

II.  Surgical  Treatment  of  Sciatica,  Neuralgia  of  the  Brachial 
Plexus,  etc. — In  cases  of  inveterate  neuralgia — for  instance,  of  the  brachial 
plexus  or  its  branches  or  of  the  sciatic  or  other  nerves — the  remedies  and 
drugs  above  described  are  first  to  be  employed.  "When  these  have  failed, 
surgery  still  offers  relief.  Nerve-stretching  (neurectasy)  has  been  adopted  in 
very  many  cases  with  excellent  results.  (See  Operations  on  Nerves.)  Even 
when  this  has  failed  we  are  not  at  the  end  of  our  resources.  In  a  few  csises 
where  the  pain  has  resisted  all  other  means  of  cure  the  spine  has  been  opened, 
the  cord  has  been  exposed,  and  the  posterior  or  sensory  roots  of  the  implicated 
nerves  have  been  exsected,  by  Abbe  and  others.  (See  chapter  on  the  Spine.) 
But  the  number  of  cases  is  as  yet  too  small  and  the  time  that  has  elapsed  too 
short  for  the  expression  of  any  final  opinion  as  to  the  advisability  of  the  opera- 
tion. The  pain  in  such  cases  is  so  severe,  however,  that  any  operation  that 
holds  out  even  a  slight  prospect  of  cure  should  be  deemed  admissible  unless 
further  experience  should  show  it  to  be  unwise. 

III.  Surgical  Treatment  of  Neuralgia  and  of  Scars  and  Stumps. 
— If  a  known  nerve  is  caught  in  a  scar  an  incision  should  be  made  and  the 
nerve  liberated  from  the  cicatrix.  If  mere  incision  and  liberation  bring  no 
relief,  a  second  operation  should  be  done  for  the  excision  of  the  nerve.  If  no 
known  nerve  is  involved,  but  the  pain  probably  comes  from  a  small  unnamed 
filament  entangled  in  the  meshes  of  the  irregular  scar  following,  for  example,  a 
lacerated  wound,  a  burn,  or  a  scald,  the  entire  scar  should  be  excised.  The 
linear  scar  which  replaces  the  irregular  and  contractile  cicatricial  tissue  of  the 
original  scar  is  much  less  likely  to  give  rise  to  such  neuralgia. 

In  stumps  two  methods  of  treatment  may  be  adopted,  of  course  after  the 
medical  means  above  described  have  been  exhausted.  The  cicatrix  of  the 
stump  should  be  excised  and  the  bulbous  ends  of  the  nerves  be  sought  for, 
drawn  down,  and  severed  with  a  clean  cut  of  a  sharp  knife.  If  this  does  not 
give  relief  a  re-amputation  should  be  done.  Sometimes,  as,  for  instance,  after 
amputation  of  the  distal  phalanx  of  the  thumb,  where  the  part  is  supplied  by 


SCRGERV    OF    THE   NERVES. 


365 


known  nerves,  a  portion  of  each  of  these  nerves  should  be  exsected ;  if  this 
does  not  relieve,  as  is  too  often  the  ease,  a  re-ainputation  may  be  required.  Not 
uneonnnonly,  however,  such  secondary  stumps  themselves  will  be  i)ainful,  and 
the  resources  of  the  surgeon  will  be  taxed  to  the  utmost  to  effect  a  cure.  It  is 
very  likely  that  in  these  cases  an  ascending  neuritis  has  been  developed,  and  if 
this  can  be  diagnosticated  a  portion  of  the  painful  nerve  may  be  exsected  in  its 
continuity  as  high  up  as  the  tenderness  is  traced,  unless  such  high  excision  of 
the  nerve  would  produce  results  so  serious  as  to  contraindicate  operation. 


Fig.  141. 


SECTION   IV.    TUMOKS  OF  NERVES. 

A  distinction  must  be  drawn  between  tumors  which  are  in  a  nerve  and 
tumors  which  are  ow  or  attached  to  a  nerve,  for  some  tumors  are  developed  in  the 
nerve-fibrils  which  make  up  the  nerve,  while  others  are  mere  extrinsic  growths. 
The  first  class  cannot,  as  a  rule,  be  removed  without  entire  excision  of  the  nerve 
itself.  Those  developed  on  the  outside  of  the  nerve  may  be  removed  without 
injury  to  the  nerve.  If,  however,  severe  neuralgic  symptoms  have  continued 
after  removal  of  the  growth,  it  will  be  best,  as  a  rule,  to  exsect  the  portion  of  the 
nerve  to  which  it  is  attached,  stretch  the  two  ends  of  the  nerve,  and  reunite  them. 

Tumors  developed  in  the  nerves  them- 
selves are  called  neuromata  (Fig.  141), 
True  neuromata,  other  than  the  bulbous  ends  of 
cut  nerves,  made  up  of  nerve-fibers  themselves, 
are  very  rare.  They  are  usually  made  up  of 
amyelinic  fibers — i.  e.  fibers  which  have  no  mye- 
line  within  the  sheath.  After  the  division  of  a  ^ 
nerve,  either  by  exsection  of  a  portion  of  it 
or  in  an  amputation,  the  proximal  ends  almost 
always  become  bulbous :  so  frequently  does  this 
occur  that  it  may  be  regarded  as  a  rule,  e 
These  tumors  have  been  called  false  neuromata 
— i.  e.  tumors  not  made  up  of  nerve-tubules,  but 
of  fibrous  tissue ;  but  Bowlby  has  shown  that  at  ' 
least  in  some  cases  a  number  of  true  nerve- 
fibers  are  found  in  them.  The  neuromata  oc- 
curring in  the  trunks  of  nerves  are  generally 
composed  of  fibrous  tissue.  Occasionally  they 
are  sarcomata  or  cysts.  While  they  are  usually 
single  or  exist  in  very  small  numbers,  instances 
have  been  recorded  in  which  even  hundreds 
existed. 

Symptoms. — When  occurring  in  the  course  of  a  nerve  such  a  tumor  fre- 
quently gives  rise  to  no  symptoms  Avhatever,  and  may  even  be  unsuspected 
until  revealed  by  a  post-mortem.  More  commonly,  however,  it  excites  such 
neuralgic  pains  as  to  lead  to  an  examination  of  the  part,  and  if  the  nerve  lie 
superficially  the  tumor  may  be  detected.  If  not,  it  causes  spasms  from  irrita- 
tion or  paralysis  from  pressure,  while  trophic  lesions  of  the  muscles,  skin,  and 
other  parts  supplied  by  the  nerves  are  often  seen.     (See  Injuries  of  Nerves.) 

Treatment. — If  such  neuromata  produce  no  pain  or  other  serious  symp- 
toms, they  should  not  be  interfered  with.  If  any  serious  symptoms  arise,  the 
tumor,  with  the  portion  of  the  nerve  in  which  it  is  developed,  should  be  removed. 
If  the  two  ends  can  be  approximated  by  stretching,  immediate  suture  should 
be  practised,  but  if  they  cannot  be  brought  together  the  gap  may  be  supplied 


J 

Neuromata  in  a  Stump  after  Amputa- 
tion of  the  foot :  a,  posterior  tibial 
artery  ;  ft,  posterior  tibial  nerve  ;  c, 
flat  "neuroma  of  internal  plantar 
nerve ;  d,  round  neuroma  of  same 
nerve  ;    e,  another  small  neuroma ; 

/,  cicatrix    of  stump  (Duplay  and 

Reclus). 


:V)()  AX    AMi:i!I('.\X    TEXT-llOOK    OF  sriiOERY. 

by  the  transplantation  of  a  suitable  portion  of  a  nerve  from  one  of  the  lower 
animals  or  from  a  nt-wiy-aniitiitated  limb.  It  is  even  possible,  when  the  ends 
cannot  be  approximated,  that  if  tlicv  can  be  sutured  together  with  catgut  threads, 
thus  bridging  the  interval  between  the  two  ends,  the  nerve  may  be  regenerated. 
Van  Lair  makes  use  of  a  cylinder  of  decalcified  bone  to  carry  the  catgut  between 
the  ends.  In  the  painful  neuromata  which  develop  in  nerves  after  their 
section  or  in  stumps  after  amputation,  after  exhaustion  of  the  medical  means 
the  part  should  be  opened,  the  nerves  dissected  out,  and  the  bulbous  extremi- 
ties resected. 

Painful  Subcutaneous  Tubercle. — A  peculiar  fonn  of  tumor  con- 
nected with  a  nerve  is  known  by  this  name.  It  is  generally  single ;  as  its 
name  indicates,  it  is  small,  often  about  the  size  of  a  pea;  it  lies  immediately 
under  the  skin  and  is  connected  with  a  sensory  filament  of  a  cutaneous  nerve. 
It  is  usually  made  up  of  fibrous  tissue.  One  symptom  which  distinguishes  it 
from  all  other  tumors  is  its  excessive  tenderness  and  pain.  This  pain  extends 
up  and  down  the  limb,  and  is  sometimes  generalized,  occasionally  accompanied 
with  spasm  of  the  muscles.  The  pain  appears  in  paroxysms  of  greater  or  lesser 
duration.  The  treatment  is  excision  of  the  tumor,  together  with  the  portion 
of  nerve-twig  in  Avhich  it  grows.  The  resulting  anesthesia  will  disappear  in 
time. 

SECTION  v.— WOUNDS  AND  IN.JUEIES  OF  NERVES. 

These  are  not  uncommon.  They  are  seen  more  frequently  in  the  upper 
extremities  than  in  the  lower,  the  nerve-trunks  being  anatomically  more  exposed 
in  the  arm  and  also  more  frequently  subjected  to  violence.  Contusion  and 
compression  are  the  most  frequent  injuries.  "Wounds  may  be  either  clean-cut 
incised  wounds  or  more  or  less  extensive  lacerated  or  contused  wounds,  such  as 
those  caused  by  missiles  of  war,  those  which  result  from  railroad  and  machinery 
accidents,  punctured  wounds,  and  the  like. 

I.  Contusions  and  Compression  of  Nerves. — Nerves  suffer  from  con- 
tusions, occasionally  from  direct  blows,  as  on  the  ulnar  nerve  at  the  bend  of 
the  elbow  or  on  the  brachial  plexus  in  the  neck.  In  addition  to  this,  disloca- 
tions, especially  of  the  head  of  the  humerus  in  the  axilla,  often  produce  serious 
contusions  and  compression,  as  Avill  also,  though  more  rarely,  the  attempt  at 
reduction  by  placing  the  unbooted  heel  in  the  axilla.  Dislocations,  and  espe- 
cially fractures  near  the  elbow,  are  liable  to  produce  contusions  and  sometimes 
laceration  of  the  ulnar  or  musculo-spiral  nerves.  In  fracture  of  the  humerus 
the  musculo-spiral  nerve  is  apt  to  be  contused,  compressed,  or  wounded,  and  the 
brachiiil  ])lexus  may  be  similarly  injured  in  fracture  of  the  clavicle.  Fracture 
of  the  pelvis  through  the  sciatic  notch  has  resulted  in  like  injury  to  the  sciatic 
nerve  at  its  point  of  emergence.  There  are  also  some  forms  of  steady  or  repeated 
compression  which  produce  trouble.  Sometimes,  though  rarely,  the  excessive 
growth  of  callus  has  been  thought  to  cause  the  pressure.  Tumors  cause  it  not 
ver}'  uncommonly,  especially  thoracic  aneurysms.  The  use  of  crutches,  espe- 
cially if  not  well  padded,  produces  a  form  of  palsy  known  ns  ''crutch  palsy." 
This  will  be  more  cmnmon.  of  course,  in  heavy  persons.  Lying  in  peculiar  posi- 
tions, especially  with  one  or  both  arms  under  tlie  head,  particularly  in  the  deep 
sleep  of  drunkards,  will  sometimes  give  rise  to  a  similar  palsy.  The  pressure 
of  the  forceps  on  the  seventh  nerve  during  delivery  sometimes  produces  facial 
palsy  in  the  child,  and  in  addition  to  this  the  pelvic  nerves  of  the  mother  may 
be  injured  from  prolonged  pressure  by  the  foetal  head  in  delayed  deliveries. 
In  all  these  cases  the  nerve  suffers  mechanically  to  a  greater  or  lesser  extent, 
and  the  fibers  are  apt  to  be  torn  or  pressed  together ;  occasionally  hemorrhage 


srn(,'i:in'  or  the  xmvES.  3G7 

uito  the  substance  of  the  nerve  occurs,  ^vhile  the  niyelinc  Is  niore  or  less 
mechanically  disturbed.  In  severe  cases  of  contusion  or  compression  there 
will  be  of  course  entire  mechanical  destruction  of  the  nerve. 

Symptoms. — These  will  vary  in  accordance  with  the  severity  of  the 
injury.  If  it  be  slight  the  symptoms  will  resemble  the  common  phenomena 
produced  when  the  ulnar  nerve  is  struck  at  the  elbow,  which  is  known  as  strik- 
ing the  "crazy  bone"  or  the  "funny  bone."  This  is  generally  attended  with 
tingling  and  a  sense  of  "pins  and  needles"  in  the  ulnar  distribution.  Loss 
of  function  is  not  apt  to  follow  immediately  unless  the  contusion  lias  been  violent. 
Occasionally,  however,  apparently  a  severe  neuritis  will  follow,  with  pain  in 
the  distribution  of  the  nerve  and  possibly  palsy  of  the  muscles  supplied,  and 
trophic  alterations  in  the  skin  and  its  appendages. 

Treatment. — This  will  depend  on  the  cause.  If  it  be  tiie  pressure  by  a 
tumor  or  by  the  dislocated  head  of  the  humerus  or  from  a  fracture,  first  of  all 
the  cause  must  be  removed  if  possible.  The  next  most  important  indication  is 
that  the  nerve  shall  have  absolute  rest, — not  rest  merely  by  non-use  of  the 
part,  but  rest  by  means  of  a  splint,  and,  if  the  contused  nerve  be  in  the  lower 
extremity,  rest  in  bed  in  addition  to  the  splint.  In  cases  of  moderate  injury  this 
perhaps  is  all  that  will  be  required,  with  possibly  the  local  abstraction  of  blood 
by  means  of  leeches  and  cups.  If  the  injury  be  more  severe,  the  injection  of 
morphine,  with  or  without  atropine,  or  its  administration  by  the  mouth,  in  order 
to  quiet  the  pain,  is  generally  indicated.  Arsenic  is  sometimes  of  value,  and 
the  repeated  application  of  galvanism  in  obstinate  cases  may  give  relief.  The 
remote  symptoms,  motor,  sensory,  and  trophic,  are  to  be  treated  as  is  described 
under  the  head  of  Wounds. 

II.  Wounds  of  Nerves. — Formerly  division  of  the  small  nerves  at  the 
bend  of  the  elbow  Avas  very  common  from  the  promiscuous  bleeding  then  in 
vogue.  At  present  by  far  the  commonest  Avounds  of  nerves  are  from  glass — 
as,  for  instance,  from  thrusting  the  hand  through  a  pane  of  glass  or  from  the 
breaking  of  a  glass  bottle — and  from  knives,  scythes,  etc.,  Avhile  the  ordinary 
accidents  of  civil  life,  such  as  punctured  Avounds  by  needles,  scissors,  and  splint- 
ers, and  the  more  extensive  lacerated  AVOunds  foUoAving  railroad  and  machinery 
accidents,  are  of  frequent  occurrence.  In  military  practice  and  occasionally  in 
civil  life  the  nerves  are  implicated  in  gunshot  Avounds.  The  damage  done  to 
motion  and  sensation  is  most  severe  after  Avounds  of  the  larger  nerve-trunks ; 
but  the  reflex  symptoms  from  such  Avounds  are  more  commonly  seen  Avhen  the 
smaller  filaments  are  implicated,  and  more  often  after  laceration  or  puncture 
than  after  a  clean  cut. 

Symptoms. — The  symptoms  of  a  nerve  Avound  are  not  distinctive  of  the 
nature  of  the  injury,  Avhether  it  be  a  contusion,  a  clean  incision,  or  a  lacerated 
or  gunshot  AA-ound.  The  immediate  symptoms  are  both  local  and  constitutional, 
and  vary  to  the  greatest  possible  degree  in  their  severity.  The  pain  may  be  so 
slight  in  some  cases  that  the  Avound  Avill  escape  notice,  or  at  most  the  patient 
Avill  imagine  he  has  been  struck  by  a  stick  or  stone.  In  other  instances  the 
pain  even  from  the  AVound  of  a  small  nerve  Avill  be  so  severe  that  he  Avill  lose 
consciousness  from  it.  This  condition  of  shock  will  sometimes  be  very  great, 
especially  in  gunshot  wounds.  It  need  not  be  described  here,  for  it  resembles 
the  shock  of  other  Avounds. 

In  one  respect,  hoAvever,  a  further  statement  is  necessary, — namely,  as  to 
the  so-called  "reflex  palsies."  In  a  number  of  instances  it  has  been  noted 
that  the  AVOund  of  a  small  nerve  (for  it  is  more  common  in  a  small  nerve  than  in 
a  large  one),  for  instance,  on  the  right  side  of  the  neck.  Avill  produce  a  palsy  of 
the  left  arm  or  left  leg  or  of  both;  or  a  Avound  of  the  thigh  may  produce  paral- 


;i(i8  AiY   AMh:ni('A.\    TEXT- HOOK    OF   SURGERY. 

ysis  of  the  arm  or  leg  of  the  opposite  side  of  the  body,  or  sometimes  of  all  four 
limbs.  This  has  been  explained  by  Brown-Sd((uard  on  the  theory  of  reflex 
j)aralysis  or  spasm  of  the  vessels  of  the  paralyzed  limb  or  limbs  themselves, 
but  the  theory  advanced  by  Mitchell,  Morehouse,  and  Keen,  that  it  is  due  to 
exhaustion  of  the  nerve-centers  of  motion  and  sensation,  seems  to  be  the  better 
explanation. 

Shock  and  pain,  ^vith ,  loss  of  motion  or  of  sensation,  or  of  both,  are  then 
the  immediate  symptoms  of  nerve  wounds.  Such  wounds  are  of  course  attended 
with  more  or  less  hemorrhage,  and  are  subject  to  the  same  danger  (»f  infection 
and  intlammation  that  attends  wounds  elsewhere  or  of  other  organs. 

It  is,  however,  the  remote  symptoms  and  results  of  nerve  wounds  that  are 
by  far  the  more  important  and  interesting  and  constitute  their  peculiarity. 
They  were  first  carefully  studied  in  our  late  civil  war  by  Mitchell,  Morehouse, 
and  Keen.  Sensation  and  motion  are  sometimes  e([ually  affected;  but  sensation 
is  apt  to  be  less  affected  than  motion,  and  if  both  are  affected,  sensation, 
as  a  rule,  will  return  earlier  than  motion.  If  the  nerve  be  a  motor  or  a  mixed 
nerve  and  its  function  be  destroyed,  the  muscles  which  it  supplies  will  soon 
show  marked  wasting,  together  with  increasing  feebleness  of  action,  or  not 
uncommonly  complete  palsy ;  and  as  a  later  result  contracture  of  ths  muscles 
will  follow,  giving  rise  not  only  to  inability  to  use  the  part,  but  also  to  serious 
deformity.  Combined  with  the  motor  disturbances  there  will  be  marked  altera- 
tions of  sensation,  and  the  skin  supplied  by  the  nerve  will  become  anesthetic 
or  freciuently  liyperesthetic  and  painful. 

A  third  series  of  changes  in  the  nutrition  of  the  parts  supplied  by  the  nerve 
follows,  usually  at  a  considerable  time  after  the  sensory  and  motor  changes. 
These  trophic  changes  do  not  take  place  at  the  seat  of  the  wound,  but  at  a  dis- 
tance from  it,  in  the  area  to  which  the  nerve  is  distributed.  They  manifest 
themselves  first  in  a  curious  appearance  of  the  skin,  which  looks  as  if  it  were 
varnished.  It  is  usually  red  and  is  very  apt  to  be  dry,  though  sometimes  it  will 
be  bedewed  Avith  perspiration,  which  is  often  acid  and  foul-smelling.  Along 
with  this  there  is  sometimes  developed  a  burning  pain,  which  Mitchell  has 
named  "causalgia."  Frequently  even  to  point  at  the  injured  hand  of  such  a 
patient  will  evoke  such  a  paroxysm  of  pain  that  he  will  draw  his  hand  away  in 
fear.  In  many  cases  he  obtains  relief  from  Avetting  the  injured  hand  or  foot, 
and  may  even  wear  a  cotton  glove  which  he  will  constantly  wet,  or  may  pour 
water  into  his  boots  in  order  to  keep  the  burning  foot  in  even  moderate  com- 
fort. The  hair  is  commonly  greatly  diminished  in  amount.  The  nails  become 
strangely  curved,  both  in  the  axis  of  the  limb  and  transversely,  shoAving  furrows 
and  ridges,  and  very  often  ulceration  of  the  matrix  occurs.  Sometimes  gan- 
grene of  the  terminal  phalanges  of  the  fingers  and  toes  Avill  set  in.  and  may 
extend  more  Avidely,  but  not  often  beyond  the  fingers  or  toes.  There  is  often 
also  an  eruption  like  chilblains  or  eczema.  Sometimes  the  larger  joints  will 
become  inflamed,  SAvollen,  and  tender  after  a  Avound  of  the  main  nerve  or  nerves 
of  a  limb.  These  neural  arthropathies  folloAv  not  only  Avounds  or  other  lesions 
of  nerves,  but  also  injuries  to  the  central  nervous  system,  either  in  the  spine 
or  in  the  brain.     They  resemble  rheumatic  arthritis  to  a  marked  degree. 

Diagnosis. — (1)  As  to  Motion. — In  making  a  diagnosis  of  the  loss  of 
motion  that  folloAvs  injury  to  any  nerve  it  is  only  necessary  to  determine  Avhat 
muscles  have  lost  their  function  and  to  compare  these  muscles  Avith  the  nerves 
wliich  supply  them.  In  order  to  test  the  strength  of  the  muscles  of  the  fore- 
arm as  a  Avhole,  the  dynamometer  must  be  used.  This  is  simply  an  oval  spring 
with  a  graduated  disc  and  a  movable  pointer.  On  grasping  it  the  registration 
by  the  pointer  on  the  graduated  scale  shows  the  relative  strength  of  the  two 


SUUGERY    OF    THE   NERVES.  369 

arms.  There  should  be  simihir  instruments  to  test  the  force  of  tlie  motions  at 
the  elbow,  wrist,  shoulder,  and  le^,  but  none  such  have  been  devised. 

(2)  As  to  Sensatiuii. — Here  the  problem  is  a  much  more  difficult  one,  not 
only  because  the  nerve-supply  of  the  skin  is  by  no  means  so  constant  as  that 
of  the  muscles,  but  also  because  the  methods  involVed  require  greater  atten- 
tion. The  loss  of  sensation  in  the  skin  varies  considerably  in  its  character. 
In  a  certain  area  there  will  be  absolute  loss  of  sensation,  or  anesthesia.  Between 
this  and  the  area  of  normal  sensation  is  a  zone  of  irregular  outline  in  which 
sensation  is  not  absent,  but  perverted.  This  is  the  region  of  dysesthesia  or 
paresthesia,  and  will  vary  much  in  different  cases.  It  must  be  remembered 
that  there  is  also  what  has  been  called  "supplementary  sensation."  By  this 
is  meant  that  the  entire  area  ordinarily  supplied  by  a  certain  nerve,  which 
should  be  entirely  anesthetic  after  division  of  its  nerve,  is  still  found  to  possess 
a  more  or  less  complete  sensation  after  such  division.  Whether  this  is  from 
anastomoses  of  neighboring  nerves  or  not  is  a  problem  which  is  as  yet  not 
solved.  To  aid  in  its  solution,  in  all  cases  in  which  a  nerve  has  been  pur- 
posely cut  or  has  been  divided  by  accident  the  areas  of  full  sensation,  pares- 
thesia, and  anesthesia  should  be  carefully  mapped  out  by  the  methods  described 
below  and  the  areas .  indicated,  that  of  total  anesthesia  by  dark  shading,  that 
of  paresthesia  by  lighter  shading.  Only  by  collecting  and  comparing  numerous 
reports  of  such  cases  can  the  physiological  anatomy  of  the  nerves  be  determined. 

In  determining  the  areas  of  anesthesia  and  paresthesia  the  surgeon  should 
be  careful  not  to  rub  the  part  nor  adopt  any  other  rude  method  of  testing,  for 
any  displacement  of  the  skin  is  perceived  readily  at  a  distance.  The  best 
methods  are  as  follows :  First,  by  a  light  pencil,  or  in  some  cases  a  feather  or 
bristle  or  any  other  means  of  delicate  touch,  the  area,  for  instance,  of  anes- 
thesia is  determined  from  point  to  point,  and  is  mapped  out.  Sometimes  for 
still  more  delicate  determination  the  mere  touching  of  the  hairs  that  grow  so 
plentifully  over  most  of  the  body  can  be  used.  An  additional  means  is  the 
ability  of  the  patient  to  recognize  the  points  of  a  pair  of  compasses  as  tAvo  points 
or  as  one.  The  pair  of  compasses  is  fitted  with  a  graduated  scale  indicating  the 
distance  between  the  two  points,  either  in  inches  or  centimeters,  and  is  called 
an  esthesiometer.  The  best  are  now  provided  with  a  small  knobbed  point  and 
a  sharp  point  to  each  arm  of  the  compasses.  An  ordinary  pair  of  compasses 
and  a  graduated  ruler,  however,  Avill  answer.  In  using  them  it  is  important 
that  the  test  be  made  alternately  on  the  two  corresponding  limbs  under  the  same 
conditions  and  Avitli  the  same  number  of  repetitions,  and  that,  for  proper  com- 
parison, it  be  done  in  each  limb  either  transversely  or  in  its  long  axis,,  for  the 
ability  to  distinguish  the  tw^o  points  varies  Avith  the  number  of  repetitions  and 
with  the  placing  of  the  points  transversely  or  lengthwise.  It  is  especially  need- 
ful to  see  that  the  two  points  touch  the  skin  simultaneously,  for  two  successive 
touches  would  of  course  be  appreciated  as  two  points,  even  when  if  touched 
simultaneously  they  would  be  perceived  as  only  one.  All  these  examinations 
should  be  made  with  the  patient  blindfolded,  so  as  to  prevent  the  assistance  of 
sight,  and  he  should  not  be  allowed  to  move  the  fingers,  toes,  or  other  parts  in 
order  to  assist  sensation  by  the  muscular  sense.  It  must  be  remembered  also 
that  normally  many  persons  cannot  distinguish  well  between  adjacent  toes, 
especially  the  third  and  fourth.  Where  sensation  has  been  lost  to  ordinary 
touch  it  will  still  be  retained  to  certain  other  stimuli,  as,  for  example,  electricity, 
and  these  also  may  be  used  as  a  means  of  diagnosis.  The  electric  wire  brush 
will  evoke  sensation  in  many  cases  where  all  other  means  fail.  The  sense  of 
temperature  should  also  be  determined  b}'  dipping  the  hands  or  feet  into  water 
of  a  known  temperature,  or  by  applying  mops  dipped  in  th^  water,  in  many 

24 


370 


.i.v  ^^fl•:li^<^^^'  text- hook  of  smaKiiv. 


cases  using  alternatt'ly  liot  and  cold  water.  As  a  nilo,  it  will  he  ioiiiid  that 
while  sensation  and  motion  may  be  equally  lost  at  the  time  of  injury,  sensation 
will  return,  sometimes  shortly,  sometimes  at  a  longer  interval,  before  motion. 
Generally  also  the  irritability  of  the  muscles  to  the  constant  galvanic  current 
is  lost  some  time  after  their  response  to  faradaic  electricity,  the  return  of  electro- 
muscular  contractility  being  in  the  reverse  order.  Voluntary  control  over  the 
muscles  is,  as  a  rule,  lost  before  response  to  electricity,  and  returns  in  reverse 
order. 

DIAGNOSIS  OF   LESIONS   OF   SPECIAL   NERVES. 

I.   Fifth  or  Trifacial   Nerve. — Figure  142  shows  the  cutaneous  distri- 
bution of  the  three  branches  of  the  fifth  nerve  (V,,  Vg,  and  Y3)  in  different 

shadinf^s.      From  a  determination  of 

Fig.  14.']. 

Fi(i.  142. 


Distribution  of  the  Cutaneous  Sensitive  Nerves 
upon  the  Head  :  wna,  omi,  the  oceiynt.  niaj.  and 
minor  (from  the  N.  cervical.  II.  and  III.);  am,  N. 
auricular,  magn.  (from  N.  cervic.  III.) ;  cs,  N.  cer- 
vical, sunertic.  (Yrom  N.  cervic.  III.);  \\,  first 
branch  ol  the  lifth  {so,  N.  supraorbit.  ;  st,  N.  supra- 
trochl. ;  it,  N.  infratrochl. ;  e,  N.  ethmoid.;  I,  N. 
lachrymal.);  I  2,  second  branch  of  the  fifth  (sjh, 
N.  subcutan.  make  sen  zygomaticus) ;  V3,  third 
branch  of  the  fifth  (at,  N.  auricuh)-tempor. ;  b,  N. 
buccinator;  to,  N.  mental.) ;  B,  posterior  branches 
of  the  cervical  nerves  (Seeligmiiller). 


Paralysis  of  Left  Facial  Nerve,  the  face  being  in 
repose  (original). 


the  region  of  hyperesthesia  or  anesthesia  the  particular  branch  involved  can 
be  ascertained. 

II.  The  Facial  Nerve  may  be  injured  in  gunshot  wounds,  in  fracture  of 
the  middle  fossa,  or  in  neciosis  of  the  petrous  portion  of  the  tem])oral  bone,  and 
may  also  be  divided  by  the  surgeon  in  the  removal  of  tumors  from  the  parotid 
and  neighboring  regions.  If  the  injury  be  far  enough  back  to  involve  the 
chorda  tympani,  taste  Avill  be  impaired.  The  palsy  which  follows  injury  of 
the  facial  nerve  is  pathognomonic.  The  eyebroAv  cannot  be  raised  or  wrinkled 
horizontally,  and  the  eyelids  can  be  only  ])artially  closed.  But  the  ))atient  soon 
learns  to  roll  the  ball  up  under  the  upper  lid  in  order  to  wet  the  cornea  and 
preserve  its  translucency.  The  ala  of  the  nose  on  the  ])aralyzed  side  does  not 
move  in  respiration  nor  by  volition,  and  control  of  the  angle  of  the  mouth  is 
lost,  saliva  and  other  liquids  dribbling  from  it.  The  patient  cannot  pucker  his 
mouth  to  whistle.  The  entire  face  on  the  side  of  the  lesion  has  an  expression- 
less stare.     AVhen'the  patient  attempts  to  laugh  or  to  close  the  eyes  tightly,  only 


SURGE/n'    or    THE    NERVES. 


371 


the  un])araly/e(I  side  of  the  face  is  Avrinkled,  tlie  other  remains  smooth.     The 
facial  bein^  purely  a  motor  nerve,  no  change  of  sensation  occurs. 

III.  The  Pneumogastric  and  its  Recurrent  Laryngeal  Branch. — 
In  a  very  fe\v  eases  in  tying  the  carotid  or  in  the  extir])ation  of  tumors  the 
pneumogastric  luis  eitlier  been  divided  or  ligated,  and  in  the  excision  of  goitre 
one  of  the  chief  dangers  is  tiie  division  of  the  recurrent  laryngeal.  Either  lesion 
produces  hoarseness  and  altered  voice  from  paralysis  of  the  vocal  cord  on  that 
side,  and  if  in  the  excision  of  goitre  the  nerves  ])e  cut  bilaterally  instant  tracheo- 
tomy must  be  done  to  prevent  suffocation.  Except  alteration  of  the  voice,  the  ef- 
fects of  section  of  the  pneumogastric  or  its  ligation  seem  to  be  extraordinarily  slight. 

IV.  The  Ulnar  Nerve. — This  is  cut  most  frequently  just  above  the 
wrist.  It  may  also  be  divided  at  the  elbow  or  in  the  upper  arm.  The  motor 
paralysis  Avill  affect  the  flexor 
carpi  ulnaris,  the  inner  half 
of  the  flexor  profundus  in  the 
forearm,  and  in  the  hand  the 
whole  group  of  hypothenar 
muscles,  the  two  ulnar  lum- 
brical  muscles,  all  the  inter- 
ossei,  the  adductor  pollicis, 
and  half  of  the  flexor  brevis 
pollicis.  The  appearance  and 
action  of  the  hand  in  ulnar 
paralysis  are  therefore  very 
characteristic.  Besides  the 
wasting  of  the  ulnar  muscles 
in  the  forearm,  the  hypothenar 
eminence  is  wasted  and  may 
become  even  hollowed,  and 
there  is  partial  wasting  of  the 
thenar  eminence.  The  inter- 
osseous spaces  also  are  fur- 
rowed from  the  wasting  of 
these  muscles.  If  an  object 
be  placed  in  the  palm  and  the 
patient  be  told  to  grasp  it, 
he  will  first  flex  the  last  two 
phalanges  of  the  fingers  by 
the  common  flexors,  and  then 
by  the  further  contraction  of 
these  muscles  will  roll  the 
flexed  fingers  into  the  palm, 
but  he  will  not  be  able  to 
grasp  an  object  by  placing 
the  tips  of  the  fingers  on  the 


Anterior  Surlatf.  Posterior  Surface. 

Distribution  of  the  cutaneous  nerves  to  the  shoulder,  arm,  and 


thenar    and    the    hvpothenar 

,         n       •  '  1      JJistriDunon  oi  lue  cutaneous  nerves  lo  me  soouiaer,  arm,  and 

eminence     by    llexion     at     tne     hand.    The  region  of  the  N.  radialls  is  represented  by  the 
knuckle,      as      can      be      done     unl^^oken.  hatched  Une,.  that  of  the.  N.ulnaris  by  the  bfoken 

in  the  normal  hand.  More- 
over, as  the  interosseous  and 
lumbrical  muscles  extend  the 
last  two  phalanges  of  the  fin- 
gers, these  joints  of  the  fingers  will  remain  constantly  in  semiflexion,  while 


hatched  linos,  a,  anterior,  6,  posterior  surface  :  sc,  Nn.  supra- 
scapular, (plexus  cervicalis) :  ax.  chief  branch  of  X.  axillar. ;  cps, 
cpi.  Nn.  cutanei  post.  sup.  and  inf  (from  N.  radialis) ;  ra,  termi- 
nal branches  of  X.  radialis:  cm,  d,  Nn.  cutanei  medius  (also  to 
the  plexus)  and  lateralis  (chiefly  to  the  N.  medianus) :  cp,  N. 
cutan.  palmar.,  N.  rad. ;  cmd,  N.  cutaii.  medialis;  me,  N.  media- 
nus ;  «,  N.  ulnaris;  epu,  N.  cutan.  palm,  ulnaris  (Henle). 


372 


AN  AMERICAN    TEXT-BOOK    OF  SURGERY. 


tlic  first  phalanges  will  be  piilltMl  bac-kwanl  in  marked  extension  by  the  now- 
unopposed  common  extensor. 

As  a  result  of  this  the  "claw  hand"  is  jiroduced,  and  all  the  more  delicate 
motions  of  the  hand  are  lost.     Fig.  145  shows  an  extremely  bad  case.     The 

scar   of  the  wound  of  the 
Fig.  l4o.  ulnar  nerve  is  seen,  at  A.    A 

lesion  of  this  nerve  is  there- 
fore of  very  serious  import- 
ance to  any  patient,  whether 
he  be  laborer,  artisan,  or  in 
the  higher  classes  of  life. 

Sensation. — As   a  rule, 

the  ulnar  nerve  supplies  the 

,g   ulnar  portion   of    the   skin 

Paralysis  of  Ulnar  Nerve  from  Wound  at  A;  contracture  of  com-  of  the  hand  both  front  and 
mon  extensor  with  posterior  luxation  of  first  phalanges  ;  B,  bead  y,rtn\r  fVio  ontivo  littlo -finrror 
cf  metacarpal  bone  (Duchenne).  oacK,  tue  eniue  nine  nnger, 

and  the  ulnar  half  of   the 
ring  finger ;  but  at  the  tip  of  the  finger  the  median  nerve  invades  somewhat 

Fig.  146.  Fig.  147. 


Loss  of  Sensation  on  anterior  and  posterior  surfaces  of  hand  after  division  of  the  ulnar  nerve  (BowlbyV 

the  otherwise  mathematical  distribution  of  the  ulnar.  There  are,  however,  in 
this  region  marked  diftVrences  in  different  patients. 

V.  The  Median  Nerve  also  is  most  frequently  divided  ju-^t  above  the 
wrist,  where  it  is  comparatively  superficial,  the  flexor  tendons  being  often 
involved  in  the  injury.  It  may  be  injured  also  higher  up  on  the  forearm  or  at 
any  point  in  the  arm. 

Motion. — The  motor  symptoms  will  depend  on  the  point  where  the  nerve 
is  injured  or  cut.  If  the  median  be  divided  above  the  elbow,  all  the  flexors 
and  pronators  of  the  arm,  with  the  exception  of  the  flexor  carpi  ulnaris  and 
the  ulnar  half  of  the  flexor  profundus,  will  be  paralyzed.  All  the  muscle?  of 
the  thumb,  except  the  adductor  and  half  of  the  flexor  brevis  pollicis,  will  be 


SURGERY   OF    THE  NERVES. 


373 


])aralyzi'(l.  In  botli  this  and  in  ulnar  paralysis  flexion  of  the  wrist  is  lost  on 
the  radial  or  ulnar  side  respectively,  but  remains  on  the  opposite  side  of  the 
forearm.  The  hand  cannot  be  pronated  except  by  its  own  wei;j;ht.  Flexion 
of  the  thumb  is  lost  in  the  distal  phalanx  and  weakened  in  the  proximal,  and, 
what  is  still  more  important,  the  thumb  cannot  be  opposed  to  the  other  fingers. 
The  last  two  j)lialanges  of  each  of  the  fingers  cannot  be  flexed,  while  flexion 
at  the  knuckles  still  remains  by  the  action  of  the  interosseous  muscles.  If  the 
injury  be  at  the  wrist,  the  nmscles  of  the  forearm  Avill  escape,  the  fingers  can 
be  flexed,  but  the  thumb  still  cannot  be  opposed  to  the  other  fingers,  and  hence 
small  objects  can  neither  be  picked  up  by  the  thumb  and  the  tips  of  the  fingers 
nor  be  well  grasped  and  retained.  The  appearance  is  again  typical.  Wasting  of 
the  forearm  is  more  marked  than  in  ulnar  paralysis,  and  the  hand  is  in  partial 
flexion  to  the  ulnar  side,  with  extension  of  the  wrist  and  fingers.  While  the 
hypotlienar  eminence  is  not  wasted,  the  thenar  eminence  is  almost  gone.  This 
too,  it  will  be  seen,  is  a  very  serious  accident  in  any  station  in  life. 

Sensation. — On  the  palmar  surface  the  area  of  anesthesia  or  paresthesia 
includes  the  radial  half  of  the  palm  and  the  palmar  surface  of  the  thumb,  index, 
and  middle  finger,  and  the  radial  side  of  the  ring  finger,  including  the  major  part 

Fig.  148.  Fig.  149. 


^     K      J 

I'  l/i 


'V 


Section  of  Median  Nerve:  areas  of  anesthesia 
(heavy  shading)  and  of  dysesthesia  (light  shad- 
ing) on  palmar  surface  of  hand  (Bowlby). 


Section  of  Median  Xerve:  regions  of  anesthesia 
and  dvsesthesia  on  dorsal  surface  of  hand 
(BowlbV). 


of  its  tip.  Posteriorly,  nearly  the  whole  of  the  fore  and  middle  %gers  becomes 
anesthetic,  and  the  radial  side  of  the  ring  finger,  but  little  or  none  of  the  dor- 
sal surface  of  the  hand. 

YI.  Radial  Nerve. — This  is  divided  occasionally  as  it  passes  over  the 
front  of  the  forearm  to  the  back  of  the  hand  just  above  the  wrist.  No  mus- 
cles are  supplied  by  it.  The  region  supplied  by  it  with  sensation,  and  there- 
fore anesthetic  after  its  section,  is  a  portion  of  the  skin  over  the  metacarpal 
bones  and  first  phalanges  of  the  thumb  and  the  forefinger. 

VII.  The  IVIusculo-spiral  Nerve. — This  is  most  frequently  injured  by 
gunshot  wounds  or  fracture  of  the  humerus  involving  the  musculo-spiral  groove. 


374 


,1,V   AMKincAX    TEXT- HOOK    OF   SVIidKIiY. 


Fk;.  150. 


Paralysis  of  Musculo-spiral  Nerve  after  Frac- 
ture of  the  Humerus  (•' wriBt-drop''; ;  but 
when  fingers  have  been  flexed  into  palm, 
a,  they  can  be  extended  b.  at  first  inter- 
phalangeal  jnints  by  lumbricals  and  inter- 
ossei.  which  are  supplied  by  the  ulnar  and 
median  nerves  (Erichsen). 


Motkni. — If  the  nerve  is  paralyzed  below  the  hraneh  going  to  the  supinator 
longus,  this  muscle  escapes  paralysis  and  its  function  as  a  flexor  of  the  forearm 

becomes  very  marked.  If  the  nerve  is 
injured  above  the  origin  of  this  branch,  the 
suj»inator longus  is  paralyzed,  and  flexion  and 
supination  are  impaired,  though  not  lost,  for 
the  biceps  acts  as  a  marked  supinator  as  well 
as  flexor,  and  is  aided  by  the  supinator  brevis. 
Extension  of  the  wrist  and  fingers  is  lost, 
and  there  is  distinct  wrist-drop,  with  inability 
to  extend  the  fingers  at  the  knuckle  (Fig. 
150).  The  last  two  phalanges,  however,  can 
still  be  extended  by  the  interosseous  and 
lumbrical  muscles.  Atrophy  of  the  exten- 
sors is  very  marked. 

Sensation. — The  loss  of  sensation  will 
differ,  depending  on  the  level  at  which  the 
nerve  is  injured. 

Several  of  the  above  nerves  may  be 
injured  at  one  time,  or  the  brachial  plexus  itself  may  be  ruptured  in  accidents 
and  occasionally  in  surgical  operations. 

A^III.  The  Great  Sciatic  Nerve. — Since  it  is  so  well  protected,  the  trunk 
of  the  sciatic  is  not  often  injured  or  cut  by  accident,  except  in  gunshot  wounds, 
but  its  external  popliteal  branch  is  sometimes  divided  in  tenotomy  of  the 
biceps  muscle  or  accidentally  just  below  the  head  of  the  fibula. 

Motion. — The  importance  of  this  branch  lies  in  the  fact  that  it  supplies  the 
anterior  flexor  muscles  of  the  foot,  and  that  its  injury  or  division  is  followed 
hj  foot-drop,  so  that  the  foot  drags  in  walking  and  the  wearing  away  of  the 
boot-sole  under  the  great  toe  is  very  marked.  If  the  main  trunk  of  the  sciatic 
is  divided  or  injured,  all  the  muscles  below  the  knee  are  involved  in  the 
paralysis.  The  patient  can  walk,  because,  as  a  rule,  the  muscles  of  the  thigh 
are  not  involved,  but  the  leg  is,  as  it  were,  flung  forward  from  the  hip  at  each 
step. 

The  loss  of  sensation  (Fig.  151)  is  generally  less  extensive  than  the  loss  of 
motion,  onlv  the  foot  and  the  outer  ]iart>  of  the  leg  being  entirely  anesthetic. 

Prognosis  after  Injuries  of  Nerves. — This  is  more  or  less  grave 
in  accordance  with  the  importance  of  the  nerve  involved,  the  extent  of  the 
injury,  and  the  time  that  has  elapsed  without  proper  treatment.  It  is,  however, 
possible,  after  a  lapse  of  months  or  sometimes  even  of  years,  to  do  much  in  the 
way  of  restoration,  sensation  being,  as  a  rule,  more  under  control  than  motion. 
If  the  time  has  been  long  and  the  injury  severe,  good  results  can  be  attained 
only  after  treatment  covering  weeks  or  months,  and  in  many  cases  can  scarcely 
be  hoped  for.  Hence  the  especial  need  for  the  early  correct  treatment  of  these 
injuries. 

Treatment  of  Wounds  of  Nerves. — The  fact  that  there  is  a  lesion  of 
a  nerve  will  not  modify  the  primary  treatment  of  the  wound  unless  the  ner\e 
be  amenable  to  suture,  as  described  below.  This  should  always  be  done  at  the 
time  of  the  accident.  The  wound  should  be  treated  in  othev  respects  precisely 
as  any  ordinary  case.  The  treatment  of  the  remote  results  due  to  nerve  injury 
are,  however,  somewhat  peculiar,  and  are  now  to  be  considered. 

Treatment  of  the  Remote  Effects  following  Nerve  Injury. — 1. 
Motion. — Un<iuestionably  the  agent  which  gives  us  the  best  promise  of  relief 
from  a  destructive  motor  lesion  is  electricity.     "When  a  motor  or  a  mixed  nerve 


s'ri?r;/:/n'  or  tjtk  xervks. 


875 


lias  been  dividtMl,  as  has  already  been  stated,  the  muscles  which  have  been 
paralyzed  very  soon  indicate  de-jjenerative  changes  affecting  tlieir  nutrition  and 
producing  a  permanent  shortening.  This  degeneration  can  be  prevented  to  a 
large  extent  by  the  daily  or  almost  daily  use  of  electricity,  wliich  will  keep 
the  muscles  in  their  normal  condi- 
tion, ready  to  resume  their  natural  '''"  ^■''• 
function  by  volition  on  the  rehabili- 
tation of  the  nerve-trunk,  which  may 
then  take  the  place  of  the  electric 
stimulus.  If  the  nerve  responds  to 
faradism,  this  is  undoubtedly  the 
best  form  to  use.  If,  however,  so 
much  time  has  elapsed  that  the 
muscles  do  not  respond  to  faradism, 
galvanism  should  be  employed  and 
the  effect  of  faradism  re-tested  from 
time  to  time,  and  as  soon  as  the 
muscles  respond  to  faradism  this 
should  be  used  in  preference.  An 
important  adjunct  to  this  is  system- 
atic daily  massage  of  the  paralyzed 
limb,  which  should  be  persistently 
employed  with  the  same  object  as 
the  use  of  electricity.  The  hot  and 
the  cold  douche  should  also  be  used, 
too;ether  with  such  oreneral  measures 
as  will  best  keep  up  the  general 
health.  If  muscular  spasms  occur, 
the  injection  of  yi-g-  of  a  grain  of 
atropine  deep  into  the  substance  of 
the  muscle  is  the  best  means  of  over- 
coming the  spasm.  If  deformities 
have  resulted,  tenotomy  is  often  indi- 
cated and  will  result  beneficially. 
If  the  joints  have  become  ankylosed 
or  otherwise  diseased,  the  adhesions 
must  be  broken  up  under  anesthesia, 
very  often  repeatedly,  and  the  joint 
stimulated  to  return  to  its  normal 
condition  by  passive  motion,  friction, 
douches,  massage,  etc.  These  efforts 
must  not  be  relaxed  until  the  lapse 
of  months  or  even  of  years  has  proved 
that  the  lesion  is  beyond  relief. 

2.  Sensation. — Anesthesia. — The 
best  means  of  stimulating  the  skin, 
apart  from  the  measures  already 
indicated,  massage,  friction,  douche, 
etc.,  is  the  electric  brush.  This  is  best  applied  with  the  faradaic  current,  the 
skin  having  first  been  dried  with  flour. 

Pain. — The  pain  varies  so  much  in  degree  that  the  treatment  must  be  cor- 
respondingly varied.  Sometimes  the  simple  application  of  cold  water  is  sufiB- 
cient.      Occasionally  the  injection  of  small  amounts  of  morphine  will  answer 


Anterior  Surface. 


Posterior  Surface. 


Distribution  of  the  cutaneous  nerves  of  the  lower 
extremity,  n,  N.  ilio-inguinal.  (plex.  lumb.);  li, 
N.  lumbo-inguinal.  (to  the  genito-crural,  plex.  lum- 
bal.); se,  N.  spermat.  ext.  <  to  the  genito-crural.);  ep,  N. 
cutan.  post.  (plex.  ischiad.);  c/,  N.  cutan.  lateral. 'plex. 
lumb.) ;  cr,  N.  crurali.s  (plex.  lumbal.) ;  oht,  N.  obtura- 
tor, (plex.  lumb. J ;  sa,  N.  saphen.  (plex.  lumbal.); 
cpe,  N.  commun.  peron.  (N.  peron.  tibial.) ;  cti,  N. 
commun.  tibial.  ;  per' .  per",  N.  peronsei  ram.  superfic. 
et  prof.;  cpm,  N.  cutan.  post.  med.  (plex.  ischiad.) ; 
cpp,  N.  cut.  plant,  propr.  (N.  tib.)  r  plm,  pll,  N.  plan- 
tar, medial,  et  lateral.  (N.  tib.)  (Henle). 


376  AN  AMERICAN   TEXT- HOOK    OF  SriiGEIiV. 

the  purpose,  and  often  rest  -svill  do  nuicli,  l»nt  in  cases  of  severe  pain,  especially 
tliat  named  by  Mitchell  "Oausal^ia,"  all  means  employed  will  sometimes  he  futile. 
The  patient  who  is  a  victim  of  such  pain  soon  learns  the  value  of  cold  water 
and  keeps  the  part  constantly  wet,  wearing  a  wet  glove  or  pouring  water  into 
his  boots.  The  most  useful  remedy  in  these  cases  i»  repeated  blistering  over 
the  course  of  the  nerve,  and  in  many  instances  this  will  give  even  complete 
relief,  ^lorphine  should  be  given  by  the  mouth  or  by  injection,  but  care  must 
be  taken  lest  the  morphine  habit  be  formed.  If  the  pain  resists  these  remedies, 
especially  when  com])ined  with  those  already  mentioned,  the  nerve  involved 
should  be  stretched,  divided,  or  exsected.  Sometimes  even  amputation  is 
required. 

SECTION   VI.— OPERATIONS  ON   NERVES. 

These  are  four  in  numt^er:  I.  Nerve-Suture  and  Nerve-Grafting;  II. 
xNeuiectasy,  or  Nerve-Stretching;  III.  Neurotomy,  or  Division  of  a  Nerve; 
and  ly.  Neurectomy,  or  the  Excision  of  a  Part  of  a  Nerve. 

I.  Nerve-Suture  and  Nerve-Grafting. — Primary  Suture. — The  old 
view^s  of  the  dangers  of  sutures  as  applied  to  nerves  are  entirely  exploded,  and 
numerous  cases  in  which  suture  of  a  nerve  has  been  practised  immediately 
after  the  injury  prove  that  recovery  of  function  is  greatly  facilitated  by  such 
suture.  Hence,  precisely  as  is  the  case  Avith  a  tendon,  a  nerve  should  always 
be  sutured  immediately  if  possible,  even  if  the  section  of  the  nerve  is  only 
partial.  Supposing  first  that  the  nerve  is  merely  divided,  without  loss  of 
substance,  and  hat  the  ends  can  readily  be  approximated,  two  or  three  sutures 
should  be  passed  not  merely  through  the  sheath  of  the  nerve,  but  through  its 
substance.  These  should  be  preferably  of  fine  silk,  and  inserted  by  sewing- 
needles.  The  part  then  should  have  absolute  rest  on  a  splint,  so  that  the  nerve- 
ends  should  not  be  torn  asunder  by  motion  of  the  limb.  Catgut,  kangaroo 
tendon,  etc.  may  also  be  used,  of  course  with  antiseptic  precautions.  In  one 
case  in  which  no  such  means  were  at  hand  an  ordinary  hare-lip  pin  Avas  inserted 
obliquely  through  the  two  ends  of  the  ulnar  nerve  and  a  loop  of  fine  silk  thrown 
over  its  "point,  brought  out  through  the  wound,  and  secured  to  the  head  of  the 
pin.  At  the  end  of  three  days  the  pin  Avas  withdraAvn,  thus  loosening  the  silk, 
which  Avas  easily  removed.  The  result  Avas  in  every  Avay  satisfactory.  If  the 
ends  are  so  far  separated  that  they  cannot  be  readily  approximated,  one  or  both 
ends  of  the  nerve  may  be  stretched  until  they  can  be  placed  in  contact,  and 
the  same  process  then  carried  out.  While  failure  has  occurred  in  a  good 
many  cases,  the  results  have  been  surprisingly  successful  in  others.  In  a  very 
fcAv  instances  apparently  primary  union  has  taken  place  and  sensation  has  been 
restored  in  tAvo  or  three  days,  or  even  less :  but  more  frequently  one,  tAvo,  or 
more  Aveeks  Avill  elapse,  and  Ave  should  not  despair  of  such  a  nerve  until  months' 
or  even  years  have  passed.  BoAvlby  has  analyzed  81  cases  of  primary  suture, 
of  whicli  32  Avere  entirely  successful,  34  were  partially  so,  and  only  14  Avere 
failures,  the  result  in  one  case  not  being  recorded.  It  is  especially  important 
to  remember  that  Ave  should  not  be  hasty  in  our  conclusions  as  to  results.  The 
early  results  may  be  disa])pointing,  but  time  must  be  allowed  for  union, 
degeneration,  and  regeneration  of  the  nerve  before  avc  can  expect  return  of 
function  in  most  cases.  Even  the  gravest  of  trophic  changes  should  not  make 
us  despair  of  the  ultimate  result.  Sensation  Avill  return,  as  a  rule,  before 
motion,  and,  in  vieAV  of  the  time  that  elapses  before  the  nerve  Avill  be  able  to 
carry  the  stimulus  of  volition  to  the  muscles,  the  value  of  electricity  in  keeping 
the  muscles  in  good  condition  must  especially  be  borne  in  mind. 


SURGE JiV    or    TIIK    XKliVES.  .377 

Secondary  Suture. — Within  the  hist  few  years,  in  a  number  of  cases 
weeks,  months,  or  even  a  number  of  years  after  tlie  injury,  when  the 
muscles  have  been  paralyzed  for  a  long  time  and  sensation  has"^  been  altered 
or  destroyed,  the  secondary  suture  of  such  divided  nerves  has  been  followed 
by  success.  This  operation,  like  all  others,  must  be  strictly  antiseptic. 
An  Esraarch  bandage  may  be  applied,  the  nerve  exposed,  and  the  two  ends 
loosened  from  their  attachments.  The  i)roximal  end  will,  as  a  rule,  be  bulbous 
and  be  found  with  ease.  It  is  often  more  difficult  to  find  the  wasted  distal  end, 
and  sometimes  it  is  best  to  cut  down  on  the  nerve  beyond  the  site  of  the  injury 
at  a  point  where  the  nerve  lies  in  its  normal  relations,  and  then  follow  up  the 
trunk  till  we  come  to  the  cut  lower  end.  The  whole  of  the  bulbous  extremity 
of  the  proximal  end  should  be  removed,  but  only  a  small  portion,  usually  not 
over  a  quarter  of  an  inch,  of  the  distal  end.  The  two  ends  should  then  be 
approximated  by  stretching,  and  the  nerve  sutured  as  before.  In  some  cases — 
('.  (T/.,  of  injury  with  loss  of  substance  of  the  musculo-spiral — it  may  be  needful 
to  resect  a  portion  of  the  bone  in  order  to  bring  together  the  widely-separated 
ends  of  the  nerve.  Bowlby's  table  of  7o  cases  of  secondary  suture  of  the  nerves 
gives  successful  results  in  32,  partially  successful  in  26,  and  failure  in  only  \~). 

Nerve-grafting. — If,  after  stretching,  the  ends  of  the  nerve  cannot  be 
api)roximated,  two  methods  are  open  to  us  :  partially  splitting  the  nerve  for  a 
certain  distance,  turning  over  what  may  be  called  the  flap  of  nerve  (Fig.  152), 


N\  ' ^^^^^^Xcr-J' '         ~^^'" 

Suture  of  a  Nerve  by  Splitting  the  Ends  (Beach). 

and  uniting  it  to  the  other  cut  end ;  or  flaps  may  be  made"  from  both  ends 
(Beach).  The  results  of  this  method  of  treatment  have  not,  however,  been 
very  satisfactory.  Possibly  the  transplantation  or  grafting  of  nerves  will 
give  better  results.  If  a  nerve  can  be  removed  from  an  amputated  limb 
(the  two  operations  of  amputation  and  nerve-suture  being  simultaneous),  a 
portion  of  human  nerve  can  be  transplanted.  If  it  be  impracticable  to  obtain 
a  portion  of  human  nerve,  a  suitable  portion  of  a  nerve  from  one  of  the  lower 
animals  can  be  removed,  placed  in  its  proper  position,  and  sutured  at  both  ends 
to  the  cut  ends  of  the  nerve.  It  is  probably  a  matter  of  indifference  whether 
this  nerve  be  a  motor,  sensory,  or  mixed  nerve,  the  nerve-tubules  being  simply 
subservient  to  the  transmission  of  the  nervous  impulse  in  either  direction.  The 
suggestion  of  Von  Bergmann  that  the  entire  limb  shall  be  shortened  by  resec- 
tion of  a  portion  of  the  bone  has  been  done  a  few  times  with  success. 

In  all  cases  after  secondarv  suture  the  use  of  galvanism,  and  later  of 
faradism,  together  with  massage,  etc.,  should  be  employed  for  a  year  or  more 
before  relinquishing  the  hope  of  a  successful  result. 

II.  Neurectasy,  or  Nerve-Stretching,  was  first  introduced  by  Nuss- 
baum  in  1872.     Vogt  has  shown  by  experiment  that  a  nerve  can  be  stretched 


37.S  AX   J.l//.7.'/r.LV    7V;A"/-/;00A'    O/'  S(Il(;i:i!Y. 

one-twentieth  of  its  length,  and  that  it  yiekls  most  at  its  spinal  extremity,  the 
amount  of  elongation  diminishing  as  \ve  ajiproach  the  perij>hery,  where  it 
becomes  almost  nothing.  In  order  to  guide  us  as  to  how  much  force  we  can 
ap|)ly,  it  is  important  to  know  what  force  will  ruj»ture  the  nerve.  Marshall 
gives  the  following  result  of  experiments  on  difl'erent  nerves: 

Cohesion  of  Human  Neixes  after  Death — Breaking  Strain  in  Pounds. 

Lbs. 

Supraorhital 6 

Infniorl.ital 12 

Mental 5i 

Brachial  plexu.s 50-64 

Ulnar 58 

Musculo-spiral fil 

Median 84 

Crural    .    .    •    • 83 

Internal  popliteal 114 

Great  sciatic — vSvmington 86-17fi 

fillaux 118-127 

Gillette 165 

Trombetta 82-288 

Ceccherelli 154-220 

It  must  be  remembered  that  the  force  necessary  to  produce  rupture  is  probably 
somewhat  greater  in  the  living  than  in  the  dead  subject.  The  nerves  most 
commonly  stretched  are  the  facial,  the  spinal,  and  the  sciatic,  especially  the 
latter.  It  should  be  noted  that  the  facial  nerve,  which  is  not  included  in  Mar- 
shall's table,  will  bear  a  strain  of  from  seven  to  twelve  pounds,  and  that  therefore 
the  head  can  be  almost  lifted  from  the  table,  and  in  some  cases  entirely  so, 
•without  rupture  of  the  nerve-trunk.  The  surgeon  generally  feels  the  rupture 
of  some  strands,  which  will  warn  him  of  the  impending  rupture  of  the  entire 
trunk.  The  great  sciatic  nerve  has  ruptured  in  various  subjects  at  a  minimum 
of  82  pounds  and  a  maximum  of  288.  It  is  therefore,  as  a  rule,  absolutely  safe 
to  lift  the  leg  or  even  the  pelvis  by  traction  upon  this  trunk.  "Whether  nerve- 
stretching  produces  any  traction  upon  the  cord  has  been  much  dis])uted.  But 
Tarnowski  has  shown  experimentally  in  rabbits  that  while  slight  traction  on  the 
sciatic  nerve  was  followed  by  a  passing  hyperemia,  when  the  traction  was  consid- 
erable hemorrhages  in  the  gray  matter  and  inflammatory  exudations  were 
caused,  followed  by  sclerosis  and  atrophy  of  the  nerve-cells  :  and  marked  effects 
have  been  noted  after  stretching  of  the  brachial  plexus.  Moreover,  inasmuch 
as  there  are  on  record  at  least  eleven  cases  of  death  from  lesion  of  the  spinal 
cord  after  nerve-stretching,  such  deleterious  influences  can  scarcely  be  denied. 
The  eftects  of  nerve-stretching  are  more  or  less  hemorrhage  and  destruction 
of  the  nerve-tubules,  differing  in  amount  with  the  force  used,  with  later  cell- 
proliferation  in  the  neurilemma.  This  tearing  of  the  nerve-tubules  is  followed 
by  degeneration  precisely  as  after  section  of  the  nerve,  followed  in  turn,  how- 
ever, by  a  much  greater  regeneration.  In  the  cord  the  changes  are  usually 
inflammatory,  from  a  slight  hyperemia  up  to  a  definite  myelitis  followed  by 
atrophy.  The  direction  of  the  stretching  is  not  a  matter  of  indifference,  for, 
as  shown  by  Tutschek,  if  a  nerve  be  stretched  by  drawing  it  in  a  direction 
away  from  the  cord,  the  sensory  fibers  are  more  dulletl  than  the  motor,  but  if 
the  traction  be  toward  the  cord  the  motor  filaments  suflTer  more  than  the  sensory. 
We  should  therefore  stretch  the  nerve  in  diff'erent  direction^  for  the  relief  of 
pain  and  of  spasm.  If  the  stretching  be  very  severe,  it  may  be  followed  by 
trophic  changes,  just  as  after  a  lesion  of  the  nerve  produced  in  any  other  way. 
Various  theories  have  been  adduced  as  to  the  mode  of  action  of  neurectasy : 


sri;(;i:i!V  or  Tin:  seiivks.  ;i7y 

the  probability  is,  however,  that  its  benefit  results  from  some  obscure  change 
in  the  nutrition  of  the  nerve,  in  its  separation  from  adhesions  either  to  neigh- 
boring parts  such  as  cicatrices,  etc.,  or  to  its  own  sheath,  and  in  many  cases 
undoubteiUy  to  absolute  rupture. 

Two  methods  may  be  adopted.  Ftrat,  hij  operation.  The  ti  imk  of  the 
nerve  is  exposed  and  loosened  from  tlie  surrounding  parts.  It  is  then  stretched 
either  by  hooking  it  up  by  the  fingers,  or  in  a  small  nerve  such  as  the 
seventh  nerve  by  a  common  pocket  button-hook  or  similar  instrument,  or 
by  Horsley's  saddle-shaped  hooks  for  the  larger  nerves.  The  second  or 
bloodless  method  is  applicable  only  to  the  great  sciatic  nerve.  The  patient 
is  etiieri'/ed,  the  leg  kept  extended  at  the  knee,  and  the  entire  lower  extremity, 
being  then  used  as  a  straight,  stiff  lever,  is  carried  into  marked  and  forceil  flex- 
ion at  the  hip.  The  results  of  the  last  method  seem  to  have  been  very  good  in 
a  number  of  cases,  but  it  must  be  borne  in  mind  that  in  adults  at  least  there 
must  be  considerable  rupture  of  the  bellies  of  the  hamstring  muscles,  and  there 
have  been  reported  two  cases  of  death  after  this  metliod. 

Conditions  to  which  Neurectasy  is  Applicable. — The  largest  num- 
ber of  operations  of  this  kind  have  been  done  for  ataxia,  and  often  with  at  least 
temporary  benefit ;  but  usually  there  has  been  only  slight  relief,  and  in  many 
cases  none.  In  spinal  disorder  of  all  kinds,  such  as  paralysis,  myelitis,  paralysis 
agitans,  athetosis,  epilepsy,  and  tetanus,  little  good  has  been  accomplished.  In 
"  tic  convulsif,"  or  spasm  of  the  facial  muscles,  the  facial  nerve  has  been  stretched 
in  over  twenty  cases.  In  a  very  small  number  the  relief  has  continued  for 
months,  and  in  Southam's  case  even  for  five  years,  but  in  most  instances  relapse 
has  followed.  The  relief  is  so  great,  however,  that  the  patient  is  generally  will- 
ing to  submit  to  repeated  operations,  and  the  operation  is  undoubtedly  to  be 
recommended.  Neurectasy  has  also  been  used  for  Avry  neck,  in  a  few  cases  with 
cure  or  benefit.  Anesthetic  leprosy  has  also  been  so  treated  with  improvement. 
In  all  cases  where  nerve-stretching  has  failed  to  relieve  it  is  possible  to  do  a 
later  neurotomy  or  neurectomy  ;  hence  very  often  neurectasy  should  precede 
these  more  severe  operations. 

III.  and  IV.  Neurotomy  and  Neurectomy. — These  two  operations  of 
simple  section  of  the  nerve  and  exsection  of  a  portion  of  it  may  be  considered 
together,  as  they  differ  only  in  the  treatment  of  the  nerve.  As  a  rule,  neurec- 
tomy is  to  be  preferred  to  simple  neurotomy.  They  are  done  occasionally  for 
muscular  spasm,  but  most  frequently  by  far  for  neuralgia.  Either  may  be 
done  as  a  primary  operation  or  secondary  after  neurectasy.  Neurotomy  can 
sometimes  be  done  subcutaneously,  as,  for  instance,  in  the  supraorbital  or  the 
infraorbital  nerve.  When  several  nerves  lie  close  to  each  other,  as  in  the  arm- 
pit, and  there  is  doubt  as  to  which  is  the  nerve  sought  for,  faradizing  each 
exposed  nerve  in  turn  will  differentiate  them.  Once  the  nerve  is  exposed  it 
can  be  stretched,  divided,  or  a  portion  of  it  exsected  as  may  be  desired.  The 
following  nerves  are  those  most  commonly  operated  on : 

1.  The  supraorbital  nerve  emerges  on  the  face  through  the  supra- 
orbital foramen  or  notch.  If  it  is  a  notch,  it  can  usually  be  felt,  but  if  a  foramen 
it  can  also  be  readily  found,  as  it  lies  at  the  junction  of  the  inner  and  middle 
thirds  of  the  eyebrow.  A  simple  curvilinear  incision  one  inch  in  length,  which 
if  made  in  the  eyebrow  will  be  hidden  by  the  hair,  is  sufficient  to  disclose  the 
nerve. 

2.  The  Superior  Maxillary  Division  of  the  Fifth  Nerve. — A  line 
drawn  from  the  supraorbital  notch  downward  between  the  two  lower  bicuspid 
teeth  intersects  the  infraorbital  and  mental  foramina.  The  infraorbital  nerve 
emerges   at  the   former  foramen.     Simple  section    of  this   nerve,  which  was 


380  J.V   AMF.IilCAX    TKXT-IK K )K    OF  SURGEItY. 

formerly  done  for  neuralgia,  has  been  very  properly  abandoned.  A  curved 
incision  an  inch  and  a  half  long  is  made  just  below  the  lower  border  of  the 
orbit.  AVliere  this  incision  intersects  the  line  above  mi'ntione<l  the  nerve  will 
be  found  under  the  levator  labii  su])erioris,  lying  much  deeper  from  the  skin 
than  would  be  supposed.  The  nerve  having  been  found,  a  silk  thread  is 
passed  under  it  by  means  of  an  aneurysm  needle,  and  the  thread  is  tied  in 
order  to  identify  and  make  traction  on  the  nerve.  The  upper  border  of  the 
incision  is  now  raised  by  a  spatula  or  retractor,  and  with  a  grooved  director  or 
other  instrument  the  periosteum  covering  the  floor  of  the  orbit  is  lifted  and  held 
up  by  the  spatula.  Even  if  not  at  once  seen,  the  canal  for  the  nerve  is  readily 
found  and  broken  in  by  pressing  on  the  floor  of  the  orbit  with  the  grooved 
director.  By  a  small  sharply-curved  hook  the  nerve  is  lifted  from  its  bed  and 
divided  far  back  in  the  orbit  by  means  of  curved  scissors.  Traction  on  the 
anterior  end  will  now  pull  out  the  entire  nerve.  Moderately  sharp  bleeding 
usually  follows  the  division  of  the  nerve  in  the  orbit,  but  is  readily  arrested  by 
packing  with  a  little  gauze.  The  bleeding  of  the  external  wound  is  controlled 
by  hemostatic  forceps. 

3.  Removal  of  Meckel's  Ganglion. — Sometimes  after  removal  of  the 
superior  maxillary  division  as  above  described,  or  better  as  a  primary  opera- 
tion. Meckel's  o^ancrlion  and  the  nerve  are  removed.  This  is  done  bv  Carno- 
chans  method,  or  better  by  Chavasse's  modification  of  it.  It  consists  of  a  T 
incision  below  the  eye,  the  horizontal  part  reaching  from  canthus  to  canthus, 
and  the  vertical  one  nearly  to  the  mouth,  but  without  entering  this  cavity. 
The  infi-aorbital  nerve  is  found,  and  as  before  is  tied  with  a  piece  of  silk. 
The  anterior  wall  of  the  antrum  is  then  perforated  by  a  three-quarter-inch 
trephine  or  a  chisel,  including  the  infraorbital  foramen.  A  half-inch  trephine 
or  a  chisel  is  applied  to  the  posterior  wall  of  the  antrum,  care  being  taken 
merely  to  penetrate  through  the  bone  and  not  to  wound  the  internal  maxillary 
artery,  which  lies  close  behind  it.  The  nerve  is  next  divided  on  the  cheek, 
and,  after  breaking  through  its  groove  in  the  floor  of  the  orbit,  the  nerve  is 
drawn  down  through  the  trephine  opening.  By  this  method  the  nerve  is  pre- 
served and  utilized  as  a  guide  to  the  ganglion.  The  nerve,  being  made  tense, 
is  now  traced  into  the  spheno-maxillary  fossa  and  to  the  foramen  rotundum.  and 
is  divided  just  below  the  foramen  with  long  delicate  curved  scissors.  To  con- 
trol the  hemorrhage  iodoform  gauze  and  small  sponges  on  sponge-holders  are 
best,  and  it  is  almost  essential  that  an  electric  light  or  forehead  mirror  be  used 
to  illuminate  the  deep  parts  of  the  wound.  Abbe  has  recently  recorded  two 
cases  in  which  he  removed  the  nerve  by  a  single  horizontal  incision  one  inch 
and  a  quarter  in  length,  breaking  down  both  the  anterior  and  posterior  walls 
of  the  antrum  with  a  simple  gouge.  After  removing  the  nerve  he  packed  the 
wound  licrhtlv  with  strips  of  iodoform  jrauze,  and  did  not  suture  it  until  he 
removed  the  gauze,  forty-eight  hours  after  the  operation.  Sensation  being 
paralyzed,  no  pain  is  caused  by  the  late  sutures. 

Instead  of  trephining  through  the  antrum,  Horsley,  after  exposing  the 
nerve,  lifts  the  contents  of  the  orbit  with  the  periosteum  of  its  floor,  lays  open 
the  canal  by  sharp-pointed  bone  forceps,  and  then  follows  the  nerve  to  the 
foramen  rotundum.  Often  the  antrum  Avill  not  be  opened.  Luecke  resects 
the  zygoma,  turns  the  temporal  muscle  up,  and  so  gains  access  to  the  ganglion. 

4.  Inferior  Dental  Nerve. — Several  operations  have  been  devised  for 
this,  but  the  best  are  as  follows : 

(1)  Bij  External  Incision. — An  incision  two  inches  long  is  made  along  the 
lower  border  of  the  jaw,  beginning  slightly  behind  the  angle.  This  is  better 
than  a  vertical  incision,  which  is  almost  certain  to  divide  some  branches  of  the 


SURGKIiV    OF    Till-:    XEliVES.  381 

seventh  nerve,  and  may  paralyze  the  muscles  of  the  mouth.  The  incision, 
bein^  well  under  the  horiler  of  the  jaw,  is  entirely  hidden  in  men  by  the 
beard  and  partly  hidden  in  women  by  the  jaw.  The  upper  edge  is  displaced 
upward  on  the  vertical  ramus,  and  after  scraping  away  the  masseter  muscle  a 
half-inch  trephine  is  applied  an  inch  and  a  quarter  above  the  angle.  This 
exposes  the  nerve  at  its  entrance  into  the  inferior  dental  foramen.  Tlie  nerve, 
having  been  brought  to  the  surface  by  a  small  sharply-curved  hook,  is  first 
stretched,  and  then  as  much  of  it  as  possible  is  exsected.  If  desired,  the  incision 
can  be  prolonged  above  and  parallel  to  the  edge  of  the  jaw,  and  the  canal  for 
the  nerve  be  laid  open  all  the  way  to  the  mental  foramen.  Commonly  rather 
copious  hemorrhage  is  caused  by  the  division  of  the  inferior  dental  artery  if  this 
is  involved  in  the  cut.  Packing  will  usually  control  it,  but  occasionally  a  liga- 
ture is  necessary.  By  this  same  incision  the  nerve  may  be  removed  without 
trephining  by  separating  the  parts  behind  the  jaw  instead  of  in  front  of  it, 
scraping  the  internal  pterygoid  muscle  instead  of  the  masseter  loose  from  the 
jaw,  and  finding  by  the  finger  the  sharp  point  of  bone  which  marks  the  inferior 
dental  foramen.  The  nerve  can  now  be  brought  to  the  surface  as  before  and 
be  stretched  and  exsected. 

Horsley  has  recently  proposed  a  new  method  by  a  vertical  incision  through 
only  the  skin  and  fat,  beginning  just  above  the  zygoma,  extending  to  the 
angle  of  the  jaw,  and  then  following  its  lower  border  as  far  as  the  facial  artery. 
This  flap  is  lifted  without  cutting  the  branches  of  the  facial  nerve.  Between 
the  upper  branch  of  the  nerve  and  Stenson's  duct  the  masseteric  fascia  is 
divided,  and  the  opening  widened  to  three  centimeters  in  diameter.  The 
parotid  is  now  retracted  toward  the  ear  and  the  posterior  border  of  the  jaw 
defined.  Next  the  posterior  two-thirds  of  the  masseter  are  divided  and  the  jaw 
cleaned,  so  that  the  sigmoid  notch  is  well  seen.  By  drilling  several  holes  and 
by  a  small  trephine  the  bone  is  removed,  so  that  the  sigmoid  notch  is  prolonged 
downward  twelve  to  fifteen  millimeters  to  the  border  of  the  inferior  dental 
foramen.  Division  of  the  periosteum  on  the  inner  surface  of  the  jaw  then 
discloses  the  inferior  dental  nerve.  This  can  be  followed  to  within  a  centi- 
meter of  the  foramen  ovale  and  exsected.  The  lingual  nerve  lies  half  an  inch 
deeper  and  somewhat  in  front  of  the  inferior  dental,  and  may  also  be  exsected. 
The  bleeding  is  free,  but  controllable.  The  internal  maxillary  artery  may 
have  to  be  ligated  and  divided.     An  electric  light  is  essential. 

(2)  The  nerve  can  also  be  reached  through  the  mouthy  as  follows :  The 
mouth  being  held  open  as  widely  as  possible  by  a  gag  on  the  opposite  side,  the 
mucous  membrane  is  incised  along  the  anterior  border  of  the  ramus  of  the 
lower  jaw  between  the  last  molar  teeth  of  the  two  jaws.  The  finger  can  now 
be  inserted  between  the  internal  pterygoid  muscle  and  the  ramus  of  the  jaw. 
The  muscle  being  separated  from  the  bone,  the  same  sharp  projection  of  bone 
at  the  opening  of  the  inferior  dental  foramen  before  referred  to  is  found  and  the 
nerve  broucrht  to  the  surface  with  a  hook.  The  long  internal  lateral  ligament 
of  the  jaw  must  not  be  mistaken  for  the  nerve.  Hemorrhage  was  very  profuse 
in  two  instances  on  record,  and  gave  considerable  trouble. 

5.  Removal  of  the  Gasserian  Gang-lion. — In  not  a  few  cases  after  the 
above  operations,  especially  on  the  superior  maxillary  and  inferior  dental  nerves, 
the  neuralgia  returns,  and  in  order  to  remedy  the  pain  Rose,  Andrews,  and  others 
have  removed  the  Gasserian  ganglion  itself.  This  ganglion  lies,  it  will  be  re- 
membered, on  the  anterior  surface  of  the  petrous  bone  underneath  the  dura, 
but  above  a  layer  of  the  periosteum  which  lies  between  the  ganglion  and  the 
base  of  the  skull.  Mr.  Rose's  later  method  is  as  follows:  The  eyelids  are  first 
sewed  together  to  protect  the  ball,  the  sutures  being  removed  on  the  fourth 


3S2 


j.v  AMiJUc.w  Ti:\"r-ii<)()K  or  sri:<;i:in'. 


Fui.  15:?. 


"»■— «»asfirftssaiai3(^E»o-i^ 


day.  A  ciirvod  iiuMsion  is  iiiailr  tVom  liall"  an  inch  below  tlie  external  an;^n- 
lar  ])rocess  along  the  zygoma  to  its  posterior  extremity,  then  downward  to  the 
angle  of  the  jaw,  and  finally  along  the  lower  border  of  the  jaw  to  the  facial 
artery.  The  flap  is  then  dissected  forward  without  wounding  the  facial  nerve 
or  Stenson's  duct.  The  zygoma  is  first  drilled  and  then  divided,  and  turned 
downward  with  its  attached  masseter  muscle.  The  coronoid  j>rocess  is  simi- 
larly divided,  and  displaced  upward  with  its  attached  temporal  muscle,  and 
later  is  removed.  The  internal  maxillary  artery  is  then  ligated  and  divided. 
The  external  pterygoid  muscle  is  separated  from  the  great  wing  of  the  sphe- 
noid and  the  external  ])terygoid  plate.     A  long-handled  half-inch  trephine  is 

next  api)lied  a  little  ante- 
rior and  external  to  the 
foramen  ovale,  the  edge  of 
the  trephine  just  impinging 
on  the  edtje  of  the  foramen. 
The  trunk  of  the  nerve  is 
used  as  a  guide  to  the  gan- 
o;lion,  which  is  then  re- 
moved  by  small,  sharply- 
curved  hooks,  one  of  which 
has  a  cutting  concave  bor- 
der. Hemorrhaiie  gives  con- 
siderable  trouble.  An  elec- 
tric forehead  light  is  essen- 
tial in  working  at  such  a 
depth.  The  results  of  the 
first  case  after  twenty-two 
months  were  entirely  favor- 
able so  far  as  the  nerve  was 
concerned,  but  the  eye  was 
destroyed  and  had  to  be  re- 
moved— a  calamity  happily 
avoided  by  the  improved 
techni(iue  of  later  cases,  all 
of  which,  at  least  so  far, 
have  remained  free  from 
pain. 

Recently,  the  osteoplas- 
tic method  of  resection  of 
AVagner-Wolff  (p.  499)  has 
been  applied  to  this  opera- 
tion. In  1892,  Hartley, 
and  a  few  months  later 
Krause,  published  independently  identical  methods  of  opening  the  skull  by 
an  osteoplastic  resection.  The  usual  horseshoe-shape<l  incision  is  made 
through  the  scalp  directly  down  to  the  bone,  but  the  fla))  is  not  lifted  from 
the  bone.  The  vertical  and  horizontal  extent  of  the  incision  is  usually  about 
three  inches.  The  base  (Fig.  153)  thus  marked  out  is  much  smaller  than  the 
remainder  of  the  flap,  and  terminates  in  front  of  the  ear  and  behind  the 
external  angular  process  of  the  frontal  bone.  A  groove  is  then  cut  in  the 
bone  with  a  chisel,  and  the  inner  table  entirely  divided  by  an  osteotome,  after 
v.hich  two  or  three  periosteum  elevators  are  inserted  into  the  groove,  and  the 
flap,  consisting  of  bone  and  scalp  together,  is  lifted  to  such  an  extent  as  to 


Intracranial  Neurccturay  of  the  Fifth  Norve  (Hartley);  A,  manner 
of  holding;  the  ohisel  in  cutting  the  groove  through  the  bone; 
B,  llai)  lifted  and  turned  down,  exposing  the  dura  mater  and 
middle  meningeal  artery. 


SUMGERY    or    Till':   NERVES.  383 

flap,  consistin<^  of  buiu-  and  M^alp  together,  is  lifted  to  such  an  extent  as  to 
snap  the  bone  on  a  line  between  the  ends  of  the  incision.  The  niiildle  menin- 
<H'al  arterv  is  unavoidably  torn  if  it  runs  through  a  canal  in  the  anterior  infe- 
rior angle"  of  the  ])arictal  bone,  and  even  if  not  it  is  often  torn  by  the  small 
branches  passing  directly  from  it  into  the  bone. 

The  dura  is  not  opened.  The  temporo-sphenoidal  lobe  is  then  lifted  from 
the  middle  fossa  of  the  skull  until  the  second  and  third  divisions  of  the  nerve 
are  recognized.  Just  behind  their  junction  lies  the  ganglion.  The  nerves 
are  then  cut  as  close  as  possible  to  their  foramina  of  exit  and  the  ganglion  is 
broken  up,  or  if  possible  is  removed.  In  several  cases  the  bleeding  on  lifting 
the  temporo-sphenoidal  lobe  has  been  so  profuse  as  to  re(iuire  packing  by 
iodoform  gauze.  This  has  been  removed  after  three  days,  and  the  ganglion 
and  nerves  then  resected.  An  electric  forehead  light  is  almost  essential  in 
the  operation.  Tiffany  has  collected  one  hundred  and  eight  cases,  of  which 
twentv-four  died  and  eighty-four  recovered.  To  these  Carson  has  added  one 
hundred  a<lditional  cases,  with  only  twelve  deaths— a  most  encouraging 
improvement. 

Mixter  of  Boston  has  devised  an  o])eration  for  resecting  both  the  second 
and  the  third  divisions  of  the  nerve  at  the  foramina  rotundum  et  ovale,  which 
has  been  done  several  times  successfully.  He  advises  a  curved  incision  through 
the  origin  of  the  temporal  muscle,  beginning  and  ending  over  the  zygoma, 
which  fs  sawed  through  at  each  end,  care  being  taken  not  to  go  back  of  its 
tubercle,  as  the  articulation  would  then  be  opened.  The  temporal  and  pterygoid 
muscles  being  separated  and  turned  down  with  the  zygoma,  both  nerves  may 
be  reached  at  the  foramina.  This  incision  was  previously  described  by  Salzer 
as  a  method  of  reaching  the  foramen  ovale. 

6.  The  Lingual  Nerve. — This  has  occasijonally  been  operated  on  lor  tiie 
relief  of  pain  in  cancer  of  the  tongue.  A  suture  is  passed  through  the  tongue 
on  the  side  of  the  operation.  Pulling  the  tongue  forcibly  toward  the  opposite 
side  makes  the  lingual  nerve  tense,  and  it  can  be  felt  in  the  floor  of  the  moutla 
as  a  firm  band  beneath  the  mucous  membrane.  An  incision  is  made  through 
the  mucous  membrane  and  a  hook  passed  under  the  nerve,  which  is  then 
stretched  or  exsected.  If  the  tongue  is  fixed  by  the  growth,  the  nerve  may 
be  exposed  where  it  lies  in  contact  with  the  lower  jaw-bone  just  under  the 
mucous  membrane  beneath  the  first  molar  teeth. 

7.  The  Seventh  Nerve. — One  of  two  methods  may  be  adopted  to  reach 
the  nerve.  First,  the  method  of  Baum,  which  is  the  best,  as  the  nerve  is 
readily  found  and  the  scar  is  hidden  by  the  ear.  A  vertical  incision  two  and 
a  half  inches  long  is  made  behind  the  ear,  with  a  slight  angle  at  the  apex 
of  the  mastoid.  The  posterior  border  of  the  parotid  is  the  first  landmark. 
Displacing  this  forward,  the  shining  aponeurosis  of  the  sterno-cleido  is  the  sec- 
ond Clear  the  interspace  between  these  two  to  a  depth  of  one  to  one  and  a  lialt 
inches,  when  the  prevertebral  muscles  and  their  fascial  covering  are  the  next 
mark.  The  nerve  lies  in  front  of  this  fascia,  crossing  the  deep  and  narrow 
space  between  the  mastoid  and  the  vertical  ramus  of  the  jaw.  ihe  electric 
liaht  and  the  forehead  mirror  are  very  great  helps.  To  find  just  where  the 
nerve  crosses  this  space,  place  a  moist  sponge  electrode  on  the  cheek ;  the  nerve 
will  be  found  by  touching  the  tissues  at  successive  points  with  a  tine  wire 
attached  to  the  other  cord  of  the  battery.     The  current  should  be  very 

In  Haters  method  the  vertical  incision  is  made  in  front  of  the  ear.  One 
of  the  two  main  branches  of  the  nerve  will  be  exposed  in  the  parotid  gland, 
and  is  to  be  followed  back  to  the  main  trunk.  In  this  method  the  trunk  of 
the  nerve  is  apt  to  be  reached  in  front  of  the  point  where  it  gives  oft  its 


384  ^iV  AMERICAN    TEXT-BOOK   OF  SURGERY. 

branches  to  the  occipito-frontal  and  tlie  orbicularis,  and  these  branches  may 
escape  biin;;  opcM'atCMl  on. 

8.  The  Spinal  Accessory  Nerve. — This  has  been  operated  on  espe- 
cially for  wry  neck.  The  nerve  pierces  the  sterno-cleido-mastoid  niuscle.  and 
then  passes  to  the  trapezius,  supplyin;^  both  of  these  muscles.  It  may  be  ope- 
rated on  before  or  after  its  passage  through  the  sterno-cleido-mastoid:  (A)  If 
operated  on  before  it  enters  this  muscle,  the  incision  is  made  along  the  anterior 
border  of  the  muscle  downward  from  the  lobule  of  the  ear  for  two  or  tiiree 
inches.  The  muscle  being  exposed  and  turned  outward,  the  nerve  is  discov- 
ered a  little  above  the  level  of  the  hyoid  bone  where  it  enters  the  muscle. 
(B)  To  reach  the  nerve  after  it  has  emerged  from  the  sterno-cleido-mastoid 
muscle  the  incision  is  made  along  the  posterior  border  of  the  muscle  two 
inches  long,  the  center  of  the  incision  corresponding  to  the  center  of  the  muscle 
vertically.  The  nerve  will  be  found  a  little  above  the  center  of  the  wound, 
and  should  be  traced  upward  to  its  point  of  emergence  from  the  muscle  and 
exsected.     The  former  operation  is  the  better  one. 

0.  Division  of  the  Nerves  of  the  Posterior  Cervical  Muscles  for 
Wry  Neck. — Keen  has  described  an  operation  for  the  exsection  of  the  poste- 
rior divisions  of  the  first  three  cervical  nerves,  which  may  be  done  either  inde- 
pendently of  the  operation  on  the  spinal  accessory  or  as  an  adjunct  to  it. 
Noble  Smith  and  Powers  have  since  done  similar  operations. 

10.  Cervical  Plexus. — The  branches  of  the  plexus  may  be  reached  by 
means  of  an  incision  along  the  middle  of  the  posterior  border  of  the  sterno- 
cleido-mastoid  muscle. 

11.  Brachial  Plexus. — The  brachial  plexus  may  be  readily  exposed  just 
above  the  clavicle  by  the  horizontal  incision  for  the  ligation  of  the  subclavian 
artery.  The  plexus  is  reached  immediately  under  the  deep  fascia.  The  nerve- 
trunks  are  easily  recognized,  and  one  or  more  of  them  may  be  operated  on  as 
is  deemed  best.     Care  is  required  not  to  mistake  the  lowest  cord  for  the  artery. 

12.  Median  Nerve. — In  the  arm  the  median  nerve  is  readily  reached  by 
the  incision  for  ligation  of  the  brachial  artery,  at  the  inner  border  of  the  biceps 
muscle  at  its  middle.  The  nerve  usually  crosses  in  front  of  the  artery  from 
without  inward.  In  the  forearm  the  nerve  can  best  be  reached  just  above  the 
wrist-joint  by  an  incision  two  inches  long  at  the  inner  side  of  the  tendon  of 
the  palmaris  longus.  It  lies  immediately  under  the  deep  fascia.  Its  branches 
to  the  thumb  and  fingers  are  easily  reached  by  an  incision  along  the  inferior 
border  of  the  thenar  eminence.  It  lies  just  under  the  edge  of  the  palmar 
fascia. 

13.  Ulnar  Nerve. — In  the  middle  of  the  arm  the  ulnar  nerve  can  be 
reached  by  an  incision  similar  to  that  for  finding  the  median  nerve,  but  slight- 
ly farther  back.  Behind  the  elbow  it  can  be  exposed  by  an  incision  directly 
over  it  as  it  runs  in  the  groove  between  the  internal  condyle  and  the  olecranon. 
A  little  above  the  wrist  it  is  exposed  by  an  incision  on  the  radial  side  of  the 
tendon  of  the  flexor  carpi  ulnaris.  In  the  two  ])ositions  first  described  the 
nerve  lies  immediately  under  the  deep  fascia.  Just  aliove  the  wrist  it  lies 
more  deeply  under  a  second  layer  of  the  deep  fascia. 

14.  Musculo-spiral  Nerve. — This  can  be  readily  found  in  the  musculo- 
spiral  groove  by  an  incision  corresponding  to  the  groove  between  the  biceps 
and  supinator  longus  muscles.  The  deep  fascia  having  been  divided,  the 
nerve  is  found  in  the  interspace  between  these  muscles,  and  can  be  felt  as  a 
cord  rolling  between  the  finger-tips. 

15.  Radial  Nerve. — This  branch  of  the  musculo-spiral  can  also  be  easily 
found  by  a  longitudinal  incision  on  the  outer  border  of  the  forearm,  about  three 


SURGEIiV   OF  JOINTS.  385 

inches  above  the  wrist-joint,  just  where  the  nerve  passes  under  the  tendon  of 
the  supinator  h^nrjns  to  tlie  Ijack  of  the  hand. 

10.  Great  Sciatic  Nerve. — The  patient  shouhl  be  phaced  upon  liis  abdo- 
men and  an  ineisi(»n  about  four  inches  lonti;  sliouhl  be  made  in  tlie  middle  line 
of  the  le<:,  be<;innin<!;  just  below  the  <iluteo-fenioral  crease.  As  soon  as  the 
deej)  fascia  is  cut  through,  the  belly  of  the  biceps  will  be  found,  and  on  tearing 
throutrh  the  connective  tissue  at  its  outer  border  the  trunk  of  the  great  sciatic 
will  be  found  with  ease. 

17.  Tibial  Nerves. — The  anterior  and  posterior  tibial  nerves  may  be 
exposed  by  the  same  o))erations  as  for  ligation  of  their  resj)ective  arteries. 
The  posterior  tibial  may  also  be  exposed  by  a  curved  incision  Ijehind  the 
internal  nuilleolus  and  the  heel.      It  lies  just  posterior  to  the  artery. 


CHAPTER   VII. 

SUEGERY  OF  JOINTS. 

SECTION   I.— GENERAL  CONSIDERATIONS. 

Like  the  other  structures  of  the  body,  the  joints  are  subject  to  injury  and 
disease.  All  the  articulations  have  an  anatomical  construction  -Nvhich  should 
be  kept  in  mind  because  of  its  influence  upon  the  nature  and  course  of  the 
pathological  processes  that  are  observed.  The  more  or  less  expanded  ends  of 
the  bones,  in  each  of  the  larger  joints,  are  covered  with  an  incrusting  cartilage. 
They  are  bound  together  by  a  capsular  ligament,  Avell  developed  in  the  ball-and- 
socket  joints,  imperfectly  so  in  the  hinge  joints,  with  re-enforcing  bands  as  may 
be  required  ;  such  ligamentous  structures  being  firmly  attached  to  the  bones  and 
closely  connected  with  the  periosteum.  The  joint-cavity,  except  over  the  artic- 
ulating cartilages,  is  lined  by  a  synovial  membrane,  which  is  either  a  closed  sac 
or  communicates  with  adjacent  bursse.  It  is  sufficiently  lax  to  permit  of  the 
free  movement  of  the  bones  upon  each  other,  and  consequently  is  more  or  less 
folded  and  fringed,  and  holds  and  covers  larger  or  smaller  masses  of  fat.  intended 
to  lessen  shock.  Outside  the  capsule  and  supported  by  connective  tissue  are 
the  muscles  moving  the  joint,  their  bellies,  or  more  generally  their  tendons, 
often  running  in  well-formed  sheaths.  These  muscles  are  always  innervated 
by  branches  of  the  same  nerve  that  sends  filaments  to  the  joint  structures 
proper,  and  from  the  same  trunk  come  the  fibers  distributed  to  the  fasciae 
and  the  skin  over  the  insertions  of  the  muscles.  The  blood-vessels,  each  arising 
from  the  nearest  large  trunk,  quickly  break  up  into  many  small  branches  run- 
ning among  the  fibers  of  the  ligaments  in  the  subsynovial  connective  tissue 
and  in  the  synovial  membrane ;  the  incrusting  cartilages  being  nourished  by 
imbibition. 

Inflammations  of  varying  intensity  are  of  frequent  occurrence :  they  may 
be  due  to  traumatism,  to  rheumatism  or  gout,  to  the  presence  and  chemical 
products  of  micro-organisms,  or  to  disturbances  of  innervation.  They  may  be 
slight  or  severe,  acute  or  chronic.  They  may  terminate  in  resolution,  in  per- 
manent new  formations  more  or  less  deforming  and  disabling,  or  in  destruction 
of  the  articulation.  They  may  originate  in  the  joint  structures  proper,  espe- 
cially in  the  synovial  membrane,  or  they  may  extend  from  contiguous  parts, 
the  cancellous  bone-ends,  the  overlying  tendon-sheaths,  or  the  periarticular 

25 


SS6  Ai\   AM  1:1^  1<  AX    TKXT- HOOK    OF  SlJidFJiY. 

connoctivo  tissues.  Tliev  inav  be  lar'rrlv  roiiliiuMl  to  a  sin<:le  structure,  the 
synovial  membrane  being  the  part  ordinarily  aftccted,  or  they  may  involve  the 
Avhole  of  the  joint. 

The  usual  inflammatory  changes  in  blood-supply,  in  cell-development, 
and  in  function  are  all  present.  Vascular  fulness  is  observed  chielly  in  the 
acute  affections  and  in  the  synovial  membrane,  which  becomes  re<ldene(l,  it 
may  be  intensely  so,  especially  in  its  fringes.  Effusion  of  serum  takes  place 
in  the  membrane,  in  the  connective  tissue  beneath  it,  in  tiie  interspaces  of  the 
ligaments,  and  particularly  into  the  joint-cavity.  The  endothelial  cells  pro- 
liferate unduly  and  are  thrown  off,  even  to  the  extent  at  times  of  rendering  the 
synovial  fluid  milky  or  purulent  in  appearance.  Fibrinous  exudations  occur 
on  the  free  surface  and  in  the  membrane  and  capsule.  New  cell-growtli  takes 
place  in  excessive  amount  in  certain  of  tlie  infhinnnations — e.(j.  tlie  tubercular. 
Extravasations  of  blood  may  occur  into  or  beneath  tlie  synovial  membrane  or 
into  the  cavity.  The  articular  cartilage  may  undergo  no  material  change,  or 
may  become  softened  and  absorbed  under  pressure  or  by  the  action  of  the  new- 
formed  granulation-cells,  or  be  separated  in  large  flakes,  or  undergo  atrophy, 
or  become  hypertrophied  around  its  edge.  The  ligaments  also  may  be  essen- 
tially unaffected,  or  they  may  split  up  and  degenerate  in  part  or  wholly,  their 
place  being  taken  by  a  lardaceous  new  formation.  In  all  cases  function  is 
impaired,  either  as  a  whole  with  reference  to  movement  or  as  respects  the 
synovial  membrane  and  its  secretion  of  synovia,  which  latter  may  become  very 
al)undant  and  very  watery,  or  very  scant,  not  enough  to  lubricate  the  surfaces, 
which  grate  as  they  rub  against  each  other. 

SECTION  II.— SYNOVITIS. 

Except  in  acute  attacks,  mainly  due  to  injury,  an  inflammation  lighted  up 
in  the  synovial  membrane  does  not  remain  confined  to  it,  but  affects  the  other 
parts  of  the  joint,  and  is  an  arthritis  and  not  a  synovitis,  altliough  not  seldom 
even  in  very  chronic  cases  the  synovial  affection  is  the  chief  one. 

As  the  result  of  an  aseptic  wound,  of  a  subcutaneous  injury  (contusion  or 
sprain),  of  the  irritation  produced  by  a  floating  cartilage,  or  of  exposure  to 
cold  and  dampness,  simple  inflammation  may  attack  the  synovial  membrane. 
The  part  becomes  congested,  cliiefly  around  the  edges  of  the  cartilage  and  in 
the  fringes,  which  because  of  their  undue  vascularity  and  the  associated  oedema 
are  somewhat  elongated.  At  times  the  whole  membrane  is  highly  injected  and 
cedematous.  The  synovial  secretion  is  more  or  less  increased  in  amount  accord- 
ing to  the  nature  and  intensity  of  the  inflammation.  In  character  it  may 
remain  normal  or  may  become  watery.  Because  of  existing  fibrinous  exuda- 
tions it  may   be  flocculent. 

The  symptoms  are  unmistakable.  The  joint  is  painful,  especially  upon 
motion,  often  severely  so,  and  particularly  at  night.  It  is  swollen  and  tense, 
it  may  be  fluctuating.  At  the  knee  the  patella  is  floated  up  from  the  condyles, 
upon  which  it  can  readily  be  depressed,  to  rise  again  when  pressure  is  taken 
off.  By  the  muscular  contraction  of  the  flexors  the  joint  is  held  in  that  posi- 
tion which  permits  of  greatest  distention  and  is  therefore  the  most  comfortable. 
The  part  is  never  in  full  extension,  the  production  of  which  much  increases 
the  suffering.  Each  joint  has  its  position  of  greatest  ease,  which  is  sponta- 
neously and  quickly  assumed  when  inflammation  occurs.  The  swelling  is  most 
marked  in  the  spaces  between  the  ligaments  and  where  the  capsule  is  not 
crossed  by  firm  tendons.  The  local  heat  is  decidedly  raised,  but  the  skin, 
while  it  is  very  sensitive  to  pressure,  perhaps  only  at  certain  points,  is  neither 


SURGERY   or  JOINTS.  387 

tliickciUMl  nor  reddened.  ('i»iistiliiti<iii:il  syniptoniH  if  present  ai'c  only  moderate 
in  d('i!;ree.  After  a  few  hours,  or  at  most  days,  tlu^  intensity  of  the  symptoms 
suhsides,  tlie  pain  lessens,  the  swellinjf  diminishes  as  the  effusion  and  extrav- 
asated  blood  are  absorbed,  the  lind>  takes  its  natural  ])osition,  and  recovery 
quickly  folloAvs.  If  there  has  been  much  hemorrhage  into  the  cavity,  there 
may  be  afterward  some  restriction  of  motion  in  consequence  of  organization 
of  a  part  of  the  clot  and  its  adhesion  to  adjacent  sides  of  the  folded  synovial 
membrane. 

In  the  treatment  the  joint  should  l)e  placed  at  rest.  Cold  may  be  locally 
applied  by  an  ice-bag  or  a  coil  of  rubber  tubing  (Leiter)  or  by  continuous 
irrigation  ;  or  hot  applications  may  be  made,  simple  or  medicated,  the  lead- 
and-opium  lotion  being  perhaps  the  best ;  or  equable  pressure  as  firm  as  can  be 
comfortably  borne  may  be  employed,  the  affected  region  being  enveloped  in  a 
thick  layer  of  cotton  or  wool,  and  a  bandage,  preferably  of  rubber,  put  oif. 
The  cotton  or  avooI  next  the  skin  nuiy  be  moistened  with  the  hot  lead-and- 
opium  wash,  and  the  advantages  of  both  heat  and  pi*essure  be  secured  ;  or  the 
joint  may  be  at  once  immobilized  in  plaster  of  Paris.  Pressure  will  ordinarily 
prove  most  satisfactory.  Unless  the  serous  distention  of  the  joint  is  extreme 
or  there  has  been  a  large  extravasation  of  blood  into  the  cavity,  the  fluid  will 
not  need  to  be  draAvn  off,  but  may  be  left  to  the  action  of  the  absorbents.  If 
aspiration  is  done,  every  precaution  must  be  taken  to  prevent  sepsis. 

Chronic  Synovitis. — As  already  stated,  a  synovial  inflammation,  Avhat- 
ever  its  intensity,  cannot  long  continue  without  extension  of  the  morbid  pro- 
cess to  other  structures  of  the  joint  and  the  development  of  an  arthritis  ;  yet 
not  seldom  the  affection  of  the  synovial  membrane,  so  far  as  disturbance  of  its 
function  is  concerned,  remains  so  prominent  a  clinical  feature  that  the  case 
may  be  very  properly  viewed  as  one  of  chronic  synovitis.  The  active  conges- 
tion that  belongs  to  the  acute  stage,  of  which  the  chronic  is  usually  the  sequence, 
largely  disappears,  leaving  the  membrane  but  little  changed  in  appearance  from 
the  normal.  There  is,  however,  an  undue  amount  of  fluid  in  the  cavity,  and 
the  membrane  itself  is  oedematous.  Later,  if  the  disease  does  not  subside,  the 
membrane  and  the  articular  structures  become  irregularly  thickened  by  plastic 
exudation  and  the  formation  of  fibrous  tissue,  ■with  intervening  patches  where 
there  have  been  degeneration  and  softening.  The  folds  of  the  membrane  are 
not  seldom  fastened  together  by  adhesions  resulting  from  the  organization  of 
blood-clots  or  from  an  exudation  thrown  out  between  them  ;  and  at  times  from 
the  fringes  and  villi  there  are  developed,  it  may  be  in  great  number,  growths 
larger  or  smaller,  often  pedunculated,  that  push  into  the  cavity.  There  is  little 
or  no  change  in  the  temperature  of  the  part.  Though  the  joint  is  weak,  it  is 
not  specially  painful  except  upon  pressure,  and  may  not  be  so  even  then. 
Movements,  especially  in  extension,'  are  restricted,  and  generally,  as  the 
effused  fluid  has  become  absorbed,  are  attended  by  some  grating  or  creaking. 
It  is  the  presence  of  an  undue,  often  an  excessive,  amount  of  fluid  in  the  joint 
that  is  alone  to  be  here  considered,  all  the  other  conditions  being  those  of  long- 
standing arthritis  dependent  upon  diathetic,  suppurative,  or  infective  causes. 
The  symptoms  of  such  accumulation  of  fluid  are  well  marked.  The  joint  if  a 
superficial  one  (and  it  is  the  knee  that  is  by  far  the  most  frequently  affected)  is 
evidently  distended,  perhaps  very  much  so.  There  is  fluctuation  upon  palpation. 
The  muscles  in  the  vicinity  are  wasted,  it  may  be  considerably,  making  the 
articular  enlargement  the  more  prominent.  With  the  hypodermatic  needle 
fluid  may  be  drawn  off  which  will  ordinarily  be  straw-colored  or  a  little  darker, 
somewhat  viscid,  occasionally  flocculent,  and  at  times  more  or  less  blood-stained. 

The  treatment  varies  with  the  amount  of  fluid  present  and  according 


388  .I.V   AMERICAN    TKXT-lUtOK    OF   SinidEliY. 

to  the  type  of  tlie  arthritis;  for  it  must  lu-  rciiicniljcrctl  that  siijierahimflance 
of  fluid  in  a  joint  is  not  in  itself  a  disease,  but  a  symptom  of  a  traumatic, 
a  rheumatic,  a  tubercuhir,  or  a  deformini:;  artliritis,  or  even  (jf  s<une  local  or 
general  disturbance  of  the  circulation.  When  the  aft'ection  is  not  of  h»ng 
standing  and  the  articular  fulness  is  not  very  great,  rest  and  pressure  may  be 
all  that  will  be  required  to  produce  absorption,  the  joint  being  enveloped  in 
cotton  and  bandaged  (the  elastic  bandage  being  the  best)  or  preferably  immo- 
bilized with  plaster  of  Paris.  Baths,  frictions,  massage,  electricity,  blisters, 
mercurial  ointment  or  plaster,  each  has  often  been  found  of  service.  Simple 
aspiration  followed  by  immobilization  may  bring  about  recovery,  or  if,  as  is 
apt  to  be  the  case,  reaccumulation  of  fluid  takes  place,  it  Avill  l»e  in  nnich 
diminished  quantity  and  will  very  likely  be  readily  absorbed.  When  the  affec- 
tion is  of  long  standing  and  the  joint  is  much  distended,  with  associated  marked 
impairment  of  its  usefulness,  in  the  condition  which  may  properly  be  called 
hjldrarthrosls  or  lijfdrops  articuU.  when  the  methods  of  treatment  already 
spoken  of  have  been  thoroughly  tried  and  have  proved  useless,  very  excellent 
results  may  be  secured  by  aspiration  and  injection  of  a  3  per  cent,  to  />  per 
cent,  solution  of  carbolic  acid.  The  parts  having  been  thoroughly  disinfected, 
the  fluid  is  aspirated  (every  care  being  taken  to  have  the  needle  aseptic),  the 
cavity  is  irrigated  with  freshly  boiled  water  until  the  fluid  comes  out  perfectly 
clear,  and  then  the  1  to  2  per  cent,  carbolic  solution  is  injected,  after  which 
the  joint  is  immobilized.  This  method  of  treatment  should  not  be  adopted 
so  long  as  there  is  any  inflammation  in  the  joint,  and  the  o})eration  must  be 
done  with  the  most  scru])ulous  precautions  as  to  asepsis. 

SECTION    III.— ARTHRITIS. 

Inflammation  of  a  joint  as  a  whole  may  be  either  acute  or  chronic.  It  may 
be  consequent  upon  the  presence  of  pyogenic  cocci,  of  infection  by  the  bacilli 
of  tuberculosis,  or  of  the  micro-organisms  of  any  one  of  the  acute  infectious 
diseases,  or  of  gonorrhea ;  upon  rheumatism  or  gout  or  the  rheumatoid  con- 
dition, whatever  may  be  its  nature ;  upon  syphilis ;  and  upon  lesions  of  the 
nervous  system,   especially  tabes. 

(A)  Tubercular  Arthritis. — The  great  majority  of  cases  of  chronic  joint 
disease  are  tubercular,  the  bacilli  being  primarily  deposited  in  the  ])one.  the 
synovial  membrane,  or  the  capsule  and  periarticular  structures  ;  most  frequently, 
especially  in  children,  in  the  bone.  In  this  osseous  variety  of  joint  tuberculosis 
the  secondary  infection  of  the  soft  parts  takes  place  after  destruction  of  the 
cartilage  over  a  carious  area  or  over  a  wedge-sliaped  tubercular  infarct  in  the 
epiphvsis.  with  resulting  opening  of  the  joint-cavity  :  or  through  a  siinis  extend- 
ing to  the  synovial  membrane  outside  the  cartilage  or  reaching  the  capsule 
farther  out ;  or,  which  is  of  comparatively  rare  occurrence,  from  the  tubercu- 
lar periarticular  structures,  the  ligaments  and  the  synovial  membrane  becoming 
infected  by  the  extension  of  the  morbid  process.  When  the  synovial  membrane 
is  aff'ected,  whether  primarily  or  secondarily  from  a  neighboring  focus  in  the 
bone  it  matters  not,  the  developed  granulation-tissue  is  usually  abundant  and 
soon  extends  to  and  involves  the  capsule  and  the  structures  outside  of  it.  The 
parts  become  thickened,  a'dematous,  and  of  a  gelatinous  or  lardaccous  appear- 
ance, little  or  no  fluid  being  present  in  the  synovial  sac.  Occasionally  the 
membrane  is  thickly  studded  with  small  tubercules,  and  is  highly  vascular;  there 
is  little  new  formation  of  tissue,  but  an  abundant  serous  eff"usion  into  the  joint 
takes  ])lace.  In  other  cases  the  inflammation  is  a  plastic  one,  the  outgrowths 
being  few  and  large  or  papillomatous  and  very  numerous.     In  the  ordinary 


SURGERY   OF  JOINTS.  389 

fun<^ous  variety  (the  '*  gelutiiiif'orm  "  or  "  gelatinoid  dcgeneriition  "  of  many 
writers),  as  the  result  of  the  new  growth  and  the  oedcmatous  infiltration,  a 
marked  eliange  soon  takes  place  in  the  size,  shape,  and  appearance  of  the 
articulation.  The  natural  elevations  and  depressions  disappear,  the  softened 
ligaments  oft'ering  little  or  no  resistance  to  the  pressure  of  the  gi'owing  granu- 
lation-nuisses,  with  which  before  long  they  become  incorporated. 

The  contour  of  the  joint  is  globular  or,  more  properly,  spindle-shaped, 
because  of  the  decided  atrophy  of  the  parts  above  and  below  and  the  swelling 
of  the  periarticular  structures.  The  skin,  as  the  result  of  obliteration  of  the 
vessels  and  oedematous  infiltration,  is  white,  thick,  and  firmly  attached  to  the 
fascia  beneath.  A  few  large  superficial  veins  can  generally  be  seen.  Palpa- 
tion may  and  often  does  develop  pseudo-fluctuation,  because  of  the  abundance 
of  fluid  in  the  tissues,  and  true  fluctuation  in  the  exceptional  cases  in  which 
there  is  a  large  serous  accumulation  in  the  synovial  sac  or  when  the  joint  is  dis- 
tended with  the  so-called  tubercular  pus,  which  is  not  pus,  but  the  milky  fluid 
of  the  li(|uefying  caseated  masses.  Pain  is,  as  a  rule,  but  slight  in  the  strictly 
synovial  variety  ;  in  the  osteal  form  it  is  decided,  and  may  be  very  severe. 
It  is  always  to  be  elicited  by  pressure,  although  perhaps  only  over  a  limited 
space.  When  the  originally  synovial  disease  has  extended  to  the  adjacent 
epiphysis,  pain  will  be  present,  even  if  previously  absent.  The  heat  of  the 
part  is  always  increased;  but  often  the  elevation  of  temperature  is  so  slight  as 
to  be  detected  only  by  careful  use  of  the  thermometer. 

Deformity  is  a  constant  accompaniment  of  the  disease  ;  its  degree  is  greater 
or  less  according  to  the  joint  aff'ected,  the  amount  of  disease  present,  and  the 
treatment  pursued.  It  is  due  to  (1)  the  natural  tendency  of  the  parts  to  take 
the  position  of  greatest  ease ;  (2)  the  softening  and  destruction  of  the  liga- 
ments ;  (3)  muscular  contractions  induced  by  reflex  irritations.  These  causes 
often  result  in  permanent  vicious  attitudes,  assumed  and  maintained  by  the 
patient  through  a  long  period  of  time. 

Caseation  and  liquefaction  of  the  fungous  masses  take  place  here  as  else- 
where, giving,  it  may  be,  no  evidence  of  their  occurrence  when  the  disease  is 
of  limited  extent,  but  indicated  generally  by  the  formation  of  so-called  abscesses 
and  sinuses.  The  opening  of  these  sinuses  is  almost  certain  to  lead  to  pyogenic 
infection  unless  the  latter  is  prevented  by  antiseptic  treatment.  When  it  occurs 
it  results  in  a  marked  aggravation  of  the  general  and  local  morbid  state.  Very 
frequently  in  the  history  of  a  tuberculous  joint,  extending  over  months  or  years, 
a  number  of  openings  will  successively  arise,  the  sinuses  which  communicate 
with  these  limited  degenerations  of  fungous  masses,  carious  patches,  or  sequestra 
of  small  size  alternately  opening  and  closing. 

The  diagnosis  of  joint  tuberculosis  is  easy,  difliicult,  or  impossible  accord- 
ing to  the  extent,  the  character,  the  location,  and  the  duration  of  the  aff'ection. 
If  of  the  fungous  variety  in  a  superficial  joint,  advanced  to  the  stage  of  decided 
deformity,  still  more  to  that  of  abscess  and  sinus,  there  can  ordinarily  be  no  mis- 
taking the  nature  of  the  trouble.  Syphilitic  disease  has  points  in  common,  but 
it  is  of  comparatively  infrequent  occurrence,  and  generally  there  will  be  in  the 
history  of  the  individual  or  in  the  condition  of  other  parts  of  the  body  evidences 
of  a  pre-existing  specific  infection.  But  if  the  disease  is  osteal,  has  advanced 
but  little,  has  caused  only  a  slight  impairment  of  the  articular  motions,  hardly, 
it  may  be,  more  than  an  unwillingness  fully  to  use  the  joint,  is  attended  with 
little  pain  and  no  appreciable  swelling  or  atrophy,  if  the  muscular  rigidity  is  so 
little  as  to  make  it  doubtful  whether  it  exists,  and  if  finally  the  joint  is  a  deep 
one,  the  disease  very  likely  will  be  overlooked.  At  best  the  diagnosis  is  but  a 
proljable  one.   In  all  such  cases,  even  when  there  is  only  a  well-grounded  suspicion 


390  AX   AJfEnifAy    TEXT- BOOK'    OF   STRGERY. 

of  the  existence  of  tubercular  disease,  the  patient  should  be  given  the  benefit 
of  the  doubt  and  treated  for  a  time  as  though  the  disease  was  un(|uestionablv 
present. 

What  is  called  '*  pannous  synovitis"  is  rarely  met  with.  In  this  form 
the  tubercles  are  small  and  in  great  number,  the  vascularity  of  the  membrane 
intense,  new  formation  of  very  limited  extent,  and  the  ligaments  and  jjcriar- 
ticular  structures  but  slightly  affected.  The  great  serous  accumulation  in  the 
synovial  sac  will  almost  certainly  be  regarded  as  non-tubercular  in  character 
until  after  aspiration  and  examination  of  the  fluid. 

The  prognosis  depends  upon  the  extent  of  the  disease,  the  general  con- 
dition of  the  patient,  and  especially  upon  the  treatment  employed.  In  a  few 
cases,  doubtless,  the  tubercular  area  is  so  small,  the  extension  of  the  morbid 
process  so  easily  arrested,  the  new  formation  so  slight,  and  the  adhesions  and 
bands  developed  in  its  cicatrization  so  limited,  that  after  recovery  has  taken 
place  there  will  be  little,  it  may  be  practically  no  impaimient  of  the  motions 
of  the  joint.  But  in  the  great  majority  of  cases  this  does  not  occur.  The 
cartilages  are  more  or  less  extensively  destroyed,  intra-  and  extra-synovial 
bands  are  foraied.  and  the  size  of  the  joint-cavity  is  diminished.  In  propor- 
tion as  there  has  been  damage  to  the  component  structures  of  the  articulation 
must  the  functional  value  of  the  joint  be  lessened,  all  the  more  when  there  has 
been  displacement  of  one  bone  upon  the  other.  The  restriction  of  motion  may 
be  absolute.  Ossification  of  the  granulation-tissue  uniting  the  surfiices  of  the 
epiphyses,  which  have  been  deprived  of  cartilage  and  eroded  by  caries,  may 
have  taken  place  (true  bony  ankylosis),  progressing  sometimes  to  the  extent  of 
complete  fusion  of  the  two  bones ;  or  the  same  result  may  have  been  secured  with- 
out ossification,  short,  firm  fibrous  bands  existing  within  the  capsule,  the  action 
of  which  is  further  reinforced  by  ligamentous  and  periarticular  contractions 
and  adhesions  (false,  fibrous  ankylosis).  At  times,  though  recovery  has  been 
in  a  great  measure  secured,  a  sinus  or  sinuses  will  long  remain  because  of  the 
presence  of  a  limited  amount  of  carious  or  necrosed  bone  or  of  the  tuberculi- 
zation of  the  sinus  wall.  Even  where  all  morbid  action  seems  to  have  been 
arrested,  and  the  patient  for  months,  it  may  be  for  yeai-s,  has  been  free  from  all 
indications  of  disease,  the  joint  may  again  become  the  seat  of  tubercular  inflam- 
mation, either  because  of  the  setting  free  of  primarily  encapsulated  organisms 
or  because  as  a  place  of  least  resistance  it  most  readily  becomes  the  field  of  a 
new  infection.  During  the  necessarily  long  period  that  must  elapse  before 
recovery  can  take  place  there  is  an  ever-existing  danger  of  the  development 
of  visceral  or  general  tuberculosis.  Caseation,  if  extensive,  is  associated  with 
constitutional  disturbances  of  greater  or  less  severit}'.  When  sinuses  have 
opened,  septic  infection  of  the  diseased  parts  is  almost  certain  to  occur  unless 
prevented  by  antiseptic  treatment,  and  the  resulting  suppuration  exposes  the 
patient  to  the  added  risks  of  exhaustion,  amyloid  disease,  and  septicemia. 

The  treatment  is  that  of  tubercular  disease  in  general.  The  indications 
are  to  prevent,  or,  as  far  as  possible,  to  limit,  the  multiplication  of  the  bacilli 
and  the  extension  of  their  action  ;  to  favor  the  condensation  and  cicatrization 
of  the  non-tubercular  new-formed  granulation-tissue ;  failing  in  this,  to  remove 
the  infected  part.  For  the  fulfilment  of  the  first,  rest  is  of  the  utmost  import- 
ance, since  it  lessens  irritation  and  diminishes  the  blood-supply  and  the  rapidity 
of  its  flow.  It  may  be  secured  by  splints  and  muslin  or  rubber  bandages,  but 
best  by  immobilization.  The  joint  having  been  enveloped  in  a  thick  layer  of 
cotton,  the  plaster-of-Paris  bandage  is  to  be  firmly  but  not  too  tightly  applied 
(that  the  beneficial  effects  of  pressure  may  also  be  secured),  not  only  over  the 
joint,  but  also  nearly  to  the  levels  of  the  joint  above  and  that  below,  care 


SURGERY   OF  JOINTS.  391 

bciii-  taken  that  the  joint  is  held  in  a  position  of  ease  .luvin-  the  setting.    Such 
immobilization  must  be  continued  for  .veeks,  often  for  months,  new  bandages 
bein.^  applied  as  the  size  of  the  joint  diminishes.     11  this  is  employed  at  an 
earlf  peri^od  and  the  affected  limb  is  kept  quiet,  recovery  may  be  expected  in  a 
ZxX  proportion  of  cases  of  joint  tuberctdosis.     Instead  of  the  plaster-of-Paris 
banda-e.  a  fixation  or  a  traction-and-fixation  splint  may  be  employed,  and  is 
by  m.my  regarded  as  preferable,  but  in  general  the  plaster  bandage  Avill  be 
fomid  t(;  secure  more  complete  rest  of  the  joint.     Accumulations  of  fluid,  either 
intra-  or  extra-articular,  may  very  properly  be  removed  by  aspiration,  provided 
a  thorou<.hlv  aseptic  needle  is  used,  but  in  the  ordinary  cold  abscesses  conse- 
quent ui;.n>in/  inflammation  if  the  disease  is  thoroughly  treated  the  abscesse 
m^Y  safilv  be  left  to  take  care  of  themselves.     If  they  are  tapped  they  should 
also  be  Avell  irrigated,  preferably  with  an  oil  or  glycerin  so  ution  of  lodofoi-m 
?5  to  25  per  cent!  of  the  former ;  5,  or  better  10,  per  cent,  of  the  latter).     For 
the  relief  of  pain  and  localized  tenderness  ignipuncture  or  penetration  into 
the  bone  with  the  thermo-cautery  has  been  used  with  advantage. 

When  the  case  is  one  of  tubercular  dropsy,  aspiration  should  always  precede 
the  application  of  the  immobilizing  dressing,  or,  better,  aspiration  followed  by 
the  iodoform  injection.  ^ 

Much  attention  has  of  late  been  given  to  the  discovery  and  employment  of 
agents  that  will  condense  and  favor  the  cicatrization  of  the  new  tissue  outside 
of  the  tubercular  area  and  bring  about  the  destruction  or  encapsulation  of  the 
bacilli       Chloride  of  zinc  and  iodoform  are  the  remedies  most  m  favor       liiey 
are  iniected  into  and  around  the  tubercular  masses,   and  their  employment 
has  certainly  proved  of  service.     In  using  the  zinc  solution  only  a  few  drops  are 
thrown  in— three  to  five  drops  ordinarily,  at  times  as  high  as  twenty.      Ihe  tend- 
ency seems  to  be,  of  late,  to  increase  both  amount  and  strength.      Ihe  lU  per 
cent  solution  of  iodoform  in  glycerin  or  oil  has  been  much  more  largely  used 
and  unquestionablv  in  some  cases  it  does  both   destroy  the  organisms  and 
favor  the  condensation  of  the  new  tissue.     It  may  be  injected  once  a  week 
or  once  a  fortnicrht,  and  continued  until  the  case  is  evidently  well  advanced 
toward  recovery  or  until  it  becomes  certain  that  no  good  is  being  accom- 
plished.    This  can  usually  bedetermined  in  the  course  of  a  month.      V\  hen 
used  in  the  treatment  of  abscesses  or  of  joints  containing  much  fluid  tbe  in- 
iection  shoukl  always  be  preceded  bv  thorough  irrigation  with  freshly-boiled 
water  or  a  boric-acid  solution  (3  to  5  per  cent.).     Instead  of  either  of  tbe 
remedies  mentioned,  the  balsam  of  Peru  may  be  used  to  advantage. 

Of  course,  whatever  local  treatment  is  adopted,  care  must  be  taken  to  secure 
for  the  patient  as  far  as  possible  those  general  hygienic  conditions  which  are 
so  strongly  demanded  by  the  subjects  of  tubercular  disease,  no  matter  where 
located  ^and  the  ordinary  constitutional  remedies  should  be  employed. 

When  the  extent  of  the  disease  and  the  local  and  general  eflects  produced 
by  it  are  such  as  to  make  it  certain,  or  at  least  probable,  that  recovery  cannot 
take  place  under  the  treatment  indicated,  or,  if  it  may,  that  it  will  be  only  at 
great  risk  to  life  or  after  a  long  time,  and  then  with  a  bmb  far  fi-om  service- 
able, conservative  treatment  must  give  place  to  operative.  The  tubercular  tis- 
sue must  be  thoroughly  removed,  by  erasion,  by  excision,  or  by  amputation. 
These  operations  and  the  indications  for  the  adoption  of  one  rather  than  another 
are  treated  of  elsewhere  (see  Operations  on  Joints),  and  need  not  be  considered 

here 

TUBERCULAR   DISEASE   OF  SPECIAL  JOINTS. 

Hip- JOINT  Disease.— Hip-joint  disease  {morbus  eoxarius,  morbus  coxce) 
is  very  much  more  common  in  children  than  in  adults.     In  the  former  at  least 


3i)2  AX   AMERICAN    TEXT-IKX tK    OF   SURGERY. 

it  is  generally  bony  in  origin,  the  tubercular  deposit  being  in  the  majority  of 
cases  at  first  in  the  femoral  epiphysis,  a  region  naturally  subject  to  the  action 
of  repeated  shocks  and  slight  traumatisms.  In  not  a  few  patients  the  acetabulum 
is  first  aftected,  and  primary  infcctidn  of  the  soft  structures  of  the  articulation 
is  probably  by  no  means  so  infreijuent,  even  in  early  life,  as  is  often  supposed. 
Whether  in  the  beginning  osteal  or  synovial,  the  disease  naturally  presents 
three  stages :  first,  that  of  deposition  of  the  bacilli  and  the  early  irritations 
and  new  formations  consequent  thereupon ;  second,  that  of  fully-developed 
arthritis,  with  its  eftusions  and  fungous  masses;  third,  that  of  breaking  down 
of  the  infected  tissues  and  greater  or  less  disorganization  of  the  joint,  followed 
by  repair,  which  is  usually  slowly  effected  and  fur  from  perfect,  or  by  death. 
Each  stage  has  its  distinguishing  symptoms.  Because  of  the  most  apparent 
symptom,  the  second  is  often  spoken  of  as  the  stage  of  lengthening,  the  third 
as  that  of  shortening. 

In  the  first  stage  the  disease  is  very  apt  to  be  overlooked  or  misunder- 
stood for  a  considerable  time,  because  of  the  doubtful  or  slight  character  of  the 
symptoms,  though  occasionally  it  is  indicated  at  the  very  outset  by  well-marked 
signs.  Slight  lameness,  generally  little  more  than  stiffness,  is  noticed  at  times 
— as  a  rule  in  the  morning  rather  than  later  in  the  day  after  considerable  exer- 
cise has  beev  taken.  The  child  is  more  or  less  indisposed  to  play,  and  quickly 
tires.  Rigidity  of  the  muscles  about  the  joint,  especially  of  the  adductors, 
though  not  very  decided,  may  be  discovered  on  palpation.  The  muscles  of 
the  thigh  are  a  little  atrophied.  If  the  disease  is  primarily  synovial,  slight 
fulness  will  perhaps  be  observed  over  the  joint,  in  front  or  behind  the  trochan- 
ter, or  be  recognized  on  pressure.  At  times,  almost  wholly  in  the  osteal  variety, 
pain  is  complained  of,  about  the  hip,  in  the  thigh,  or  most  frequently  at  the 
knee,  but  usually  the  patient  suffers  but  little.  It  is  not  until  the  epiphysis 
has  become  extensively  diseased,  especially  on  the  side  of  the  incrusting  car- 
tilage, that  pain   l)ecnmes  a  symptom  of  importance. 

In  the  second  stage  the  disease  has  ])rogressed  so  far  that  the  symptoms 
are  decisive.  The  child  limps,  unquestionably ;  the  atrophy  of  the  thigh  is 
positive,  it  may  be  great ;  the  adductor  rigidity  is  marked.  If,  as  is  probable, 
effusion  has  taken  place  into  the  joint,  the  fulness  can  be  felt,  if  not  seen, 
and  the  hip  will  be  evidently  broadened  sidewise.  The  affected  extremity  is 
advanced  and  more  or  less  abducted  and  everted,  due  to  tilting  of  the  pelvis, 
the  weight  of  the  body  in  standing  and  walking  being  thrown  on  the  sound 
side  (Figs.  154,  155).  Occasionally,  though  rareh',  the  limb  is  adducted.  The 
gluteo-femoral  crease  is  more  or  less  lowered  and  shortened,  and  the  lines  of  the 
sulcus  between  the  nates  and,  in  girls,  that  of  the  vulva,  are  inclined.  The 
limb  is  apparently  lengthened,  but  only  apparently.  Pain  will  be  present  sooner 
or  later.  It  will  be  located  usually  in  the  anterior  and  lower  part  of  the  thigh 
and  the  antero-internal  surface  of  the  knee  in  the  course  of  the  obturator  nerve. 
It  is  often  "  starting  "  in  character,  and  most  severe  at  night  or  felt  only  at  that 
time.  But  pain  of  itself  is  an  unreliable  symptom,  and  its  absence  should  never 
be  regarded  when  other  indications  of  joint  disease  are  present.  The  hip  move- 
ments are  restricted,  chiefly,  as  a  rule,  in  full  extension  and  abduction.  These 
symptoms  are  due  to  various  causes :  the  muscular  tension  and  distant  pain,  to 
reflex  nervous  irritation ;  the  position  of  the  limb,  to  involuntary  muscular  action, 
and,  in  a  measure  perhaps,  to  distention  of  the  joint  when  effusion  has  taken 
place ;  the  starting  pains,  to  sudden  forcing  of  the  articular  surfaces  together. 
These  pains  occur  chiefly  at  night,  Avhen  the  protecting  muscles  about  the  joint 
are  less  under  control,  aiid  generally  indicate  more  or  less  extensive  destruction 
of  the  articular  cartilage.     The  effusion  within  the  joint  is  slight  in  the  osteal 


srnnEiiv  OF  joints. 


393 


variotv  of  tlio  disease  so  lonji;  as  it  is  simply  osteal,  but  is  usually  considerable 
when  "the  soft  structures  are  attected,  whether  such  aftection  l)e  primary  or  sec- 


FiG.  154. 


F'lo.  1  •")"). 


Position  in  Coxalgia  (Albert). 


Position  in  Coxalgia  (Albert). 


ondary.  Not  seldom  it  becomes  very  great,  and  causes  marked  swelling  in  front 
of  the  trochanter  major,  and  still  more  behind  it.  Because  of  the  resulting  intra- 
articular pressure  the  pain  is  likely  to  be  severe,  and  the  malposition  of  the  extrem- 
ity in  flexion  and  abduction  with  seeming  elongation  to  be  much  increased. 

The  constitutional  symptoms  are  often  severe. 

Even  when  large  in  amount  the  eifusion  may  spontaneously  disappear  to 
a  greater  or  lesser  extent,  but  not  seldom  the  pressure  upon  the  weakened 
diseased  capsule  is  so  great  that  rupture  occurs,  and  the  fluid  is  poured  out  into 
the  periarticular  tissues,  which  it  tuberculizes.  Abscesses  and  sinuses  will 
probably  follow  (Fig.  156).  Both  local  and  constitutional  symptoms  are,  as  a 
rule,  for  a  time  much  lessened  in  severity  as  soon  as  the  tension  is  relieved. 
As  the  intra-articular  fluid  disappears,  by  absorption  or  after  rupture,  the  joint 
surfaces  come  in  contact.  The  irritated  muscles  act  more  directly  upon  the 
already  damaged  head  and  perhaps  the  acetabular  rim,  the  bony  parts  are 
crowded  together  and  more  or  less  rapidly  broken  down  and  worn  away,  and 
progressively  increasing  flexion,  abduction,  and  shortening  result,  sometimes 

^^^"The^ so-called  third  stage  is  now  thoroughly  established.  The  femoral 
head  is  often  much  deformed,  and  is  progressively  pushed  upward  and  out- 
ward as  erosion  of  the  acetabular  rim  takes  place.  Actual  luxation  rarely 
occurs    the   head  ordinarily  remaining   within  the   capsule,  which    attaches 


394 


AN  AMEBIC  AX    TEXT- HOOK    OF  SURGERY. 


itself  farther  and  farther  out  on  the  bone  (Fi<,'.  I.'jT).      The  flexion  of  tlie  thi<rh 

upon  the  pelvis,  which  has  been  ))resent  in  greater  or  lesser  degree  from  the 

very  commencement  of  the  disease,  is  now  decided  and 

1- j(i.  156.  fixed.     When  the  limb  is  brought  down  in  extension  so 

^j       that  the  posterior  surface  of  the  thigh  and  that  of  the 

W.       knee  rests  upon  the  bed  or  table,  the  lumbar  spine  is 

carried  forward,  and  a  marked  lumbar  curve  is  at  once 

develiiped.  which  di8a])pears  as  soon   as  the  knee  is 

raised.     To  determine  this  point,  which  is  one  of  great 

Fig.  1o7. 


Common  Site  of  Hip  Abscess 
(Bradford  and  Lovett). 


Intra-acetabular  Luxation  in  Coxalgia  (Tillmannsi. 


importance,  the  patient  should  be  stripped  and  laid  on  the  floor  or  a  firm  table. 
The  sound  leg  can  be  flexed  and  extended  at  both  the  knee  and  the  hip 
without  any  influence  upon  the  lumbar  spine  (Fig.  158,  A).  But  Avhen  the 
diseased  leg  is  extended  the  lumbar  curve  becomes  so  marked  that  there  is 
often  space  for  the  arm  of  the  surgeon  to  be  thrust  under  it  (B).  Flexion  of 
this  leg  and  hip  is  followed  by  the  disappearance  of  the  curve.  The  reason 
for  this  is  that  the  femur  and  pelvis  are  held  so  rigidly  together  by  the  muscles 
that  they  move  as  if  ankylosed,  and  the  tilting  of  the  pelvis  in  the  extension  of 
the  thigh  necessarily  produces  the  lumbar  curve.  The  adduction  of  the  limb 
which  in  this  stage  succeeds  to  the  abduction  of  the  second  stage  is  commonly 
not  very  great.  As  the  result,  however,  of  neglect  of  treatment  it  may  reach 
an  excessive  degree,  the  thigh  in  such  cases  beintj  usuallv  very  stronglv  flexed 
and  carried  across  that  of  the  sound  side.  The  whole  extremity,  including  the 
gluteal  region,  is  greatly  atrophied. 

AVhen  the  so-called  abscess  has  opened  or  been  opened,  secondary  septic  in- 
fection is  almost  certain  to  take  place  unless  jirevented  by  antiseptic  treatment. 
At  times,  though  rarely,  when  there  has  been  no  perforation  of  the  skin,  the 
pyogenic  cocci  find  access  to  the  part  by  the  blood-stream.  Upon  the  occur- 
rence of  such  mixed  infection  the  parts  suppurate,  with  more  or  less  increase 
of  local  heat  and  tenderness  and  manifestation  of  the  general  symptoms  of  the 
"hectic"  state.  The  later  symptoms  vary  greatly  according  as  the  case  pro- 
gresses favorably  or  otherwise.     When  recovery  takes  place,  the  discharge, 


SURGERY    OF  JOINTS. 


395 


if  there  has  been  any,  lessens,  the  sinuses,  or  at  least  some  of  them,  close,  the 
patient  is  wholly  or  'in  a  great  measure  free  from  j.ain,  and  the  general  health 


B  f 


Effects  on  the  Lumbar  ^piue  of  Flexing  and  Extending  the  Diseased  Leg  in  Hip  Disease  (Albert). 

improves.  Partial  or  complete  ankylosis  of  the  joint  takes  place,  and  is  either 
fibrous  or  bony.  In  time  the  weight  of  the  body  can  be  borne  on  the  limb 
with  comfort,  the  inevitable  shortening  being  made  good  by  a  thick  sole  or  a 
raised  shoe.  When,  on  the  other  hand,  the  case  does  badly,  new  abscesses  and 
sinuses  form,  the  discharge  increases,  the  deformity  becomes  greater  and  greater, 
the  constitutional  symptoms  are  graver,  and  there  are  very  likely  clear  indica- 
tions of  the  existence  of  visceral  tuberculosis  or  of  amyloid  disease.  _ 

The  prognosis  depends  largely  upon  the  treatment.  If  the  disease  is 
recognized  early  and  properly  treated,  recovery  will  generally  follow  in  children, 
though  it  is  a  well-established  fsict  that  a  majority  of  the  patients  are  likely  to 
die  from  some  form  of  visceral  tuberculosis  before  reaching  full  maturity. 
In  adults  the  chances  of  recovery  are  decidedly  less.  The  disease  may  be 
arrested  at  any  point  in  its  course,  and  the  earlier  this  is  efi"ected  the  more 
nearly  perfect  will  be  the  recovery.  The  three  stages,  it  should  be  remem- 
bered, are  not  always  regularly  passed  through  ;  and  if  they  are,  the  transition 
from  one  to  the  other  may  be  either  slow  or  very  abrupt.  From  the  nature 
of  the  cause  the  disease  must  be  one  of  long  duration,  and  at  whateve^r  point  it 
is  arrested,  recovery  will  often  be  apparent  rather  than  real,  and  will  be  fol- 
lowed by  relapses,  it  may  be,  after  many  years.  The  future  usefulness  of  the 
limb  will  be  in  proportion  to  the  adhesions  that  have  formed  and  the  amount 
of  damage  done  to  the  articulation.  Even  in  the  third  stage,  if  favored  by 
fair  hygienic  surroundings  and  a  tolerably  good  state  of  health,  under  proper 
treatment,  local  and  general,  the  patient,  especially  if  a  child,  may  be  expected 
to  recover,  though  only  after  months  or  even  years,  and  with  a  hip  ankylosed  at 
a  more  or  less  vicious  kngle  and  a  limb  decidedly  and,  it  may  be,  greatly  short- 
ened. The  ankylosis  may  be  fibrous  or  bony  or  mixed.  In  a  comparatively 
small  number  of  cases,  after  long-protracted  disease,  the  fusion  of  the  femur 
and  the  innominate  bone  is  so  complete  that  it  is  impossible  even  upon  section 
to  determine  exactly  the  line  of  union.  Fig.  159  shows  a  case  of  ankylosis 
of  both  hips  at  such  an  angle  that  the  patient  could  not  stand  erect. 

As  respects  treatment,  the  earlier  it  is  instituted  the  sooner  and  more 
perfectly  may  the  patient  be  expected  to  recover.  The  prime  indication  is  to 
secure  rest,  as  absolute  as  possible,  of  the  diseased  part.     When  the  disease  is 


396 


AN  AMEBIC  AN    TKXT-ltOOk'    OF  SURGERY. 


recognized  early,  in  the  great  majority  ofcasos  prolonged  recumbency,  especially 
if  combined  ^vitll  extension  by  weight  and  pulley,  -will  arrest  its  progress.     A 


Fk;.   l.")i). 


Double  Aiikykisis  from  Hiji  joint  Disease  (original 


very  simple  yet  efficient  apparatus  for  securing  the  desired  rest  is  the  gas-pipe 
frame  of  Bradford  (made  of  \  in.  gas-pipe  joined  at  the  four  corners  by 
"  shoulders  "),  which  serves  at  once  as  a  stretcher  upon  which  the  patient  may 
be  carried  and  a  fixed  frame  to  Avhich  a  fixation  or  traction  apparatus  may  be 
attached.  Care  must  always  be  taken  to  make  the  extension  in  the  line  of 
the  deformity  ;  that  is,  in  the  line  of  the  flexed  and  abducted  or  adducted 
thigh,  which  is  to  be  lowered  and  the  abduction  or  adduction  corrected  as  the 
progress  of  the  case  may  permit. 

All  the  varieties  of  mechanical  treatment  that  have  been  used — and  they 
are  many — have  for  their  immediate  object  the  securing  of  fixation  or  traction 
or  a  combination  of  the  two.  In  the  first  class  are  to  be  placed  the  ])laster- 
of-Paris  dressing,  the  wire  cuirass  of  Bonnet,  the  "plaster  breeches"  of 
Sayre,  the  leather  splint  of  Vance,  the  long  splint  of  Thomas,  etc.  Thomas's 
splint  (Fig.  160),  without  doubt  the  most  useful  of  the  fixation  appliances,  is, 
in  brief,  a  bar  of  malleable  iron  about  \  in.  wide,  extending  from  the  inferior 
angle  of  the  scapula  to  the  lower  third  of  the  leg,  so  shaped  as  to  accommo- 
date itself  to  the  curve  of  the  buttock,  and  held  in  position  by  three  hoop- 
iron  bands,  the  upper  encircling  three-fourths  of  the  chest,  the  second  two- 
thirds  of  the  thigh  on  a  level  an  inch  or  two  below  the  perineum,  and  the 
third  two-thirds  of  the  calf.  The  apparatus  is  held  in  place  by  bandages  and 
straps,  and  if  the  ])atient  is  going  about,  the  sound  foot  is  raised  by  a  patten 


SURGERY    or   JOfXTS. 


397 


to  a  lieight  ^vlli(•ll   i.rcvciits  the  toes  of  the  foot  of  the  diseased  side  touch- 
iiitr  the^i^roimd,  and  compels  the  use  of  two  crutches  in  Avalking  (Fig.  160). 


Fk;.  161. 


Fio.  1G2. 


Fio.  163. 


Thumas's  Splint. 


Phelps's  Splint. 


Taylor's  Splint. 


Lovett's  Splint. 


Recognizing  the  fact  that  fixation  cannot  be  absolute,  and  that  it  does  not 
overcome  muscular  contraction  with  the  resulting  injurious  pressure  between 
the  head  of  the  femur  and  the  acetabulum,  the  great  majority  of  American 
surgeons  are  employing  some  form  or  other  of  traction  splint,  a  more  or  less 
extensive  modification  of  the  Davis  splint  of  forty  years  ago,  early  improved 
upon  by  Sayre  and  Taylor.  In  these  splints  opportunity  is  afforded  for 
alterino-  their  length  at  will  by  drawing  away  the  sliding  lower  rod  of  the 
apparatus  from  the  upper,  or  by  acting  upon  the  foot-piece  through  the  aid 
of  a  windlass,  the  counter-force  through  the  perineal  bands  preventing  the 
body  from  following  (Fig.  162).  Pressure-symptoms  are  thus  prevented  or 
relieved  and  recovery  correspondingly  promoted.  When  by  the  use  of  one 
of  these  splints  fixation  is  not  sufficiently  secured  (which  is  comparatively 
seldom),  a  combined  traction  and  fixation  splint  may  be  employed,  many 
useful  forms  of  which  have  been  devised,  among  them  those  of  Phelps  and 
Lovett  (Figs.  161,  163).  .       ,      ,         , 

General  treatment,  if  called  for  by  an  enfeebled  and  tubercular  state,  is 
indicated,  but  local  medicinal  treatment  is  of  no  value,  except  that  which  will 
secure  the  destruction  of  the  bacilli  and  the  condensation  and  cicatrization  of 
the  newly-formed  granulation-masses,  such  as  the  injection  into  and  around  the 
joint  of  iodoform,  chloride  of  zinc,  or  acid  phosphate  of  lime.  When  the  cap- 
sule is  much  distended  or  there  is  large  extra-articular  accumulation,  aspiration 
of  the  fluid  will  give  great  relief.  In  a  few  cases  the  bone  has  been  tunnelled 
through  the  trochanter  and  neck  and  a  permanent  drain  established.  When  the 
so-called  abscess  is  nearing  the  surface,  whether  it  shall  be  opened  or  be  left  to 
itself  to  undergo  absorption,  as  many  times  happens,  or  be  spontaneously  emp- 
tied, will  depend  upon  whether  or  not  it  is  causing  much  local  distress.  If  it  is, 
it  should  be  aseptically  opened  and  drained,  the  after-use  of  iodoform  injections 
being  of  much  service.  If  it  is  not,  careful  attention  to  the  maintenance  of 
quietude  is  all  that  will  be  necessary.     If  spontaneous  opening  is  imminent,  it  is 


398 


^liV   AMi:iU('AX    TEXT- HOOK    OF   Si' liO Eli  Y. 


Fi<i.  104. 


bettor  to  anticipate  it  liy  iiunsion,  as  the  danger  of  infection  by  pyogenic  organ- 
isms will  be  thus  done  away  with  or  reduced  to  a  minimum.  In  the  more  severe 
<3ases,  when  the  tuberculosis  of  the  bone  and  joint  is  extensive,  excision  or  era- 
sion  may  be  done,  either  early  by  choice  or  late  from  necessity,  that  which  is  done 
€arly  giving,  of  course,  the  best  result.  Though  such  operative  interference, 
because  of  its  aseptic  or  antiseptic  character,  is  now  not  attended  with  much 
dan<Ter  to  life,  and  may  be  expected  to  lessen  decidedly  the  period  of  treatment, 
yet  it  does  not  materially  diminish  the  lial)ility 
to  the  occurrence  of  other  or  general  tubercular 
disease ;  recovery  is  almost  always  with  con- 
siderable shortening,  and  the  functional  value 
of  the  extremity  is  often  no  better  than  that  after 
spontaneous  cure,  and  at  times  not  so  good.  The 
resulting  deformity  can,  if  necessary,  be  well 
iind  easily  corrected  by  osteotomy  through  the 
neck  of  the  femur,  or  better  below  the  lesser 
trochanter  (Fig.  164). 

Fortunately,  if  the  case  is  seen  early  and 
properly  treated,  the  necessity  of  deciding  the 
question  Avhether  or  not  operation  shall  be  done 
Avill  seldom  arise,  and  excision  is  called  for 
much  less  frequently  now  than  it  was  a  genera- 
tion ago.  When  performed,  a  splint  or  some 
protecting  apparatus  should  be  Avorn  for  a  long 
time  afterward  until  the  parts  have  become  firm. 
Many  if  not  most  of  the  early  relapses  are  due 
to  neglect  of  such  mechanical  after-treatment. 

Knee-joint  Disease. — Of  the  larger 
joints,  the  knee,  next  to  the  hip,  is  the  one  most 
frequently  aifected  with  tubercular  disease.  In 
children  the  disease  is  as  a  rule  primarily 
osteal,  beffinnins:  in  the  femur  oftener  than  in 
the  tibia,  very  rarely  in  the  patella.  In  adults, 
however,  in  more  than  half  the  cases  it  shows 
itself  first  in  the  soft  parts.  The  arthritis  is  so  generally  and  so  typically 
fungous  that  the  term  ''white  swelling,"  used  without  qualification,  is  always 
understood  to  mean  tubercular  disease  of  the  knee. 

The  symptoms  in  the  osteal  form  are  at  first  ill  defined.  There  is 
usually  slight  laiiu'iicss,  with  pain  in  the  region  of  the  affected  epiphysis,  more 
severe  at  night,  but  often  oidy  tenderness  on  pressure,  generally  over  a  limited 
space — by  preference  the  internal  condyle  of  the  femur.  Later  there  is  expan- 
sion of  the  condyles.  The  tendons  about  the  joint  are  somewhat  tense,  and 
there  is  some  atrophy,  especially  of  the  parts  just  above  the  joint  on  the  anterior 
surface  of  the  thigh'.  Attempts  fully  to  extend  the  leg  are  resisted  and  cause 
pain.  As  soon  as  synovial  inflannnation  has  been  set  up,  the  resulting  effusion 
produces  fulness  of  the  joint,  most  noticeable  on  the  sides  of  the  ])atolla  and  of 
its  ligauient.  When  this  is  infected  ])y  extension  from  the  ei)i))hysis  or  by 
primary  location  of  the  bacilli  in  the  soft  structures  in  the  joint  itself,  the  symj)- 
toms  become  more  marked,  and  soon  unmistakable.  There  are  rigidity  and 
atrophy  of  the  part,  and  lameness,  but  in  many  cases  this  is  accompanied  with 
so  little  pain  that  the  patient  continues  for  a  long  time  to  run  about.  The  leg  is 
decidedly  flexed,  and  the  flexion  steadily  increases.  But  especially  and  cha- 
racteristically there  is  swelling,  the  firm  spindle-shaped  enlargement  of  fun- 


Ke>ult  after  Double  Subcutaneous 
Osteotomy  of  the  Femur  in  the 
Case  in  Fig.  154  (original^ 


SURGERY    OF   JOINTS. 


399 


gous  disease,  in  wliifli  tin-  natural  contour  of  the  joint  is  lost  and  the  skin  over 
it  is  pale.  Because  of  this  swelling  the  disease  is  not  likely  to  he  mistaken  for 
anything  else,  at  least  in  children,  though  in  adults  osteo-sarcoma  has  not  so 
very  rarely  been  regarded  as  tubercular  disease.  This  error  of  diagnosis  should 
not  occur,  certainly  if  the  case  has  been  seen  from  an  early  day,  since  the 
mali'i-nant  aft'ection  at  first  and  often  for  a  long  time  causes  enlargement  not  of 


Fio. 165 


Fig.  167. 


Ankylosis  and  Contractures 
in  Tuberculosis  of  the 
Knee-joint  (Tillmanns). 


Subluxation  in  Knee-joint 
Disease  (Schreiber). 


inKyiOSlS    Ol    iviiee-juilll,  .     mc     Liuia   la    uio- 

placed  backward  (Mutter  Museum,"  Col- 
lege of  Physicians,  Philadelphia). 

the  joint,  but  of.  the  parts  just  above  or  below  it.  Caseation  and  liquefaction 
of  the  tubercular  tissue  give  rise  to  so-called  abscesses,  which  in  time  undergo 
absorption,  or,  more  often,  open  spontaneously  or  are  opened  by  the  surgeon. 
Through  the  resulting  sinus  diseased  bone  may  frequently  but  not  always  be 
felt.  Not  seldom  the  leg  is  drawn  back  to  and  beyond  a  right  angle  (Fig.  165), 
and  pathological  lu.xation  is  often  produced  in  badly-treated  cases  (Figs.  166, 
167),  after  which,  as  a  rule,  the  severity  of  the  symptoms  markedly  diminishes. 
Such  a  luxation  may  occur  also  in  spite  of  treatment. 

According  to  its'intensity,  and  still  more  to  the  thoroughness  of  early  treat- 
ment, the  disease  terminates  in  one  or  other  of  three  ways  :  (1)  There  may  be 
recovery,  with  more  or  less  deformity  and  impairment  of  function,  secured  after 
a  few  weeks  or  more  often  months,  or,  not  uncommonly,  only  after  years  of 
discharge,  with  the  elimination  of  dead  tissues  both  hard  and  soft,  and  the 
destruction  of  the  articulation.  (2)  Disorganization  follows  either  slowly  or 
rapidly,  and  if  extensive  and  accompanied  with  grave  constitutional  symptoms 
may  compel  operation,  followed  by  recovery,  which  may  be  speedy  or  slow, 
complete  or  partial.  In  the  latter  case  sinuses  remain,  which  will  continue 
to  discharge  for  a  long  time  or  even  for  the  rest  of  life.  (3)  The  patient  dies 
from  exhaustion,  from  tuberculosis  of  other  parts,  from  amyloid  disease,  or 
from  septic  infection,  whether  an  operation  has  or  has  not  been  done.  When 
the  case  is  recognized  early  and  properly  treated  for  a  sufficient  length  of 
time,  recovery  with  a  useful  limb  may  be  expected. 

The  treatment  is  that  of  joint-tuberculosis  in  general.  Rest  must  be 
secured  by  thorough  immobilization— by  plaster  of  Paris  or  by  some  form 
of  splint  securing  fixation  or  both  traction  and  fixation,  as  in  Sayre's 
knee-splint.       No    physiological    use    of    the    joint    should   be    permitted. 


400  .l.Y   AMERK'Ay    TKXT-llOOK    OF  SUIlGETiV. 

If  the  patient  must  walk,  he  shouhi  do  so  onlv  with  crutches,  tl»e  sound  foot 
having  been  sufTiciently  raised  by  a  high  shoe  to  prevent  that  of  the  diseased 
extremity  from  coming  in  contact  with  the  ground.  If  abscesses  form,  they 
shoiihl  be  opened  if  the  local  and  constitutional  symptoms  are  decided. 
Iodoform  and  chloride-of-zinc  injections  at  times  are  of  great  service,  but 
are  not  required   in  the  majority  of  cases  coming  under  early  observation. 

If  non-operative  treatment  fails,  the  tubercular  tissue  must  be  removed  by 
erasion,  excision,  or  amputation.  No  absolute  rule  can  be  established  as  to  the 
time  at  which  and  the  conditions  for  which  operation  should  be  done,  but  at  the 
present  day,  as  the  mortality  attending  erasion  or  excision  is  but  slight,  opera- 
tions are  done  earlier  than  before  and  in  much  less  desperate  conditions  of  the 
joint,  and  the  results  therefore  are  better.  Though  every  case  must  be  a  law 
to  itself,  it  may  be  said  in  a  general  way  that  operation  is  indicated,  (1)  when 
the  disease  has  been  of  relatively  rapid  development :  (2)  when  in  spite  of  rest 
and  the  ordinary  constitutional  remedies,  employed  for  a  reasonable  length  of 
time,  the  tuberculization  of  tissue  is  extending  and  the  tubercular  masses  are 
softening  and  breaking  down,  and  the  patient  is  steadily  losing  strength  and 
weight:  (oj  when  the  disorganization  of  the  joint  is  extensive,  as  indicated  by 
grating  on  movement,  by  abnormal  freedom  of  motion  from  destruction  of  the 
ligaments,  by  abscesses  and  sinuses,  and  by  profuse  suppuration.  Whether 
erasion  or  excision  is  the  better  operation,  especially  when  the  patient  is  a  child, 
has  not  as  yet  been  determined.  Theoretically  erasion  is  preferable,  since  it 
takes  away  only  diseased  tissue,  and  by  sparing  the  region  of  the  epiphyseal 
line  does  not  interfere  with  the  after-growth  of  the  femur  in  length.  But  it  is 
by  no  means  easy  thus  to  get  rid  of  all  the  infected  tissue,  and  unless  this  is 
done  recurrence  will  certainly  take  place.  Even  when  the  joint  is  excised 
tubercular  foci  (PI.  XI,  Fig.  2)  may  not  seldom  be  left  in  the  bone  outside  the 
line  of  section. 

Amputation  is  called  for  only  in  those  cases  of  extensive  disorganization  in 
which  there  has  long  been  marked  enfeeblement  of  the  general  strength  becau.se 
of  pain  and  suppuration,  or  when  excision  or  erasion  has  failed  to  arrest  the 
local  extension  of  the  tuberculosis.  In  the  former,  especially  in  adults,  removal 
of  the  limb  is  more  likely  to  save  life  and  enable  the  patient  afterward  to  earn 
a  living,  and  the  operation  is  really  conservative.  Xot  seldom  it  ha.s  happened 
that  though  by  removal  of  the  joint  the  limb  has  been  saved,  it  has  proved 
only  an  encumbrance. 

Ankle-joixt  Disease. — Disease  of  the  ankle-joint,  if  primarily  of  the 
articulation,  is  more  frequently  of  synovial  than  of  bony  origin  :  if  bony,  the 
starting-point  is  more  frequently  in  the  astragalus  than  in  the  bones  of  the  leg. 
Not  very  seldom  it  is  in  a  malleolus,  the  outer  rather  than  the  inner.  In  many 
cases  it  is  secondary  to  tuberculosis  of  the  tarsus,  and  at  times  to  disease  of  the 
sheaths  of  the  tendons  crossing  the  joint. 

If  synovial,  the  symptoms  observed  early  are,  interference  with  the  free 
movement  of  the  articulation  and  more  or  less  well-marked  fulness  on  the  ante- 
rior surface  outside  the  flexor  tendons  and  on  the  sides  of  the  tendo  Achillis. 
If  osseous,  besides  the  intermitting  inability  or  at  least  unwillingness  fully  to 
flex  and  extend  the  foot,  there  will  be  present  for  a  time  only  the  pain,  spon- 
taneous or  elicited  by  pressure,  which  belongs  to  osteitis,  following  which  expan- 
sion of  the  bone  and  intra-articular  eff'usion  will  cause  noticeable  swelling. 
When  the  disease  is  well  established  the  region  of  the  joint  has  the  globular 
contour  with  associated  atrophy  of  adjacent  parts  that  is  so  characteristic  of 
fungous  arthritis,  and  the  foot  is  held  in  decided  extension.  The  skin  is  pale, 
or  deeply  colored  from  congestion.     Sinu.ses  are  developed  comparatively  late. 


SURGE  in'    or  JOIXTS.  401 

That  the  disease  is  not  in  the  os  calcis  or  in  and  about  the  middle  tarsal  articula- 
tion will  be  indicated  by  the  locality  of  the  swelling,  below  or  in  front  of  the 
ankle  region. 

The  prognosis  is  that  of  tubercular  arthritis  in  general,  grave  or  not 
according  to  the  age  and  constitutional  state  of  the  patient,  and  especially  to 
the  period  of  its  recognition  and  the  thoroughness  of  treatment. 

Treatment. — As  soon  as  the  diagnosis  is  made,  walking  upon  the  foot 
should  be  sto{)ped  and  the  joint  immobilized,  care  being  taken  in  the  applica- 
tion of  the  plaster-of-Paris  bandage  to  place  the  foot  at  a  right  angle  with  the 
leg.  The  bandage  must  be  renewed  as  often  as  the  swelling  subsides.  After 
a  time,  if  the  disease  still  progresses,  iodoform  or  zinc  injections  may  be  used 
with  advantage.  When  the  joint  structures  become  disorganized,  erasion  or 
excision,  typical  or  atypical,  is  indicated,  and  should  be  done  without  delay. 
Even  when  the  tarsus  has  become  extensively  diseased  and  the  tibia  and  fibula 
are  infected  beyond  the  epiphyseal  line,  removal  of  the  tubercular  tissue,  both 
in  the  bone  and  in  the  soft  parts,  may  be  followed  by  recovery  with  a  firm  and 
useful  limb.  But  such  removal  must  be  thorough,  all  diseased  tissue  being 
removed  from  the  medullar}^  cavity  of  the  leg-bones,  the  tendon-sheaths,  the 
meshes  of  the  connective  tissue  outside  the  joint, — wherever  it  may  be.  If  this 
cannot  be  accomplished,  amputation  should  be  done  or  the  osteoplastic  resec- 
tion of  WladimirofF-Mikulicz.  If  the  medullary  canal  is  opened  by  amputa- 
tion, all  of  the  infected  marrow  must  be  thoroughly  scraped  out  and  the  canal 
disinfected  and  drained. 

Shoulder-joint  Disease. — The  shoulder  is  much  less  frequently  the  seat 
of  tubercular  disease  than  might  be  expected  from  its  range  of  movement  and 
its  exposed  position.  Children  are  at  times  attacked,  but  disease  of  this  artic- 
ulation is  rare  in  them  as  compared  with  disease  of  the  hip,  knee,  or  elbow. 
Young  adults  are  the  more  common  subjects,  though  it  is  at  times  met  with, 
and  as  a  rule  in  a  very  destructive  form,  in  persons  w^ell  advanced  in  life. 
Any  of  the  varieties  of  the  disease  may  be  seen  ;  and  caries  sicca  more  often 
attacks  this  joint  than  any  other  (Fig.  61,  p.  272). 

The  symptoms  vary  according  to  the  form,  though  impairment  of  func- 
tion is  common  to  all.  In  other  than  the  dry  variety  the  affected  region  is 
enlarged  and  of  globular  shape,  firm  to  the  touch  when  fungous  masses  are 
present,  fluctuating  if  there  is  intra-articular  fluid  in  excess  or  if  a  periarticular 
abscess  has  formed.  Such  an  abscess  may  point  in  the  axilla,  or,  following 
the  course  of  the  muscles,  on  the  anterior  surface  of  the  arm,  on  the  side  of  the 
chest,  near  the  posterior  axillary  fold,  or  over  the  scapula.  Pain  to  a  consid- 
erable degree  may  be  present,  and  is  often  very  severe  in  the  ordinary  dry 
variety  when  suppuration  occurs.  In  caries  sicca,  except  in  those  rare  cases 
in  which  abscess  is  developed  at  a  late  period,  there  is  no  abnormal  fulness  of 
the  region  ;  on  the  contrary,  the  parts  are  greatly  atrophied.  Because  of  the 
destruction  of  the  head  of  the  humerus,  unattended  by  excessive  new  formation, 
a  hollow  is  produced  under  the  acromion  process  which  may  excite  a  suspicion 
of  luxation,  all  the  more  because  of  the  existing  undue  prominence  of  the 
coracoid  process.  Movement,  especially  in  adduction,  is  resisted,  and  even 
under  an  anesthetic  is  found  to  be  much  limited. 

The  diagnosis  in  any  of  the  varieties  and  at  any  stage  is  often  diflScult 
and  uncertain,  the  aff'ection  being  confounded  with  bursal  disease,  with  chronic 
rheumatism,  or  with  hysteria,  especially  the  last  two.  The  history  of  the  case 
and  examination  of  the  aspirated  fluid  will  probably  indicate  the  non-existence 
of  bursitis.  Chronic  mono-articular  rheumatism  is  not  likely  to  be  present 
in  a  young  adult,  and  it  is  at  such  period  of  life,  as  a  rule,  that  ca7'ies  sicca 

26 


402  AN  AMERICAN   TEXT-BOOK    OF  smOERV. 

IS  found.  Iji  an  hysterical  Joint  tlicro  is  no  restriction  of  motion  when  tlic 
patient  i.s  auL'stlietized. 

The  prognosis  is  favorable  in  the  majority  of  cases,  particularly  of  the 
dry  variety,  t'S])t'cially  if  the  parts  are  early  jnit  at  rest  and  kejit  so. 

Immobilization  is  essentially  the  only  treatment  requiretl  so  long  as 
abscesses  do  not  form.  When  they  have  formed  and  the  suppuration  is  free 
the  head  of  the  humerus  Avill  usually  have  to  be  excised.  Tlie  final  result  of 
excision  is  ordinarily  excellent,  the  new  joint  being  firm  and  quite  movable; 
sometimes  it  is  very  loose  (flail-joint,  dangle-joint),  liut  even  then  it  may  prove 
serviceable. 

Elbow-joint  Disease. — The  elbow  is  tubercular  much  more  often  than 
either  of  the  other  large  joints  of  the  upper  extremity.  The  disease  shows 
itself  usually  in  children,  and  is  of  synovial  origin  in  the  majority  of  cases. 
When  osteal  the  primary  focus  is  more  likely  to  be  in  the  epiphysis  of  the 
humerus  than  in  that  of  the  ulna  or  of  the  radius ;  in  the  latter  it  is  rarely 
seen.  Even  when  the  joint  disease  is  extensive  the  tubercular  bone  affection 
may  be  only  on  one  side  of  the  interarticular  line,  in  which  case  the  bone  or 
bones  on  the  other  side  will  ordinarily  be  found  docidcdly  rarefied. 

iKi.  ins. 


Tubercular  Disease  of  Elbow  (original). 


The  symptoms  here,  as  elsewhere,  are  not  well  marked  in  the  beginning, 
especially  in  the  osteal  variety.  Spontaneous  pain  may  or  may  not  be  present, 
but  pain  can  always  be  caused  by  pressure.  There  is  some  stiffness  of  the  joint, 
and  the  forearm  is  somewhat  flexed.  As  soon  as  effusion  occurs  into  the  joint 
or  new  formation  to  any  decided  degree  takes  place,  fulness  will  be  noticed  on 


SURGEIiV    or  JOISTS.  403 

the  sides  of  the  olecranon  process  and  above  it ;  not  until  much  later  on  the  ante- 
rior surface,  because  of  the  firm  resistance  of  the  overlying  muscles  and  fasciae. 
When  the  disease  is  well  developed  the  region  is  markedly  spindle-shaped,  the 
arm  and  forearm  much  atrophied,  the  flexion  permanent  at  an  angle  of  about 
140°,  the  hand  pronated  (Fig.  108).  Increase  of  local  heat  may  occasionally 
be  recognized  by  touch.  All  movements  are  painful.  If  abscesses  form  they 
will  probably  open  through  the  posterior  surface  of  the  joint. 

Treatment. — As  soon  as  the  disease  is  detected  the  joint  should  be  immo- 
bilized in  flexion,  the  rectangular  position  being  secured  as  soon  as  it  can  be 
tolerated — from  the  beginning,  if  it  is  not  too  painful.  If  abscesses  form  and 
open,  the  dressing  must  be  so  fenestrated  as  to  permit  of  free  discharge.  Iodo- 
form injections  should  be  made  through  the  sinuses  into  the  abscess-sac  or  the 
opened  joint-cavity;  such  injections  or  those  of  chloride-of-zinc  solution  may 
be  made  subcutaneously  before  sinuses  have  formed.  After  weeks  or  usually 
months  of  fixation  of  the  joint,  especially  if  it  was  commenced  early,  recovery 
may  be  expected ;  in  the  more  fortunate  cases  it  may  be  with  quite  complete 
preservation  of  the  motions  of  the  articulation,  but  much  more  often  with 
ankylosis.  It  is  because  of  the  likelihood  of  the  occurrence  of  a  stiff  joint 
that  the  parts  should  be  fixed  at  a  right  angle,  or  even  less — i.  e.  the  angle  at 
which  the  extremity  will  be  most  useful.  AVhen  the  joint  has  become  exten- 
sively disorganized,  erasion  or  excision  should  be  done  without  delay.  The 
result  of  such  an  operation  at  this  joint  is  as  a  rule  very  satisfactory,  excellent 
motion  being  often  secured.    Very  rarely  amputation  of  the  arm  will  be  required. 

"Wrist-joint  Disease. — Except  in  connection  with  the  same  disease  of 
adjacent  parts,  especially  of  the  carpus,  tuberculosis  of  the  wrist-joint  is  rarely 
seen.  Though  it  may  be  primary  and  synovial,  it  is  commonly  secondary  to 
caries  of  the  bones  of  the  wrist,  or,  much  less  often,  to  fungous  teno-synovitis. 
It  attacks  both  children  and  adults,  even  persons  beyond  middle  age.  If  primary, 
ordinarily  it  soon  extends  to  the  bones  beyond  the  wrist,  and  even  when  first 
seen  the  case  presents  the  symptoms  of  carpal  disease.  The  joint  motions  are 
restricted  and  painful.  The  affected  region  is  enlarged,  especially  on  the  dor- 
sum, the  forearm  and  hand  being  decidedly,  often  greatly,  atrophied.  The 
fingers  are  extended,  seemingly  lengthened.  Disorganization  takes  place  at  a 
comparatively  early  period. 

The  treatment,  as  in  like  disease  of  other  joints,  is  by  immobilization  and 
injection,  by  preference  of  the  iodoform  emulsion.  Ignipuncture  has  been 
successfully  employed  by  a  few  surgeons.  If  commenced  early  and  steadily 
followed  up,  in  a  large  proportion  of  cases  treatment  will  effect  a  cure,  though 
the  wrist  will  almost  certainly  be  a  stiff  one :  but  the  time  required  is  often 
very  great,  measured,  it  may  be,  by  years.  Because  of  this  length  of  time  and 
of  the  much-crippled  or  entirely  useless  hand  that  so  often  remains,  it  is  as  a 
rule  wise  to  operate  by  erasion  or  excision  if  after  several  months  of  conserva- 
tive treatment  marked  improvement  in  the  local  condition  has  not  been  secured. 

Sacro-iliac  Joint  Disease. — Disease  of  the  sacro-iliac  articulation 
(sacro-coxalgia)  is  of  infrequent  occurrence.  It  is  very  much  more  common  in 
young  adults  than  in  children,  and  seldom  appears  in  individuals  over  thirty- 
five  years  of  age.  It  is  likely  to  be  mistaken  for  hip-joint  disease.  As  a  rule 
it  pursues  an  unfavorable  course.  Its  pathological  changes  are  essentially  the 
same  as  those  of  tubercular  disease  of  other  joints.  There  are  the  usual  effu- 
sions (which  if  intra-articular  are  necessarily  limited)  and  exudations,  abundant 
new  formation  of  infected  granulation-tissue,  destruction  of  cartilage  and  bone, 
and  the  development  of  cold  abscesses,  internal  or  external.  The  fluid  of  such 
abscess,  if  internal,  may  pass  down  behind  the  rectum  into  the  ischio-rectal 


404  AX  AMElilCAN    TEXT- BOOK   OF  SURGERY. 

fossa  or  by  perforation  into  the  bowels,  or,  following  the  muscular  planes,  may 
reach  the  neighborhood  of  the  sciatic  notch,  of  Poupart's  ligament,  or  the 
upper  part  of  the  thigh,  or  may  pass  along  the  sciatic  nerve  to  the  region 
behind  the  greater  trochanter ;  if  external,  the  abscess  will  probably  be  found 
over  the  joint  near  the  edge  of  the  ilium.  If  an  abscess  does  not  form,  recovery 
may  be  expected,  with  an  ankylosed  joint ;  if  an  abscess  does  form,  especially 
an  internal  one,  the  probabilities  are  very  strong  that  the  patient  will  die, 
though  he  may  even  yet  recover  after  extensive  bone  destruction  and  later 
fusion  of  the  sacrum  and  ilium.  When  the  affection  has  occurred  in  early 
childhood  it  may  be  the  cause  of  pelvic  distortion,  of  much  importance  in  the 
female. 

The  symptoms  are  ill  or  well  defined  according  to  the  stage  of  the 
disease.  At  an  early  period  there  will  be  discovered  scarcely  more  than  a  little 
stiffness,  discomfort  in  standing  or  walking  for  any  length  of  time,  and  pain,  which 
is  neither  constant  nor  severe,  in  the  region  of  the  joint  or  sometimes  in  the 
thigh.  Later,  at  a  time  when  the  case  is  most  likely  to  come  under  observation, 
pain  is  decided  when  any  motion  is  made,  and  may  be  present  when  the  patient 
is  lying  down.  This  will  certainly  be  the  case  sooner  or  later  when  an  attempt 
is  made  to  rest  upon  the  affected  side.  Crowding  of  the  ilia  together  will 
always  cause  suffering.  The  pain  is  not  simply  in  the  region  of  the  joint,  but 
as  a  rule  radiates  in  various  directions,  according  to  the  course  of  the  nerves  that 
pass  in  close  proximity  to  the  articulation,  especially  the  sciatic,  the  anterior 
craral,  the  obturator,  and  the  genito-crural.  The  thigh  is  more  or  less  flexed 
upon  the  pelvis,  with  tension  of  the  psoas,  and  the  patient  throws  his  weight 
upon  the  sound  side.  The  affected  limb  seems  elongated,  or  there  may  be 
quickly  alternating  apparent  lengthening  and  shortening.  The  patient  walks 
with  a  decided  limp.  The  soft  parts  over  the  joint  posteriorly  may  be  swollen 
or  flattened.  Usually  after  a  considerable  time  the  pus  will  show  itself  beside 
the  anus,  in  the  outer  part  of  the  groin,  behind  the  trochanter,  or  near  the 
iliac  crest  posteriorly:  and  before  very  long,  if  not  opened  by  the  knife,  it 
will  be  spontaneously  evacuated.  True  suppuration  is  very  apt  now  to  occur 
because  of  an  added  infection  by  the  pyogenic  cocci,  with  corresponding 
increase  in  the  gravity  of  the  previously  existing  constitutional  symptoms  due 
to  the  tuberculosis. 

The  disease  is  likely  to  be  mistaken  for  neuralgia  of  the  joint,  for  lumbago, 
for  vertebral  or  sacral  caries,  for  sciatica,  and  especially  for  hip-joint  disease. 
The  location,  limitation,  duration,  and  character  of  the  pain  will  serve  to  dis- 
tinguish it  from  the  various  neuralgic  and  myalgic  affections.  There  will  be  an 
absence  of  the  ordinary  local  signs  of  spinal  caries.  If  there  is  caries  or  necrosis 
of  the  sacrum  or  ilium  away  from  the  articulation,  there  will  probably  be  a 
history  of  severe  injury,  with  the  after-symptoms  of  bone  contusion  or  wound. 
From  hip-joint  disease  the  differential  diagnosis  may  not  be  readily  made.  The 
attitude  of  the  patient,  the  flexion  and  apparent  elongation  of  the  limb,  the 
pain,  which,  if  present,  will  be  located  in  front  of  or  behind  the  hip.  or  even  at 
the  knee, — are  all  much  like  what  is  observed  in  morbus  coxarius.  But  careful 
examination  will  show  that  the  motions  of  the  hip  are  unrestricted ;  pressure 
over  the  joint  and  crowding  the  head  of  the  femur  against  the  acetabulum  will 
cause  no  pain  if  the  ilium  alone  is  steadily  fixed  ;  there  is  no  adductor  rigidity; 
if  the  expanded  wings  of  the  ilia  are  pressed  together  severe  pain  is  produced, 
as  it  is  by  any  motion  of  the  limb  the  action  of  which  is  continued  upward 
through  the  pelvis;  there  is  steady  pain  in  the  region  of  the  sacro-iliac  junc- 
tion ;  the  anterior  superior  iliac  spine  on  the  affected  side  is  more  prominent 
and  upon  a  lower  level  than  that  of  the  sound  side. 


SURGERY   OF  JOTXTS.  405 

Tlie  treatment  will  vary  according  as  tliere  is  or  is  not  an  abscess.  In  the 
latter  case  rest  and  counter-ii-ritation  are  of  extreme  value.  The  first  is  secured 
by  fixation  of  the  whole  pelvis  and  the  limb  of  the  affected  side  by  apparatus 
or  plaster  of  Paris ;  the  last  by  the  application  of  the  actual  cautery.  If  this 
treatment  fails  and  abscesses  have  formed,  they  should  be  evacuated  and  injected 
with  the  iodoform-glycerin  emulsion,  or  freely  opened  if  possible,  curetted,  and 
kept  thoroughly  drained.  When  the  pain  in  the  joint  is  very  severe  and  the 
formation  of  an  abscess  is  strongly  threatened,  free  opening  of  the  joint  should 
be  made,  if  necessary  with  the  trephine.  Of  course  all  these  operations  must 
be  done  aseptically  and  the  Avound  and  cavities  protected  from  septic  infection ; 
and  rest,  as  absolute  as  possible,  should  be  maintained  until  healing  is  complete. 

Besides  the  tubercular  affection,  this  joint  is  the  seat  also  of  rheumatic, 
gonorrheal,  and  septic  inflammations.  The  first  two  are  comparatively  mild, 
and  are  usually  recovered  from,  occasionally  without  ankylosis.  The  septic 
arthritis,  very  generally  of  puerperal  origin,  is  almost  certain  to  destroy  life 
in  a  short  time,  in  spite  of  any  treatment,  local  or  constitutional,  that  can  be 
adopted. 

(b)  septic  arthritis. 

Infection  by  the  bacteria  of  suppuration,  chiefly  the  staphylococcus  aureus 
and  the  streptococcus  pyogenes,  produces  an  acute  arthritis  which,  if  not  prompt- 
ly and  actively  treated,  and  sometimes  in  spite  of  treatment,  results  in  destruc- 
tion of  the  part  and  not  seldom  in  loss  of  life.  The  infection  may  be  produced 
in  one  of  several  ways :  (1)  directly  through  an  open  wound  made  by  a  dirty 
instrument,  or  one  in  which  there  is  lodgment  of  a  foreign  body  carrying  the 
pyogenic  cocci,   or  through  a  later  infection  of  an  originally  aseptic  track  ; 

(2)  by  an  opening  of  a  joint-cavity  in  the  progress  of  an  osteo-myelitis  or  by 
the  extension  of  suppurative  disease  of  the  articular  or  periarticular  structures ; 

(3)  through  the  transmission  to  and  deposition  in  the  synovial  membrane  of  the 
micro-organisms  present  in  the  blood  of  a  pyemic  patient.  However  produced, 
if  the  infecting  organisms  are  many  and  the  case  is  left  to  itself,  a  high  grade 
of  inflammation  of  the  joint  structures  is  rapidly  developed,  with  an  abundant 
formation  of  pus.  Exudation  occurs  into  the  synovial  membrane,  the  subsv- 
novial  connective  tissue,  and  the  capsule,  all  of  which  soon  become  disorgan- 
ized. The  articular  cartilages  break  down,  either  quickly  in  masses  of  consid- 
able  size,  or  more  slowly  at  many  points,  through  erosion  by  granulations.  The 
ligaments  soften  to  such  an  extent,  it  may  be,  as  to  permit  of  undue  motion  of  the 
bones  upon  each  other  or  of  their  complete  luxation.  The  periarticular  struc- 
tures are  filled  with  newly-formed  infected  granulation-tissue,  in  the  breaking 
down  of  which  abscesses  form  extending  in  various  directions  above  and  below 
the  joint,  and  soon  an  opening  through  the  skin  takes  place. 

The  symptoms  are  such  as  might  be  expected  from  the  intensity  of  the 
joint  inflammation.  The  pain  is  very  severe,  generally  worse  at  night:  the 
swelling  is  great ;  the  skin  is  red  and  hot ;  fluctuation  is  distinct ;  the  parts 
above  and  below  are  oedematous.  The  joint  is  flexed  to  the  angle  at  which 
intra-articular  tension  is  least.  Any  attempt  at  motion  much  increases  the 
suffering.  The  constitutional  symptoms  are  always  grave,  and  are  proportionate 
to  the  extent  and  rapidity  of  development  of  the  local  disease.  There  is  gene- 
rally an  initial  chill,  or  at  least  well-marked  chilliness.  The  temperature  quickly 
runs  up  several  degrees,  remaining  high,  with  no  very  great  fluctuations,  or  show- 
ing a  well-defined  septic  curve.  The  pulse,  strong  and  full  it  may  be  at  first, 
soon  becomes  rapid  and  weak.  The  "•  typhoid  "  state,  more  or  less  complete, 
quickly  sets  in.     In  the  very  acute  cases  death  from  septicemia  mav  occur 


406  AX  AMERICAX    TEXT-BOOK    OF   SURGERY. 

within  a  few  days.  Ordinarily  with  the  opening  of  the  abscesses  and  the 
resulting  relief  of  tension  decided  improvement,  at  least  for  a  time,  takes  place 
in  the  symptoms,  both  local  and  general.  In  those  cases  in  which  the  joint 
affection  shows  itself  in  the  course  of  a  pyemia  the  chief  local  symptom  is 
swelling ;  the  joint,  or  not  infrequently  several  joints  simultaneously  affected, 
becoming  greatly  distended  with  pus  in  the  course  of  a  few  hours,  the  synovial 
membrane  and  the  articular  structures  in  general  showing  upon  examination 
little  or  no  evidence  of  being  inflamed. 

In  the  treatment,  as  in  that  of  similar  disease  of  bone,  safety  lies  only 
in  prompt  opening  up  of  the  suppurating  area,  followed  by  thorough  disinfec- 
tion and  subsequent  free  drainage.  In  some  of  the  milder  cases  aspiration  of 
the  joint  with  antiseptic  irrigation  will  arrest  the  progress  of  the  disease; 
but,  as  a  rule,  it  is  much  better  to  incise  the  capsule  and  thus  secure  the 
complete  evacuation  of  the  pus.  Most  rigid  antiseptic  treatment  should  be 
pursued  until  the  parts  are  entirely  healed,  and  the  joint  must  be  thoroughly 
immobilized,  care  being  taken  to  correct  as  far  as  possible  any  existing  displace- 
ment. Recovery  is  generally  by  ankylosis,  often  bony  and  complete ;  but 
occasionally,  because  of  early  and  thorough  treatment,  the  articular  motions 
are  preserved. 

.  The  constitutional  treatment  is  that  of  suppurative  disease  in  general — care- 
ful feeding  and  stimulation,  quinine,  and.  later,  such  tonics  as  may  be  required. 
If  the  suppuration  continues  in  an  exhausting  degree  despite  the  local  treatment 
adopted,  and  the  joint  is  extensively  disorganized,  operative  interference  is 
demanded.  Erasion  may  be  done,  or,  better,  atypical  resection.  Often  the 
joint  and  the  neighboring  structures  are  so  widely  destroyed  and  the  general 
condition  of  the  patient  is  so  bad  that  only  by  amputation  can  it  be  hoped  to 
save  life.  The  pyemic  joint  is  commonly  but  a  symptom  of  a  constitutional 
state  that  will  cause  death  in  a  few  hours,  or  at  most  in  a  few  days,  and  the 
arthritis  demands  no  treatment.  When  the  affection  is  of  but  moderate  inten- 
sity, the  articular  complication  should  be  treated  in  the  ordinary  way. 

(c)   INFECTIVE    ARTHRITIS. 

Very  similar  to  the  suppurative  arthritis  just  described  is  that  met  with  in 
connection  with  an  acute  infectious  disease,  such  as  small-pox,  measles,  scarlet 
fever,  typhoid  fever,  or  erysipelas.  It  is  due  to  one  or,  in  many  cases,  to  both 
of  two  causes — viz.  the  presence  in  the  joint  of  the  ordinary  septic  bacteria, 
or  the  pyogenic  action  of  the  specific  micro-organism  of  the  existing  disease,  that 
of  erysipelas  being  very  closely  akin  to,  perhaps  identical  with  the  streptococcus 
pyogenes.  The  svmptoms,  prognosis,  and  treatment  are  the  same  as  those  of 
the  ordinary  septic  joint  inflammation.  In  the  typhoid  arthritis  of  the  hip, 
which  joint  is  especially  likely  to  be  attacked,  spontaneous  dislocation  occurs 
in  a  number  of  cases.  It  is  often  produced  spontaneously,  sometimes  by 
movements  of  the  patient  or  by  careless  handling  of  the  limb  at  a  time  when 
the  capsule  is  largely  distended  with  fluid  and  the  femoral  head  consequently 
is  to  some  extent  lifted  out  of  the  acetabulum,  and  when  the  ligaments  and 
muscles  are  greatly  weakened. 

But  the  suppurative  is  not  the  only  form  of  arthritis  found  associated  with 
the  diseases  mentioned,  nor  even  the  most  common.  Not  very  rarely  during 
the  height  of  the  affection,  more  often  in  the  period  of  subsidence  and  conva- 
lescence, a  joint  or  joints  (polyarticular  involvement  being  usually  a  result  of 
scarlatina  or  small-pox)  will  be  found  swollen,  hot,  and  painful,  as  if  affected 
with  rheumatism.     Such  inflammation  may  be  attributed  in  part  to  the  affection 


srh'(;i:/n'  of  joints.  407 

of  the  nervous  system  belonging  to  the  disease,  and  in  part  to  the  irritative 
action  upon  the  synovial  nionibrane  of  blood  containing  the  specific  organisms, 
but  still  more  to  their  chemical  products.  Resolution  ordinarily  takes  place  in 
the  course  of  a  few  days,  and  no  treatment  is  required  other  than  keeping  the 
parts  quiet,  enveloping  them  in  cotton  secured  with  a  bandage,  or  making  hot 
applications,  simple  or  medicated. 

(d)  goxokhhkal  arthritis  (gonorrheal  rheumatism,  post-gonorrheal 

arthritis). 

Joint  affections  of  several  kinds  are  freciuently  found  associated  with  gonor- 
rhea. There  may  be  often  only  a  more  or  less  severe  intermittent  arthralgia, 
"which  soon  passes  away ;  or  there  may  be  a  chronic  inflammation  with  abundant 
effusion  into  the  joint-cavity  (hydrarthrosis),  chiefly  that  of  the  knee;  or  an 
acute  sero-plastic  arthritis ;  or  a  suppurative  inflammation,  which  is  compara- 
tively rare. 

For  a  long  time  the  disease  was  called  gonorrheal  rheumatism,  and  even 
now  it  is  generally  so  named.  The  joint  affection,  whether  characterized  by 
intra-articular  effusion,  by  articular  and  periarticular  exudations,  or  by  the 
presence  of  pus,  is  not  rheumatic,  though  a  patient  with  gonorrhea  may  have 
rheumatism,  and  a  rheumatic  joint  because  of  such  antecedent  disease  may  be 
more  susceptible  to  the  toxic  action  of  the  gonococcus  or  of  the  mixed  gonor- 
rheal and  pyogenic  infection.  The  more  carefully  the  gonococcus  of  Neisser 
has  been  sought  in  the  fluids  and  tissues  of  the  afi"ected  joints,  the  more 
frequently  it  has  been  found,  and  in  cases  in  which  it  cannot  be  detected  there 
is  good  reason  for  believing  that  its  ptomaines  are  the  exciting  cause  of  the 
metastatic  arthritis.  When  joint  disease  of  somewhat  similar  character  is 
developed  in  non-gonorrheal  urethral  fever,  as,  e.  g.,  after  the  passage  of  a 
catheter  or  sound,  it  is  possibly  due  to  the  taking  up  from  the  injured  mucous 
membrane  of  the  urethra  of  the  common  pyogenic  cocci,  or  it  may  be  due  indi- 
rectly to  their  chemical  products.  The  affection  very  rarely  attacks  women.  It 
may  appear  at  any  period  in  the  course  of  the  urethritis,  but  occurs  much  more 
often  in  the  third  and  fourth  week  than  later,  especially  in  its  acute  form.  Any 
articulation  may  be  its  seat,  though  in  nearly  one-half  of  the  cases  it  is  the 
knee,  and  in  about  two-thirds  the  knee,  the  ankle,  or  the  joints  of  the  fingers 
or  toes.  Generally  it  is  mono-articular;  rarely  more  than  two  or  three  joints 
beinfj  attacked  either  at  the  same  time  or  in  succession. 

The  symptoms  vary  according  to  the  form  of  the  arthritis.  In  the  chronic 
variety  attended  with  abundant  intra-articular  effusion  there  is  impairment  of 
function,  and,  of  course,  marked  swelling,  but  the  joint  is  not  painful  or  is  but 
slightly  so,  except  duringthe  time  of  an  acute  exacerbation,  which  is  occasionally 
observed.  In  the  acute  form  the  suff"ering  is  intense,  persistent,  worse  at  night, 
and  much  aggravated  by  movements,  even  slight  ones.  The  parts  are  swollen  and 
hot,  the  skin  is  red,  and  the  joint  is  held  in  the  position  of  greatest  ease.  Atro- 
phy of  the  structures  above  and  below  is  quickly  produced.  There  are  decided 
elevation  of  temperature  and  acceleration  of  pulse,  and.  because  of  the  fever 
and  suffering,  rapid  loss  of  strength  and  weight.  When  suppuration  occurs, 
which  is  seldom,  the  local  and  general  symptoms  are  intensified.  The  disease 
terminates  in  resolution,  in  ankylosis,  or  in  destruction  of  the  joint ;  most  fre- 
quently by  far  in  ankylosis  (fibrous)  either  partial  or  complete,  due  to  organiza- 
tion of  the  plastic  exudations  both  articular  and  periarticular.  The  serous 
accumulation  in  the  joint,  in  spite  of  any  treatment,  will  often  remain  unchanged 
for  many  weeks,  or  it  may  be  months. 


408  AN  AMERICAN    TEXT- HOOK    OF  SURGERY. 

In  the  treatment  of  gonorrheal  as  in  tliat  of  other  forms  of  arthritis  rest 
is  of  prime  importance.  As  long  as  there  is  any  inflammation  present  the  joint 
sliouhl  be  kept  immobilized.  Blisters,  mercurial  a])i»lieations,  fomentations, 
cauterizations,  all  of  which  liave  been  employed  again  and  again,  can  accom- 
plish but  a  fraction  of  the  good  that  results  from  the  quietude  and  equable 
coinpression  secured  by  the  plaster-of-Paris  bandage.  But  immobility  of  the 
joint  must  not  be  maintained  for  too  long  a  time,  lest  ankylosis,  to  which,  as 
has  been  stated,  there  is  a  strong  natural  tendency,  be  established ;  if  on 
the  other  hand  passive  motion  is  too  early  resorted  to,  the  inflammation  will  be 
lighted  up  again.  The  only  safe  rule  to  adopt  is  to  keep  the  parts  quiet  until 
all  inflammatory  symptoms  seem  to  have  subsided,  and  then  gently  to  move  the 
joint.  If  the  pain  Avhich  follows  disappears  spontaneously  within  a  few  hours, 
twenty-four  at  the  outside,  no  harm  has  been  done,  and  the  motions  may  be 
continued  and  increased.  If  the  pain  continues,  the  parts  should  be  again  im- 
mobilized for  a  time.  An  existing  hydrarthrosis  may  be  aspirated  and  car- 
bolic-acid injections  used.  If  suppuration  occurs,  aspiration  and  thorough 
antiseptic  irrigation  may  be  employed,  and  the  joint  then  immobilized  Avitli  a 
fair  prospect  of  success.  If  such  treatment  is  not  quickly  followed  by  marked 
amelioration  of  the  symptoms,  the  cavity  must  be  opened  and  drained  as  in 
suppurative  arthritis  due  to  other  causes.  Absorption  of  exudations  and  dis- 
appearance of  adhesiojis,  Avhen  not  very  close  or  strong,  will  be  much  iavored 
by  the  employment  of  massage,  baths,  and  douches  continued  for  as  long  a 
time  as  may  be  necessary  after  the  removal  of  the  immobilizing  dressings.  If 
ankylosis  has  taken  place,  it  must  be  broken  up  or  the  joint  excised  ;  such  ope- 
ration, however,  will  seldom  be  found  necessary. 

(e)  rheumatic  arthritis. 

Rheumatic  articular  affections  are  common,  and  are  both  acute  and  chronic. 
In  the  acute  variety  the  joint  inflammation  is  very  rarely  mono-articular. 
One  or  several  joints  may  be  attacked  at  first,  and  other  joints  are  apt  to  be 
quickly  aff"ected,  with  at  times  rapid  and  complete  subsidence  of  the  inflamma- 
tion in  the  articulations  in  which  it  was  primarily  located. 

The  symptoms  are  those  of  acute  synovitis,  pain,  extreme  sensitiveness 
to  pressure,  and  heat  and  swelling  due  in  part  to  effusion  into  the  periarticular 
structures,  but  chiefly  into  the  cavity.  Suppuration  never  occurs  unless  there 
has  been  a  mixed  infection.  As  the  arthritis  is  but  a  part  of  a  general  disease 
which  is  medical  and  not  surgical,  and  ends  Avith  very  few  exceptions  in  resolu- 
tion, leaving,  jtt  least  after  a  single  attack,  no  changes  in  the  structures  or  the 
functional  value  of  the  articulation,  it  need  not  be  here  considered. 

The  chronic  variety  may  be  such  from  the  start  or  may  be  the  result  of  re- 
peated acute  attacks,  each  of  moderate  severity.  The  inflammation  often  causes 
no  material  alterations  in  the  joint  structures,  the  synovial  membrane  being  only 
a  little  thickened  and  its  vascularity  diminished,  with  a  diminution  in  the  amount 
of  synovial  secretion  and  the  production  of  a  grating  or  creaking  on  motion  as 
a  consequence.  On  the  other  hand,  there  is  occasionally  an  excess  of  fluid  in 
the  joint.  At  times  the  arthritis  is  decidedly  plastic,  the  membrane,  the  cap- 
sule, and  the  periarticular  structures  being  much  thickened,  with  the  formation 
of  bands  and  adhesions  restricting  motion  even  to  a  considerable  degree.  The 
cartilages  are  usually  unaffected,  but  may  be  irregularly  thickened  and  thinned. 

Treatment  consists  in  the  prevention  of  acute  or  more  often  subacute 
exacerbations  which  serve  to  increase  the  weakness  and  stiffness  of  the  affected 
joint,  and  in  the  securing  of  absorption  of  the  exudations  and  resulting  adhe- 


SURGERY    or  JOINTS. 


409 


sions  to  such  an  extent  as  may  be  possible.  The  first  is  to  be  accomplished  by 
avoidance  of  the  excitini;  causes,  cold  and  dampness,  and  by  the  proper  protection 
of  the  joint  by  wann  woollen  clotliinj^  ;  the  second  by  the  employment  of  hot 
baths,  frictions,  and  massage  and  due  use  of  the  joint,  together  with  the  inter- 
nal administration  of  the  ordinary  anti-rheumatic  remedies — the  salicylates,  the 
iodide  of  potassium,  the  salts  of  lithium,  etc.  Partial  ankylosis  should  be 
broken  up  under  ether,  and  followed  by  massage,  the  douche,  and  active  and 
passive  motion.  Mucii  attention  lias  lately  been  directed  to  the  employ- 
ment of  dry  heat  of  high  degree  (270°  to  380°  F.,  132°  to  165'"  C.) 
applied  by  means  of  special    apparatus  (Fig.   169).     Very  decided  allevi- 


Apparatus  for  the  Employment  of  Hot  Air  in  the  Treatment  of  Arthritis. 

ation  of  pain  and  increase  of  movement  of  partialh^  fixed  joints  have 
been  secured ;  but  the  treatment,  while  serving  a  most  excellent  purpose 
in  relieving  pain,  cannot  be  regarded  as  curative.  It  has  been  found  of 
more  service  in  rheumatic  and  gouty  cases  than  in  those  of  osteo-arthritis. 
The  immediate  local  results  of  the  application  of  the  hot  air  are  marked 
hyperemia,  free  sweating,  and  relaxation  of  contractions  and  adhesions ; 
there  is  also  some  general  increase  of  temperature  and  pulse-rate.  Care 
must  be  taken  to  avoid  setting  fire  to  the  patient's  clothing.  An  appa- 
ratus heated  by  electricity  has   recently  been  devised. 


(f)  gouty  arthritis. 

Whatever  may  be  the  essential  nature  of  gout,  its  most  constant  manifestation 
is  in  the  joints,  in  the  smaller  much  more  often  than  in  the  larger — e.  g.  those 
of  the  fingers,  and  especially  the  metatarso-phalangeal  articulation  of  the  great 
toe.  Deposits  of  the  urates,  chiefly  sodium  urate,  occur  in  the  connective 
tissue  of  the  joint ;  they  produce  destruction  of  the  cartilages,  unless  it  be  true, 


410  .liV  AMFJUCAX    TKXT-noOK    OF  SURGERY. 

as  has  been  maintained  by  sonic,  tliat  tlic  deposit  can  take  place  only  in  carti- 
lafje  that  is  in  a  state  of"  necrosis.  As  a  result  ot"  the  irritation  consequent 
upon  the  presence  of  the  abnormal  salts,  there  is  overf!;rowth  of  the  connective 
tissue,  ■with  later  contraction  of  the  new-formed  fibrous  tissue,  followed  by  altera- 
tions in  the  shape  of  the  joint  and  impairment  of  its  motions.  Repeated  attacks 
of  acute  inflanimation  occur,  of  jjreater  or  lesser  intensity  according;  to  circum- 
stances. Frequently  the  urates  form  masses  of  considerable  size  in  the  affected 
joint  (chalk-stones,  tophi),  which  may  lon^  remain  without  excitiiiff  any  i)articu- 
lar  disturbance,  may  <;ive  rise  to  the  formation  of  an  abscess,  or  may  often 
cause  ulceration  of  the  skin  and  exposure  of  the  chalk-stone.  As  is  the  case 
in  rheumatism,  the  joint  affections  of  gout  are  but  symptoms  of  a  diathetic 
state,  the  consideration  of  which  belongs  to  the  physician  rather  than  to  the  sur- 
geon, except  so  far  as  they  may  produce  disabling  contractions  and  deformities. 


(g)    OSTEO-ARTIIRITIS    (chronic    rheumatoid    ARTrtRITIS,    RHEUMATIC    GOUT, 

ARTHRITIS    deformans). 

For  many  years  a  disease  in  certain  respects  much  resembling  rheumatism, 
in  others  resembling  gout,  has  been  recognized.  As  a  rule  having  few  excep- 
tions, it  is  very  chronic;  goes  steadily  on  from  bad  to  worse;  often  produces 
extreme  deformities;  and  disables  its  subjects,  even  to  the  extent  of  altogether 
preventing  motion  in  the  affected  joints.  Of  the  many  names  that  have  been 
given  to  it,  that  of  osteo-arthritis  is  to  be  preferred.  It  is  occasionally  acute, 
when  the  patient  is  generally  a  young  woman,  though  this  form  of  the  affection 
may  be  met  with  in  children.  The  disease  is  ordinarily  seen  in  middle  or 
advanced  life,  even  up  to  extreme  old  age.  Women  are  more  often  attacked 
than  men.  Of  the  smaller  joints  those  of  the  hands  and  feet,  of  the  larger  the 
hip  and  knee,  are  the  ones  usually  diseased  ;  as  a  rule,  two  or  three  of  the  larger 
joints  are  affected  at  a  time ;  when  mono-articular  it  is  most  frequently  located 
in  the  hip  or  knee. 

Its  assumed  causes  are  many.  As  predisposants  there  are  heredity,  a  rheu- 
matic or  gouty  family  or  personal  history,  long-continued  hard  work,  mental 
worry,  an  occupation  or  residence  favoring  exposure.  The  exciting  cause  has 
been  found  in  cold,  in  dampness,  in  injury,  in  the  wretchedness  of  poverty, 
and  in  a  trophic  neurosis  of  undetermined  origin,  at  times  doubtless  septic. 
It  is  one  of  the  earlier  degenerative  affections,  and  anything  that  will  impair 
the  general  strength  may  be  a  cause,  especially  anything  weakening  the  nervous 
system.  The  poor  are  very  subject  to  it,  but  perhaps  no  more  so  proportion- 
ately than  the  well-to-do,  the  privations  of  the  one  class  being  offset  by  the 
nervous  strains  of  the  other.  A  curious  illustration  of  the  possible  causative 
effect  of  dampness  and  want  of  sunlight  may  be  afforded  by  the  fact  that  the 
disease  has  been  found  in  five  out  of  sixteen  skeletons  of  gorillas  examined  in 
various  European  museums,  the  native  home  of  the  gorilla  being  in  the  depths 
of  the  African  forests ;  although  more  probably  in  this  case  the  true  cause  is 
to  be  found  in  the  abnormal  and  depressing  effects  of  captivity. 

The  advocates  of  the  neural  theory  of  causation  believe  that  "  the  articular 
lesions  are  peripheral  manifestations  of  a  degenerative  change  in  the  center  for 
joints  situated  in  the  medulla  oblongata." 

The  articular  cartilages  are  first  affected.  There  occurs  a  fibrillary  degen- 
eration of  the  intercellular  substance,  with  abundant  new  growth  of  the  cartilage- 
cells,  and  soon  a  breaking  down  and  disappearance  of  both,  leaving  the  surface 
eroded  and  velvety,  or,  less  often,  smooth  and  thinned.  By  pressure  of  the 
adjoining  bone  marked  central  thinning  is  produced,  the  extent  and  precise 


SURGFAiY   OF  JOINTS. 


411 


location  of  which  are  detorniiiKMl  by  the  ])ressure.  Later  tlierc  arc  coinplete 
disappearance  of  the  cartilage  and  exposure  of  the  underlying  bone.  This  in 
its  turn  wastes  aAvay,  with  resulting  changes  in  its  shape.  Not  seldom  the 
external  layer  becomes  sclerosed,  even  of  ivory-like  hardness,  and  by  pressure 
is  worn  down  uniformly  or  in  grooves.  While  the  central  part  of  the  articu- 
lating surface  is  weai-ing  away,  the  peripheral  is  increasing  in  thickness,  and 


Fig.  170. 


Advanced  Osteo-arthritis  of  the  Elbow,  with  eburnated  and  grooved  articular  surfaces  and  enormous 

lips  of  bone  (Moullin). 

grows  out  into  lips  hanging  over  the  edge,  which  later  partly  or  wholly  ossify 
(Fig.  170). 

The  synovial  fringes  enlarge,  new  ones  form,  and  outgrowths  are  devel- 
oped. The  original  cartilage-cells  of  the  membrane  proliferate  greatly. 
Adhesions  of  adjacent  sides  of  the  fringes  take  place.  Many  of  the  out- 
growths become  pedunculated,  and  some  of  them  may  be  detached,  consti- 
tuting one  variety  of  "floating   cartilage." 

The  capsule  and  ligaments,  at  first  only  congested  and  oedematous, 
after  a  time  as  a  rule  undergo  fibrous  degeneration,  with  later  the  formation 
of  adhesions  and  contractions.  They  seldom  ossify.  Occasionally,  instead  of 
becoming  harder  and  firmer,  they  soften  and  permit  undue  movement  of  the 
joint  surfaces,  even  to  the  extent  of  the  production  of  luxation.  The  irritated 
periosteum  over  the  end  of  the  aflfected  bone  throws  out  new  bone,  the  oste- 
ophytes at  times  being  numerous  and  of  considerable  length.  The  interior 
of  the  joint  is  generally  dry,  but  occasionally  contains  fluid  in  large  quantity 
(hydrarthrosis).  Hernia  of  the  synovial  membrane  may  be  produced,  or  a 
communication  established  with  a  neighboring  bursa.  Muscular  atrophy  occurs 
early.  The  tendons  passing  over  the  joint  may  harden  and  contract,  may  ossify, 
may  become  detached  from  the  bone,  or  may  soften  and  disappear.  At  the 
shoulder  the  long  head  of  the  biceps  is  commonly  destroyed. 

As  the  result  of  changes  in  the  shape  of  the  articulating  surfaces,  of  new 
growths  upon  their  edges,  and  of  degeneration  of  the  synovial  membrane,  the 


412  AX  AMERICAN    TEXT-HOOK    OF  SURGERY. 

ligaments,  the  muscles,  and  the  tendons,  deformity  and  restriction  of  movement 
soon  follow  and  become  greater  and  greater.  In  the  hand,  where  the  disease 
so  commonly  manifests  itself,  jironation  occurs,  with  the  fingers  strongly  in- 
clined to  the  ulnar  side  and  held  in  flexion  or  extension.  On  the  sides  of  the 
finger-joints,  especially  the  distal  ones,  there  may  generally  be  found  small,  hard, 
pea-like  nodules  (the  nodosities  of  Heberden).  In  certain  very  mild  cases  the 
knobbed  condition  of  the  fingers  may  be  almost  the  only  observed  indication 
of  the  existence  of  the  disease.  Several  of  the  vertebrte  or  all  of  them  may 
be  tied  together  by  a  bridge  of  bone,  often  said  to  be  produced  by  an  ossifica- 
tion of  the  anterior  common  ligament,  but  really  by  a  new  formation  in  place 
of  the  ligament,  which  has  undergone  absorption.  In  a  few  cases  almost  every 
joint  in  the  body  has  been  found  firmly  fixed,  the  patient  being  incapable  of 
movement.  While  all  these  changes  are  going  on  in  the  joint  there  are  very 
slight  or  even  no  constitutional  disturbances  present.  Suppuration  does  not 
take  place  either  in  or  about  the  joint,  except  in  rare  cases. 

The  symptoms  of  the  chronic  variety,  when  the  disease  is  well  developed, 
are  unmistakable,  the  only  other  affections  likely  to  be  thought  of  being  chronic 
rheumatism  and  gout.  The  coexisting  enlai-gement  and  distortion  of  several 
joints;  the  grating  and  creaking  on  movement;  the  slow  progress  of  the 
malady ;  the  long  continuance  of  the  ability  to  go  about  and  attend  to  business ; 
the  absence  of  severe  pain ;  the  normal  temperature  and  pulse ;  the  want  of 
the  proper  symptoms  of  rheumatism  and  gout, — all  these  taken  together  render 
the  diagnosis  easy  and  certain.  In  the  acute  variety,  occurring  generally  in 
children  and  young  adults,  the  intensity  and  rapid  development  of  the  disease, 
the  symmetrical  joint  involvements,  the  articular  enlargements,  and  the  early 
manifestation  of  muscular  atrophy  indicate  the  nature  of  the  affection.  When 
only  a  single  joint  is  affected — and  this  is,  as  has  been  stated,  far  more  often 
the  hip — the  diagnosis  for  a  time  may  be  uncertain.  Like  the  other  varieties, 
it  is  generally  seen  in  old  persons  {inalum  coxoe  senile),  but  is  occasionally  met 
with  in  young  subjects.  It  frequently  follows  contusion,  as  from  a  fall  on  the 
trochanter.  Nothing  specially  abnormal  may  be  noticed  for  a  time,  but  after 
a  number  of  weeks  or  even  months  the  limb  will  be  shortened  and  the  joint 
motions  much  restricted.  Such  a  case  has  often  been  mistaken  for  an  old 
unrecognized  fracture  of  the  neck  of  the  femur.  Long  ago  it  Avas  described 
by  Bell  as  an  "interstitial  absorption"  of  the  neck,  but  in  such  cases  not 
simply  an  interstitial  but  a  general  and  extensive  absorption  of  both  head  and 
neck  has  taken  place,  with  the  formation  of  new  bone  along  the  neck  in  sub- 
stitution of  that  taken  away.  The  destructive  and  formative  changes  about 
the  joint  are  in  no  material  respect  difterent  from  those  observed  in  the  ordinary 
polyarticular  variety. 

Of  late  Spender  has  called  attention  to  certain  symptoms  that  are  developed 
early,  before  any  distinct  evidence  is  afforded  of  articular  changes.  These  are 
(1)  rapidity  of  the  heart's  action  and  increased  arterial  tension,  due  to  dis- 
turbance of  the  inhibitory  action  of  the  pneumogastric ;  (2)  the  appearance  of 
bronzed  and  discolored  patches  upon  the  skin;  (3)  clamminess  of  and  atrophic 
changes  in  the  skin  because  of  vaso-motor  disturbances  ;  (4)  pain  in  the  muscles 
of  the  ball  of  the  thumb  or  along  the  inner  side  of  the  wrist.  The  importance 
of  these  symptoms,  if  they  prove  to  be  constant  ones,  is  very  great,  as  only  at 
an  early  stage  is  the  disease  curable.  When  joint  changes  to  any  considerable 
extent  have  taken  place,  the  damage  is  irreparable,  and,  probably,  further 
progress  of  the  malady  cannot  be  arrested. 

The  treatment  must  l)e  l)y  the  removal  as  far  as  possible  of  all  depressing 
causes,  the  improvement  of  the  general  nutrition,  and  the  administration  of 


SURGERY   OF  JOINTS.  413 

drugs  and  tlio  emplovinont  of  measures  tliat  Avill  i)romote  absorption.  Cod- 
liver  oil  is  rf  much  value,  as  is  arsenic  in  tlie  early  sta^^'es ;  later  on  arsenic 
has  proved  to  be  decidedly  injurious.  The  iodides,  especially  that  of  iron,  are 
beneficial,  as  are  electricity,'  baths,  douches,  and  massage.  Various  thermal 
and  sulphur  springs  have  enjoyed  considerable  reputation  as  affording  relief. 
Blisters  and  other  strong  counter-irritants,  especially  the  actual  cautery,  have 
been  em])loved,  but  it  is  very  doubtful  if  they  ever  do  much  good.  If 
hydrarthrosis  is  present,  compression  or  better  aspiration  and  carbolic  injections 
should  be  employed.  Here  is  the  one  great  exception  to  the  rule  of  securing 
rest  to  a  diseased  joint.  Immobilization  is  not  indicated,  but  active  and 
passive  movements  should  be  employed  as  long  and  as  freely  as  possible. 

(h)  neuropathic  arthritis,  or  tabetic  arthropathy  (CHARCOT'S  disease). 

Since  it  was  first  described  by  Charcot  in  1868  a  peculiar  ost-eo-arthritis  in 
patients  affected  with  locomotor  ataxia  has  been  frequently  observed.     The  j  omt 
chan<Tes  are  in  the  main  those  of  osteo-arthritis  in  general,  but  there  are  certain 
differences  of  importance.     The  disease  is  much  more  acute,  and  affects  chiefly 
the  larcre  joints,  particularly  the  knee.     There  is  little  or  no  pain,  and  constitu- 
tional  disturbances  are  absent.     Without  any  injury  having  been  received,  the 
ioint  suddenly  swells,  and  soon  a  large  intra-articular  effusion  occurs,  which  alter 
a  time  disappears  through  absorption  or  organization.     Extensive  and  at  times 
very  rapid  ulceration   and  wearing  down  of  cartilage  and  bone  take  place. 
New  formations  are  as  a  rule  very  limited,  though  an  hypertrophying  variety 
is  sometimes  met  with.     The  lesion  often  extends  some  distance  up  the  shatt 
and  pieces  of  bone  are  separated  as  though  there  had  been  a  comminuted 
fracture.     Marked  grating  and  crackling  even  on  slight  movement  are  per- 
ceived earlv.     The  ligaments  quickly  break  down,  with  resulting  great  mobility, 
it  may  be  in  every  direction.     Dislocation,  or  characteristic  deformity  without 
complete  luxation,  occurs.      Great  atrophy  of  the  affected  limb  is  soon  observed. 
All  these  changes  may  take  place  while  the  patient  is  confined  to  bed,  proving 
conclusively  that  the  rapidity  and  extent  of  the  lesions  are  not  due  to  over-use 
of  an  osteo-arthritic  joint  the  sensibility  of  which  has  been  greatly  diminished 
or  practically  altogether  lost  because  of  the  existing  tabes.      Ordinary  osteo- 
arthritis may  occur  in  a  tabetic  patient,  but  it  does  not  run  the  acute  course 
that  is  so  characteristic  of  tabetic  avthropathy  proper.     That  the  disease  does 
not  depend  upon  degeneration  of  the  peripheral  nerves  is  shown  by  the  absence 
in  a  considerable  proportion  of  cases  of  any  marked  changes  m  such  nerves. 
Everything  seems  to  indicate  that  the  disease  is  a  peculiar  one,  depending  upon 
changes  tlmt  have  taken  place  in  the  spinal  cord,  perhaps  in  the  anterior  horns. 
The  treatment  is  practically  confined  to  protection  of  the  affected  joints 
from  injury,  and  to  limitation  of  the  abnormal  movement  by  position  or  by 
apparatus. '   If  dislocation  of  a  joint  in  the  lower  extremity  has  occurred,  it 
will  probably  be  necessary  for  the  patient  to  keep  his  bed.     In  a  few  cases 
excision  has  been  done,  but  the  results  have  not  been  satisfactory. 

(l)    HYSTERICAL   JOINTS. 

More  than  half  a  century  ago  Brodie  directed  attention  to  cases  of  seeming 
articular  disease  in  which  no  joint  lesion  was  present,  and  which  were  only 
manifestations  of  hysteria.  Since  then  such  cases  have  been  found  to  be  of 
frequent  occurrence.  In  the  great  majority  of  instances  the  patients  are 
women,  especially  young  women.     Generally  they  are  well  educated,  m  easy 


414  ^l.V  AMERICAN    TEXT- HOOK    OF  SURGERY. 

circumstances,  and  hij^hly  impressionable,  often  the  subjects  of  some  ovarian 
or  uterine  disturbance.  Tbe  knee  and  liip  are  tbe  joints  commonly  affected  ; 
tlie  trouble  may  come  on  sudiU'nly  and  -without  known  cause  or  after  a  sligbt 
injury,  or  folhjw  a  mihl  arteritis  wliich  has  ((uickly  disa))peared.  Tbe  patient 
imagines  that  she  has  serious  disease  which  causes  great  local  distress  and 
decidedly  or  entirely  prevents  passive  motion  except  at  the  cost  of  much  suffer- 
ing. Active  motion  may  seem  as  impossible  as  though  tbe  muscles  were 
paralyzed,  or,  as  is  usually  the  case,  may  be  executed  w  ithout  special  difficulty, 
but  in  a  rather  feel)le  way.  The  ])arts  are  generally  normal  in  size  and  aj)pear- 
ance  except  as  affected  by  a  slight  amount  of  atrophy  from  disuse,  or  are  at 
times  somewhat  swollen  and  a  little  reddened,  commonly  l)ecause  of  the  appli- 
cations that  luive  been  made.  There  is  great  hyperesthesia  of  the  skin,  the 
least  touch  causing  pain,  much  more  than  that  produced  by  firm  pressure. 
There  may  be  an  api)arent  rigidity  of  the  muscles  about  the  articulation,  but 
this  at  once  and  completely  disaj)poars  when  the  patient  is  anesthetized.  The 
joint  may  from  the  first  1)0  held  fixed  in  extension  or  flexion,  but  will  rarely 
be  found  at  that  angle  of  flexion  which  secures  the  greatest  ease  and  which  is 
characteristic  of  a  true  arthritis.  Very  often  the  position  of  the  limb  varies 
from  time  to  time,  the  change,  it  may  be,  occurring  suddenly. 

The  local  temperature  is  normal,  or  even  subnormal,  because  of  the  sluggish 
circulation,  though  transient  and  variable  increase  of  heat  may  be  noticed  that 
may  even  appear  quite  regularly  at  certain  hours  of  the  day.  It  is  of  the 
highest  importance  that  the  true  nature  of  the  affection  should  be  determined 
at  an  early  period.  Tiiese  cases  are  often  misunderstood,  and  the  patient  is 
treated  for  actual  articular  disease,  traumatic,  rheumatic,  or  even  tubercular, 
and  in  consequence  becomes  a  permanent  cripple. 

The  diagnosis  is  to  be  establislied  by  observing,  first,  the  marked  dispro- 
portion existing  between  the  subjective  and  the  objective  symptoms,  a  dispro- 
portion so  characteristic  of  all  manifestations  of  hysteria ;  second,  the  intense 
hyperesthesia ;  third,  the  absence  of  any  evidence  of  degeneration  of  the  tissues ; 
fourth,  the  com})lete  relief  of  symptoms  Avhen  the  attention  of  the  patient  is 
directed  from  herself  and  her  malady ;  and  fifth,  the  entirely  normal  outline 
of  the  joint  and  complete  freedom  of  its  motions  during  the  anesthetic  sleep. 
It  should  not  be  forgotten  that  in  any  case  of  suddenly  appearing  disease  of 
the  knee  or  hip  in  a  young  woman,  especially  if  she  is  of  a  neurotic  tempera- 
ment, the  antecedent  probabilities  are  ail  in  favor  of  the  hysterical  nature  of 
the  affection.  But  before  concluding  that  it  is  of  such  nature  care  must  be 
taken  to  make  sure  that  there  are  not  in  and  about  tbe  joint  evidences  of  an 
organic  lesion.  Tbe  extreme  difficulty  at  times  of  learning  the  real  character 
of  the  disease  and  the  deceptive  character  of  this  neuro-mimesis  or  nerve- 
mimicry  are  shown  by  the  fact  that  in  some  cases  surgeons  have  connnenced  an 
excision  or  amputation  only  to  find  upon  exposure  of  the  joint  structures  that 
there  was  nothing  the  matter  with  them. 

The  treatment  is  constitutional,  supporting,  and  tonic,  and  directed  to 
any  existing  visceral  disease.  Moral  treatment  is  esj)ecially  needed.  Unless 
the  confidence  of  the  patient  is  gained  and  she  realizes  tbe  truth  of  the  state- 
ment made  to  her  that  she  has  no  joint  disease,  she  will  not  get  well.  Of  local 
treatment  the  less  the  better.  Electricity,  frictions,  batlis,  massage,  all  are 
very  apt  to  keep  the  attention  of  the  patient  fixed  upon  her  affection.  The 
joint  should  never  be  immobilized,  and  no  brace  of  any  kind  should  be  apjdied, 
as  fixation  of  the  articulation  will  almost  certainly  cause  the  formation  of  dis- 
abling adhesions.  Hypnotic  suggestion  has  been  found  curative  in  certain 
cases. 


SURGERY    OF  JOTXTS.  415 


SECTION  IV.— NEURALGIA  OF  JOINTS, 
Neuralgic  pain  in  a  joint  may  be  due  to  constitutional  or  to  local  causes — i.  e. 
to  disease  of  the  brain  or  spinal  cord;  to  neurasthenia;  to  malaria;  to  syphilis; 
to  nerve  injury;  to  pressure  upon  the  main  trunk  high  up  or  upon  branches 
near  the  articulation  by  a  tumor  or  an  inflammatory  new  growth ;  to  affection 
of  organs  more  or  less  remote,  as  in  the  hip  in  cases  of  uterine  or  ovarian 
disease.  Like  similar  pain  elsewhere,  it  is  intermittent  and  variable  in 
intensity,  and  is  unassociated  with  any  apparent  permanent  change  in  the 
articular  or  periarticular  structures.  It  is  to  be  treated  in  the  ordinary  way, 
by  improvement  of  the  hygienic  surroundings,  by  regulated  exercise,  and  by 
the  therapeutic  or  operative  removal  of  the  existing  cause.  In  a  few  cases  it 
has  been  asserted  that  there  has  been  a  neuralgia,  generally  located  in  the  knee, 
so  intense  and  so  persistent  that  it  could  be  relieved  by  nothing  short  of  nerve- 
stretching,  neurectomy,  or  amputation.  It  may  well  be  questioned  if  some  or 
even  all  of  these  cases  were  not  really  hysterical  aff"ections  instead  of  arthralgias. 
Occasionally  peripheral  neuritis  consequent  upon  traumatism,  the  pressure  of 
a  tumor,  or' disease  of  bone  has  given  rise  to  arthritis  that  has  ended  in  anky- 
losis and  deformity. 

SECTION  v.— WOUNDS  AND  INJURIES  OF  JOINTS. 

Wounds  of  joints  are  of  two  classes,  non-penetrating  and  penetrating.  The 
former  are  of  little  importance  as  long  as  they  do  not  suppurate,  but  when  they 
suppurate  there  is  danger  of  extension  of  the  inflammation  to  the  joint.  If 
attended  with  loss  of  substance,  the  resulting  cicatricial  contractions  may  more 
or  less  interfere  with  articular  movements.  However  slight  such  a  wound  may 
be,  it  is  wise  to  stop  all  motion  of  the  joint,  to  clean  and  close  the  opening; 
and  to  apply  an  antiseptic  compress.  In  a  few  days  complete  repair  may  be 
expected. 

Penetrating  ivoiinds,  on  the  other  hand,  are  always  serious  accidents.  If 
they  are  properly  treated  recovery  follows  in  a  large  proportion  of  cases ;  if 
improperly  treated  or  neglected  they  are  almost  certain  to  result  in  local  destruc- 
tion, not  seldom  in  loss  of  life.  Aside  from  compound  dislocations  and  com- 
plicated fractures,  which  are  considered  elsewhere,  they  are  generally  produced 
by  gunshot,  by  stabs,  or  accidentally  by  tools  of  trade.  In  a  few  cases  in 
originally  non-penetrating  injuries  communication  with  the  joint  is  established 
later,  often  through  a  bursa. 

The  symptoms  vary  according  to  the  nature  of  the  vulnerating  body, 
the  joint  opened,  and  the  extent  of  the  injury,  though  there  will  be  always 
observed  a  discharge  of  synovia  more  or  less  mixed  with  blood,  and  in  a 
short  time  swelling  of  the  parts  from  hemorrhage  and  intra-articular  eff"usion. 
The  discharge  of  synovia  in  small  quantity,  however,  is  not  pathognomonic, 
since  it  may  come  from  an  unconnected  bursa ;  but  if  synovial  fluid  to  any 
considerable  amount  is  poured  out,  penetration  of  the  joint  should  be  accepted 
as  a  fact.  In  large  wounds  the  articulating  surfaces  can  be  seen  or  felt. 
Pain  and  bleeding  are  always  present  in  greater  or  less  degree,  but  are  not 
indications  of  penetration,  as  they  are  equally  associated  with  wounds  that 
do  not  open  the  cavity.  If  protected  from  septic  infection,  the  opening  in  the 
capsule  readily  closes,  the  efl'used  serum  and  extravasated  blood  are  absorbed, 
the  synovitis  quickly  subsides,  and  recovery  takes  place  with  little  or  no  impair- 
ment of  the  functional  value  of  the  part,  though  some  weakness  and  a  slight 
restriction  of  motion  are  apt  to  continue  for  a  time.      When  such  a  wound  is 


416  AN   AMERICAN    TEXT- BOOK    <)E  SURGERY. 

made  by  an  unclean  instrument,  or  if  at  any  time  before  healing  it  becomes 
septic,  the  symptoms  are  very  different  and  the  prognosis  is  grave.  By  the 
end  of  about  the  third  or  fourth  day  after  the  receipt  of  the  injury,  or  at  such 
period  as  infection  of  a  primarily  aseptic  wound  may  occur,  the  symptoms  of 
suppurative  synovitis,  already  described,  become  manifest.  If  promptly  and 
vigorously  treated,  the  joint  may  and  generally  will  be  saved,  though  prob- 
ably in  a  decidedly  damaged  condition.  It  is  not  in  the  fact  that  the  wound 
involves  an  articulation,  but  in  the  risk  of  its  becoming  septic,  that  the  great 
danger  lies.  Here,  as  elsewhere,  every  effort  must  be  directed  toward  prevent- 
ing this  occurrence. 

By  far  the  most  dangerous  of  the  joint  wounds  are  those  produced  by 
gunshot.  In  military  surgery  until  recently,  whether  the  articulation  was 
extensively  crushed  by  the  passage  into  or  through  it  of  a  large  ball  or  piece 
of  shell  or  opened  by  Assuring  of  the  extremity  of  the  wounded  bone,  unless 
amputation  or  excision  was  primarily  performed  a  suppurative  arthritis  was 
developed  within  forty-eight  or  seventy-two  hours,  and  quickly  proved  fatal, 
or  was  recovered  from  only  after  weeks  or  months,  and  that  with  a  greatly 
damaged  limb.  When  only  the  joint  was  injured  there  might  be  produced  an 
articular  empyema,  or  the  pus,  travelling  along  the  connective-tissue  planes  or 
the  tendon-sheaths,  widely  infected  the  soft  parts.  How  far  under  the  peculiar 
circumstances  attending  the  receipt  and  early  treatment  of  joint  wounds  in 
war  it  may  be  possible  by  "first  aid''  and  after  antiseptic  treatment  to  pre- 
vent such  wounds  from  becoming  septic  is  a  question  as  yet  unsettled,  though 
the  limited  experience  of  a  few  surgeons  in  late  wars  renders  it  highly  probable 
that  very  much  may  be  accomplished. 

But  in  civil  life,  in  which  the  wounds  are  commonly  produced  by  pistol- 
balls,  it  has  been  clearly  shown  that  under  proper  treatment  the  joint  injury 
in  the  great  proportion  of  cases  may  be  conducted  to  a  safe  termination,  even 
to  the  extent  of  preservation  in  large  measure  of  the  articular  movements. 

Treatment. — Such  a  wound  should  never  be  examined  with  dirty  fingers 
or  a  dirty  probe.  The  track  of  the  ball  and  the  probable  extent  of  the  damage 
done  should  be  determined  only  with  an  aseptic  instrument  or  a  thoroughly 
cleaned  finger.  As  a  rule  having  very  few  exceptions,  a  piece  of  cloth  carried 
in  with  the  ball  can  be  detected  only  by  the  finger,  and  the  presence  of  such  a 
foreign  body  is  almost  absolutely  certain  to  infect  the  wound.  The  opening 
and  the  track  being  enlarged  if  necessary,  all  foreign  bodies  and  all  com- 
pleted detached  pieces  of  bone  should  be  removed  and  the  wound  carefully 
disinfected  as  after  compound  fractures.  A  drainage-tube  should  then  be  intro- 
duced, through  and  through  drainage  being  secured  if  required.  Antiseptic 
dressings  should  then  be  applied  and  the  joint  immobilized.  "When  the  bone 
injury  has  been  so  extensive  as  to  necessitate  operation,  atypical  rather  than 
typical  resection  should  be  done. 

As  in  the  larger  wounds  in  war,  so  in  the  smaller  ones  in  civil  life,  the  fate 
of  the  part  if  not  of  the  wounded  man  himself  is  in  the  hands  of  him  who  first 
sees  him  ;  in  other  words,  if  septic  infection  is  prevented  a  good  recovery  may 
be  expected.  If  the  wound  becomes  septic  the  cavity  and  the  suppurating 
tracks  about  must  be  opened  up  and  thoroughly  cleaned,  sequestra  removed  as 
they  become  separated,  and  proper  general  treatment  pursued.  Ankylosis 
of  the  joint,  frecjuently  complete,  is  the  ordinary  termination  if  part  and  life 
are  saved. 

Sprains. — By  far  the  most  common  joint  injury  is  sprain.  This  is  pro- 
duced bv  a  sudden  wrench  or  twist  of  the  articulation,  and  is  experienced  most 
frequently  in  the  ankle  and  wrist,  in  the  former  because  of  a  misstep  or  a  fall 


SURGERY   OF  JOTXTS.  417 

upon  tilt'  ioot,  ill  thelatterbecauseof  a  fall  iiix.ii  the  hand.  Its  degree  may  vary 
from  that  wliieh  is  so  sliglit  tliat  its  eifects  (|uickly  subside  to  tliat  which  is  asso- 
ciated with  luxation  or  fracture  or  both.  The  line  of  disidaceiiient  may  pass 
through  any  section  of  the  investing  capsule,  according  to  the  mode  of  produc- 
tion of  tlie  injury,  but  it  most  often  is  through  that  part  in  which  motion  is 
physiologically  least :  hence  in  the  hinge-joints  it  is  lateral.  By  the  abnormal 
movement  the  synovinl  membrane  is  unfolded  on  one  side  and  compressed  on 
the  other,  and  when  the  normal  limit  of  such  cliange  is  reached  the  membrane 
is  torn  and  crushed.  The  ligaments,  though  their  fibers  cannot  stretch,  do 
elont^ate  somewhat  as  a  change  is  produced  in  their  structural  reticulations  (as 
illustrated  in  the  Indian  puzzle),  but  the  limit  is  quickly  reached,  and  further 
extension  produces  laceration.  The  degree  of  tearing  varies  according  to  the 
severitv  of  the  wrench,  from  that  of  only  a  few  fibers  to  that  of  the  entire  liga- 
ment, to  its  detachment  from  the  bone,  to  the  production  of  fracture  or  disloca- 
tion, and  to  rupture  of  distant  muscles.  Laceration  of  the  vessels  and  slight  or 
extensive  hemorrhage  into  the  joint-cavity,  the  meshes  of  the  articular  structures, 
and  the  connective  tissue  outside  necessarily  occur.  Intra-articular  extravasa- 
tion to  any  considerable  amount  is  indicative  of  severe  injury  and  adds  greatly 
to  the  gravity  of  the  case.  The  accident  is  most  common  in  young  and  middle- 
aged  adults,  is  most  likely  to  affect  a  joint  that  has  previously  been  sprained, 
and  is  much  more  easily  produced  in  a  deformed  limb  or  one  in  which  the  mus- 
cles are  feebly  developed  and  the  ligaments  relaxed  ;  hence  its  frequency  in  the 
weak-ankled. 

The  symptoms  are  well  marked,  the  only  question,  as  a  rule,  being 
whether  or  not  the  case  is  a  simple  sprain  or  whether  there  is  an  existing  luxa- 
tion or,  more  often,  fracture.  Pain  is  instantly  produced,  and  is  always  severe. 
Not  very  rarely  the  patient  faints.  After  the  first  sharp  attack  there  occurs 
a  period  of  comparative  ease,  followed,  either  quickly  or  more  commonly 
after  the  lapse  of  some  hours,  by  a  return  of  suff'ering.  due  to  tension  and  in- 
flammation. Before  long  the  parts  become  swollen.  If  there  is  much  hemor- 
rhage into  the  joint-cavity,  the  fulness  may  be  observed  within  a  very  short 
time,  but  ordinarily  only  after  a  few  hours ;  it  is  then  due  in  part  to  extravasa- 
tion, but  chiefly  to  efi'usion  into  the  cavity  of  the  joint  and  the  periarticular 
structures.  The  swelling  is  especially  noticeable  in  those  parts  of  the  articula- 
tion in  which  there  is  least  pressure  exerted  by  tendons  and  ligaments.  Move- 
ment of  the  joint  is  arrested  either  wholly  or  in  large  measure.  If  the  ankle  or 
the  knee  is  affected  the  patient  cannot  walk  at  all,  or  can  walk  only  with  a  limp. 
After  a  time,  usually  several  days,  subcutaneous  extravasations  are  seen,  wdth 
resulting  color-changes  in  the  skin.  If  in  a  hinge-joint  a  lateral  ligament  has 
been  completely  torn  across,  the  gap  may  commonly  be  felt,  and  an  abnormal 
movement  of  the  joint  can  always  be  effected.  Laceration  of  a  muscle  can  be 
detected  by  touch,  as  also  can  a  fracture  with  or  without  separation  of  the  frag- 
ments, as  in  the  lower  end  of  the  radius  or  through  a  malleolus.  In  the  ankle, 
as  pointed  out  by  Callender,  "  sprain  fracture  "  may  occur.  This  is  a  fracture 
of  a  part  of  the  articular  surface.  Its  existence  cannot  be  discovered  by  touch. 
This  accident  explains  many  of  the  cases  of  ankylosis  of  the  ankle  following 
what  is  apparently  a  mere  sprain. 

The  prognosis  varies  with  the  joint  affected,  the  extent  of  damage  done, 
and  especially  the  promptness  and  efficiency  of  treatment.  When  there  has 
been  a  large  hemorrhage  into  the  cavity,  blood-clots  often  remain  for  a  consid- 
erable time;  occasionally  their  organization  and  fusion  with  the  adjacent  syno- 
vial membrane  result  in  adhesions  which  decidedly  restrict  the  after  movements 
of  the  joint. 

27 


418  AN  AMERICAN    TEXT- HOOK    OF  SURGERY. 

The  treatment  has  for  its  object,  as  far  as  possible,  tlie  prevention  ortlie 
limitation  of  the  inflammation  in  and  about  the  joint.  In  the  niihler  cases  rest, 
with  cold  or,  much  better,  hot  applications,  may  be  all  that  will  be  re({uired. 
Compression  is  of  decided  service,  a  layer  of  cotton  or  wool  being  wrapped 
around  the  joint  and  held  in  place  by  a  moderately  tight  bandage  of  flannel  or 
rubber.  After  the  active  inflammation  has  subsided,  massage  is  of  great  value, 
and  its  early  employment  is  advised  by  many  surgeons.  Free  active  and  pas- 
sive motion  of  the  joint  from  the  first,  as  has  been  strongly  advised  by  some, 
is  painful,  and  cannot  be  otherwise  than  injurious  when  the  sprain  is  a  severe 
one.  By  far  the  best  treatment,  as  a  rule,  is  immobilization  of  the  joint  by 
the  application  of  a  plaster-of-Paris  bandage.  If  applied  soon  after  the  acci- 
dent has  occurred,  it  will  very  much  lessen  congestion,  hemorrhage,  and  effu- 
sion, and  diminish  the  time  of  confinement.  If  there  has  been  a  large  amount 
of  blood  poured  out  into  the  joint,  it  should  be  withdrawn  through  an  aseptic 
aspirator  needle  before  the  dressing  is  applied.  One  great  advantage  of  this 
method  of  treatment  is  that  it  will  permit  of  the  patient's  going  about  and 
attending  to  business  if  necessary — on  crutches  if  the  sprain  is  of  the  knee  or 
the  ankle,  Avith  the  arm  in  a  sling  if  the  affected  joint  is  of  the  upper  extremity. 
Immobilization  applied  at  once  and  maintained  for  a  number  of  weeks,  espe- 
cially if  the  patient  is  kept  quiet  and  the  limb  elevated,  will  in  great  measure 
prevent  the  occurrence  of  the  weak,  swollen,  painful,  and  crippled  condition  of 
the  joint  that  so  often  follows  a  severe  sprain  treated  in  other  ways.  Even  if 
there  has  been  a  fracture  or  a  dislocation,  this  method  of  treatment  is  the  best 
that  can  be  employed. 

Ankylosis. — As  the  result  of  cicatricial  contractions  of  new-formed  granu- 
lation-tissue in  and  about  a  joint,  its  motions  are  restricted,  and  the  articulation 
is  said  to  be  ankylosed.  Limitations  of  movement  due  to  loss  of  substance  in 
the  skin  and  underlying  soft  parts  consequent  upon  severe  injuries,  or  due  to 
contractions  of  muscles  and  tendons,  are  not,  properly  speaking,  cases  of  anky- 
losis, though  they  are  at  times  associated  with  the  ankylosing  effects  of  articular 
and  periarticular  inflammation,  and,  it  may  be  in  marked  degree,  increase  the 
disability  due  to  such  inflammation. 

That  ankylosis  may  be  produced,  there  must  have  been  (1)  a  blood-clot  adhe- 
rent to  the  folds  of  the  synovial  membrane  which  later  has  become  fused  with 
them  ;  or  (2)  the  organization  of  an  exudate  within  the  joint  commonly  attached 
to  eroded  parts  of  the  articular  cartilage,  though  at  times  deposited  only  in  an 
interosseous  ligament;  or  (3)  similar  change  in  an  exudate  in  the  subsynovial 
and  interligamentous  connective  tissue ;  or  (4)  degeneration  of  ligaments,  with 
after-contraction  of  the  substitution  granulation-tissue  and  the  formation  of 
adhesions  to  the  adjacent  parts;  or  (5),  what  most  often  occurs,  a  combination 
more  or  less  extensive  of  two  or  more  of  these  conditions.  Until  a  few  years 
ago  it  was  believed  that  simple  disuse  of  a  joint  would  be  followed  by  ankylosis, 
but  this  is  now  known  to  be  an  error,  at  least  as  to  the  larger  joints.  Without 
inflammation  of  some  form  or  other,  ankylosis  cannot  take  place.  The  restricting 
band  or  bands  may  be  of  limited  extent  outside  the  cavity  and  of  considerable 
length  within,  or  they  may  be  very  extensive  in  and  about  the  capsule  and  very 
short  between  the  ends  of  the  bones.  The  inflammation  may  terminate,  as  it 
commonly  does,  in  the  formation  of  fibrous  tissue,  or  may  go  on  to  ossification, 
partial  or  complete.  When  the  latter  change  has  taken  place  within  the  joint- 
cavity,  where  osseous  union  is  generally  found,  there  must  have  been  a  prior 
opening  up  of  the  cancellous  tissue  of  both  the  articulating  bones.  If  the  bone 
deposit  is  external,  it  may  occupy  the  place  of  a  degenerated  ligament  and  adja- 
cent connective  tissue,  having  started  from  the  periosteum  and  passed  over  the 


SURGERY   OF  JOINTS. 


419 


Fig. 171. 


joint  as  a  natural  splint  altogetlior  preventing  any  movement ;  or  it  may  be  in 
patches,  larger  or  smaller,  in  the  parts  outside  the  synovial  membrane. 

According  to  the  degree  of  organization  of  the  new-formed  tissue,  ankylosis 
IS  fibrous  or  bony ;  as  respects  the  extent  of  restriction  of  movement,  it  is  ^;ar- 
tial  or  complete. 

Except  when,  as  after  certain  fractures  and  in  cases  of  osteo-arthritis,  the 
ankylosis  is  due  to  displaced  fragments  and  stalactitic  outgrowths,  or  when  there 
has  been  but  a  limited  bone  deposit  in  the  periarticular  structures,  bony  anky- 
losis is  a  complete  one.  It  is  not,  however,  by  any  means  always  associated 
with  entire  obliteration  of  the  joint-cavity,  for,  as  has  already  been  stated, 
there  may  be  only  an  outside  bridge ;  and  when  the  union  is  an  internal  one 
very  often  there  will  remain  for  years  or  through  a  long  life  a  small  synovial 
cavity.  The  fusion  of  the  articulating  bones  is  seldom  so  complete  that  the 
line  of  junction  is  not  recognizable  on  section,  but  occasionally  it  is  impossible 
to  find  where  one  bone  ends  and  the  other  begins,  even  the  medullary  cavities 
being  so  directly  continuous  as  to  constitute  but  a  single  one. 

Bony  ankylosis  is  commonly  a  termination  of  septic  (often  an  osteo-myelitic) 
or  tubercular  inflammation,  while  fibrous  ankylosis,  which  may  be  met  with  after 
any  form  of  joint  inflammation,  is  very  generally  due  to  a  traumatic,  a  gonor- 
rheal, or  a  rheumatic  arthritis. 

In  the  fibrous  variety  the  adhesions  may  be  so  extensive  and  short  as  prac- 
tically to  prevent  all  motion  at  the  joint,  or  so  lax  as  to  interfere  but  little  with 
the  ordinary  movements  ;  or,  as  is  more  commonly  the  case,  they  may  be  sufficient 
decidedly  to  limit  the  use  of  the  limb.  In  the  cases  in  which  this  variety  most 
strongly  resembles  the  bonv,  even  when  motion 
at  the  articulation  cannot  be  recognized,  its 
fibrous  nature  is  proved  by  the  pam  attending 
manipulations  and  the  manifestation  within 
a  fcAV  hours  of  the  symptoms  of  irritation  or 
inflammation,  especially  a  local  rise  of  tem- 
perature. 

The  ill  effects  of  an  ankylosis  are  propor- 
tionate to  the  resulting  interference  with  the 
physiological  use  of  the  joint ;  they  depend, 
therefore,  not  only  on  restriction  of  motion, 
but  also,  and  to  a  greater  extent,  on  the  an- 
gle of  fixation.  A  knee  completely  anky- 
losed  in  the  straight  position  is  much  better 
than  one  held  in  permanent  flexion  or  one 
which  is  movable  and  yet  cannot  be  fully  ex- 
tended (Fig.  171).  An  ankylosis  of  the  elbow 
that  prevents  the  forearm  from  being  flexed 
at  a  riorht  anjile  with  the  arm  is  much  more 
crippling  than  one  in  which  extension  cannot 
be  carried  beyond  a  right  angle.  At  the 
shoulder,  ankle,  and  hip  loss  of  motion  is 
often  compensated  in  a  great  measure  by  the 
free  movement  of  the  scapula,  at  the  knee, 
and  at  the  sacro-iliac  junction  respectively.  AVhen  ankylosis  occurs  in  a  young 
child  more  or  less  interference  with  the  after-growth  of  the  bone  may  be  expected. 

The  treatment  will  depend  upon  the  variety,  the  angle,  and  the  joint 
affected.  When  the  nature  and  extent  of  an  articular  inflammation  make  it 
probable   that   ankylosis  will  occur,  such   inflammation  should  be  limited  as 


Angular  Ankylosis  nf  the  Knee 
(Bradford  aiiil  Lovett). 


420  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

mucli  ;is  possible,  especially  by  rest :  c.iro,  liowever,  must  ])o  taken  not  iiiiduly 
to  prolon<^  innnobilizatioii,  particularly  in  cases  of  rhcunnitic  origin,  in  Avhich 
after  a  time  regular  passive  motion  should  be  made.  In  certain  fractures,  nota- 
bly those  about  tiie  elbow,  it  has  been  advised  by  many  practically  to  disregard 
the  fracture  after  a  few  days,  and  by  passive  motion  prevent  the  joint  from  liecom- 
ing  stiff;  but  it  is  better  to  treat  the  fracture  in  the  ordinary  way,  remembering 
that  immobilization  most  thoroughly  limits  inflammation,  and  that  the  adhesions 
are  duo  to  inflammation.  Both  at  the  elboAV  and  at  the  knee  (after  fractui'e  of 
the  patella)  a  resulting  flbrous  ankylosis,  if  forcibly  broken  u]),  will  commonly 
be  (juickly  reproduced,  hut  with  active  use  of  the  joint  will  generally  spon- 
taneously disappear  in  the  course  of  a  few  months  or  at  most  in  a  year  or  two. 
When  the  ankylosis  is  bony  and  the  position  a  good  one,  no  treatment  should 
be  pursued,  unless  it  be  at  the  elbow,  where  by  excision,  partial  or  complete,  a 
serviceable  movable  joint  may  often  be  secured.  When  the  angle  is  a  vicious 
one,  excision  should  be  done  or  the  malposition  corrected  by  osteotomy ;  at  the 
hip  the  latter  is  much  the  preferable  ojjeration.  Forcible  breaking  down  of 
bony  adhesions  should  never  be  done ;  destructive  inflammation  of  the  part  is 
very  likely  to  follow,  the  original  disease  having  been  almost  certainly  septic  or 
tubercular ;  and  if  it  does  not,  the  surfaces  will  unite  again  by  bone. 

By  massage,  by  frictions,  by  baths,  by  regulated  movements,  by  the  use 
of  electricity,  especially  by  massage  and  movements,  much  may  be  accomplished 
in  the  removal  of  periarticular  exudations  and  adhesions. 

But  in  the  majority  of  cases  a  fibrous  ankylosis  will  require  for  its  removal 
either  a  forcible  rapid  breaking  up  of  the  adhesions  and  straightening  of  the 
limb  or  a  slowly-effected  correction  of  the  deformity  by  continuous  or  inter- 
mittent traction,  by  weight-extension,  or  by  apparatus.  As  a  rule,  the  former 
method  is  to  be  preferred.  If  the  tendons  about  the  joint  are  contractured, 
they  should  be  divided  a  few  days  before  the  straightening  is  to  be  done,  so 
that  the  little  wound  of  the  skin  may  be  entirely  healed,  as  otherwise  it  may 
be  a  starting-point  for  an  extensive  laceration.  Very  generally  the  tendons 
are  only  contracted,  and  that  more  apparently  than  really,  and  will  yield  readily 
enough  when  the  limb  is  extended.  When  it  is  the  knee  that  is  the  seat  of 
the  difficulty,  as  is  so  often  the  case,  the  patient  may  be  upon  his  back  or 
prone;  in  the  latter  position  leverage  can  more  readily  be  exerted.  The  limb 
being  grasped  above  the  ankle  and  above  the  knee,  firm,  steady  movements  in 
flexion  and  extension  are  to  be  made  until  the  leg  can  be  fully  and  easily 
extended  upon  the  thigh,  Avhen  the  whole  limb  is  to  be  enveloped  in  cotton  and 
immobilized  by  plaster  of  Paris,  the  dressing  being  kept  on  for  two  or  better 
for  three  weeks.  During  the  straightening  the  rupture  of  the  adhesions  can 
be  both  felt  and  heard,  ^fhe  operation  is  usually  free  from  danger  and  folloAved 
by  little  or  no  local  or  constitutional  disturbance. 

But  accidents,  and  serious  ones,  may  occur.  The  main  vessels  may  have 
become  shortened  and  adherent,  and  may  be  ruptured  when  the  limb  is  straight- 
ened; or  there  may  be  laceration  of  one  of  the  ])0])liteal  nerves,  with  result- 
ing paralysis;  or  the  skin  and  adherent  fascia  may  be  extensively  torn ;  or  long- 
encapsulated  pyogenic  cocci  may  be  set  free  and  develop  extensive  suppuration 
in  the  leg  or  thigh.  No  one  of  these  accidents  is  to  be  expected ;  any  one  of 
them  may  happen.  Because  of  the  danger  of  setting  free  the  infecting  organ- 
isms and  producing  destructive  inflammation  of  the  joint  and  structures  out- 
side, forcible  breaking  up  of  ankylosis  following  either  septic  or  tubercular 
disease  should  not  be  done.  By  the  employment  of  weight-extension  or  by  an 
apparatus  permitting  of  a  gradual  widening  of  the  abnormal  angle  the  deformity 
can  usually  be  corrected  after  a  time. 


SURGERY   or  .lOTNTH. 


421 


Nodules  of  Fibro-carlilages, 
some  attached  by  elongated 
pedicles  and  some  loose 
(Cruveilhier). 


SECTION  VI.-LOOSE   BODIES  IN  JOINTS. 
Loose  bodies  sometimes  occur  in  the  larger  joints,  in  nine  cases  out  of  ten 
in  the  knee.      Thev  consist  of  fibrous,  bony,  or  cartilaginous  tissue  or  a  mixture 
of  them.     So  commonly  are  they  cartilaginous  that  they  are  otten  called  by 
the  general  name  of  "floating  cartilages."     They  are 
sometimes  free  in  the  cavity  of  the  joint,  orlessjrequently 
attached  by  a  long  or  a  short  pedicle  (Fig.  1T2).     (Occa- 
sionally they  are  multiple,  but  more  commonly  there  are 
only  one,  two,  or  three.    In  size  they  vary  from  that  of  a 
pea  or  bean  up  to  that  of  the  last  joint  of  the  thumb. 
When  multiple  they  are  usually  very  small.     They  arc 
developed  in  several  ways,  originating  (T)  from  villous 
outf^rowths  from  the  synovial  membrane,  wliich  are  more 
and°more  crowded  off  from  the  surface,  the  contained  car- 
tilage-cells growing,  and  after  a  time  often  ossifying  in  the 
center;  (2)  from  detached  osteophytes  of  osteo-arthritis  ; 
(3)  from  outgrowths  from  the  articular  cartilage ;  (4)  from 
detached  pieces  of  cartilage,  with  or  without  a  bony  sub- 
stratum, which  have  been  separated  either  by  sudden  vio- 
lence or  slowly  by  "  quiet  necrosis ;"  (5)  from  blood-clots, 
either  in  the  cavity  itself  or  much  more  probably  in  the  sy- 
novial villi ;  (6)  from  fibrin  poured  out  in  an  acute  inflam- 
mation, or,  much  more  often,  in  a  rheumatic  subject,  over 
a  limited  space  under  the  synovial  membrane,  which  it 
pushes  inward  until  pedunculation  and  later  separation  of  the  nodule  take  place; 
(7)  from  overc^rowth  of  the  cartilage-cells  normally  contained  in  the  synovial 
membrane;  (8)  from  detached  tuberculized  fringes  or  small  parts  of  the  infectea 
membrane.     The  first  is  by  far  the  most  common  origin,  the  others  being  rare, 
most  of  them  (3,  5,  6,  7)  very  rare.     By  many  it  has  been  denied  that  the 
floating  cartilage  ever  is  a  piece  chipped  off  the  articulating  end  of  the  bone, 
but  sufficiently  numerous  specimens  prove  that  this  accident  occasionally  occurs. 
However  produced,  they  usually  undoubtedly  follow  traumatism,  which  is 
often  sli^^ht,  or  else  are  associated  with  a  rheumatic  or  osteo-arthritic  diathesis. 
They  are  found  in  adults  under  middle  age  as  a  rule,  and  m  men  far  oftener 
than  in  women.     When  very  small  and  numerous  they  are  not  usually  attended 
by  other  symptoms  than  those  of  chronic  arthritis.     When  there  are  but  one 
or  two,  and  these  of  considerable  size,  they  demand  treatment  because  of  the 
pain  and  disability  produced  by  them.     Occasionally  by  pressure  they  produce 
absorption  and  erosion  of  the  bony  surface  with  which  they  are  in  contact. 

Symptoms.— Sooner  or  later  the  presence  of  such  a  body  is  followed  by 
a  sli-ht  weakness  and  fulness  of  the  joint,  the  patient  at  times  feeling  the 
nodule  at  various  parts  of  the  joint,  oftenest  in  the  neighborhood  of  the  pate  la. 
Occasionally  the  cartilage  will  be  caught  somewhere  between  the  femur  and  the 
tibia.  Instantly  pain  is  experienced,  so  intense,  it  may  be,  as  to  cause  nausea 
and  faintin-.  Motion  of  the  joint  is  arrested,  and  the  patient  perhaps  falls. 
The  inabilitV  to  flex  or  extend  the  joint  continues  until  the  loose  body  is  dis- 
lodged by  various  movements.  Moderate  or  often  considerable  effusion  into 
the'ioint-cavity  soon  occurs,  but  is  quickly  absorbed,  the  joint  then  resuming 
its  previous  condition.  Similar  attacks  follow  one  another  with  increasing  f^^- 
quencv,  and  after  each  the  recovery  is  progressively  es.s  complete,  until  finally 
the  effusion  becomes  permanent,  and  the  joint  is  markedly  weakened. 

The  diagnosis  is,  as  a  rule,  easy.  A  small  body  which  shps  away  from 
under  the  finger  can  be  detected  first  in  one  and  then  m  another  pai't  of  the  joint. 


422  AN  AMERICAN    TEXT- HOOK    OF  SURGERY. 

"When  it  cannot  be  felt  its  presence  can  only  be  inferred  from  the  .siuhh-n 
attacks  of  disability.  The  only  affection  witji  which  it  can  be  confounded  ia 
the  so-called  "  internal  deran<,'enient  of  the  knee-joint,"  which  is  caused  bv  the 
slipping  or  dislocation  of  one  of  tiie  semilunar  cartilages.  'J'his  also  causes  a 
sudden,  intensely  painful  arrest  of  motion  at  the  knee,  followed  by  acute  syno- 
vitis ;  but  the  joint  is  more  likely  to  be  held  in  the  locked  condition,  and  after 
the  effusion  has  subsided  an  irregularity  can  usually  be  detected  just  above  the 
border  of  one  of  the  tuberosities  of  the  tibia.  This  is  the  edge  of  the  semi- 
lunar cartilage,  dislocated  forward  or  backward. 

Treatment. — When  such  a  sudden  attack  of  pain  and  disability  occurs, 
the  loose  cartilage  nuist  l>e  displaced  by  forced  flexion  and  extension  at  the 
knee,  under  an  anesthetic  if  necessary,  after  which  the  joint  should  be  immo- 
bilized for  a  number  of  days.  The  only  radical  treatment  is  removal  of  the 
loose  body  by  opening  the  joint.  Modern  antiseptic  methods  have  made  the 
operation  a  perfectly  safe  one,  in  marked  contrast  to  the  ver}^  serious  results 
which  formerly  followed  the  opening  of  this  joint.  The  loose"  body  is  first  to 
be  fixed,  if  possible,  either  by  the  fingers  or  by  a  steel  pin  thrust  into  it,  often 
a  procedure  of  great  difficulty  owing  to  its  density.  An  incision  is  then  made 
directly  into  the  joint,  as  near  the  cartilage  as  possible.  This  is  pressed  out, 
or  if  any  difiiculty  is  experienced  the  finger  or  a  blunt  hook  or  forceps  is 
passed  into  the  joint  and  the  cartilage  seized.  The  edges  of  the  wound  in  the 
synovial  membrane  are  to  be  united  by  buried  catgut  sutures,  and  the  cutaneous 
wound  is  closed  and  dressed  as  usual.  The  leg  should  be  immobilized  either 
by  a  plaster-of-Paris  dressing  or  a  splint. 

SECTION  VII.— DISPLACED  SEMILUNAR  CARTILAGE. 

This  has  long  been  termed  "internal  derangement  of  the  knee-joint," 
but  is  now  known  to  be  due  to  the  slipping  or  displacement  of  one  of  the  semi- 
lunar cartilages,  mo.st  frequently  the  internal.  It  may  occur  in  health,  the 
coronary  ligament  being  torn  away  ;  but  it  is  commonly  associated  Avith  chronic 
synovitis  or  osteo-arthritis,  in  which  diseases  the  attachments  of  the  cartilages 
are  relaxed  and  more  easily  torn.  The  cartilage  may  be  merely  slipped  between 
the  ends  of  the  bones,  or  it  may  be  rolled  upon  itself  and  entirely  detached 
from  the  tibia.  Having  once  occurred,  the  accident  is  liable  to  be  freijuently 
repeated. 

The  symptoms  are  sudden  and  severe  pain,  with  inability  to  stand  or 
walk,  the  leg  being  partially  flexed  and  the  joint  locked.  Swelling  follows 
quickly,  but  subsides  after  displacement  of  the  cartilage.  When  the  luxation 
has  occurred  ftxMjuently,  however,  the  effusion  is  more  permanent  and  the  limb 
weak. 

Treatment. — At  the  time  of  the  accident  replacement  of  the  cartilage  is 
effected  by  flexion  and  extension  with  rotation  of  the  knee,  if  necessary  under 
an  anesthetic.  Sometimes  the  patient  will  execute  this  maneuver  himself  bet- 
ter than  the  surgeon.  Occasionally  replacement  is  impossible.  When  the 
cartilage  has  been  replaced  the  joint  quickly  resumes  its  normal  condition,  an 
elastic  knee-cap  being  often  employed  to  steady  and  assist  it.  If  the  disability 
is  very  great  or  reduction  impossible,  the  joint  should  be  opened  and  the 
cartilage  seized  and  Ijrought  back  to  its  normal  position,  where  it  should  be 
fixed  by  sutures  carried  through  the  periosteum  of  the  tuberosity.  It  has  been 
removed  with  excellent  functional  results.     Absolute  asepsis  is  re(iuir('(l. 


DISL  OCA  TJOX^.  423 


CHAPTER    VIII. 
DISLOCATIONS. 

Defixitioxs. — A  dislocation  is  a  ])ennanent,  abnormal,  total,  or  partial 
displacement  from  each  other  of"  the  articular  portions  of  the  bones  entering 
into  the  formation  of  a  joint. 

A  temporarji  displacement,  followed  immediately  by  a  return  to  place,  con- 
stitutes a  sprain. 

When  the  oj)posin(^  articular  surfaces  are  completely  separated  or  touch  each 
other  only  by  their  edges,  the  dislocation  is  complete;  lesser  forms  of  displace- 
ment are  termed  partial  or  incomplete,  or  subluxations.  In  the  ball-and- 
socket  joints  the  dislocation  is  said  to  be  complete  Aviien  the  center  of  the 
globular  head  rests  outside  the  rim  of  the  concave  socket. 

A  coexisting  wound  of  the  soft  parts  that  establishes  communication  between 
the  outside  air  and  the  cavity  of  the  joint  makes  the  dislocation  compound  ; 
and  the  coexistence  of  other  important  lesions  that  seriously  affect  the  treat- 
ment and  prognosis  makes  it  complicated. 

When  the  corresponding  joints  of  a  bone  symmetrically  placed  on  both 
sides  of  the  median  line  of  the  body,  as  the  lower  jaw  or  a  vertebra,  are  dislo- 
cated, the  dislocation  is  said  to  be  bilateral.  It  is  total  when  both  ends  of  a 
bone,  as  the  clavicle,  are  dislocated,  or  when  a  small  bone  having  several  joints, 
as  a  carpal  or  a  tarsal  bone,  is  widely  displaced.  Dislocations  are  double  when 
symmetrical  on  both  sides  of  the  body,  as  of  both  shoulders.  Dislocations  are 
said  to  be  multiple  when  two  or  more  bones  are  simultaneously  dislocated,  as 
two  or  more  fingers,  a  shoulder,  and  a  hip.  Both  these  last  two  terms  are  some- 
times used  in  the  sense  of  total. 

Ordinarily  a  dislocation  is  traumatic,  and  occurs  abruptly  in  a  normal  joint 
as  the  result  of  external  violence  or  of  the  sudden  contraction  of  the  patient's 
muscles  upon  the  bones  forming  the  joint,  but  occasionally  it  takes  place  grad- 
ually (or  suddenly)  without  recognizable  violence  in  joints  that  have  been  so 
altered  by  disease  as  to  facilitate  the  displacement ;  such  dislocations  are  com- 
monly known  as  spontaneous  or  patholoyieal.  Congenital  dislocations  are 
those  that  occur  during  intra-uterine  life,  and  are  usually  the  result  of  defect- 
ive development. 

Nomenclature. — As  a  general  rule,  the  distal  member  of  the  joint  is  the 
one  said  to  be  dislocated ;  thus  we  speak  of  a  dislocation  of  the  humerus,  and 
not  of  the  scapula,  when  the  scapulo-humeral  joint  is  dislocated;  an  almost 
universal  exception  to  this  rule  is  the  term  dislocation  of  the  outer  end  of  the 
clavicle,  used  instead  of  dislocation  of  the  acromion  or  of  the  scapula.  Some- 
times the  name  of  the  joint  or  of  the  region  is  used,  as  dislocation  of  the 
shoulder,  hip,  elbow.  Terms  indicating  direction  correspond  to  the  change  in 
the  position  of  the  distal  segment  of  the  joint,  as  backward  dislocation  of  the 
elbow,  meaning  that  the  upper  ends  of  the  radius  and  ulna  ai-e  displaced  back- 
ward. Special  names  indicative  of  the  new  relations  of  the  displaced  bones 
are  applied  to  some  of  the  commoner  varieties,  as  subcoracoid  dislocation  of 
the  shoulder,  iliac  or  dorsal  dislocation  of  the  hip. 

Statistics. — Dislocations  are  less  frequent  than  fractures  in  the  proportion 
of  1  to  10 ;  {hose  of  the  shoulder  are  the  most  frequent,  those  of  the  elbow 


424  AX   A.VFJUCAX    TEXT-IIOOK    OF   SURGERY. 

next.  Tlio  |)i()))Ovtioiis  vary  in  diftercnt  statistics,  but  in  general  terms  it  may 
be  said  that  dislocations  of  the  shoulder  consUtutc  from  one-half  to  two-thirds 
of  all  dislocatio)is. 

Age. — Dislocations  may  occur  at  any  age  from  the  very  moment  of  birth  ; 
the  absolute  frequency  is  greater  between  the  ages  of  twenty  and  thirty  ;  the 
relative  frequency,  computed  according  to  the  number  of  people  living  at  the 
different  ages,  is  greatest  in  the  three  decades  between  forty  and  seventy. 
Below  the  age  of  twenty  years  dislocations  of  the  shoulder  are  rare,  those  of 
the  oll)ow  frequent;  above  that  age  those  of  the  elbow  are  rare,  those  of  the 
shoulder  frequent.  It  has  been  pointed  out  that  dislocations  of  the  elbow  are 
produced  in  childhood  by  the  same  violence — i.  e.  falls  upon  the  outstretched 
hand — that  produces  fracture  of  the  humerus  in  adults,  and  dislocations  of  the 
shoulder  in  adults  by  that  which  produces  fractures  of  the  clavicle  in  children 
— i.  e.  falls  upon  the  shoulder. 

ETIOLOGY   AND    MECHANISM. 

The  causes  are  {a)  pj'edisposing,  and  (b)  immediate  or  detei-mining. 

(a)  Predisposing  Causes. — Normal  predisposing  causes  are  found  in  the 
conformation  of  certain  joints  which  diminishes  the  area  of  contact  of  the 
opposing  ai-ticular  surfaces  in  certain  positions  or  establishes  conditions  of  lev- 
erage favorable  for  the  rupture  of  opposing  ligaments,  as  in  hyper-extension  of 
the  elbow ;  or  which  avoids  the  opposition  of  ligaments,  as  in  the  movement 
forward  of  the  condyles  of  the  lower  jaw;  and  also  in  the  greater  exposure  of 
certain  joints  to  external  violence.  Normal  freedom  of  motion  is  more  of  a 
protection  against  dislocation  than  a  predisposing  cause  thereto,  because  the 
necessary  rupturing  strain  is  not  ordinarily  put  upon  the  opposing  ligaments 
before  the  limit  of  motion  has  been  reached.  A  predisposing  cause  at  the 
elbow  is  found  in  the  outward  deviation  of  the  forearm  from  the  long  axis  of 
she  arm.  Pathological  predisposing  causes  are  distention  of  the  joint  by  an 
effusion,  destruction  or  softening  of  the  ligaments  by  violence  or  disease,  and 
the  fracture  of  bony  processes  or  of  one  of  a  pair  of  parallel  bones. 

{h)  Immediate  or  Determining  Causes. — These  are  external  violence 
and  muscidar  action.  External  violence  may  be  exerted  directly  upon  the  end 
of  the  bone  that  is  displaced,  as  in  a  dislocation  of  the  head  of  the  humerus  by 
a  fall  or  a  blow  upon  the  prominent  part  of  the  shoulder;  or  indirectly  through 
and  parallel  to  the  shaft  of  the  bone;  or  in  a  more  complex  manner  by  moving 
the  limb  beyond  the  normal  limit  of  the  range  of  motion,  so  as  to  rujjture  the 
ligaments,  and  then  forcing  the  liberated  bone  out  of  its  place. 

Muscular  action  dislocates  by  communicating  a  momentum  to  the  limb 
which  acts  in  the  same  manner  as  external  violence  when  the  limit  of  the 
range  of  motion  is  reached,  or  by  acting  directly  upon  the  end  of  the  bone 
to  draw  it  out  of  its  socket.  Thus  a  woman  dislocated  her  shoulder  by  raising 
her  arm  quickly  to  strike  a  blow,  a  man  dislocated  both  shoulders  by  drawing 
himself  upward  by  his  hands,  another  by  raising  his  arm  to  paint  a  ceiling, 
others  during  epileptic  convulsions;  dislocation  of  the  lower  jaw  may  be  pro- 
duced by  yawning.  Some  individuals  can  voluntarily  dislocate  certain  joints 
by  the  contraction  of  certain  muscles  or  groups  of  muscles ;  in  others  a  lia- 
bility to  dislocation  of  some  one  joint  by  slight  causes  exists  (recurrent  or 
habitual  dislocation)  as  the  result  of  a  primary  traumatic  dislocation,  or  of  the 
paralysis  of  certain  muscles,  or  of  other  pathological  conditions. 


DISL  O  CA  TIONS.  425 

PATHOLOGY    OF    RECENT    DISLOCATIONS. 

Except  in  very  rare  instances,  one  or  more  of  the  ligaments  of  a  joint  and 
its  capsule  are  torn  during  a  dislocation;  in  the  ball-and-socket  joints  the  rent 
in  the  capsule  is  on  the  side  toward  which  the  round  head  of  the  distal  bone  is 
displaced ;  in  other  joints  the  ligaments  on  either  side  or  on  both  sides  may  be 
torn,  the  position  and  extent  of  the  injury  varying  with  the  mode  of  production 
and  the  range  of  displacement.  There  is  reason  to  think  that  both  the  capsule 
and  the  ligaments  escape  rupture  in  the  simpler  dislocations  of  the  lower  jaw, 
and  a  few^  cases  have  been  reported  in  which  those  of  the  shoulder  have  similarly 
escaped.  In  joints  relaxed  by  paralysis  of  the  corresponding  muscles  or  by 
an  effusion  within  the  capsule,  dislocation  habitually  occurs  without  laceration. 

Attached  muscles  that  are  put  upon  the  stretch  may  be  ruptured  or  torn 
from  their  attachments,  perhaps  bringing  Avith  them  in  the  latter  case  the  scale  or 
apophysis  of  bone  to  which  they  are  attached.  Opposing  prominences  of  bone 
or  portions  of  a  prominent  articular  edge  or  rim  may  be  broken  off,  as  the  cor- 
onoid  process  of  the  ulna  or  the  edge  of  the  head  of  the  radius  in  a  backward 
dislocation  of  the  elbow,  or  the  rim  of  the  glenoid  or  cotyloid  cavity.  One 
articular  surface  may  be  deeply  indented  by  impact  against  the  edge  of  the 
other  surface. 

Associated  injuries  of  adjoining  parts  may  exist  as  complications. 
The  shaft  of  the  dislocated  bone  or  of  a  parallel  bone  may  be  broken  ;  the 
dislocated  end  may  be  split ;  the  neighboring  blood-vessels  or  nerves  may 
be  ruptured  or  bruised;  adjoining  organs  may  be  lacerated  or  compressed; 
the  soft  parts  and  the  integument  may  be  torn.  Fracture  of  the  shaft  or  of 
the  neck  of  the  dislocated  bone  may  constitute  a  serious,  perhaps  an  insurmount- 
able, obstacle  to  reduction,  because  of  the  difficultv  of  communicating  the 
necessary  movements  to  the  dislocated  end ;  the  commonest  example  is  frac- 
ture of  the  surgical  neck  of  the  humerus  in  combination  with  dislocation  of 
the  shoulder.  Fracture  of  the  articular  end  of  the  dislocated  bone  is  rare, 
although  there  is  reason  to  think  that  limited  bruising  of  the  head  of  the 
humerus  by  impact  against  the  edge  of  the  glenoid  fossa  is  not  very  uncom- 
mon. Partial  fracture  of  the  rim  of  the  socket  of  an  enarthrodial  joint  or 
avulsion  of  an  apophysis  is  common,  and  does  not  ordinarily  constitute  an 
important  complication.  Rupture  of  neighboring  blood-vessels  is  most  frequent 
at  the  shoulder,  where  it  usually  consists  in  rupture  or  avulsion  of  the  subscap- 
ular or  circumflex  artery.  Of  injuries  of  nerves  the  most  common  is  that  of 
the  posterior  circumflex  at  the  shoulder.  At  the  knee  and  the  elbow  the  main 
arterial,  venous,  and  nerve  trunks  are  occasionally  torn.  Injuries  of  adjoining 
viscera  are  rare.  In  backward  dislocation  of  the  sternal  end  of  the  clavicle 
the  trachea  or  oesophagus  is  sometimes  pressed  upon  ;  and  in  one  reported  case 
the  dislocated  humerus  Avas  forced  through  the  wall  of  the  chest,  the  bone  retain- 
ing its  new'  position  and  the  patient  surviving  many  years. 

In  uncomplicated  cases  reduction  is  habitually  followed  by  repair  of 
the  torn  capsule  and  ligaments,  but  complete  restitution  to  the  normal  condition 
may  be  prevented  by  faulty  repair  of  some  of  the  lesions,  by  periarticular 
thickening,  by  subperiosteal  formation  of  bone  in  the  young,  or  by  more  or 
less  persistent  sensitiveness  of  the  joint.  Thus  at  the  shoulder  the  ruptured  ten- 
don of  the  supraspinatus  and  the  upper  part  of  the  capsule  may  fail  to  reunite, 
and  the  patient  be  thereby  exposed  to  frequent  recurrence  of  the  dislocation, 
or  the  fracture  and  retraction  of  the  greater  tuberosity  may  annul  or  weaken 
the  powder  of  active  external  rotation,  or  injury  to  the  circumflex  nerve  may 
result  in  more  or  less  prolonged  paralysis  and  wasting  of  the  deltoid.     At  the 


42G 


AX  A.VERrCAX    TKXT-IlOOk'    OF  SURGERY 


Fkj.  17:^. 


elbow  the  stripping  up  of  the  periosteum  from  the  posterior  aspect  of  the  external 
condyle  may  load  to  such  thickcnina;  of  the  bone  as  will  limit  extension. 

In  dislocations  that  remain  unreduced  the  displaced  and  lacerated  con- 
nective tissue  becomes  thicken('(l  and  c(jndenscd  about  tiie  head  of  the  bone, 

sometimes  uniting  directly  with  it.  some- 
times forming  a  new  capsule  al)out  it 
which  is  more  or  less  broadly  continuous 
with  the  old  one ;  the  torn  ligaments  and 
muscles  contract  new  adhesions  which 
serve  to  fix  the  bone  in  its  new  position 
and  limit  its  motion.  The  untorn  por- 
tion of  the  capsule  is  drawn  across  the 
other  articular  surface  (e.  g.  the  glenoid 
fossa),  and,  if  the  contact  is  close,  unites 
permanently  with  it ;  if  the  contact 
is  not  close,  the  cavity  of  the  socket 
fills  up  with  fibrous  tissue  of  new  for- 
mation. The  dislocated  head  comes  to 
rest  against  an  adjoining  surface  of 
bone,  and  under  the  influence  of  its 
pressure  the  bone  and  the  periosteum  are 
stimulated  to  the  production  of  new  bone 
about  tiie  point  of  contact,  and  thus 
is  formed  a  bony  rim.  a  veritable  new 
socket,  possibly  covered  Avith  fibro-car- 
tilage  (Fig.  173).  The  ossifying  process 
may  extend  to  the  adjoining  soft  parts 
and  produce  large  and  irregular  masses 
of  bone  continuous  with  one  and  possibly 
with  both  of  the  members  of  the  joint. 
A  very  important  feature  is  the  occasional  binding  fast  of  neighboring  large 
vessels  or  nerves  to  the  dislocated  bone.  The  result  of  all  these  changes  is 
that  the  dislocated  bone  becomes  permanently  fixed  in  its  new  position,  and  its 
return  to  its  former  one  can  be  eflected  only  with  lacerations  similar  to,  and 
usually  much  more  extensive  and  serious  than,  those  which  accompanied  its 
first  displacement;  furthermore,  the  socket  from  which  it  Avas  displaced  has 
been  shut  off"  by  the  adherent  capsule  or  filled  up  with  new  tissue. 


Old  Supracotyloid  Dislocation  of  tlie  Femur,  with 
very  complete  new  acetabulum  (Kninleiii). 


SYMPTOMS. 


Deformity,  including  in  this  terra  changes  in  contour  and  attitude,  is  always 
present,  and  is  frequently  so  marked  as  to  be  almost  diagnostic  on  inspection 
alone.  The  one  demonstrative  sign  of  dislocation  is  the  recognized  presence 
of  the  head  of  the  bone  in  an  abnormal  positon  ;  and  this  sign  should  always  be 
sought  for  in  preference  to  others  that  are  less  demonstrative,  but  perhaps  more 
easily  recognized.  It  is  obtained  by  palpation  of  the  region,  by  systematic 
exploration  of  the  bony  prominences,  and  by  the  identification  of  abnormal 
prominences  or  of  those  abnormally  situated,  by  means  of  gentle  movements 
communicated  to  the  limb.  Thus  in  the  common  anterior  dislocation  of  the 
shoulder  the  finger  recognizes  the  absence  of  the  normal  bony  resistance  offered 
by  the  head  of  the  humerus  beloAV  the  acromion  in  front,  and  finds  a  new  one 
below  or  to  the  inner  side  of  the  coracoid  process.  Avhich  shares  in  rotatory 


DISLOCATIONS. 


427 


A' 


Diagrams  to  show  the  effect  of  attitude  \\\n>n  the  meas- 
ured length  of  the  arm  (A)  in  dislocation  of  the  right 
shoulder,  and  (A')  when  the  bones  are  in  normal  posi- 
tion; B,  W ,  the  acromion  (original). 


moveraonts  coiunmnii-atiMl  to  the  anii  ;   and  the  surgeon  also  notes  that  the  axis 
of  the  limb  if  })roloiio;e(l  upward  passes  throu<i:h  this  proniiiienee. 

^leaifureiiioitx. — Many  eonfusing  statements  concerning  shortening  or 
elongation  of  the  limb  in  different  dislocations  have  been  made.  Error  may 
arise  through  failure  to  place  the  compared  limbs  in  symmetrical  positions,  con- 
tradiction through  the  choice  of  different  lines  of  measurement.  It  may  be 
positively  stated  that,  -with  one  or  two  extremely  rare  exceptions,  such  as  dis- 
location forward  of  both  bones  of  the  forearm,  s/iorteiihiq  can  always  be  found 
if  the  measurement  is  made  on  the  proper  side  and  with  the  limb  in  a  suitable 
attitude.      The  proper  side  is  the 

one  away  from  which  the  head  of  ■  Fir;.  174. 

the  bone  has  been  dislocated  :  the 
suitable  attitude  is  the  one  in  which 
the  limb  is  inclined  toward  this 
side.  Thus,  at  the  shoulder  the 
measurement  should  be  made  from 
the  tip  of  the  acromion  to  the  ex- 
ternal condyle  of  the  humerus,  and 
the  arm  should  be  in  abduction. 
Fig.  174  illustrates  the  sources  of 
error  and  contradiction.  A  repre- 
sents an  anterior  dislocation  of  the 
right  shoulder  seen  from  in  front ; 
A',  the  same  shoulder  with  the 
bones  in  place.  Measured  in  abduction,  B  C  is  shorter  than  B'  C  or  B  JJ 
or  B'  D' ;  measured  with  the  arm  alongside  the  chest,  B  I)  h  as  long  as, 
perhaps  longer  than,  B'  I)' . 

In  typical  dislocations,  those  in  which  certain  ligaments  and  portions.of 
the  capsule  remain  untorn,  the  attitude  of  the  limb  is  characteristic,  because 
of  the  limitation  of  movement  imposed  by  the  untorn  bands  :  thus  in  the 
common  anterior  dislocation  of  the  shoulder  the  elbow  is  held  away  from  the 
side ;  in  the  common  dorsal  dislocation  of  the  hip  the  thigh  is  flexed  and 
adducted. 

As  the  consequence  of  this  opposition  of  the  untorn  ligaments,  the  normal 
range  of  motion  is  restricted  in  certain  directions  while  it  is  unaffected  in  others. 
In  the  hinge  joints  the  normal  range  of  motion  is  restricted  and  abnormal 
lateral  mobility  exists.  The  statement  is  frequently  made  that  mobility  is 
increased  in  fracture  and  diminished  in  dislocation.  In  that  form  the  state- 
ment is  entirely  misleading :  ordinarily  the  mobility  that  is  found  in  fracture  is 
wholly  abnormal  and  exists  between  two  parts  of  the  same  bone;  the  mobility 
whose  absence  or  restriction  is  noted  in  dislocation  is  mobility  between  two 
separate  bones.  Normal  mobility  may  be  restricted,  both  in  fractures  and  in 
dislocations,  by  the  opposition  of  the  muscles  aroused  by  fear  of  pain.  In 
dislocation  of  the  elbow^  backward  abnormal  lateral  mobility  exists,  just  as  it 
does  in  fracture  of  the  lower  end  of  the  humerus. 

The  production  of  the  dislocation  is  usually  accompanied  by  severe  pain^ 
which  may  persist  for  some  time  or  may  promptly  give  place  to  a  feeling  of 
soreue.ss,  with  pain  when  the  member  is  moved  or  the  region  handled.  Per- 
sistence of  severe  pain  appears  to  indicate  that  some  of  the  soft  parts  are  not 
torn,  but  are  kept  forcibly  stretched. 

Treatment. — As  a  rule,  a  recent  dislocation  should  be  reduced  at  the 
earliest  practicable  moment.  The  conditions  which  may  make  delay  advisable 
are  great  inflammatory  reaction  and  swelling  and  great  shock,  due  usually  to 


42« 


i.v  A^fI:RI('Ay  text-book  of  surgery. 


7yf      ^ 


Piagram  to  show  the  effect  of  the  position  of  a  limb  upon  the  tension 
of  a  ligament  (original'). 


associated  injuries,  which  may  contraindicate  the  infliction  of  pain  or  the  use 
of  anesthetics. 

The  choice  of  a  suitable  method  of  reduction  (l(.'i)eiids  upon  the  reco*'- 
nition  of  tlie  obstacles  to  reduction.  In  most  cases  these  are  of  two  kinds: 
the  contraction  of  the  muscles,  excited  by  pain  or  the  fear  of  pain,  and  the 
resistance  offered  by  untorn  ligaments  or  portions  of  the  capsule  to  move- 
ments of  the  limb  in  certjiin  directions.  Other  obstacles  are  the  interposi- 
tion of  a  portion  of  the  capsule,  common  in  certain  dislocations  {e.  g. 
the  metacarpo-phalangeal),  but  rare  in  others,  and  unusual  relations  to 
certain  adjoining  muscles  created  by  a  wide  movement  of  the  dislocated 
bone. 

In  "typical"  dislocations,  those  in  which  the  limb  assumes  and  retains  a 
characteristic  attitude,  -which  has  been  shown  to  be  due  to  the  action  of  untorn 
ligaments  or  portions  of  the  capsule  in  resisting  movement  in  certain  directions, 

it   is   essential   that    the 
^^^-  1"'5-  limb    should    be    placed 

in  a  position  and  moved 
only  in  a  direction  in 
which  the  opposition  of 
these  untorn  structures 
will  not  be  encountered. 
Fig.  175  shows  diagram- 
matically  the  position 
{A)  in  which  the  liga- 
ment {L)  opposes  and 
that  (J5)  in  which  it  per- 
mits the  movement  of 
the- limb  in  the  direction  indicated  by  the  arrow,  and  by  which  the  head  would 
be  restored  to  its  socket  (.V).  In  "atypical"  dislocations  the  laceration  of  the 
ligaments  and  capsule  is  .so  extensive  that  they  offer  little  or  no  opposition  to 
movement  in  any  direction.  In  the  typical  forms,  therefore,  certain  well-defined 
manipulations  are  needed  whether  anesthesia  is  or  is  not  employed  to  remove 
the  opposition  of  the  muscles :  in  the  atypical  forms  reduction  is  usually  very 
easy  by  moderate  traction  and  coaptation,  without  special  attention  to  the 
attitude  of  the  limb  during  the  manipulation. 

Reduction  by  manipulation  is  a  term  applied  to  a  succession  of  gentle 
movements  communicated  to  the  dislocated  limb  by  which  the  sides  of  the  rent 
in  the  capsule  are  separated  from  each  other  and  the  head  of  the  bone  is  rolled 
back  into  place  by  the  aid  of  the  untorn  ligaments.  The  method  is  applicable 
only  to  typical  dislocations,  and  the  best-known  examples  are  Kocher's  method 
for  the  reduction  of  anterior  dislocations  of  the  shoulder,  and  Bigelow's  for 
that  of  dorsal  dislocations  of  the  hip,  the  details  and  mechanism  of  which 
will  be  described  in  the  appropriate  places. 

The  opposition  of  the  muscles,  by  which  is  meant  a  persistent  contraction 
of  those  attached  to  the  dislocated  bone  wliich  prevents  its  movement  toward 
its  socket,  ma}"  be  annulled  by  anesthesia,  or  overcome  by  forcible  or  per- 
sistent traction,  or  avoided  by  momentarily  distracting  the  patients  attention. 
The  use  of  anesthetics  has  made  the  reduction  of  most  dislocations  very  easy. 
It  should  be  pushed  to  the  point  of  complete  muscular  relaxation:  this  is  some- 
times obtained  during  the  short  period  of  primary  anesthesia  which  usually 
precedes  by  some  minutes  the  condition  of  complete  anesthesia,  and  in  the 
simpler  cases  reduction  may  be  then  obtained  :  but  if  the  manipulations  are 
likely  to  be  at  all  prolonged,  or  if  the  patient  is  feeble  or  diseased  or  suffering 


DISL  O CA  TIONS.  429 

f'roiii  sliock,  it  is  safV-r  to  wait  for  complete  general  anesthesia.  The  proportion 
of  cases  in  wliich  dcatli  lias  followed  the  use  of  an  anesthetic  in  the  reduction 
of  dislocations  is  exceptionally  hu-ge,  and  seems  probably  to  be  due  to  its  timid 
and  insufficient  use ;  the  anesthesia  not  being  complete,  the  reduction  causes 
dangerous  shock  by  pain.  Such,  at  least,  appears  to  be  the  explanation  of  the 
disproportionate  fatality  of  minor  but  painful  operations  under  an  anesthetic. 
Ether  is  safer  tlian  chloroform  for  the  purpose. 

The  use  of  pulleys,  which  formerly  was  general,  is  noAV  rare  in  the  reduc- 
tion of  recent  dislocations,  having  been  replaced  by  anesthetics  or  by  the  pro- 
longed application  of  moderate  traction,  the  muscles  yielding  gra'dually  to 
fatigue.  This  gradual  traction  can  be  made  by  a  weight  and  pulley  or  by- 
india-rubber,  or,  in  some  cases,  by  the  weight  of  the  dependent  limb  in  a  suit- 
able position.  Even  without  anesthesia,  if  the  attention  of  the  patient  be 
diverted  the  muscles  will  sometimes  be  seen  to  relax,  and  then  by  a  sudden 
sharp  blow  the  bone  may  be  replaced. 

In  cases  in  which  reduction  is  prevented  by  the  interposition  of  a  portion 
of  tiie  capsule,  as  at  the  metacarpo-phalangeal  joint,  or  of  a  muscle  or 
tendon,  as  occasionally  at  other  joints,  an  open  arthrotomy  may  be  necessary. 
Under  the  protection  of  antiseptics  this  operation  is  reasonably  safe,  but  the 
risk  appears  to  be  least,  in  the  case  of  the  larger  joints,  if  it  is  done  while  the 
injury  is  fresh,  on  the  first  or  second  day,  or,  failing  this,  if  it  is  postponed  to 
a  much  later  period,  after  the  reaction  has  subsided  and  the  extravasated  blood 
has  been  reabsorbed,  about  the  third  or  fourth  week. 

In  old  dislocations  the  manipulations  used  in  recent  ones  will  sometimes 
succeed  after  the  adhesions  that  bind  the  dislocated  bone  in  its  new  position 
have  been  ruptured  by  forcible  movements  of  the  limb,  but  usually  strong 
traction  is  also  required  to  draw  the  bone  to  its  place.  Interference  in  such 
cases  is  unavoidably  blind  and  uncertain  ;  more  extensive  lacerations  are  neces- 
sary to  free  the  bone  than  those  occasioned  by  the  original  dislocation,  and  the 
changed  relations  of  important  vessels  and  nerves  are  such,  and  their  fixation 
by  cicatricial  tissue  is  so  firm,  that  serious  injury  may  be  done.  It  seems  much 
safer,  therefore,  in  many  cases  to  resort  to  a  cutting  operation  if  the  attempt  is 
to  be  made  to  restore  the  bone  to  its  place.  Furthermore,  the  structural 
changes,  are  occasionally  so  great  that  even  if  the  dislocation  is  reduced  the 
condition  of  the  joint  will  fall  far  short  of  the  normal,  and  the  limb,  in  such 
cases,  will  be  no  more  useful  than  while  the  dislocation  existed.  Hence  in 
some  instances  it  is  as  well  to  let  the  dislocated  bone  remain  unreduced. 

The  accidents  that  may  follow  attempts  at  reduction  are  numerous  and 
varied.  The  skin  may  be  torn  by  excessive  and  improperly  applied  traction, 
the  bone  may  be  broken,  vessels  and  nerves  may  be  ruptured,  suppuration  may 
be  excited,  and  death  may  folloAv  through  the  agency  of  the  anesthetic  or  the 
shock  of  the  manipulations. 

Fracture  of  the  bone  may  occur,  and  may  involve  the  shaft,  the  neck,  or 
the  bony  prominences,  the  fracture  of  the  olecranon  in  old  backward  disloca- 
tions of  the  elbow  being  the  commonest  example  of  the  latter.  It  has  been 
noted  that  the  bones  of  a  dislocated  limb  sometimes  show  exceptional  fragility, 
apparently  the  result  of  interstitial  changes  provoked  by  disuse  or  altered  con- 
ditions of  nutrition  consequent  upon  the  primary  injury. 

Injuries  of  vessels  are  most  frequent  and  important  in  the  common  forms 
of  anterior  dislocation  of  the  shoulder,  and  of  these  the  commonest  appears 
to  be  the  rupture  of  the  subscapular  or  circumflex  artery  or  its  avulsion  from 
the  axillary.  The  axillary  artery  itself  has  been  torn  completely  across,  or  its 
inner  and  middle  coats  ruptured;   the  axillary  vein  has  rarely  been  injured. 


430  Ay  A.u/:/:/(A\  ri:xT-]i(>f)k'  of  si^nanm'. 

llupture  of  an  artcrv  at  the  slioulder  is  followt-il  l»y  rajdd  extravasation  of 
blood  in  the  axilla ;  pulsation  at  the  wrist  may  ])ersist.  The  condition  i.s  a 
grave  one:  of  47  cases  31  ended  fatally  (Stinison).  Methods  of  treatment 
that  iiave  proved  snccessfiil  are  digital  pressure,  ligature  of  the  subclavian, 
and  disarticulation  at  the  .shoulder.  Double  ligature  at  the  point  of  injury 
has  been  uniformly  fatal. 

Injuries  to  main  nerrcs  are  more  rare :  the  roots  of  the  brachial  plexus 
have  been  torn  out  in  reducing  a  dislocation  of  the  shoulder ;  in  some  cases 
paralysis  of  the  limb  lias  f)llowed  reduction. 

Sijnrope  and  sH'llen  <h'at1i  have  also  followed  reduction  in  a  very  few  cases: 
iti  some  of  them  it  was  probably  due  to  rupture  of  a  vessel  or  of  large  nerves ; 
in  one  case  fat  embolism  of  the  lungs  wjis  found. 

After-treatment. — After  reduction  of  a  dislocation  no  other  treatment  is 
usually  renuired  than  immobilization  of  the  limb  for  a  few  days  in  a  suitable 
position,  and  the  subsequent  avoidance  for  a  few  weeks  of  attitudes  which  would 
favor  recurrence.  In  dislocations  of  some  joints  (clavicle),  and  in  certain  forms 
of  dislocations  of  others,  the  tendency  to  recurrence  is  so  great  that  special 
measures  are  requisite  to  prevent  it.  Passive  motion  if  made  at  all  should 
be  kept  within  a  painless  range. 

The  condition  of  habitual  dislocation  can  hardly  be  relieved  except  by- 
operation. 

CONGENITAL   DISLOCATIONS. 

Under  this  term  are  included  certain  dislocations  which  do  not  appear  or  are 
■not  recognizable  until  after  the  lapse  of  some  months  or  years,  but  the  causes 
of  which — faulty  development  of  the  joint,  paralysis,  etc. — are  supposed  to 
have  existed  at  birth.  From  it  are  excluded  those  traumatic  dislocations  which 
are  prodnced  in  ufero  or  durinsf  deliverv. 

Congenital  dislocations  of  the  hip  (Fig.  176)  are  by  far  the  most 
frequent,  about  !'<)  per  cent,  of  all :  they  are  much  more  common  in  females 
than  in  males,  the  proportion,  according  to  different  statistics,  varying  from  60 
to  90  per  cent.  One  or  both  joints  may  be  involved.  The  typical  congenital 
dislocation  of  the  hip  is  due  to  a  defective  development  of  the  acetabulum  as 
carried  on  by  the  Y  cartilage,  which  permits  the  head  of  the  femur  to  pass, 
under  the  influence  of  the  weight  of  the  bodv  or  of  the  contraction  of  the 
muscles,  upon  the  dorsum  of  the  ilium.  Exceptional  cases  in  which  it  pa.sses 
upon  the  pubes  or  into  the  obturator  foramen  have  occurred,  but  they  are 
very  rare.  Usually  the  head  of  the  femur  is  smaller  than  normal  and  the  neck 
short.  As  the  child  begins  to  walk,  the  changes  increase,  the  displacement  is 
finally  arrested,  and  compensatory  changes  in  the  attitude  of  the  pelvis  and 
spine  appear,  the  upper  part  of  the  pelvis  being  tilted  forward,  and  the  lumbar 
spine  showing  a  marked  curvature  forward.  If  only  one  hip  is  involved,  the 
child  limj)s  in  walking ;  if  both  are  involved,  there  is  no  limp,  but  the  attitude 
of  the  body  and  the  gait  are  peculiar.  The  tilting  of  the  pelvis  disappears 
when  the  child  is  recumbent  or  when  the  thighs  are  flexed:  the  shortening 
of  the  thighs  can  sometimes  be  overcome  by  traction. 

Of  the  reduction  of  such  a  dislocation,  in  the  usual  sense  of  the  term,  there 
can  of  course  be  no  (piestion,  for  the  normal  structure  of  the  joint  does  not 
exist,  and  the  most  that  can  be  attained  is  to  diminish  the  deformity  and  func- 
tional disability.  Much  has  been  gained  in  some  cases  by  traction  continued 
for  many  months,  by  which  the  head  of  the  femur  has  been  drawn'nearer  the 
acetabulum  and  fixed  there  by  condensation  of  the  tissues  about  it.  and  per- 
haps by  the  growth  of  a  new  bony  rim  or  .socket  on  the  ilium.     Palliative 


DISIJX'A  rioNS. 


431 


Fio.  171; 


measures  have  also  been  iiscriilly  ciuploye.l  in  the  form  of  firm  corsets  of  felt 
or  leather  which  kept  the  pelvis  from  tilting.  In  some  unilateral  cases  the 
aftected  limb  has  been  kept  fixed  in  abduction,  so 
as  to  make  it  relatively  longer  in  walking.  Opera- 
tive measures,  usually  the  creation  of  a  socket  by 
chiselling,  liave  of  late  been  resorted  to  with  a  fair 
measure  of  success.  Ilotta  performs  the  follow- 
infT  operation:  An  incision  is  made  similar  to 
Langenbeck's  incision  for  resection  of  the  hij)- 
joint.  The  head  of  the  femur  is  separated  from 
the  i)elvis,  and  all  of  the  short  muscles  connecting 
the  upper  end  of  the  femur  and  the  pelvis  are  cut. 
The  acetabulum  is  gouged  out  and  the  dislocation 
is  reduced.  The  head  of  the  bone  is  held  in 
place  while  the  thigh  is  slowly  extended  to 
strctcli  tlu-  muscles  which  are  parallel  to  the 
femur. 

In  Loren/Zs  operation  an  incision  is  made 
between  the  tensor  vaginae  femoris  and  sartorius 
muscles  and  the  joint  is  opened.  Gouge  out  the 
acetabulum,  and  if  necessary  pare  down  the  head 
of  the  femur.  The  short  muscles  are  not  cut. 
The  bone  is  drawn  into  place  by  mechanical 
means  if  necessary.  In  bad  cases  the  hamstrings 
are  cut  with  a  tenotome.  The  thigh  must  be 
maintained  in  extension  and  slight  abduction. 

Among  the  rarer  forms  of  dislocation  of  the  hip 
found  at  birth  or  appearing  shortly  thereafter  are  those  due  to  dropsy  of  the 
joint  in  utero,  and  those  succeeding  paralysis  of  one  of  the  groups  of  muscles. 
In  such  cases  a  reduction  may  perhaps  be  eifected,  and  the  surgeon's  efforts 
must  then  be  directed  to  preventing  its  recurrence.  Congenital  dislocations  at 
the  shoulder  appear  also  to  be  due  to  defective  development  of  the  glenoid 

Among  congenital  dislocations  of  the  knee,  the  most  frequent  is  that  in 
which  theleg  is  in  extreme  hyperextension,  the  foot  sometimes  resting  against 
the  abdomen'!     They  have  usually  been  easily  corrected. 


Double  Congenital  Dislocation  of 
the  Hip  (Stimsoii;. 


SPONTANEOUS   DISLOCATIONS. 

Under  this  term  are  included  those  in  which  the  dislocation  occurs,  usually 
without  external  violence,  as  the  result  of  predisposing  changes  in  the  articular 
surfaces  or  in  the  ligaments  or  of  the  unopposed  action  of  certain  muscles, 
others  being  paralyzed.  Those  due  to  destruction  of  the  bones  are  incidents 
of  the  diseases  that  produce  the  destruction,  and  will  not  be  considered  here. 
Those  due  to  dropsical  distention  of  the  joint  are  of  more  importance,  for  they 
are  capable  of  reduction  and  may  easily  escape  notice  at  first.  They  occur  in 
the  course  of  the  eruptive  fevers,"less  frequently  in  that  of  the  continued  fevers 
(Keen)  or  of  articular  rheumati.sm,  and  are  most  common  at  the  hip.  The 
effusion  in  the  joint  makes  the  occurrence  easy;  the  habitual  attitude  in  bed. 
the  patient's  position,  resting  on  his  side  with  the  thighs  flexed  and  the  upper 
one  adducted,  is  also  favorable,  and  the  contraction  of  the  muscles  usually 
does  the  rest. 

Paralytic  or  "  myopatliic  "  dislocations  are  most  common  at  the  shoulder. 


432  ^^V   AMJJinCAX    TEXT- HOOK    OF  HUUiiKRY, 

The  weight  of  the  limb  being  unopposed  by  the  scapular  muscles,  the  head  of 
tiie  humerus  sinks  and  is  easily  disphice<l  forward  or  backward. 

SPECIAL  DISLOCATIONS. 
DISLOCATIONS  OF  THE  LOWER  JAW. 

These  constitute  about  4  per  cent,  of  all  dislocations,  are  more  frequent  in 
women  than  in  men,  and  may  be  unilateral  or  bilateral.  The  displacement  is 
forward,  the  condyle  resting  in  front  of  the  eminentia  articularis  at  tiie  root  of 
the  zygoma.  This  forward  displacement  is  an  exaggeration  of  the  normal 
forward  movement  of  the  condyle  in  opening  the  mouth.  The  interarticular 
iibro-cartilage  may  accompany  the  condyle  or  may  remain  behind,  its  anterior 
attachment  to  the  condyle  being  torn. 

Dislocations  backward  are  very  exceptional,  a  few  cases  having  been  re- 
ported in  Avhich,  by  a  blow  upon  the  chin,  one  or  both  condyles  have  been 
driven  backward,  breaking  through  the  anterior  wall  of  the  external  auditory 
meatus.  By  a  similar  blow  very  rarely  the  condyle  has  been  driven  into  the 
cranial  cavity.     In  what  follows  only  the  forward  dislocations  are  considered. 

The  usual  cause  of  forivard  dislocation  is  the  wide  opening  of  the  mouth, 
either  voluntarily  in  laughing,  yawning,  or  introducing  some  large  object,  or 
in  manipulations  about  the  mouth,  as  by  a  dentist.  Fixation  is  due  to  the  pas- 
sage of  the  condyle  in  front  of  the  line  of  the  lateral  ligaments,  the  attach- 
ments of  which  to  the  jaAv  are  exceptionally  low.  The  internal  pterygoid  and 
masseter  aid  in  the  fixation,  partly  by  maintaining  the  elevation  of  the  angle 
of  the  jaw  and  partly  by  opposing  the  backward  movement  that  would  aid 
reduction.  The  engagement  of  the  coronoid  process  of  the  inferior  maxilla  in 
front  of  the  malar  bone,  which  has  been  alleged  to  be  a  cause  of  the  fixation, 
rarely  occurs,  if  ever. 

The  symptoms  are  inability  to  close  the  mouth,  some  projection  of  the 
lower  jaw,  and  the  presence  of  the  condyle  in  advance  of  its  normal  position. 
In  unilateral  dislocation  the  chin  is  deviated  to  the  opposite  side  and  the  inter- 
ference with  function  is  less. 

Theoretically,  the  dislocation  should  be  most  easily  reduced  by  opening 
the  mouth  more  widely  to  relax  the  lateral  ligaments,  and  then  pressing  the 
jaw  backward;  but  the  involuntary  contraction  of  the  muscles,  unless  the 
patient  is  anesthetized,  will  be  a  serious  obstacle.  A  fiiirly  successful  method 
is  by  forcible  pressure  with  the  thumbs  downward  and  backward  upon  the 
lower  molar  teeth.  In  bilateral  dislocation  it  is  sometimes  easier  to  make 
reduction  on  each  side  separately. 

The  liability  to  frequent  recurrence  which  sometimes  ensues  has  been  com- 
bated by  opening  the  joint  and  suturing  the  meniscus  to  the  periosteum  at  the 
margin  of  the  articulation.  The  injection  of  tincture  of  iodine  into  the  joint 
has  also  been  proposed. 

DISLOCATIONS  OF  THE  STERNUM. 

Dislocation  of  one  of  the  normal  segments  of  the  sternum  from  another  is  a 
rare  injury,  and  one  not  ahvays  to  be  distinguished  clinically  from  a  fracture. 
We  describe  dislocation  of  the  body  from  the  manubrium,  and  of  the  ensifoim 
process  from  the  body. 

Dislocation  of  the  Body  from  the  Manubrium. — The  lower  border 
of  the  manubrium  is  on  a  line  joining  the  sternal  ends  of  the  second  costal 
cartilages,  which  articulate  with  both  segments.      Dislocations  forward  and 


DI8L  O  CA  TIONS.  433 

backward  have  been  observed,  the  former  being  the  more  common.  Forward 
dislocation  has  been  caused  by  direct  violence  (a  blow  upon  the  sternum),  by 
indirect  violence  (compression  of  the  sides  of  the  chest),  by  nmscular  action 
(the  eftbrt  made  in  exercising  on  parallel  bars),  and  possibly  by  forced  dorsal 
flexion  of  the  trunk.  It  may  be  complete  or  incomplete.  In  the  complete 
form  the  lower  fragment  may  override  the  upper  one  as  much  as  an  inch, 
the  anterior  fibro-})eriosteal  envelope  being  torn  and  the  posterior  one  being 
stripped  from  the  second  segment.  The  costal  cartilages  retain  their  attach- 
ments to  the  manubrium.  Backward  dislocations  appear  to  have  been  caused 
only  by  direct  violence  received  upon  the  second  segment.  Either  form  is 
frequently  associated  with  dislocation  or  fracture  of  the  ribs  or  of  the  costal 
cartilages. 

The  general  symptoms,  interference  with  respiration  and  circulation,  may 
be  very  severe.  The  diagnosis  is  made  by  recognition  of  the  change  in  the 
anterior  aspect  of  the  sternum  and  of  the  relations  of  the  line  of  separation  to 
the  second  costal  cartilages.  In  forward  dislocation  the  shallow  depressions  at 
the  upper  corners  of  the  body  for  articulation  with  the  second  costal  cartilages 
may  be  recognized.  The  well-known  gravity  of  the  injury  appears  to  depend 
mainly  on  associated  lesions. 

Reduction  is  made  by  forcible  dorsal  jflexion  of  the  trunk  and  direct  pres- 
sure on  the  projecting  fragment.  In  one  or  two  instances  it  has  been  aided  by 
the  coughing  of  the  patient  or  by  his  making  a  deep  inspiration.  In  some 
cases  in  which  the  dislocation  has  remained  unreduced  it  has  caused  no  dis- 
ability. 

Dislocations  of  the  Ensiform  Process  are  very  rare ;  the  apex  may  be 
directed  either  forward  or  backward.  The  most  prominent  symptom  in  some 
cases  has  been  persistent  vomiting,  relieved  by  draAving  the  apex  of  the  pro- 
cess forward  with  the  fingers  or  with  a  sharp  hook  introduced  through  the  skin. 

DISLOCATIONS  OF  THE  RIBS  AND  COSTAL  CARTILAGES. 

Dislocation  of  the  Head  of  the  Rib. — Nine  cases,  several  of  them 
verified  by  autopsy,  have  been  reported,  the  head  of  the  rib  having  been 
thrown  forward  by  a  blow  upon  the  rib  from  behind.  In  one  the  head  had 
been  forced  through  the  pleura  into  the  lung. 

Chondro-costal  Separation. — A  half-dozen  examples  of  this  injury 
are  on  record ;  the  causes  have  been  external  violence  and  prolonged  or  vio- 
lent coughing.  The  treatment  is  the  same  as  that  of  fracture  of  the  rib  or 
cartilage. 

Chondro-sternal  and  Chondro-chondral  Dislocations. — A  few  cases 
of  dislocation  of  the  costal  cartilages  from  the  sternum  or  from  each  other  have 
been  reported,  besides  those  associated  with  fracture  or  dislocation  of  the  ster- 
num. The  causes  have  been  external  violence  received  upon  the  chest  and 
muscular  action  exerted  through  the  pectoralis  major.  Both  forward  and  back- 
ward displacements  have  been  observed ;  the  former  were  easily  reduced  by 
pressure,  but  readily  recurred. 

DISLOCATIONS  OF  THE  CLAVICLE. 

The  clavicle  may  be  dislocated  at  either  end  or  at  both  ends  simultaneously. 

Sternal  End. — The  joint  possesses  an  intra-articular  fibro-cartilage  which 
has  its  strongest  attachment  above  to  the  upper  edge  of  the  end  of  the  clavi- 
cle, and  below  to  the  cartilage  of  the  first  rib.  The  clavicle  may  be  dislocated 
forward,  backward,  or  upward,  in  this  order  of  frequency. 

28 


434  AA^   AMKRICAX    TEXT- BOOK    OF  SURGERY. 

Dislocation  forward  appears  to  be  most  frequently  caused  by  forcible 
movement  of  the  shoulder  downward  and  backward,  in  which  the  center  of 
the  clavicle  comes  to  rest  upon  the  first  rib,  and  the  inner  end  is  thus  thrown 
forward  as  the  outer  one  is  lowered  and  carried  backward.  In  cases  of  habit- 
ual dislocation  the  bone  slips  out  of  place  when  the  arm  is  raised  beside  the 
head  or  when  the  shoulder  is  thrown  back  as  in  puttin<^  on  a  coat.  In  a  case 
reported  by  Stimson  the  liability  to  displacement  was  gradually  developed  in  a 
youth  of  nineteen  years,  so  that  it  occurred  whenever  the  elbow  was  raised  to 
the  height  of  the  shoulder,  the  bone  returning  to  its  place  as  the  arm  was  low- 
ered. The  dislocation  may  be  complete  or  incomplete :  in  the  former  the  end 
of  the  bone  rests  upon  the  front  of  the  sternum  to  the  inner  side  of  or  below 
its  normal  position.  Occasionally  a  piece  is  broken  from  the  end  of  the  clavi- 
cle or  the  eilge  of  the  articular  surface  of  the  sternum. 

The  symptoms  consist  in  the  marked  projection  and  abnormal  position 
of  the  end  of  the  clavicle,  with  local  pain,  sinking  of  the  shoulder  downward 
and  inward,  and  inability  to  use  the  arm. 

Reduction  is  effected  by  drawing  the  shoulder  backward  and  by  suitable 
pressure  on  the  end  of  the  clavicle ;  and  recurrence  is  prevented  by  immol>ili- 
zation  of  the  shoulder.  This  is  the  difficult  part  of  the  treatment,  and  many 
plans  have  been  tried,  such  as  a  figure-of-8  bandage  about  the  two  shoulders, 
the  turns  crossing  on  the  back ;  prolonged  rest  in  bed  upon  the  back  to  avoid 
the  influence  of  the  weight  of  the  arm  in  reproducing  the  displacement;  moulded 
caps  of  leather  or  gutta-percha  fitted  to  the  end  of  the  clavicle  and  held  in 
place  by  straps  about  the  chest ;  and  direct  pressure  by  a  hernial  truss  the  pad 
of  which  rests  upon  the  end  of  the  clavicle  while  the  spring  passes  to  the  back 
under  the  axilla  of  the  uninjured  side. 

The  liability  to  recurrence  may  be  extremely  troublesome.  In  Stimson's 
case  it  was  overcome  by  three  injections  of  a  dram  of  alcohol  into  the  peri- 
articular tissues  at  intervals  of  a  fortnight,  the  arm  being  meanwhile  confined 
to  the  side  of  the  body.  The  same  condition  subsequently  developed  in  the 
other  clavicle  of  the  same  patient,  and  was  cured  by  a  single  injection. 

DiSLOCATiox  BACKWARD  may  be  caused  by  direct  violence  received  upon 
the  front  of  the  inner  end  of  the  bone  or  by  the  forcing  of  the  shoulder  forward 
and  inward ;  it  may  be  complete  or  incomplete,  and  in  the  former  case  the  dis- 
placement is  also  inward  or  inward  and  downward,  so  that  the  bone  presses 
upon  the  trachea  and  oesophagus  and  causes  dyspnea  or  dysphagia. 

Symptoms. — The  dislocation  is  to  be  recognized  by  the  absence  of  the  end 
of  the  bone  from  its  normal  position  and  its  presence  in  its  new  position,  which 
may  be  determined  by  palpation  or  by  attention  to  the  direction  of  the  access- 
ible portion  of  the  bone.     The  shoulder  hangs  somewhat  forward  and  inward. 

Reduction  is  effected  by  drawing  the  shoulder  outward  and  backward, 
and  recurrence  is  prevented  by  maintenance  of  the  shoulder  in  this  position. 
In  a  number  of  cases  in  which  the  dislocation  remained  unreduced  it  was  borne 
without  inconvenience,  but  in  one  in  which  the  displacement  was  subsequently 
increased  by  progressive  distortion  of  the  spine  the  interference  with  deglutition 
was  such  that  it  became  necessary  to  excise  the  end  of  the  bone. 

Dislocation  upward  has  been  caused  by  the  forcible  depression  of  the 
shoulder:  in  a  case  reported  by  Stokes  it  was  gradually  produced  on  both  sides, 
apparently  by  the  action  of  the  sterno-cleido-mastoids  "in  forced  inspiratory 
efforts  produced  by  great  dyspnea  due  to  ascites."  The  end  of  the  bone  is 
displaced  inward  as  well  as  upward,  passing  behind  the  sternal  head  of  the 
sterno-cleido-mastoid,  and  resting  in  the  episternal  notch.  Reduction  is 
made  by  drawing  the  shoulder  outward  and  by  direct  pressure  on  the  end  of 


DISLOCATIONS. 


435 


Fig 


Upward  Dislocation  of  Acromial  End  of 
Right  Clavicle  (original^. 

be   overcome  by  drawing   the 


the  bone.      ^laljiaisne's  hooks,  devised  f<n-  the  treatment  of  fracture  of  the 
patella,   have   been  used   to  prevent   recur- 
rence, one  being  fixed  in   the  clavicle,   the 
other  in  the  front  of  the  sternum. 

Acromial  End. — The  common  disloca- 
tion is  upward  or  upward  and  outward,  so 
that  the  end  of  the  clavicle  overlaps  the 
acromion  (Fig.  177).  Fracture  of  the  edge 
of  the  articular  surface  of  either  bone  may 
accompany  the  dislocation.  The  cause  is 
usually  a  blow  or  fall  upon  the  shoulder. 

In  the  great  majority  of  cases  the  end  of 
the  clavicle  simply  rises  more  or  less  above 
the  level  of  the  acromion  without  overriding 
it,  and  can  be  easily  pressed  down  into  place 
if  the  arm  is  at  the  same  time  pressed  up- 
ward ;  but  the  displacement  recurs  as  soon  as 
the  pressure  is  removed.  The  manipulation 
may  be  accompanied  by  crepitus  if  there  has 
been  fracture  of  the  edge  of  the  articulation, 
but  the  injury  can  be  readily  distinguished 
from  a  fracture  of  the  outer  part  of  the  clav- 
icle by  attention  to  the  relations  of  the  pro- 
jecting bone  to  the  acromion  and  by  com- 
parative measurements  of  its  length.  If  it 
overrides  the  acromion,  the  overriding  can 
shoulder  outward. 

Retention  of  the  bone  in  place  after  reduction  has  presented  so  many 
difficulties  that  some  have  taught  that  it  is  not  worth  while  to  attempt  it, 
especially  since  the  persistence  of  the  dis- 
location ordinarily  causes  no  loss  of  func- 
tion ;  but  the  method  recommended  by 
Stimson  is  so  simple  and  efficient  that  it 
should  always  be  tried  (Fig.  178).  A 
long  strip  of  adhesive  plaster  three  inches 
wide  is  placed  with  its  center  under  the 
point  of  the  flexed  elbow  and  its  ends 
carried  up  in  front  of  and  behind  the  arm, 
crossed  over  the  end  of  the  clavicle,  and 
secured  to  the  front  and  back  of  the  chest 
respectively  while  the  bone  is  held  in  place 
by  pressure  upon  the  clavicle  and  elbow. 
Recurrence  can  be  readily  detected  through 
the  plaster  by  the  finger  or  the  eye.  For 
additional  security  the  forearm  should  be 
supported  in  a  sling  and  the  arm  bound  to 
the  chest. 

Subacromial  Dislocation. — A  few 
cases  have  been  reported  in  which  the  end 
of  the  clavicle  was  displaced  downward  and 
engaged  under  the  acromion,  the  causes 
being  respectivelv  direct  violence  upon  the      ,,     .     „,         ^  ..    „        ^  r.-  , 

^  i.  ^  ■  ,  1      r>     1         1  Adhesive  Plaster  Dressing  for  L  pward  Dislo- 

Upper  surface  Ot    the   outer    end  OI    the  ClaV-     cation  ofAcromial  End  of  clavicle  (original). 


Fig.  178. 


436  ^l.V  AMERICAN   TEXT- BOOK   OF  SURGERY. 

icle,  a  fall  upon  the  shoulder,  and  muscular  action  while  the  arm  was  raised. 
Reduction  was  easily  made  })y  drawing  the  shoulder  outward,  and  a  tendency  to 
recurrence  was  observed  in  only  one  case. 

SuBCORACOiD  Dislocation. — Two  surgeons  have  reported  cases  of  this 
singular  dislocation,  in  which  the  clavicle  is  displaced  forward  and  downward 
below  the  coracoid  process,  but  the  reports  are  viewed  with  some  suspicion. 

Simultaneous  Dislocation  of  both  Ends  of  the  Clavicle  has  been 
reported  in  about  a  dozen  cases,  the  cause  usually  having  been  extreme  violence 
by  which  the  shoulder  was  pressed  inward;  in  all  the  sternal  end  wa5  dislocated 
forward,  the  acromial  end  upward. 

DISLOCATIONS  OF  THE  SHOULDER. 

These  are  as  frequent  as  all  other  dislocations  taken  together ;  they  are 
rare  in  youth  and  old  age,  and  much  more  frequent  in  men  than  in  women. 
The  frequency  is  readily  accounted  for  by  the  formation  of  the  joint  and  by 
its  exposure  to  external  violence. 

The  glenoid  fossa  looks  forward  as  well  as  outward,  and  the  head  of  the 
humerus  in  leaving  it  laterally  passes  forward  and  inward  or  backward  and 
outward ;  it  may  also  pass  downward  or,  in  very  rare  cases,  upward.  The 
secondary  displacements  succeeding  to  these  primary  ones  are  numerous  and 
varied,  and  are  commonly  produced  by  subsequent  changes  in  the  attitude  of 
the  arm.  Four  principal  groups  may  be  made  according  to  the  primary  dis- 
placement, and  subdivided  according  to  the  points  at  which  the  head  of  the 
bone  comes  to  rest  or  according  to  other  clinical  features,  as  follows : 

(  Subcoracoid  ;  very  common. 
Anterior       .....      -^  Intracoracoid ;  exceptional. 

(^  Subclavicular. 

{Subglenoid ;  uncommon. 
Erecta ;  very  rare. 
Subtricipital.  (?) 

T,    ,    •  f  Subacromial ;  rare, 

rosterior      .         .         .         .         •      ^  c  v.     • 

(  Subspinous  ;  very  rare. 

Upward        .....         Supraglenoid ;  very  rare. 

In  the  anterior  dislocations  the  displacement  is  also  more  or  less  downward 
(also  of  course  inward),  and  in  the  downward  ones  it  is  usually  also  forward 
and  inward,  and  consequently  the  two  merge  into  each  other  without  a  sharp 
line  of  division  ;  as  the  term  is  used  here,  the  anterior  include  in  the  subcoracoid 
subdivision  many  of  those  known  in  the  older  terminology  as  subglenoid.  The 
latter  term  is  correspondingly  restricted  to  include  only  those  in  which  the 
head  of  the  humerus  lies  very  low. 

ANTERIOR   dislocations. 

These  present  two  varieties,  the  subcoracoid  and  the  intracoracoid,  accord- 
ing to  the  distance  to  which  the  head  of  the  humerus  is  displaced  inward :  an 
extreme  form  of  the  latter  is  sometimes  called  the  subclavicular. 

Subcoracoid. — In  this,  the  commonest  form,  the  head  of  the  humerus  lies 
beneath  the  coracoid  process,  in  contact  with  it  or  at  a  variable  distance,  a  finger- 
breadth  at  the  most,  below  it.  The  extent  of  displacement  inward  also  varies, 
from  just  suflBcient  to  keep  the  head  balanced  on  the  anterior  edge  of  the  glen- 


DISLOCATIONS, 


437 


oid  fossa  to  that  in  which  three-fourtlis  of  the  diameter  of  the  head  lies  to  the 
inner  side  of  the  coracoid  process ;  greater  displacements  inward  are  termed 
intracoraeoid. 

The  injury  may  be  caused  by  direct  violence,  as  a  blow  or  fall  upon  the 
shoulder;  indirect  violence,  as  a  lUll  upon  the  hand  or  the  elbow:  forcible  abduc- 
tion or  outward  rotation  of  the  limb  ;  or  muscular  action.  Muscular  action  can 
produce  a  dislocation  either  by  directly  pulling  the  head  out  of  its  socket,  as 
in  convulsions,  or,  much  more  frequently,  by  im{»arting  a  sudden  movement  to 
the  limb  which  creates  conditions  of  leverage  and  impulsion  similar  to  those  of 
indirect  violence. 

The  capsule  is  torn  at  its  inner  and  lower  portion,  the  rent  extending  for  a 
greater  or  lesser  distance  along  the  margin  of  the  glenoid  fossa.  Exceptionally, 
there  may  be  no  rent  in  the  capsule.  In  "  typical  "  cases  the  outer  and  upper 
portion  of  the  capsule  remains  untorn  and  aids  in  determining  the  attitude  of 
the  limb  and  the  limitation  of  its  movements.  The  subscapularis  muscle  may 
be  pushed  inward  or  torn  for  a  variable  distance  upward  from  its  lower  margin. 
The  interposition  of  its  untorn  portion  between  the  head  of  the  humerus  and 
the  coracoid  process  accounts  for  the  interval  between  these  bones  observed  in 
some  cases.  The  supraspinatus  may  be  ruptured  or  torn  from  the  humerus ; 
also,  but  less  frequently,  the  infraspinatus,  and  rarely  the  teres  minor.  Avul- 
sion of  a  portion  of  the  greater  tuberosity  may  take  the  place  of  this  rupture. 
The  head  of  the  humerus  may  rest  against  the  edge  of  the  glenoid  fossa  or  far- 
ther inward  against  the  side  of  the  neck  of  the  scapula ;  its  articular  surface  is 
occasionally  bruised  by  impact  against  the  edge  of  the  fossa.  The  tendon  of  the 
long  head  of  the  biceps  is  occasionally  torn  from  its  attachment,  and  when  the 
greater  tuberosity  has  been  broken  off  it  may  slip  to  the  outer  side  of  the  head. 

Symptoms. — The  elbow  hangs  a  little  away  from  the  side,  the  outer  aspect 
of  the  deltoid  is  flattened,  and  the  anterior  and  outer  fulness  of  the  shoulder  is 
lost  (Fig.  171*).     Viewing  the  arm  from  Fig.  179. 

in  front,  the  axis  of  the  humerus  is  seen 
to  pass  to  the  inner  side  of  the  glenoid 
fossa,  and  the  anterior  fold  of  the  axilla 
is  lowered.  On  palpation  the  normal 
bony  resistance  below  the  front  and 
outer  side  of  the  acromion  is  absent, 
and  an  abnormal  one  is  found  below 
the  coracoid  process  which  shares  in 
slight  rotatory  movements  communi- 
cated to  the  arm.  In  the  higher  forms 
the  head  can  be  felt  only  indistinctly, 
if  at  all,  in  the  axilla.  Voluntary 
movements  are  usually  lost ;  passively, 
the  arm  can  be  easily  abducted,  but 
cannot  be  so  far  adducted  as  to  bring 
the  hand  upon  the  opposite  shoulder 
and  the  elbow  to  the  front  of  the 
cliest  (Dugas'  sign).  Measurement 
from  the  acromion  to  the  elbow  while 
the  arm  is  abducted  shows  the  distance  to  be  less  than  on  the  opposite  side 
with  the  arm  in  the  same  position. 

In  making  a  diagnosis  every  effort  should  be  used  to  determine  the 
position  of  the  head  of  the  bone  and  its  continuity  with  the  shaft.  In  very 
fat  patients  this  may  be  difficult  or  even  impossible  without  the  aid  of  an 


Double  Subcoracoid  Luxation  of  Both  Shoulders 
(original). 


438 


^iV^  AMERICAN   TEXT-BOOR'    OF  SURGERY. 


Fig.  180. 


anesthetic.  "Where  there  is  associated  fracture  of  the  anatomical  neck,  a 
rare  complication,  the  only  means  of  diagnosis  if  the  patient  is  fat  may  be 
the  shortening  of  the  abducted  limb. 

In  intracoracoid  dislocation  the  head  of  the  humerus  is  displaced  farther 
inward,  either  by  the  prolonged   action  of  the  dislocatiiig  violence  or,  more 

commonly,  by  a  greater  primury 
displacement  downward  by  which 
the  subscapularis  is  widely  torn, 
and  then  on  lowering  the  elbow 
the  head  of  the  humerus  passes 
upward  and  inward.  The  rent 
in  the  capsule  is  correspondingly 
greater.  In  a  case  reported  by 
Stimson  the  head  of  the  hume- 
rus had  passed  below  and  to  the 
inner  side  of  the  untorn  subscap- 
ularis, the  tendon  of  which  thus 
formed  an  insuperable  obstacle 
to  reduction  and  made  arthrot- 
omy  necessary. 

The  symptoms  are  sim- 
ilar to  those  of  the  subcoracoid 
form  ;  the  elbow  is  more  widely 
abducted,  the  deltoid  more  flattened,  the  head  of  the  humerus  easily  recog- 
nizable in  the  subclavicular  fossa.  Occasionally  the  arm  is  fixed  in  complete 
horizontal  abduction. 

Treatment. — Reduction  is  usually  easy,  but  occasionally,  as  in  the  case 
just  mentioned,  may  be  impossible  except  by  operation. 

Fig.  182. 


Fig.  181. 


Kocher'.s  ML'thnd  cif  UciliutidU  by  Manipuliition.     First 
movt'iueiit,  (lutwaril  rotation  (<'op])i). 


Kocher's  Method  of  Reduction.    Second  movement, 
elevation  of  elbow  (Ceppi). 


Kocher's  Method  of  Kednction.  Tliird 
niovenient,  inward  rotation  and  lower- 
ing of  elbow  (Ceppi). 


Kocher's  metliod  is  very  successful  in  the  higher  forms  of  subcoracoid  dis- 
location, but  frequently  fails  in  the  lower  and  in  the  intracoracoid.  It  may  be 
employed  with  or  without  the  aid  of  anesthesia.  The  elbow  is  Hexed  at  a  right 
angle  and  pressed  closely  against  the  side  ;  then  the  forearm  is  turned  as  far  as 


DISLOCATIONS. 


439 


Fk;.  183. 


possible  away  t'lvmi  the  tn-uiik  (external  rotation  of  the  arm)  (Fig.  180).  Unless 
the  head  of  the  humerus  rolls  outward  in  front  of  and  below  the  acromion  dur- 
ing this  movement,  the  attempt  will  fail.  Then,  while  the  external  rotation  is 
maintained,  the  elbow  is  carried  well  forward  and  upward  (Fig.  181),  the  arm 
rotated  inward,  and  the  elbow  lowered  (Fig.  ]8ii).  Sometimes  it  is  useful  to 
have  an  assistant  })ress  the  head  outward  with  his  fingers  or  by  a  band  in  the 
axilla  during  the  later  steps. 

Traction  outward  is  also  a  very  useful  method,  although  it  involves  a  cer- 
tain degree  of  risk  to  the  axillary  vessels,  especially  in  the  aged.  The  patient 
is  laid  on  his  back  on  the  floor,  and  the  surgeon,  seated  beside  him,  placing 
one  foot  against  his  chest,  seizes  the  arm  at  the  elbow,  and  draws  it  steadily 
outward  in  full  abduction.  If  this  does  not  bring  the  bone  into  place,  an 
assistant  may  press  its  head  upward  with  his  fingers,  his  thumbs  resting  on 
the  acromion.  Or,  the  patient  lying  on  the  bed,  the  surgeon  makes  traction 
on  the  arm  for  a  few  moments,  and  then,  while  maintaining  the  traction  with 
one  hand,  swings  the  arm  toward  the  side  over  his  closed  fist  in  the  axilla. 
This  is  similar  in  action  to  the  old  method  of  the  unbooted  heel  in  the  axilla, 
but  is  less  dangerous. 

Occasionally  reduction  can  be  made  by  taking  the  patient  unawares.  He 
is  made  to  stand  up,  and  the  surgeon,  standing  beside  him,  holds  his  wrist, 
with  the  elbow  flexed  at  a 
right  angle,  and  gently  moves 
the  arm  and  engages  him  in 
conversation.  Little  by  little 
the  deltoid  is  seen  to  relax, 
and  then  a  smart  blow  down- 
ward upon  the  fold  of  the 
elbow  with  quick  external  ro- 
tation of  the  arm  will  eff'ect 
reduction  in  a  considerable 
proportion  of  cases  (Cole). 

In  intracoracoid  disloca- 
tions traction  outward  should 
be  used. 

In  older  cases  foi'cible  ro- 
tation is  needed  to  break  up  ad- 
hesions, after  which  Kocher's 
method  may  succeed  or  forci- 
ble traction  may  be  required. 

The  cases  in  which  com- 
plete reduction  is  prevented 
by  the  interposition  of  a  por- 
tion of  the  capsule  or  of  a 
tendon  are  very  rare. 


Subglenoid  Iti^lnciUuii  ^^unison) 


DOWNWARD    DISLOCATIONS. 

This  class  includes  those  rare  ones  in  w  hich  the  head  of  the  humerus  rests 
below  the  glenoid  fossa  on  the  tendon  of  the  long  head  of  the  triceps,  and  those 
more  common  ones  in  which  it  lies  somewhat  higher  and  to  the  inner  side 
under  the  lower  and  anterior  edge  of  the  glenoid  fossa.  The  name  by  which 
they  are  commonly  known  is  subglenoid.  The  class  also  includes  a  rare  form, 
the  lutatio  erecta,  and  a  doubtful  one,  the  suhtricipital. 

The  cause  is  forcible  abduction  of  the  arm,  by  which  the  capsule  is  torn 


440  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

at  its  lower  part,  followed  by  rotation  or  impulsion  wliich  engages  the  head 
bevond  the  edge  of  the  fossa.  The  lower  part  of  the  tendon  of  the  subscap- 
ularis  may  be  torn,  and  the  greater  tuberosity  appears  habitually  to  be  in  part 
broken  off  by  the  traction  of  its  attached  muscles. 

The  syrnptoms  are  similar  to  those  of  subcoracoid  dislocation,  but  more 
marked.  The  elbuw  is  abducted,  the  shoulder  flattened,  the  acromion  prom- 
inent, and  the  head  of  the  humerus  can  be  readilv  felt  in  the  axilla  (Fig. 

183). 

Treatment. — Theoretically,  the  best  method  of  reduction  would  be  to 
raise  the  elbow  as  far  as  possible  and  then  to  make  traction,  but  as  this  in- 
volves some  ri.sk  to  the  a.xillary  vessels  it  is  better  to  use  an  anesthetic  and 
reduce  by  traction  in  moderate  abduction,  with  direct  pressure  upward  and 
outward  upon  the  head  of  the  humerus. 

Luxatio  Erectd. — In  this  rare  form  the  arm  is  held  vertically,  the  forearm 
resting  on  the  top  of  the  head  and  held  there  by  the  patient  to  escape  the 
pain  caused  by  lowering  it.  In  the  half-dozen  cases  reported  the  cause  ap- 
pears to  have  been  forcible  elevation  of  the  arm.  Reduction  was  easily 
made  by  traction  upward  without  changing  the  attitude  of  the  limb  until 
after  the  head  had  been  drawn  into  its  socket. 

Suhtriripital  Dislocation. — Of  this  only  a  single  case  has  been  reported.  The 
head  of  the  humerus  was  thought  to  have  passed,  after  dislocation  downward,  back- 
ward behind  the  tendon  of  the  long  head  of  the  triceps,  and  then  to  have  been 
raised  to  a  higher  level  behind  the  glenoid  fossa  by  the  lowering  of  the  elbow. 

POSTERIOR  DISLOCATIONS. 

These  include  two  varieties,  the  subacromial  and  the  subspinous,  which  dif- 
fer only  in  the  extent  of  the  displacement.  Some  English  writers  make  only 
one  class  and  give  the  name  subspinous  to  all.  The  dislocation  is  infrequent, 
and  the  subacromial  variety  is  much  the  more  frequent  of  the  two. 

The  cause  appears  to  be  pressure  of  the  head  of  the  humerus  outward  and 
backward,  either  directly  or  through  the  elbow,  aided  by  adduction  and  internal 
rotation  of  the  arm. 

Autopsies  and  experiment  upon  the  cadaver  show  that  the  capsule  is  torn  on 
its  outer  side  and  above  and  below,  the  lesser  tuberosity  is  sometimes  broken 
off,  the  supraspinatus  ruptured  or  torn  away  with  its  facet  of  insertion,  the  teres 
minor  and  triceps  are  sometimes  torn.  In  the  subacromial  variety  the  head  of 
the  humerus  lies  below  the  projecting  outer  portion  of  the  acromion,  with  its  ana- 
tomical neck  resting  on  the  outer  edge  of  the  glenoid  fossa  and  its  articular  sur- 
face directed  outward.  In  the  subspinous  variety  the  head  is  displaced  farther 
backward  below  the  spine  of  the  scapula,  and  perhaps  separated  from  it  by  the 
interposed  infraspinatus. 

Symptoms. — The  arm  hangs  by  the  side  in  inward  rotation,  with  the 
elbow  directed  slightly  forward.  The  fulness  of  the  shoulder  is  lost  in  front 
and  increased  behind.  The  absence  of  the  head  of  the  humerus  in  front  and 
its  presence  behind  can  be  recognized  by  palpation  :  the  coracoid  and  the  ante- 
rior part  of  the  acromion  are  abnormally  prominent.  Voluntary  movement  is 
lost,  passive  motion  restricted  and  painful. 

Treatment. — Reduction  appears  to  be  easy  in  both  recent  and  old  cases 
by  traction  forward  upon  the  arm  or  by  direct  pressure  forward  upon  the  head 
of  the  humerus,  but  recurrence  is  frequent,  presumably  because  of  the  loss  of  the 
support  of  the  subscapularis.  "When  the  dislocation  has  remained  unreduced 
the  disability  has  been  greater  than  is  usual  in  anterior  dislocations.       , 


DISL  O  CA  TIONS.  44 1 

UPWARD    DISLOCATIONS. 

The  possibility  of  the  occurrence  of  this  very  rare  form  l'^*-  1^4. 

has  been  proved  by  a  few  clinical  cases  and  two  autopsies. 
Amono;  the  causes  were  a  fall  upon  the  elbow,  a  blow  down- 
ward upon  the  acromion  while  the  arm  was  raised,  and  an 
epileptic  convulsion.  In  one  case  certainly,  and  possibly  in 
two  others,  the  coracoid  process  was  broken. 

The  head  of  the  humerus  lies  in  the  interval  between  the 
acromion  and  the  coracoid,  closely  in  front  of  the  clavicle 
and  usually  above  its  level.  The  arm  hangs  by  the  side,  the 
elbow  directed  somewhat  backward.  Active  and  passive 
movements  arc  greatly  restricted   (Fig.  184). 

Reduction   was  effected  in  three  cases  by  traction,  and 
by  elevation  of  the  elbow  in  one,  but  the  dislocation  at  once      su^7i^,iiKr^(i  DiJ- 
recurred  in  the  latter.     In  three  old  cases  reduction  failed.  location  (Albert). 

COMPLICATIONS  OF   DISLOCATION   OF  THE  SHOULDER. 

Compound  dislocations  are  very  rare,  and  are  usually  caused  by  extreme 
violence,  which  is  associated  with  extensive  laceration  of  the  soft  parts  in  the 
neighborhood  of  the  dislocation,  and  inflicts  other,  and  perhaps  fatal,  injuries  at 
the  same  time.  The  wound  in  the  skin  is  commonly  in  the  axilla.  The  gravity 
of  the  condition  arises  either  from  associated  injury  done  to  the  arteries  of  the 
axilla  or  from  the  extent  of  the  laceration  of  the  soft  parts  and  the  probability 
of  suppuration.  Infection  is  likely  to  take  place  before  treatment  can  be  begun, 
the  extravasated  blood  favors  its  rapid  spread,  and  the  extent  and  irregularity 
of  the  laceration  make  subsequent  cleansing  almost  impossible.  Nevertlieless, 
some  very  satisftictory  recoveries  have  been  reported.  The  treatment  calls 
for  the  thorough  antiseptic  cleansing  of  the  parts,  the  reduction  of  the  disloca- 
tion, renewed  cleansing,  and  thorough  drainage  of  the  cavity  of  the  joint. 
Probably  in  most  cases  it  would  be  best  not  to  close  the  wound  in  the  skin, 
but  instead  to  pack  rather  deeply  with  the  iodoform  gauze  for  a  few  days. 
Excision  of  the  head  of  the  humerus  may  be  advisable  to  favor  drainage  and 
oppose  ankjdosis. 

Fractures. — These  may  involve  any  of  the  prominences  of  the  humerus 
or  scapula  or  the  anatomical  or  the  surgical  neck  of  the  humerus.  The  upper 
part  of  the  greater  tuberosity  is  sometimes,  perhaps  frequently,  torn  off"  by  trac- 
tion through  its  attached  muscles  in  anterior  dislocation ;  the  periosteal  attach- 
ments may  persist  and  the  displacement  consequently  be  slight,  or  the  piece 
may  be  entirely  detached,  and  may  even  lodge  in  the  glenoid  fossa  and  consti- 
tute a  serious  obstacle  to  reduction.  The  fracture  may  be  recognized  by  local- 
ized pain  and  crepitus  and  by  loss  or  diminution  of  voluntary  outward  rotation. 

The  lesser  tuherosity  has  been  found  broken  off'  only  in  backward  disloca- 
tion by  traction  through  the  attached  subscapulars.  The  acromion  has  been 
broken  by  a  blow  upon  it  from  above,  which,  continuing,  has  then  dislocated 
the  humerus  doAvnward  and  forward. 

The  coracoid  process  has  been  rarely  broken ;  once  certainly  in  connection 
with  supracoracoid  dislocation!  The  glenoid  fossa  is  probably  often  broken 
at  its  edge,  and  the  fragment  may  be  large  enough  to  interfere  seriously  with 
the  maintenance  of  the  humerus  in  its  socket. 

Fracture  of  the  Anatomical  or  of  the  Surgical  Neck  of  the  Humerus. — The 
former  is  a  much  rarer  complication  than  the  latter:  it  appears  to  be  caused  after 
the  head  has  left  its  socket  by  impact  against  the  anterior  edge  of  the  glenoid 
fo.s.sa,  which  acts  like  a  wedge  along  the  anatomical  neck  and  splits  off"  the  head. 


442  ^l^V  AMERICAN   TEXT-BOOK    OF  SCRGERY. 

It  is  (lilluMilt  (if  rcc'(»^Miition.  The  diagnostic  points  an'  the  recognition  of  the 
head  in  its  abnormal  j)ositi()n  beneatli  the  coracoid  process  and  its  failure  to 
move  with  the  shaft,  the  normal  or  nearly  normal  position  of  the  greater  tube- 
rosity, the  direction  of  the  axis  of  the  humerus  toward  the  glenoid  fossa,  and 
the  absence  of  the  limitation  of  passive  movements  peculiar  to  dislocations. 
Possibly  crepitus  may  be  obtained. 

In  fracture  of  the  surgical  neck  the  recognition  of  the  dislocation  is  easier, 
because  the  greater  tuberosity  remains  out  of  place  together  with  the  head ; 
there  is  the  same  absence  of  characteristic  limitation  of  motion  and  the  same 
normal  direction  of  the  axis  of  the  humerus ;  the  tuberosity  fails  to  move  with 
the  shaft,  and  crepitus  is  almost  certainly  to  be  felt. 

The  small  almost  hemispherical  head  may  sometimes,  after  fracture  of  the  ana- 
tomical neck,  be  pressed  back  into  place  with  the  fingers,  and  may  even  resume 
its  ])roper  relations  to  the  shaft  and  reunite  with  it.  In  dislocation  with  frac- 
ture of  the  surgical  neck  the  dislocation  may  sometimes  be  reduced  under 
an  anesthetic  by  direct  pressure  upon  the  head  and  traction  on  the  arm. 
McBurney  effected  reduction  in  one  case  by  cutting  down  through  the  deltoid 
upon  the  lower  end  of  the  upper  fragment,  drilling  a  hole  in  it,  and  inserting 
into  this  hole  a  strong  right-angled  hook,  by  means  of  which  he  made  forcible 
traction  and  rotation  upon  the  fragment.  This  failing,  the  choice  lies  between 
attempting  reduction  after  the  fracture  has  been  united  or  establishing  a  false 
joint  at  the  seat  of  fracture. 

Injuries  to  the  Blood-vessels  and  Nerves. — The  axillary  artery  or 
one  of  its  branches,  especially  the  circumliex  and  subscapular,  may  be  ruptured 
in  a  dislocation,  but  of  the  reported  cases  of  such  injury  the  majority  appear  to 
have  been  caused  by  attempts  to  reduce.  The  accident  is  to  be  recognized  by 
the  rapid  extravasation  of  blood  into  the  axilla  and  down  the  arm  and  over 
the  chest.  The  radial  pulse  may  persist,  for  the  injury  is  more  frequently  of 
an  arterial  branch  than  of  the  artery  itself.  The  pressure  of  the  extravasated 
blood  seriously  interferes  with  the  circulation,  and  operative  interference  may 
be  required  because  of  the  persistent  hemorrhage  or  because  of  the  imminence 
of  gangrene.  The  various  methods  of  treatment  have  been  pressure,  ligature 
of  the  subclavian  or  of  the  axillary  artery,  and  disarticulation  at  the  shoulder. 
The  resultant  rate  of  mortality  is  high. 

The  posterior  branch  of  the  circumflex  nerve  appears  very  frequently  to  be 
bruised  or  stretched,  with  consequent  temporary,  or  possibly  permanent,  loss 
of  sensibility  in  the  skin  covering  the  deltoid,  and  of  voluntary  control  of  the 
deltoid  muscle.  It  is  Avell,  before  attempting  reduction,  to  test  the  sensibility 
of  the  skin  in  the  indicated  region,  in  order  that  the  loss  of  power  in  the 
deltoid  Avlien  subsequently  recognized  shall  not  be  wrongly  attributed  to  the 
means  enq)loyed  in  reduction. 

The  after-treatment  rarely  calls  for  more  than  immobilization  of  the 
joint  for  a  fortiiiglit  and  the  avoidance  of  abduction  for  a  week  or  two  longer. 

The  prognosis  is  good  in  respect  both  of  reduction  and  of  complete  restora- 
tion of  function.  The  cases  in  which  an  uncomplicated  dislocation  cannot  be 
reduced  are  extremely  rare.  The  subsequent  usefulness  of  the  limb  may,  how- 
ever, be  impaired  by  persistent  stiffness  and  tenderness,  especially  in  the  old 
and  rheumatic,  by  paralysis  of  the  deltoid,  or  by  a  liability  to  recurrence. 

When  the  dislocation  remains  unreduced  the  arm  is  ordinarily  fiiirly  useful, 
the  lost  mobility  of  the  joint  being  compensated  for  in  part  by  increased 
mobility  of  the  scapula,  but  occasionally  it  happens  that  the  pressure  of  the 
displaced  head  causes  so  much  j)ain  or  the  immobility  is  so  marked  that  an 
operation  is  called  for  to  relieve  it. 


DISLOCATIONS. 


44;i 


Treatment  of  Old  Unreduced  Dislocations. —  If  tlic  dislocation  can- 
not be  reduced  by  the  usual  uietliods  after  freely  breakinff  the  adhesions  by 
forcible  rotation  and  traction,  the  surgeon  has  bis  choice  bet-ween  reduction  by 
open  arthrotomy  and  excision  of  the  head  of  the  humerus.  The  former  has 
furnished  a  few  good  results,  but  it  has  more  often  proved  impossible  to  make 
reduction  or  the  usefulness  of  the  limb  has  not  been  increased.  The  method 
of  open  arthrotomy  is  by  an  anterior  incision.  Excision  of  the  head,  through 
an  anterior  incision  or  through  one  in  the  axilla,  relieves  pressure  and  gives  a 
movable  joint ;  but,  as  the  division  of  the  bone  is  made  below  the  tuberosities, 
active  rotation  is  lost.  Subcutaneous  division  and  also  open  division  of  the 
periarticular  tissues  have  been  employed  a  few  times  successfully,  as  has  also 
intentional  fracture  of  the  surgical  neck  to  improve  the  position  or  to  create  a 
false  joint. 

Habitual  dislocation,  that  is,  the  liability  to  recurrence  of  the  disloca- 
tion on  certain  movements  of  the  arm,  has  been  successfully  relieved  in  two  cases 
by  Ricard  by  an  operation  which  consisted  in  exposing  the  front  of  the  joint  by 
an  incision  along  the  line  between  the  deltoid  and  pectoralis  magnus,  and  a 
second  one  running  from  the  upper  end  of  the  first  outward  along  the  margin 
of  the  acromion  ;  through  this  the  anterior  portion  of  the  deltoid  is  detached 
and  turned  back.  Then  without  opening  the  joint  the  lengthened  and  thinned 
portion  of  the  capsule  .on  the  inner  side  is  pinched  up  in  a  transverse  fold, 
which  is  made  permanent  by  two  or  three  vertical  silk  sutures  which  include 
part  of  the  tendon  of  the  subscapularis  below  and  the  unchanged  thick  upper 
portion  of  the  capsule  above. 


DISLOCATIONS  OF  THE  ELBOW. 

These  are  second  in  order  of  frequency,  and  are  much  more  common  in 
persons  under  twenty-five  years  of  age  than  in  others.  They  present  a  great 
variety  of  forms,  for  the  radius  and  ulna  may  be  displaced  together  backward, 
forward,  inward,  or  outward,  or  the  two  bones  may  be  displaced  each  in  a 
different  direction,  or  either  may  be  dislocated  alone,  the  other  remaining  in 
place.     The  following  table  is  taken  from  Stimson : 

Dislocations  backward : 

Backward  and  outward. 

Backward  and  inward. 
Lateral  dislocations : 

Incomplete  {™^J;j_ 

Complete  outward. 
Forward  dislocations : 

Incomplete,  or  first  deo;ree. 

Complete,  or  second  degree. 

With  fracture  of  the  olecranon. 
Divergent  dislocations : 

Antero-posterior. 

Transverse. 


Dislocations  of  the  forearm 
(both  bones)  on  the  arm. 


Dislocations    of    the     ulna 
alone   .         .         ... 


Dislocations  of  the   radius 
alone   .... 


Congenital  and  pathological 
dislocations. 


upward.  I  J-  Ipcomplete,  or  first  degree. 


1,2.  Backward  and  uuvYtuu.  T  o    n        Ti.      ■  j  i  -- 

'  ^  [1.  Complete,  or  second  degree. 

3.  Backward  and  outward,  behind  the  radius. 

1.  Backward. 

2.  Outward. 

3.  Forward. 

4.  By  elongation,  or  the  subluxation  of  children. 

5.  Associated  with  fracture  of  the  ulna. 


444 


AN  AMERICAN   TEXT-llOOK   OF  SURGERY. 


¥iG.  1S5. 


Dislocation  of  both  Bones  Backward. — This  is  the  most  common  of 
the  dislocations  at  the  elbow :  two  varieties,  showing  additional  displacement 
inward  or  outward,  are  noted,  but  the  variation  from  the  displacement  directly 
backward  has  no  practical  importance    (Fi^.  185). 

The  cause  is  usually  a  fall  upon  the  outstretched  hand,  and  the  mechanism 
in  such  cases  is  either  hyper-extension  of  the  elbow,  with  the  formation  of  an 
am^le  opening  backward,  or  an  increase  of  the  normal  outward  deviation  of 
the  forearm,  followed  by  a  twist  which  brings  the  coronoid  process  below  and 
then  behind  the  humerus.  The  theory  of  dislocation  by  hyper-extension  finds 
some  additional  support  in  the  api)arent  relation  between  the  frequency  of  the 
injury  in  chiMren  and  the  fact  that  in  most  young  people  the  limb  can  be 
easily  extended  beyond  the  straight  line.  In  either  case,  as  experiment  shows, 
the  internal  lateral  ligament  is  torn,  and  the  external  one  is  either  ruptured  or 
torn  away  from  the  bone,  perhaps  retaining  its  connection  with  the  periosteum, 
which  is  stripped  off  the  back  of  the  external  condyle  as  the  head  of  the  radius 
passes  backward.  The  capsule  is  torn  in  front,  the  internal  epicondyle  (epi- 
trochlea)  is  sometimes  broken  off,  apparently  by  traction  exerted  through  the 
flexor  muscles  attached  to  it,  and  sometimes   instead  of  this  the  muscular 

attachments  are  ruptured.  The  coronoid  process 
is  occasionally  broken,  as  may  also  be  a  portion  of 
the  head  of  the  radius,  the  cause  in  each  case  being 
pressure  against  the  condyle ;  both  fractures  are 
rare  complications,  and  probably  occur  only  in 
cases  in  Avhich  the  dislocation  is  caused  by  great 
violence  while  the  joint  is  in  partial  flexion. 

Symptoms. — The  elbow  is  jjartly  flexed  ;  the 
region  is  swollen  ;  if  the  thumb  and  middle  finger 
are  placed  on  the  internal  and  external  epicondyles, 
and  the  forefinger  on  the  olecrantjn.  the  displace- 
ment of  the  latter  is  readily  recognized,  and  then 
if  the  head  of  the  radius  is  sought  for  it  will  be 
found  behind  the  external  condyle  as  a  bony 
prominence  Avhich  rotates  when  the  hand  is  pro- 
nated  and  supinated.  Passive  flexion  and  exten- 
sion arc  possible  within  a  narrow  range,  and  in 
full  extension  abnormal  lateral  mobility  can  be 
recognized.  If  the  swelling  is  not  too  great,  the 
tendon  of  the  triceps  can  be  felt  or  seen  curving 
backward  to  the  olecranon  when  the  joint  is 
flexed.  The  trochlear  prominence  of  the  humerus 
is  sometimes  recognizable  in  the  flexure  of  the 
elbow,  and  may  be  very  prominent. 
Treatment. — Reduction  in  recent  cases  is  generally  very  easy,  especially  if 
the  opposition  of  the  muscles  is  overcome  by  anesthesia;  it  is  then  usually  possi- 
ble to  slip  the  bones  into  place  by  pressure  upon  their  projecting  ends  or  by  trac- 
tion at  the  wrist.  A  plan  that  is  often  remarkably  easy  and  successful  without 
anesthesia  is  that  in  which  the  elbow  is  slightly  over-extended  and  the  bones 
then  drawn  into  place  by  traction  upon  the  forearm.  There  are  cases  in  which 
the  dislocation  can  be  thus  reduced  and  reproduced  at  will  with  the  greatest 
ease  and  without  causing  any  pain.  The  method  by  forcible  flexion  of  the 
elbow  about  the  surgeon's  knee  placed  in  the  fold  of  the  joint,  while  at  the 
same  time  the  forearm  is  forcibly  pressed  away  from  the  arm  by  the  knee, 
has  been  in  use  for  centuries,  and  is  generally  successful,  although  theoretically 


Dislocation  of  the  Elbow  Back- 
ward fStimson). 


DISL  O  CA  TIONS.  44o 

faulty.  It  is  likeiy  to  tail  whenever  one  or  the  other  lateral  ligament  is  insuf- 
ficiently torn.  If  sufficient  time  has  passed  to  have  permitted  the  formation 
of  strong  adhesions,  they  must  first  be  broken  by  forcible  flexion,  and  Ity  this 
manipulation  it  may  happen  that  tiie  olecranon  j)rocess  will  be  broken. 

(Jompomid  didocationa  are  to  be  treated  according  to  the  principles  govern- 
ing in  such  injuries,  and  they  often  yield  very  satisfactory  results.  The  choice 
lies  between  excision  of  the  end  of  the  humerus  and  deduction  with  ample 
provision  for  drainage.  The  former  may  be  expected  to  give  a  movable  but 
comparatively  weak  joint;  the  latter  carries  the  greater  chance  of  dangerous 
suppuration  with  ultimate  ankylosis  and  a  strong  but  stiff  limb. 

The  after-treat nic lit  calls  only  for  immobilization  of  the  limb  for  about 
three  weeks.  Passive  motion  to  prevent  ankylosis  is  not  required,  and  is  likely 
to  do  harm  ;  the  stiffness  that  exists  Avhen  the  arm  is  removed  from  its  dressings 
will  gradually  disappear  under  the  natural  use  of  the  limb.  Massage  and  hot 
and  cold  douches  can  be  used  Avith  advantage  at  an  earlier  date.  In  children 
there  is  the  chance  that  the  irritation  of  the  injury,  and  especially  the  stripj)ing 
up  of  the  periosteum  from  the  humerus,  may  result  in  an  abnormal  production 
of  bone  that  will  mechanically  limit  the  mobility  of  the  joint;  but  passive  mo- 
tion will  not  prevent  this  result. 

Lateral  Dislocations  of  the  ELBOw^ — The  radius  and  ulna  may  be 
together  dislocated  incompletely  to  either  side,  or  completely  to  the  outer  side, 
the  coronoid  process  generally  remaining  anterior  to  the  humerus.  It  would 
appear  from  the  observations  of  some  surgeons  that  incomplete  dislocations, 
especially  to  the  inner  side,  are  tolerably  frequent  and  often  pass  unrecog- 
nized, being  mistaken  for  backward  dislocation  or  for  fracture  of  the  humerus. 

The  cause  is  usually  a  fall  upon  the  outstretched  hand,  and  the  mechanism 
appears  to  be  an  exaggeration  of  the  outward  angle  of  the  elbow,  by  which  the 
internal  lateral  ligament  is  torn  and  the  ulna  moved  directly  downward  away 
from  the  trochlea,  the  radius  and  capitellum  remaining  in  contact  by  their 
edges ;  a  gliding  lateral  movement  follows,  by  which  the  forearm  is  moved 
either  inward  or  outward  to  produce  one  or  the  other  form. 

Incomplete  Inward  Dislocation. — The  sigmoid  cavity  of  the  olecranon 
lies  below  and  embraces  the  internal  epicondyle,  and  the  radius  lies  in  front  of 
and  somewhat  below  the  trochlea,  the  sharp  inner  edge  of  the  latter  being  inter- 
posed between  it  and  the  coronoid  process.     Both  lateral  ligaments  are  torn. 

The  forearm  is  pronated  and  slightly  flexed;  its  axis  is  parallel  to  and  a, 
little  to  the  inner  side  of  that  of  the  arm.  The  olecranon  and  external  con- 
dyle are  prominent,  the  internal  epicondyle  masked,  the  head  of  the  radius  to 
be  felt  below  and  to  the  inner  side  of  its  normal  position.  Flexion  and  exten- 
sion appear  to  be  easy  and  not  very  painful. 

Heduction  is  made  by  traction  upon  the  extended  forearm  and  direct  lateral 
pressure  at  the  elbow.  In  cases  that  have  remained  unreduced  the  usefulness 
of  the  limb  appears  not  to  have  been  much  impaired. 

Incomplete  Outward  Dislocation. — The  radius  and  ulna  are  dis- 
placed outwardly  so  far  that  at  least  the  central  longitudinal  ridge  of  the  sig- 
moid cavity  of  the  olecranon  has  passed  beyond  the  outer  rim  of  the  trochlea ; 
the  radius  lies  partly  below  or  entirely  beyond  the  external  condAde.  Both 
lateral  ligaments  are  torn,  and  in  a  considerable  proportion  of  cases  the  epi- 
trochlea  is  broken  off,  and  even  displaced  so  far  downward  and  outward  that 
it  lodges  in  the  groove  of  the  trochlea.  The  elbow  is  more  or  less  flexed,  and 
the  forearm  pronated  and  either  parallel  to  the  arm  and  somewhat  external 
to  it  or  abducted.  The  internal  condyle  is  prominent  and  the  skin  tightly 
stretched  over  it;  the  external  condyle  is  masked  by  the  projection  of  the 


446 


AX   AMERICAN   TEXT-BOOK   OF  SURGERY. 


Fig.  186. 


head  of  the  radius.  The  olecranon  is  j)roniincnt.  and  the  tendon  of  the  tri- 
ceps curves  sharply  backward  and  outward  to  it  :  tla-  head  of  the  radius  can 
be  easily  felt  (Fig.' ISC). 

The  first  indication  for  treatment  is  to  disengage  the  ridge  of  the  sigmoid 

fossa  from  the  gro<jve  between  the  troch- 
lea and  capitellum,  which  may  be  done 
by  traction,  or  by  hyper-extension,  or  by 
abduction  of  the  extended  ft»rearm  if  the 
radius  still  rests  against  the  external  con- 
dyle so  as  to  furnish  a  fulcrum  ;  then  the 
bones  must  be  i)ushed  laterally  into  place 
by  pressure  ujjon  the  head  of  the  radius. 
If  the  broken  epitrochlea  is  lodged  in 
the  groove  of  the  trochlea,  it  may  seri- 
ously oppose  reduction,  and  in  some 
cases  it  has  prevented  it. 

Complete  Outward  Dislocation. 
— There  are  three  varieties,  according 
to  the  extent  of  the  displacement.  In 
the  first  the  radius  and  ulna  are  moved 
directly  outward  so  far  that  the  inner 
edge  of  the  sigmoid  cavity  of  the  olec- 
ranon lies  against  the  outer  surface  of 
the  external  condyle,  and  the  radius  is 
still  farther  to  the  outer  side  or  has  been 
moved  upward  by  pronation  of  the  fore- 
arm. In  the  second  (sometimes  called 
subepicondylar)  the  forearm  is  flexed 
and  rotated  inward  ninety  degrees,  so 
that  the  anterior  surface  of  the  ulna  looks  inward  and  its  sigmoid  cavity 
embraces  the  outer  aspect  of  the  external  condyle,  the  radius  lying  above  it 
and  in  front  of  the  supracondylar  ridge.     In  the  third  (supra-ei)icondylar) 

the  bones  are  moved  still  farther 
up  along  the  outer  border  of  the 
humerus,  and  sometimes  also  back- 
ward so  that  the  coronoid  process 
and  the  head  of  the  radius  lie  be- 
hind the  suj)in:i  tor  ridge  (Fig.  1H7). 
The  cause  is  a  fall  ujton  the 
hand  or  elbow  or  a  blow  upon  the 
inner  side  of  the  forearm  near  the 
elbow. 

The  diagnosis  is  made  by 
recognition  of  the  j)rominent  ends 
of  the  bones,  the  broadening  of 
the  elbow,  and  the  direction  of  the 
bones  of  the  forearm.  In  the  first 
variety  the  elbow  is  more  likely  to 
be  extended ;  in  the  two  others  it 
is  flexed. 

Reduction  is  usually  easy  because  of  the  extensive  laceration  of  the  liga- 
ments. In  cases  in  which  reduction  has  not  been  made  the  limb  has  been 
very  useful  and  motion  at  the  elbow  free. 


Outwar.l    -ui.iM-cijicondylar)  Dislucatiou  of  the 
Elbow  (original). 


Fig.  187. 


Complete  Outward  Dislocation  of  the  Elbow :  A,  radius  ; 
B,  olecranon  ;  C,  internal  condyle  (Hamilton). 


DISLOCATIONS.  447 

Forward  1)I^^L0(•.\TI().\  of  the  Elbow. — Of  this  rare  injury  twenty 
cases  have  been  rej)<)rte(l,  seven  of  wliieh  were  eonipound,  and  six  of  these 
seven  were  further  eoniplieated  by  fraeture  of  the  oleeranon.  In  most  of  the 
cases  the  cause  was  violence  received  upon  the  back  of  the  flexed  elbow.  When 
the  olecranon  is  l)roken  its  tip  remains  in  place,  and  the  ulna  and  radius  are 
displaced  upward  u}>ou  the  anterior  surface  of  the  humerus.  The  cases  not 
cc)m])licated  by  this  fracture  present  two  varieties  or  degrees :  first,  that  in 
whieh  the  upper  end  of  the  olecranon  rests  against  the  under  surface  of  the 
humerus;  seeond,  that  in  whieh  it  has  passed  to  the  anterior  surface  of  the 
humerus :  in  the  latter  the  triceps  always  appears  to  have  been  torn  away  from 
the  olecranon.  Reduction  was  made  in  all  but  one  of  the  simple  cases,  and  in 
that  one  the  nature  of  the  injury  was  not  recognized  and  the  limb  was  am])U- 
tated.  Of  the  seven  compound  cases,  four  suppurated ;  two  of  these  came  to 
amputation,  and  one  recovered  Avith  a  stift'  joint. 

Divergent  Dislocation  of  the  Radius  and  Ulna. — Of  this  two 
varieties  have  been  observed  :  the  aniero-jjosterior  (11  cases),  in  which  the  ulna 
passed  up  behind,  and  the  radius  in  front  of,  the  humerus ;  and  the  transverse 
(1  case),  in  Avhich  the  olecranon  lay  behind  the  epitrochlea  and  the  radius  on 
the  outer  aspect  of  the  external  condyle.  The  cause  in  several  of  the  cases 
appears  to  have  been  forcible  abduction  of  the  forearm,  by  which  the  internal 
lateral  ligament  was  ruptured,  followed  by  internal  rotation  of  the  forearm. 
In  two  cases  reduction  failed,  and  in  one,  only  the  ulna  could  be  replaced. 

Dislocation  of  the  Ulna  Alone. — This  is  very  rare.  The  ulna  is 
displaced  backward  and  more  or  less  outward  behind  the  radius  by  internal 
rotation  of  the  forearm  upon  the  head  of  the  radius  as  a  center,  and  then  car- 
ried upward  far  enough  to  engage  the  coronoid  process  behind  the  humerus  by 
adduction  of  the  forearm.  The  mode  of  pi'oduction  appears  to  be  hyper-exten- 
sion or  abduction  of  the  extended  forearm  until  the  internal  lateral  ligament 
ruptures,  and  then  internal  rotation  (pronation)  and  adduction. 

The  forearm  is  usually  in  full  extension  and  adducted ;  flexion  is  very 
painful,  rotation  free.  The  trochlea  is  prominent  in  front,  and  the  olecranon 
is  prominent  behind ;  the  head  of  the  radius  is  in  place. 

Dislocations  of  the  Radius  Alone. — Four  forms  are  recognized, — back- 
ward, outward,  forward,  and  downward ;  but  the  character  of  the  latter  is  still 
iisputed. 

Backward. — The  head  of  the  radius  is  displaced  backward,  and  some- 
times carried  a  little  upward  behind  the  humerus  by  abduction  of  the  fore- 
arm or  by  the  aid  of  an  associated  fracture  of  the  ulna  or  rupture  of  the  inter- 
osseous ligament,  which  permits  the  radius  to  move  upward  independently  of  the 
ulna.  The  mode  of  its  production  is  not  understood.  The  orbicular  liga- 
ment ha»  been  found  torn,  and  also  the  external  ligament  at  its  posterior  part. 
Reduction  has  been  easily  effected  in  recent  cases  by  direct  pressure  forward 
on  the  head  of  the  radius,  but  in  some  instances  the  interposition  of  the  orbicular 
ligament  has  prevented  reduction. 

Outward. — This  form  is  very  rare,  and  most  of  the  reported  cases  Avere 
of  long  standing  when  reported ;  in  some  of  them  the  inner  portion  of  the 
head  of  the  radius  had  been  broken  off.  The  diagnosis  is  made  by  the  recog- 
nition of  the  head  of  the  radius  outside  of  its  normal  position  and  of  the  ulna 
in  its  proper  place. 

Forward. — This  is  more  common  than  the  two  preceding  forms,  and  a  not 
infrequent  accompaniment  of  fracture  of  the  shaft  of  the  ulna  by  a  fall  upon 
the  hand.  The  head  of  the  radius  is  displaced  forward,  and  perhaps  upward 
by  abduction  of  the  forearm   or  by  a  total  movement  of  the  radius  in  that 


448  .l.V   AMERICAN    TEXT-BOOK    OF  SURdKRY. 

direction,  so  that  it  rests,  wlit'ii  the  elbow  is  flexed,  against  tlie  anterior  sur- 
face of  the  external  eondyle  above  its  normal  position.  The  orbieular  liga- 
ment and  outer  portion  of  tiie  anterior  li<^anient  are  torn.  Tiie  limb  can  be 
abducted;  full  extension  and  liexion  to  a  ri<fht  angle  are  possible:  suj)ination 
is  limited.  The  head  of  tiie  radius  can  be  felt  in  the  fold  of  the  elbow  in 
front  of  its  normal  position.  Keduction  has  been  sometimes  easy,  sometimes 
difficult  or  impossible.  The  best  method  of  reduction  appears  to  be  adduction 
of  the  extended  forearm,  followed  by  direct  pressure  upon  the  head  of  the 
radius.  In  cases  of  fracture  of  the  shaft  of  the  ulna  this  dislocation  should 
ahvays  be  looked  for. 

Downward,  i»r  Dislocation  by  Elongation,  or  Subluxation  of  Young 
Children. — This,  though  of  fretiuent  occurrence,  is  observed  almost  exclu- 
sively by  the  family  practitioner  or  the  dispensary  surgeon.  The  theory  of  its 
nature  which  is  most  widely  held  is  that  oifered  by  Duverney  in  1751 — namely, 
a  displacement  of  the  head  of  the  radius  downward  so  far  that  it  engages  under 
the  lower  border  of  the  orbicular  ligament. 

The  clinical  history  is  characteristic :  a  child,  usually  under  three  years  of 
age,  is  pulled  by  the  hand ;  it  cries  out  with  pain,  and  refuses  to  use  the  limb, 
which  hangs  by  the  side,  partly  flexed  at  the  elbow  and  pronated.  There  is 
sensitiveness  on  pressure  over  the  head  of  the  radius,  and  a  slight  interval  can 
sometimes  be  felt  between  the  latter  and  the  condyle.  Passive  motion  is  free 
in  every  direction  except  supination.  On  forcible  supination  a  slight  click  is 
sometimes  felt,  and  the  child  at  once  begins  to  use  the  arm. 

Old  Unreduced  Dislocations. — The  solidity  of  the  adhesions  that  unite 
the  displaced  olecranon  to  the  back  of  the  humerus  is  such,  and  the  production 
of  new  bone  by  the  irritated  and  loosened  periosteum  in  the  young  is  so  prompt, 
that  dislocations  early  become  irreducible  by  ordinary  methods.  If  the  limb 
is  extended  and  stiff",  the  position  can  be  improved  by  forcible  flexion,  with  or 
without  fracture  of  the  olecranon,  or  resort  may  l)e  had  to  open  arthrotomy 
with  division  or  removal  of  the  obstacles,  or  to  excision.  If  open  arthrotomy 
is  done,  the  incisions  must  be  so  planned  that  the  adhesions  on  the  inner  and 
outer  sides  of  the  humerus  can  be  divided,  and  the  sigmoid  cavity  freed  of  the 
fibrous  tissue  which  usually  fills  it.  The  choice  lies  between  two  lateral  incis- 
ions and  a  posterior  transverse  or  U-shaped  incision,  through  Avhich  the  triceps 
is  divided  close  above  the  olecranon  and  the  joint  freely  opened  from  behind; 
the  first-named  method  is  generally  preferred. 

DISLOCATIONS  AT  THE  WRIST. 

Dislocation  of  the  Lower  Radio-ulnar  Joint. — By  general  usage 
the  ulna  is  spoken  of  as  the  dislocated  bone.  The  dislocation  may  boiforward 
or  backward. 

In  the  backward  variety  the  cause  has  been  exaggerated  pronation,  either 
voluntary,  as  in  wringing  clothes,  or  by  external  violence.  The  end  of  the 
ulna  forms  a  marked  prominence  on  the  back  of  the  Avrist,  and  sometimes  over- 
laps the  radius  slightly.     Reduction  by  direct  pressure  is  easy. 

In  the  forward  variety  external  violence  is  the  common  cause.  The  ulna 
projects  anteriorly,  and  sometimes  overlaps  the  radius  as  in  the  backward  vari- 
ety.    Reduction  by  direct  pressure  is  easy. 

Dislocation  of  the  Carpus  from  the  Radius. — This  may  take  place 
backward  or  forward,  and  in  two  cases  was  outward  ;  it  may  be  complete  or 
incomplete,  and  may  be  accompanied  by  fracture  of  the  anterior  or  the  posterior 
lip  of  the  radius.     The  cause  is  forcible  flexion  or  extension  of  the  wrist  or 


DfSLOCATrOXS. 


449 


direct  violence.  lu  the  incom])lete  forms  the  cuneiform  maintains  its  relations 
with  the  triangular  fibro-cartilage,  while  the  scaphoid  and  semilunar  are  dis- 
placed from  the  radius  ;  in  one  case  the  semilunar  remained  attached  to  the 
radius,  while  the  rest  of  the  carpus  was  displaced  backward. 

The  common  Colles's  fracture  of  the  lower  end  of  the  radius  was  long 
thought  to  he  a  dislocation  of  the  wrist  backward.  The  differential  diagnosis 
IS  to  be  made  by  attention  to  the  position  of  the  styloid  process  of  the  radius, 
to  its  relations  with  that  of  the  ulna  and  with  the  proj^ecting  mass  on  the  back 

Fig.  188. 


Diagrammatic,  to  indicate  the  deformity  in  [A)  dislocation  of  the  wrist  backward,  and 
(B)  Colles's  fracture  of  the  radius  (Stiinson). 

of  the  wrist,  and  with  the  metacarpus.  Fig.  188  shows  the  deformity  in  the 
two  injuries. 

In  dislocation  forward  the  carpal  bones  form  a  rounded  prominence  on  the 
front  of  the  wrist,  and  the  lower  end  of  the  radius  presents  as  a  sharply-defined 
line  posteriorly,  with  a  well-marked  depression  below  it  corresponding  to  the 
prominence  in  front.     Reduction  is  easy  by  traction  and  direct  pressure. 

Spontaneous  suhJuxation  fortvard  has  been  recently  described  by  Made- 
lung.  It  occurs  gradually  in  adolescents  or  young  adults,  and  is  characterized 
by  the  absorption  or  arrest  of  growth  of  the  anterior  portion  of  the  articular 
surface  of  the  radius,  with  corresponding  displacement  forw^ard  and  upward  of 
the  carpus.  The  end  of  the  ulna  projects  markedly,  and  the  antero-posterior 
diameter  of  the  wrist  is  much  increased ;  dorsal  flexion  is  limited. 

Dislocations  of  the  Carpal  Bones.-»-A  very  few  cases  of  dislocation  of 
the  second  row  of  the  carpus  backward  or  forward  from  the  first  have  beeu 
reported. 

Isolated  dislocation  of  every  one  of  the  bones  of  the  carpus  except  the 
cuneiform  has  been  reported.  The  semilunar  is  the  one  most  frequently  dis- 
located, the  injury  having  been  compound  in  half  the  cases  reported,  and  the 
displacement  forward  in  all  but  one. 

Carpo-metacarpal  Dislocation. — The  metacarpal  bone  of  the  thumb  is 
the  one  most  frequently  dislocated,  the  displacement  being  usually  backward 
and  more  often  incomplete  than  complete.  The  cause  in  backward  dislocation 
is  eithef  forcible  flexion  of  the  member  or  direct  violence.  The  base  of  the 
metacarpal  bone  can  be  seen  and  felt  as  a  prominence  between  the  tendons  of 
the  extensor  primi  and  extensor  secundi  internodii.  Reduction  is  usually  easy 
by  direct  pressure,  but  there  is  often  a  marked  tendency  to  recurrence,  which 
must  be  opposed  by  a  splint  or  by  maintaining  the  member  in  abduction  and 
extension  for  one  or  two  weeks.  Dislocations  forward  and  outward  of  the 
same  bone  have  been  observed. 

Isolated  dislocations  of  the  second  and  third  metacarpals  have  also  been 
observed,  and  dislocation  backward  of  the  four  inner  and  forward  of  all  five 
metacarpals. 

Dislocations  of  the  Thumb  and  Fingers. — Dislocation  of  the  metacarpo- 
phalangeal joint  of  the  thumb  is  quite  common,  and  has  received  much  atten- 

29 


450 


^.V   AMEUrCAX    TEXT- HOOK    OF  SURGERY. 


Backward 

I-'lu.  ISi). 


tion  because  of  the  (lilliculty  fVe(iuently  experienced  in  reduction  of  the  back- 
ward variety — a  diHiculty  the  cause  of  whicli  is  now  generally  believed  to  be 
the  interposition  of  the  anterior  or  glenoid  ligament,  with  its  included  sesamoid 
bones. 

lislocation  of  the  tluuub  presents  three  forms:  incomplete, 
complete,  and  comjilex.  The  first  is  a  form  which  can  be 
voluntarily  produced  by  many  persons  b}'  contraction  of 
the  extensor  of  the  first  joint.  The  first  phalanx  moves 
backward  and  stands  at  a  right  angle  to  the  metacarpal 
bone,  from  which  position  it  can  be  returned  with(jut 
difficulty  to  its  place  by  the  action  of  the  flexors. 

In  the  coinplete  form  the  phalanx  is  carried  back- 
ward and  upward   on   the   dorsum  of  the  metacarpal, 
usually  by  forced  extension,  the  anterior  ligament  is 
torn  away  from  the  metacarpal  bone  and  drawn  back- 
ward witli  its  sesamoid  l)ones  along,  and  even  past,  tiie 
articular  surface  of  the  head,  while  the  tendon  of  the 
long  flexor  slips  to  one  side  of  the  head,  usually  the 
inner,  although  it  may  exceptionally  remain  in  ])lace, 
stretched  along  the  head  of  the  metacarpal.     The  first 
phalanx  is  in  extension  at  a  right  angle,  the  terminal 
phalanx  in  flexion,  the  head  of  the  metacarpal  is  promi- 
nent in  the  thenar  eminence  (Fig-  18'J). 
In  the  complex  form,  a  form  produced  from  the  comjilete  by  forced  flexion 
of  the  thumb,  the  glenoid  ligament  is  turned  upward  so  as  to  lie  between  the 
phalanx  and  the  head  or  dorsum  of  the  metacarpal.     The  thumb  is  in  straight 


Simple  ComjiletL'  Disloca- 
tion of  Right  Thumb. 
The  long  flexor  tendon  is 
displaced  to  the  inner 
side  (Fiiriihevif ). 


Fk;.  190. 


Complete  Dislocation  of  the  Thumb,   outer  side.    The  hook  raises  the  periosteal  continuation  of  the 
lateral  ligament,  exposing  the  reflected  sesamoid  bone  (Farabeuf ). 


extension,  parallel  and  posterior  to  the  metacarpal  ;  its  base  can  be  felt  as  a 
prominence  ])eliind,  and  the  head  of  the  metacarj)al  in  front  (Fig.  190). 

The  essential  point  in  reduction  is  to  avoid  the  transformation  of  the 
complete  into  the  complex  form.  The  extension  must  be  maintained  or  even 
increased,  and  then  the  thumb  should  be  pressed  bodily  downward  until  the 
anterior  edge  of  its  base  overlaps  the  articular  surface  of  the  metacarpal,  when 
it  can  be  turned  into  place  by  flexion  ;  in  this  way  the  glenoid  ligament  and 
the  sesamoid  bones  are  pushed  before  the  phalanx.  If  this  fiiils,  the  surgeon 
can  sometimes  succeed  by  combining  rotation  of  the  thumb  with  pressure  down- 
ward, so  as  to  free  first  one  side  and  then  the  other — a  sort  of  unbuttoning  of 
the  head  of  the  metacarpal  from  the  grasp  of  the  glenoid  ligament  and  the 
attached  heads  of  the  short  flexor.  In  the  complex  form  the  same  method 
must  be  employed,  but  it  is  necessary  to  use  more  force,  so  as  to  ])ring  the 


DISLOCATIONS.  451 

tliuinl)  fiirtluT  (lowinvanl  and  free  the  e(l<,'e  of  the  li;,faiiU'nt  wliicli  has  been 
turned  up^vard. 

It'  manipulation  fails,  a  longitudinal  incision  should  be  made,  aseptically 
of  course,  on  the  palmar  aspect  of  the  joint,  cutting  directly  down  upon  the 
head  of  the  metacarpal;  by  tlrawing  the  edges  of  the  incision  apart  the  glenoid 
ligament  is  exposed,  and  its  free  edge  should  then  be  nicked  at  its  center  and 
lifted  }»nst  the  head  of  the  bone. 

In  forward  dislocation,  usually  due  to  forced  flexion,  the  base  of  the 
phalanx  lies  anterior  to,  and  perhaps  a  little  to  one  side  of,  the  head  of  the 
metacarpal,  and  the  posterior  and  lateral  ligaments  are  torn.  It  is  recognized 
by  the  projection  of  the  head  of  the  metacarpal  on  the  dorsum,  and  of  the 
base  of  the  phalanx  in  front.  It  is  easily  reduced  by  direct  pressure  aided  by 
traction,  or  by  increasing  the  flexion  and  then  pressing  the  phalanx  bodily 
downward  as  in  the  dorsal  form. 

Metacarpo-phalangeal  Dislocation  of  the  Fingers. — These  joints 
have  a  glenoid  ligament  similar  to  that  of  the  thumb,  and  sometimes  a  sesamoid 
bone  is  developed  in  it.  There  is  the  same  difficulty  in  reduction  of  the  back- 
ward dislocations.  It  is  due  to  the  same  cause  and  is  to  be  met  by  the  same 
measures. 

Dislocations  of  the  Phalanges. — These  may  be  forAvard,  backward,  or 
lateral.  Reduction  is  •  usually  easy,  although  it  is  possible  that  the  thick 
anterior  ligament  may  become  interposed  as  at  the  metacarpal  joint. 

dislocations  of  the  pelvis  and  coccyx. 

The  bones  of  the  pelvis  may  be  dislocated  from  each  other  or  from  the 
sacrum  at  the  pubic  or  sacro-iliac  symphysis,  but  the  lesion  is  commonly  asso- 
ciated with  fracture  of  the  pelvis,  to  which  the  reader  is  refen-ed. 

Dislocation  of  the  coccyx  is  a  rare  injury,  more  common  in  women 
than  in  men,  and  is  accompanied  by  symptoms  of  pain,  disability,  and  nervous 
disturbances  that  are  present  also  in  cases  in  which  there  is  no  dislocation  or 
fracture. 

Forward  dislocations  have  been  caused  by  violence  received  upon  the  region 
of  the  coccyx.  The  pain  is  severe  and  radiates  through  the  trunk  and  limbs, 
and  is  increased  by  any  movement.  The  finger  in  the  rectum  recognizes  the 
coccyx  flexed  forward,  and  if  it  is  pressed  backward  into  place  the  pain  ceases. 
The  tendency  to  recurrence  is  great,  and  if  it  is  manifested  the  surest  method 
of  treatment  would  probably  be  to  excise  the  bone — an  operation  that  is  very 
successful  in  the  allied  cases  in  which  there  is  no  dislocation. 

dislocations  of  the  hip. 
These  form,  according  to  different  statistics,  from  2  to  nearly  10  per  cent, 
of  all  dislocations ;  they  have  been  observed  at  all  ages  from  six  months  to 
ninety-one  and  a  half  years,  and  are  much  more  frequent  in  men  than  in 
women.  The  head  of  the  femur  may  be  primarily  displaced  in  any  of  the  four 
principal  directions,  and  may  undergo  a  number  of  secondary  displacements. 
The  "typical"  cases,  as  shown  by  Bigelow,  are  those  in  which  the  Y-ligament 
remains  untorn  in  whole  or  in  part  and  imposes  a  definite  attitude  upon  the 
limb.  This  ligament  has  the  form  of  an  inverted  Y  ;  the  base  of  the  A  is 
attached  to  the  anterior  inferior  spine  of  the  ilium  and  the  surface  of  the  bone 
immediately  external  to  it  and  above  the  edge  of  the  acetabulum,  and  its  fibers, 
diverging  downward,  form  two  strong  bands,  the  inner  and  outer,  which  are 


452  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

attached  respectively  to  the  iiuier  iuul  outer  ]>ortioiis  of  tlic  imtfi'ior  inter- 
trochiiiiterie  line. 

Coiiijjound  dislocations  are  very  rare. 

Dislocation  of"  the  liip-joint  may  occur  durin;^  or  especially  after  typiioid 
and  occasionally  after  other  eruj)tive  fevers.  The  dislocation  is  due  to  over- 
distention  of  the  capsule  and  elongation  of  the  ligaments  which  follow  a 
suhacute  synovitis.  The  assumption  of  an  hahitual  attitude  may  prove  a 
factor  in  the  production  of  a  dislocation.  The  exciting  cause  of  dislocation 
is  a  slight  force  (turning  in  hed — lifting  the  patient).  Keen  helieves  that  in 
many  cases  muscular  contraction  is  the  cause.  The  dislocation  takes  place 
upon  the  dorsum  of  the  ilium  and  is  seen  almost  exclusively  under  twenty 
years  of  age.  Freciuently  the  dislocation  is  not  discovered  at  the  time  of  its 
occurrence,  but  is  noted  some  time  afterward.  If  the  dislocation  is  discov- 
ered soon  after  its  occurrence  reduction  can  he  readily  effected  ;  hut  if  it  is 
not  discovered  for  some  time  reduction  may  be  impossible. 

In  the  most  conniion  form  the  head  of  the  femur  passes  backward  out  of 
the  socket  while  the  thigh  is  flexed,  adducted,  and  rotated  inward ;  if  tlie 
flexion  is  in  great  part  maintained,  the  head  remains  close  behind  the  ace- 
tabulum, but  if  the  flexion  is  diminished  the  head  rises.  The  head  may  also 
pass  directly  to  this  higher  position  by  leaving  its  socket  when  the  thigh  is 
but  slightly  flexed.  The  earlier  writers  made  two  classes  of  these  two  forms, 
calling  the  former  "dislocation  into  the  ischiatic  notch,"  and  the  latter  "dis- 
location upon  the  dorsum  of  the  ilium,"  and  supposed  the  latter  to  be  the  more 
frequent.  Later  investigations,  notably  those  of  Malgaigne  and  Bigelow, 
showed  that  the  difference  was  generally  due  to  a  secondary  displacement,  the 
head  most  frequently  leaving  the  socket  at  the  lower  point,  and  rising  in  the 
higher  cases  in  consequence  of  the  lowering  of  the  knee.  This  has  led  to  a 
general  abandonment  of  the  division,  and  to  the  grouping  of  all  the  cases  as 
"dorsal,"  or  "backward."  The  following  classification,  taken  from  Stimson, 
resembles  that  used  for  dislocations  of  the  shoulder ;  the  names  of  the  principal 
classes  indicate  the  direction  of  the  primary  displacement,  and  those  of  the 
varieties  indicate  either  the  place  at  which  the  head  comes  to  rest  or  some 
marked  clinical  feature : 


Dislocations  backward 


Dislocations  downward  and 
inward 


Dorsal,  comprising  the  "iliac"  and  the  "ischiatic,"  or  those 
"  upon  the  dorsum  ilii"  and  "into  the  ischiatic  notch"  of 
older  writers. 

Anterior  oblique. 

Everted  dorsal,  comprising  the  "supraspinous"  and  some  of 
the  "  supracotyloid." 

Obturator. 

Perineal. 


Dislocations    forward    and  ]  o  v    I  t)  i  • 

upward        .         .         .      }  Suprapubic  j  Pubic. 
^  .  ■'  [  Intrapelvic. 

Dislocations  directly  upward  (supracotyloid  or  subspinous). 
Dislocations  downward  on  the  tuberosity  of  the  ischium. 

BACKWARD  DISLOCATIONS. 

In  this  class  the  head  of  the  femur  passes  over  the  posterior  lip  of  the  ace- 
tabulum, and  lodges  close  behind  it,  or  behind  and  above  it,  in  the  common 
"dorsal"  form  in  which  the  limb  retains  the  attitude  of  flexion,  adduction, 
and  inward  rotation  Avhich  it  had  when  the  dislocation  occurred.     Occasionally, 


DISLOCATIONS. 


4o3 


but  very  rarely,  the  head  un(lern;ocs  furtlier  disphvcement  forward  and  iriAvard 
by  outward  rotation  of  tlie  linil),  with  ahihiction,  and  extension — the  "everted 
dorsal  "  variety  ;  and  IJij^elow  has  described  a  still  more  rare  variety  in  which 
outward  rotation  is  combined  Avith  Ilex  ion  and  marked  adduction,  the  head 
rests  above  the  acetabulum,  and  the  lower  part  of  the  neck  lies  at  its  upper 
and  posterior  margin — the  "anterior  oblique"  variety. 

1.  Dorsal  Dislocation. — This  is  by  far  the  most  common  form ;  it 
includes  those  described  as  dislocations  "upon  the  dorsum  ilii,"  "into  the 
sciatic  notch,"  "iliac,"  "ischiatic,"  "dorsal,"  and  "dorsal  below  the  tendon" 
of  various  writers.  The  head  of  the  femur  leaves  the  joint  posteriorly  at  a 
higher  or  lower  level ;  it  may  pass  below  the  tendon  of  the  obturator  internus, 
or  between  it  and  the  pyriformis,  or  above  the  latter ;  it  usually  rests  close  to 
the  margin  of  the  acetabulum,  seldom  if  ever  reaching  the  great  sciatic  notch, 
but  occasionally  passing  up  to  the  dorsum  of  the  ilium. 

The  cause  is  external  violence  acting  from  below  upward  in  the  direc- 
tion of  the  long  axis  of  the  femur,  and  tending  to  push  the  knee  toward 
the  pelvis  while  the  thigh  is  flexed,  adducted,  and  rotated  inward,  or  exag- 
gerated adduction  and  inward  rotation  combined  with  flexion.  It  may  be 
produced  by  transformation  of  a  thyroid  dislocation  by  flexion,  adduction, 
and  inward  rotation. 

The  capsule  is  irregularly  torn  in  its  posterior  and  lower  portion,  and  is 
occasionally  detached  from  the  femur,  or,  more  rarely,  from  the  acetabulum. 
In  the  regular  or  typical  cases  the  Y-ligament  is  untorn.  The  ligamentum 
teres  is  torn  away  from  the  femur  or  ruptured.  The  quadratus  femoris  and  the 
gemelli  are  usually  ruptured,  and  the  tAvo  obturators  and  the  pyriformis  may 
be  more  or  less  torn. 

It  seems  to  have  been  satisfactorily  shown  that  in  the  greater  number  of 
cases  the  head  leaves  the  socket  at  a  relatively  low  point  (the  so-called  ischiatic 
form),  and  then  rises,  as  the  knee 

is  lowered,  behind  the  obturator  T^tg.  192. 

internus  (Fig.  191),  or  pushes  that 
muscle  upward ;  less  frequently 
it  leaves  the  socket  at  a  higher 
point  (the  primary  iliac  form)  and 
remains  in  front  of  the  obturator 


Fig. 


Pyr^f' 


Odl.Ext. 


m.Inl.    Ei 


Dislocation  below,  and  then  Ijehind  and  above, 
the  Obturator  Internus  (Stimson). 


MacCorniac's  Specimen  of  Recent  Dorsal 
Dislocation.  The  head  of  the  femur 
lies  just  behind  the  acetabulum,  be- 
low the  pyriformis  and  above  the  ob- 
turator internus  and  the  torn  gemel- 
lus muscles  (MacCormae). 


internus  (Fig.  192).  The  lowest  point  at  Avhich  it  has  been  known  to  lodge  is 
the  base  of  the  spine  of  the  ischium,  the  highest  (possibly  with  rare  exceptions) 
a  point  on  the  ilium  in  front  of  the  highest  part  of  the  great  sciatic  notch. 


4r,4 


.i.v  jj//;/.'/r.Lv  Ti:xr- HOOK  or  sinoKin'. 


Fig.  103. 


The  edge  of  the  acetahuhmi  may  be  chi|)j)0(l  or  even  extensively  hroken;   the 
head  of  tlie  trnnir  has  l)een  l)roken  onee  or  twiee. 

The  symptoms  are  marked:  tlie  liml»  is  aihhicted,  rotated  inward,  and 
more  or  less  Hexed  (Fig.  1!>8),  so  that  its  knee  rests  upon  the  front  of  the 
opposite  thigh  when  the  patient  is  reeumbent,  its  toes  on  the  dorsum  of  the 
other  foot  when  he  is  upright.  Flexion  may  be  masked  by  the  tilting  of  the 
pelvis,  in  which  case  marked  lordosis  of  the  lumbar  s])ine  can  be  recognized 
by  passing  the  hand  under  the  patient  as  he  lies  on  his  back.  The  upper 
and  outer  part  of  tlie  thigh  is  broadened,  the  troclianter  rises  above  a  line 
'drawn  from  the  anterior  superior  spine  of  the  ilium  to  the  tuberosity  of  the 
ischium  (Nelaton's  line),  and  the  head  of  the  femur  may  be  obscurely  felt  in 
the  buttock. 

Voluntary  movements  are   lost,   but   passive   flexion   and  adduction  are 
possible;  extension,  abduction,  and  outward  rotation  impossible. 

Because  of  its  adduction  the  limb  appears  much  shortened ;  actual  short- 
ening will  be  found  on  measurement  if  the  other  limb  is  symmetrically  placed, 
but  this  is  not  usually  needed  to  make  the  diagnosis.  The 
symptoms  and  the  whole  appearance  of  the  limb  are  so 
characteristic  that  the  nature  of  the  injury  can  hardly 
fail  to  be  recognized  ;  a  much  more  common  error  is  to 
mistake  a  fracture  of  the  neck  of  the  femur  for  a  disloca- 
tion. 

2.  Everted  Dorsal  Dislocation. — As  the  name 
indicates,  this  exceptional  form  differs  from  the  common 
one  in  the  substitution  of  outward  for  inward  rotation  of 
the  limb,  a  substitution  that  is  made  possible  by  rupture 
of  the  outer  branch  of  the  Y-lig^™eiit.  If  the  head  of 
the  femur  remains  behind  the  socket,  flexion  and  some 
adduction  persist,  but  if  it  has  moved  upward  and  for- 
ward to  a  position  near  to  and  above  the  anterior  inferior 
spine  of  the  ilium,  there  will  be  extension  and  slight  ab- 
duction. 

3.  Anterior  Oblique  Dislocation. — In  this,  of 
which  there  appears  to  be  only  one  recorded  case,  the 
limb  crosses  the  opposite  thigh,  everted,  and  with  the 
knee  extended. 

Treatment  of  Backward  Dislocations. — The  es- 
sentials in  making  reduction  are  to  relax  the  untorn  por- 
tions of  the  cai)sule  and  the  Y-ligJ^nient ;  then  to  bring  the 
head  of  the  bone,  if  necessary,  opposite  the  rent  in  the  cap- 
sule, and  to  lift  it  into  place  by  traction  or  manipulation,  or  by  abduction  and 
outward  rotation,  Avhich  accomplishes  the  same  end  through  the  agency  of  the 
remaining  ligaments.  The  patient  is  placed  flat  on  his  back,  the  pelvis  steadied 
by  downward  pressure  of  the  surgeon's  foot  or  of  an  assistant's  hand  upon  the 
anterior  superior  spine  of  the  corresponding  ilium ;  the  knee  is  flexed  at  a  right 
angle,  the  thigh  rotated  farther  inward,  flexed  to  a  right  angle  (sometimes  even 
beyond),  and  then  lifted  bodily  upward  and  rotated  outward  and  lowered  in  ab- 
duction. The  lifting  can  be  made  easier  by  making  a  long  loop  of  a  bandage  and 
passing  it  over  the  Surgeon's  shoulders  and  under  the  hollow  of  the  patient's  knee. 
Or  the  patient  may  be  laid  on  his  face  on  a  bed  or  table  in  such  a  way  that 
his  thighs  extend  beyond  its  margin.  The  sound  limb  is  held  horizontal  by  an 
assistant,  and  the  dislocated  one  allowed  to  hang  vertically  down,  the  knee 
flexed,  and  the  ankle  held  by  the  surgeon.     While  the  surgeon  gently  swings 


Dorsal  Dislocation  of  the 
Femur  (Cooper). 


DISLOl'ATIONS. 


45r> 


the  limb  tVuui  side  to  side  and  diverts  the  patient's  attention  the  niiiseles  will 
be  seen  to  relax,  and  the  bone  will  often  slip  into  place  without  further  manip- 
ulation or  with  the  aid  only  of  a  slij^ht  (juiek  pressure  downward  upon  the  calf. 

Occasionally  these  methods  fail,  the  head  seeming  to  bo  firmly  caught  by 
some  opjHising  bony  projection.  After  several  failures  another  repetition, of 
the  attempt  uuiy  instantly  succeed,  or  traction  made  by  an  assistant  in  the 
direction  of  the  axis  of  the  slightly  Hexed  and  adducted  thigh  while  the  sur- 
geon presses  inward  against  the  great  trochanter  nuiy  be  successful.  Anesthe- 
sia is  a  great  help. 

Occasionally  the  manipulation  transforms  the  dislocation  into  a  thyroid  one; 
it  can  be  restored  to  its  original  form  by  reversing  the  movement :  flexion  in 
abduction  and  outward  rotation,  followed  by  adduction  and  rotation  inward. 

The  everted  dorsal  and  anterior  oblique  are  reduced  by  first  converting 
ihem  into  the  dorsal  form  and  then  treating  them  as  such. 


Fig.  194. 


DISLOCATIONS  DOWNWARD  AND  INWARD. 

The  head  of  the  femur  escapes  at  the  lower  or  lower  and  inner  part  of  the 
socket,  and  either  lodges  in  the  obturator  foramen,  obturator  or  tlnjroid  disloca- 
tion, or  passes  farther  inward  to  the  perineum,  perineal  dislocation.  The  limb 
is  flexed,  abducted,  and. rotated  outward. 

1.  Obturator  Dislocation. — This  is  commonly  caused  by  violence  re- 
ceived upon  the  back  of  the  pelvis  while  the  thigh  is  somewhat  flexed  and 
abducted,  but  it  may  be  produced  by  forced  abduction  alons.  As  the  Y-liga- 
ment  is  untorn  and  the  head  is  displaced  downward  and  inward,  the  limb  is 
held  in  abduction  and  flexion,  and  cannot  be  extended  or  adducted ;  after  flex- 
ion it  can  be  adducted.  If  the  patient  stands  upright  the  injured  limb  is  held 
forward  and  appears  to  be  lengthened  in  consequence  of  the  lowering  of  that 
side  of  the  pelvis.  If  a  comparative 
measurement  is  made  while  the  thighs 
are  well  flexed,  shortening  will  be 
found.  The  trochanteric  region  is 
flattened,  the  adductors  tense.  If 
the  patient  is  thin,  the  head  of  the 
femur  may  perhaps  be  felt  on  deep 
pressure  through  the  adductors. 

It  has  been  stated  on  excellent  au- 
thority that  a  number  of  patients  have 
been  able  to  walk  immediately  after 
the  accident  and  have  not  sought 
treatment  until  after  several  days. 

Reduction  is  made  by  flexion  of 
the  hip  to  a  right  angle,  traction  while 
making  adduction,  and  then  rotation 
inward  while  lowering  the  knee  ;  fur- 
ther outward  instead  of  inward  rota- 
tion in  the  last  step  may  also  succeed. 
2.  Perineal  Dislocation. — As 
the  head  of  the  femur  in  this  form  is 
displaced  farther  inward,  the  flexion 
and  abduction  of  the  limb  are  much 


Perineal  Dislocation  of  Hip  (original). 


more  marked,  more  so  than  can  be  together  obtained  in  a  normal  limb.  I  here 
is  half  an  inch  shortening,  perhaps  more.  The  cause  is  forcible  extreme  ab- 
duction, and  the  laceration  of  the  soft  parts  must  be  extensive  (J^ig.  194). 


4o(j  .i.v  ami:ju<a.\  'nixT-iiooK  or  surgery. 

In  two  cases  reported  ])y  Stiiiisoii  reduction  was  easily  made  under  ether 
by  flexion,  traction,  adduction,  and  lnwerinj:  of  the  limit. 

DISLOCATIONS   Ul'WAUI)   AND   FOKWAki)   AND   INWAKI)   AND   FOJiWAKD 

(SUPRAPUBIC). 

The  liead  of  tlie  fenmr  may  rest  u))on  the  upper  ramus  of  tlie  pul)es  at  tlie 
ilio-])ectineal  eminence  or  farther  inward  near  tlie  symphysis,  Jn  tlie  latter 
case  it  is  thought  to  have  reached  this  position  by  risint;  from  the  obturator 
foramen,  a  transformation  of  an  obturator  into  a  suprapubic  dislocation  ;  in  the 
former  it  leaves  the  socket  at  its  upper  and  inner  part  by  hyper-extension  or 
abduction  and  outward  rotation  of  the  limb.  The  psoas  and  iliacus  muscles 
are  stretched  across  the  neck,. and  the  femoral  vessels  are  usually  raised  by  the 
head. 

The  ilio-pectineal  is  the  more  common  form  ;  in  it  the  limb  is  markedly 
everted  and  slightly  abducted.  The  head  of  the  femur  can  be  readily  felt  in 
the  groin.     The  outer  and  posterior  aspects  of  the  hip  are  flattened. 

Reduction  is  made  by  traction  in  the  axis  of  the  limb  as  it  lies,  in  order 
to  bring  the  head  down  past  the  pubic  ramus;  then  flexion  while  pressure  is 
made  against  the  head  to  prevent  it  from  moving  upward  again ;  and  finally 
rotation  inward. 

DISLOCATIONS   DIRECTLY   UPWARD   (SUPRACOTYLOID). 

In  this  form  of  dislocation,  of  which  only  a  very  few  cases  have  been  reported, 
the  head  of  the  femur  is  displaced  upward  and  lodges  below  and  a  little  to  the 
outer  side  of  the  anterior  inferior  spine  of  the  ilium.  The  cases  are  too  few  to 
permit  much  generalization,  but  it  can  be  said  that  the  limb  is  always  everted 
and  sometimes  abducted ;  the  trochanter  is  moved  upward  and  backward,  and 
the  head  may  be  felt  on  deep  pressure.  Some  of  the  patients  have  been  able 
to  walk  with  a  limp  and  have  not  sought  treatment  until  after  several  days. 

There  is  a  close  resemblance  between  these  cases  and  those  in  which  the 
head  of  the  femur  is  brought  above  the  acetabulum,  but  at  a  higher  level,  by 
adduction  after  a  suprapubic  dislocation  or  by  eversion  after  a  dorsal  one  (everted 
dorsal). 

DISLOCATION   DOWNWARD   UPON  THE  TUBEROSITY  OF  THE  ISCHIUM. 

This  form  also  is  very  rare,  since  the  head  can  easily  undergo  secondaiy 
displacement  upward  and  backward,  transforming  the  dislocation  into  a  dorsal 
one,  or  forward  by  abduction  and  eversion,  transforming  it  into  an  obturator 
one.  The  limb  is  sharply  flexed,  and  may  be  somewhat  abducted  and  everted 
or  inverted. 

Reduction  has  usually  been  easy  by  traction  in  flexion. 

COMPLICATIONS  OF   DISLOCATION  OF  THE  HIP. 

Compound  dislocations  are  very  rare,  are  produced  by  great  violence, 
and  are  usually  fatal.  The  complication  has  been  observed  only  once  in  a  dor- 
sal, and  two  or  three  times  each  iji  anterior  and  obturator  dislocations. 

Injury  of  the  femoral  vessels  has  occurred  only  in  suprapubic  and 
obturator  dislocations. 

Fracture  of  the  neck  of  the  femur  has  occurred  a  number  of  times 
during  attempts  to  reduce  a  dislocation.  It  is  of  much  importance,  for  it 
makes  reduction  practically  impossi])le.  and  if  the  fracture  is  at  the  narrow 


J)JSL OCA  TJONS.  457 

part  of  the  neck,  necrosis  of  the  head  is  likely  to  follow.  The  most  that  can 
be  done  is  to  put  the  liinb  in  a  favorable  position,  or  to  excise  the  head  and 
neck  in  young  patients  in  tlic  lioju'  of  getting  a  iii()va1)h' joint. 

TREATMENT  OF  UNREDUCED   DISLOCATIONS. 

Attempts  that  have  been  made  to  reduce  old  dislocations  of  the  hip  by 
arthrotomv  have  mostly  been  unsuccessful,  either  through  failure  to  effect 
reduction,' through  necrosis  of  the  head  of  the  femur,  or  through  the  death 
of  the  patient ;  the  only  successes  (two  cases)  were  obtained  by  the  late  Dr. 
Parkes  of  Chicago.  Excision  of  the  head,  or  of  the  head,  neck,  and  tro- 
chanter, and  subtrochanteric  osteotomy,  have  been  resorted  to  with  consider- 
able success  in  diminishing  the  disability.  In  many  cases  a  fairly  useful  limb 
will  ultimately  result  even  without  any  operative  interference. 

PATHOLOGICAL   DISLOCATIONS. 

These  may  occur  as  the  result  of  rhachitic  changes  in  the  bones,  of  paraly- 
sis of  some  of  the  muscles,  of  articular  inflammations  in  the  course  of  various 
specific  fevers,  and  may  occur  even  in  a  normal  joint  as  the  result  of  prolonged 
maintenance  of  the  limb  in  flexion  and  adduction.  It  may  occur  gradually  and 
painlessly,  and  perhaps  escape  observation  until  it  is  too  late  to  remedy  it. 

Allis's  Researches. — Allis  classifies  all  possible  dislocations  of  the  upper 
end  of  the  femur  into  <lislocations  inward—/,  e.,  upon  the  pubo-ischiatic 
plane ;  and  outward—/,  c.,  upon  the  ilio-ischiatic  plane.  The  method  of  re- 
duction is  similar  in  all  cases.  It  consists  of  two  steps.  By  means  of  the 
first  the  liead  is  drawn  or  lifted  to  a  point  near  the  socket ;  by  the  second, 
the  head  is  pried  into  the  socket  through  a  fulcrum  furnished  by  the  hands 
of  an  assistant.  To  make  the  best  use  of  this  method  the  pelvis  should  be 
securely  strapped  to  the  floor.  In  recent  cases  the  pelvis  may  be  held  fairly 
secure  by  a  strong  assistant  bearing  down  upon  the  anterior  superior  spines. 
The  surgeon  slwidd  never  put  forth  more  strength  than  would  be  required  to 
lift  a  weight  equal  to  that  of  the  patient's  leg. 
'  Dislocation  of  the  Right  Femur  Inward.— V\^CQ  the  patient  upon  the 
floor.  The  first"assistant  presses  down  upon  the  spines  of  the  ilium.  I  he 
suro-eon  flexes  the  thigh  to  a  right  angle  and  makes  traction  outward  by  the 
beiit  knee.  The  second  assistant  now  presses  deeply  with  the  thumbs  or 
finger-tips  at  a  point  opposite  the  pubes  and  at  the  junction  of  the  thigh  with 
the  trunk.  The  surgeon,  now  regarding  this  pressure  as  a  fulcrum,  raises 
the  knee— but  at  the  same  time  continuing  the  traction— and  carries  it 
obli(|uely  inward  toward  the  pubes.  Reduction  will  take  place  with  a  slight 
iar  perceived  by  both  assistants.  ,   .    ,    .       ^      i        i. 

Dislocation  'of  the  liiqht  Femur  Outward.— 'Y}ie  pelvis  being  fixed  as  be- 
fore, the  surgeon  makes  traction  upward  by  the  bent  knee.  V\  hen  the  head 
of  the  femur  rises  upon  the  pelvis  below  the  socket  the  surgeon  bends  tor- 
ward  as  if  he  would  draw  the  head  into  it.  At  this  moment  the  second 
assistant  ^rasps  the  base  of  the  thigh  with  his  two  hands,  forcing  his  thumbs 
deeply  in^'at  a  point  just  beyond  the  great  trochanter;  and  the  surgeon, 
reo-ardin.T  this  pressure  as  a  fulcrum,  and  still  continuing  his  traction,  brings 
the  limb'downward  in  extension.  In  case  of  failure  in  either  case,  strap  the 
pelvis  to  the  floor  and  proceed  as  before. 

Allis  asserts  that  dislocations  of  the  femur  (inward  or  outward),  when 
accompanied  bv  fracture  of  the  shaft  of  the  femur  below  the  great  trochanter, 
can  be  as  readi'lv  and  easilv  restored  by  the  above  methods  as  when  no  com- 


458  AX    AMi:h'J(AX    TEXT- 1  look'    or  St'RGERY. 

plications    exist.      ( )m'    tliiiiir,    liowovor,    is    alisoliiti'ly    iiccossary — viz.,    the 
patient's  pelvis  must   be  strapjied   tu   the   tloor. 

DI.SLOCATION    OF   TilE    KNKK. 

Dislocsitions  of  tlie  knee  are  infrequent,  and  aic  divided  into  the  fonvard, 
backward^  outward,  iniiuird,  smd  bji  rotation,  oeeurrin"/;  in  that  order  of  fre- 
quency. The  dislocation  is  frequently  compound,  and  often  complicated  by 
injury  of  the  popliteal  vessels,  which  may  consist  in  complete  rupture  or  in 
such  bruising  that  a  thrombus  will  form  and  lead  to  gangrene.  Either  popli- 
teal nerve  may  also  be  injured.  These  possibilities  add  greatly  to  the  gravity 
of  the  prognosis  in  all  the  severe  forms  of  di.slocation,  and  even  the  return  of 
pulsation  in  the  arteries  at  the  ankle  after  reduction  is  not  proof  tliat  the  artery 
is  uninjured  and  gangrene  not  to  be  feared. 

Dislocation  forward  may  be  complete  or,  more  commonly,  incomplete. 
The  cause  is  hyper-extension  of  the  knee  or  direct  violence  received  on  the  front 
of  the  thigh  or  the  back  of  the  leg  near  the  knee.  AVhen  complete,  the  tibia 
lies  in  front  of  the  condyles  and  may  be  displaced  upward  a  considerable  dis- 
tance,— four  inches  in  one  recorded  case ;  the  laceration  of  the  soft  ])arts  is 
extensive.  In  the  incomplete  form  the  articular  surfoces  of  the  tibia  and  femur 
are  still  partly  in  contact,  and  the  laceration  is  much  less.  If  the  dislocation  if 
compound,  the  wound  in  the  skin  is  posterior  and  transverse.  The  character 
of  the  injury  is  readily  recognized  by  inspection  and  palpation,  and  reduction 
is  easily  made  by  traction  and  direct  pressure. 

Backward  Dislocation  may  be  complete  or  incomplete,  and  is  most  fre- 
quently due  to  violence  received  upon  the  front  of  the  leg  or  the  back  of  the 
thigh.  The  muscles  behind  the  knee  may  be  freely  lacerated,  and  the  patella  is 
sometimes  dislocated  outward.  The  leg  is  usually  in  full  extension  or  hyper- 
extension,  and  is  sometimes  deviated  to  one  side. 

Reduction  is  easy  by  traction  and  direct  pressure.  In  a  few  cases  in 
which  reduction  was  not  made  the  limb  was  fairly  useful. 

Lateral  Dislocations  are  much  more  infrequent  than  either  the  forward 
or  the  backward ;  they  may  be  outward  or,  more  rarely,  inward,  complete  or 
incomplete,  but  the  complete  variety  is  extremely  rare.  The  common  cause 
of  the  incomplete  dislocation  is  forced  abduction  of  the  leg  for  the  outward, 
and  forced  adduction  for  the  inward  variety.  The  injury  is  recognized  by  the 
lateral  projection  of  the  head  of  the  tibia  on  one  side,  and  of  the  condyle  of  the 
femur  on  the  other;  the  patella  is  usually  deviated  toward  the  side  of  the  dis- 
location. Reduction  has  ordinarily  been  easy  by  traction  and  direct  pressure. 
The  importance  of  obtaining  firm  union  of  the  ruptured  lateral  ligaments  makes 
it  advisable  to  keep  the  limb  immobilized  and  unused  for  several  weeks. 

In  Dislocation  by  Rotation  the  leg  is  rotated  about  its  long  axis  or  about 
an  axis  parallel  with  it  and  passing  through  the  center  of  one  of  its  upper  con- 
dylar surfaces.  The  dislocation  is  termed  outward  or  inward  according  to  the 
direction  in  which  the  toes  are  turned.  In  rotation  aliout  the  central  axis  both 
condylar  surfaces  are  displaced,  one  forward,  the  other  backward,  and  the  dis- 
location is  said  to  be  complete ;  in  the  other  form  the  cond^dar  surface  which 
corresponds  to  the  axis  of  rotation  remains  in  place,  and  the  other  is  displaced 
forward  or  backward,  constituting  incomplete  dislocation.  The  injury  is  rare, 
and  almost  all  cases  have  been  of  outward  rotation.  Additional  backward  or 
outward  displacement  may  be  associated  with  the  rotation.  Reduction  appears 
to  have  been  easily  effected. 


DISLOCATloys.  459 

DISLOCATION    OF   THE   SKMIMNAIi   CARTILAOES. 

Either  .seniilnn;ii-  fartila^e  may  he  (h'taclu-d  at  either  eii<l  or  peripherally, 
ami  displaced  toward  the  intereondyloid  notch  or  to  the  outside,  or  it  may  be 
laceiated.  The  injury  may  he  i)ro(luced  duriii<^  a  dislocation  or  a  sprain  or  hy 
rotation  of  the  leg  or  flexion  of  the  knee.  The  internal  cartilage  is  the  one 
more  commonly  affected. 

The  symptoms  are  very  like  those  excited  by  a  loose  cartilage  in  the  joint: 
sudden,  painful  locking  of  the  joint,  usually  occasioned  by  some  definite  move- 
ment, and  recurring  with  greater  or  less  freciuency.  Attention  has  been  espe- 
cially directed  to  the  injury  of  late,  and  our  knowledge  has  been  increased  by 
the  data  supplied  by  several  operations  undertaken  for  its  relief.  The  displace- 
ment of  the  cartilage  may  sometimes  be  recognized  by  palpation  along  the 
upper  articular  edge  of  the  tibia  in  front. 

The  locking  of  the  joint  can  be  relieved  Avithout  much  difficulty  by  various 
manipulations,  such  as  extension  followed  by  sudden  flexion,  rotation  of  the 
leg,  or  pressure  upon  the  projecting  cartilage.  To  prevent  recurrence,  various 
pads  and  braces  have  been  recommended  the  object  of  which  is  either  to  oppose 
the  displacement  directly  or  to  prevent  the  amount  of  flexion  of  the  knee  which 
is  a  necessary  preliminary  to  the  occurrence.  The  operation  that  has  been  most 
done  of  late  consists  in  opening  the  joint  by  an  incision  along  the  side  of  the 
patella,  exploration  through  it  to  determine  the  exact  nature  of  the  lesion,  and 
then  such  treatment  of  the  cartilage  as  may  seem  proper,  usually  excision  of 
the  whole  or  of  a  part,  or  fixation  to  the  tibia  along  the  peripheral  border  by 
suture. 

DISLOCATIONS  OF  THE  PATELLA. 

The  patella  may  be  displaced  to  the  outer  or  to  the  inner  side,  or  may  be 
more  or  less  rotated  about  its  longitudinal  axis,  "edgewise"  or  "vertical"  dis- 
locations, or  the  two  forms  may  be  combined  in  varying  degrees  (Fig.  195). 
Displacement  upward  or  downward  after  rupture 
of  the  ligamentum  patelh^  or  of  the  tendon  of  the 
quadriceps  respectively  will  not  be  here  considered 
as  a  dislocation.     (See  Rupture  of  Tendons.) 

Displacement  to  the  outer  side  is  very  much 
more  frequent  than  displacement  to  the  inner  side. 
The  causes  and  mode  of  production  of  the  various 
forms  are  much  the  same,  either  muscular  action  or 
external  violence  acting  directly  on  the  patella 
Gradual  dislocation  outward  may  result  from 
hydrarthrosis  of  the  knee  or  from  genu  valgum. 

Outward    Dislocation. — This  may  be  com-  _ 

plete  or  incomplete.     In  complete  outward  disloca^-     ^.^^^^^^,,_  ,_,.  ^,^^.  variuus^Blli^a- 
tion  the  patella  rests  against  the  outer  surface  of        tions  of  the  FateUa  (Stimson). 
the  external  condyle  either  by  its  inner  border,  or, 

more  commonly,  by  its  posterior  surface,  or  by  its  anterior  surface,  its  outer 
border  being  directed  forward  (Fig.  195,  1,  2,  and  3).  It  may  reach  this  posi- 
tion either  while  the  knee  is  extended  or  while  it  is  flexed  at  about  a  right 
angle.  The  internal  lateral  ligament  of  the  patella — i.  e.  the  fibrous  expan- 
sion at  the  attachment  of  the  vastus  internus — is  ruptured  longitudinally,  the 
rent  sometimes  extending  several  inches  upward  into  the  muscle,  and  this  may 
be  torn  away  from  the  patella. 

The  nature  of  the  injury  is  easily  recognized,  for  the  patella  can  be  felt 
in  its  abnormal  position  :   when  rotation  of  the  patella  is  combined  with  out- 


4()()  Ay   AMEh'/CA.y    TEXT-J'.OOK    OF  SURGERY. 

ward  dislocation  it  may  be  mure  difficult  to  determine  Avhether  it.s  outer  or  its 
inner  border  is  directed  forward. 

Reduction  has  usually  been  readily  made  by  direct  pressure,  after  the 
quadricej)s  has  been  relaxed  by  extension  of  the  knee  and  flexion  of  the  hip. 
In  a  case  seen  by  the  writer  simple  extension  of  the  knee  reduced  the  dis- 
location. 

Incomplete  dislocations  are  those  in  which,  the  knee  being  extended,  the 
patella  rests  above  and  partly  to  the  outer  side  of  the  articular  surface  of  the 
femur,  and  those  habitual  dislocations  in  which,  during  flexion  of  the  knee, 
the  patella  moves  outward  and  its  outward  border  turns  backward. 

Outward  Edgewise  or  Vertical  Dislocations. — In  these  the  patella  is  moved 
outward  and  turned  upon  its  longitudinal  axis  in  such  a  wav  that  its  inner 
border  rests  in  the  groove  of  the  trochlea,  its  outer  border  projects  forward, 
and  its  articular  surface  looks  outward.  The  degree  of  rotation  mav  varv  from, 
say,  45°  to  100°  or  110°  (Fig.  195,  4  to  7).  Its  fixation  in  this  position  is 
due  to  the  tension  of  the  overlying  soft  parts.  Reduction  has  usually  been 
effected  by  extension  of  the  knee  and  direct  pressure  on  the  patella.  ' 

Complete  reversal,  the  outer  border  passing  in  front  to  the  inner  side,  has 
been  reported  in  only  two  cases. 

Inward  Dislocations  are  the  same,  mutatis  mutandis,  as  the  outward, 
but  they  are  very  much  more  rare. 

Congenital  and  Pathological  Dislocations. — Congenital  dislocations 
appear  to  be  very  rare,  most  of  the  cases  reported  as  such  being  actually  habit- 
ual or  permanent  dislocations  developed  during  infancy  or  childhood.  The 
causes  of  these  habitual  dislocations  are  not  always  clear :  in  some  the  dis- 
placement seems  plainly  to  depend  upon  a  defoimity  of  the  limb,  genu  valgum, 
but  in  most  it  can  only  be  said  that  the  affection  develops  gradually,  the  patella 
usually  slipping  outward  as  the  knee  is  flexed.  The  use  of  the  limb  is  more  or 
less  interfered  with  by  pain,  and  sometimes  by  diminution  of  voluntary  control. 
The  treatment  consists  in  measures  designed  mechanically  to  oppose  the  occur- 
rence of  the  displacement,  such  as  a  knee-cap  or  a  splint  that  limits  flexion. 
In  a  recent  case  benefit  was  obtained  by  excision  of  a  portion  of  the  internal 
lateral  ligament  of  the  patella :  in  another  by  pinching  up  a  longitudinal 
fold  and  securing  it  bv  a  continuous  suture. 

DISLOfATIONS  OF  THE  FIBULA. 

Upper  End. — The  upper  end  of  the  fibula  may  be  dislocated  outward  and 
forward,  or  backward  or  upward.  The  injury  is  a  rare  one,  even  if  those  cases 
are  included  in  which  it  is  associated  with  fracture  of  the  tibia. 

Outward  and  Forward. — In  the  seven  reported  cases  the  occasion  has 
been  a  fall,  and  the  production  of  the  di.slocation  appears  to  have  been  associ- 
ated with  forcible  depression  and  inversion  of  the  front  part  of  the  foot,  so 
that  it  has  been  suggested  that  the  immediate  cause  was  traction  exerted  through 
the  extensor  muscles  that  are  attached  to  the  front  of  the  fibula.  The  displace- 
ment is  easily  recognized,  and  reduction  is  readily  effected  by  direct  pressure 
upon  the  head  of  the  fibula. 

Backward. — In  three  of  the  five  reported  cases  the  cause  appears  to  have 
been  the  forcible  contraction  of  the  biceps.  Reduction  was  generally  easy, 
but  in  two  the  dislocation  recurred,  and  persi.sted  in  one  of  them. 

Upward. — There  are  three  reported  cases,  but  in  only  one  of  them  is  the 
diagnosis  beyond  question.  In  this  one  (Boyer)  the  patient  appears  to  have 
also  suffered  a  dislocation  outward  at  the  ankle  or  a  lesion  resembling  a 
Pott's  fracture,  in  which,   however,  the  fibula  instead  of  being  broken  was 


1> ISL OCA  TJONS.  4(j  1 

pushed  upward.     The  restoration  of  the  foot  to  its  place  corrected  the  upper 
dislocation. 

Lower  End. — A  very  few  cases  have  been  reported  in  wliich  the  lower 
end  of  the  fibula  has  been  forced  from  its  attachment  to  the  tibia  and  the  foot 
and  has  been  dislocated  backward.  In  a  unirjuc  case  observed  by  Stimson  the 
lower  end  of  the  iibula  had  been  dislocated  backward  from  the  tibia,  but  had 
preserved  its  connection  with  and  its  relations  to  the  foot;  the  injury  occurred 
while  the  patient  was  wrestling  with  another  lad,  and  was  apparently  produced 
by  forcible  abduction  of  the  front  of  the  foot. 

DISLOCATIONS  OF  THE  FOOT. 

TiBio-TARSAL  DiSLOCATiOXS. — Four  principal  groups  are  made,  according 
to  the  direction  in  which  the  foot  is  displaced :  backward,  fortvard,  outward, 
and  inward. 

Backward. — The  cause  is  commonly  extreme  plantar  flexion,  by  which 
the  lateral  ligaments  are  torn,  when  the  liberated  foot  slips  backward  and  the 
astragalus  is  fixed  behind  the  tibia  Avhen  the  plantar  flexion  is  relieved.  Frac- 
ture of  the  external  malleolus,  less  frequently  of  the  internal,  may  coexist. 
Incomplete  dislocation  is  a  frequent  accompaniment  of  Pott's  fracture.  The 
foot  appears  shortened  in  front  and  the  heel  lengthened,  but  if  there  is  some 
swelling  the  dislocation  may  easily  pass  unrecognized  unless  a  careful  examina- 
tion and  comparison  with  the  other  foot  are  made. 

Forward. — This  form  is  very  rare.  The  injury  may  be  caused  by  exag- 
gerated dorsal  flexion  or  by  direct  pressure  forward  upon  the  heel.  The  foot 
appears  lengthened  in  front,  the  heel  shortened ;  the  body  of  the  astragalus 
can  be  felt  in  front  of  the  tibia. 

Inward. — There  are  two  varieties:  in  one,  by  supination  and  adduction 
of  the  foot,  the  astragalus  is  turned  down  out  of  its  mortise  so  that  its  upper 
articular  surface  lies  beloAv  and  in  front  of  the  external  malleolus ;  in  the  other 
(thought  to  be  secondary  to  a  backward  dislocation)  the  toes  are  turned  more 
or  less  directly  inAvard,  the  foot  lying  nearly  or  quite  in  the  transverse  plane. 
Reduction  has  always  been  easy. 

Outward. — Most,  if  not  all,  of  the  cases  described  under  this  title  appear 
to  have  been  Pott's  fractures,  either  typical  or  with  unessential  variations. 

SUB-ASTRAGALOID   DISLOCATIONS. 

The  other  bones  of  the  foot  may  be  dislocated  from  the  astragalus  hacJc- 
ward,  forward,  outivard,  or  inward  and  backward.  The  first  two  forms  are 
very  rare :  the  outward  and  inward  are  more  common,  and  are  produced  by 
forcible  eversion  and  inversion  of  the  foot  respectively.  Fractures  of  the 
astragalus  and  of  the  external  malleolus  have  been  observed  as  complications. 
Of  55  reported  cases  of  all  kinds  (Stimson),  24  were  compound.  Of  24  simple 
cases  in  which  reduction  was  attempted,  it  was  eff'ected  in  14  and  the  ultimate 
result  was  good;  of  the  remaining  10  cases  and  the  7  in  Avhich  reduction  was 
not  attempted,  secondary  amputation  was  done  in  4,  and  secondary  excision  of 
the  astragalus  in  4  ;  in  5  the  functional  result  was  good  notwithstanding  the 
persistence  of  the  displacement.  Of  the  compound  cases,  primary  amputation 
was  done  in  3,  and  excision  of  the  astragalus  in  10. 

DISLOCATION  OF  THE  ASTRAGALUS. 

This  is  a  more  common  injury ;  the  cause  is  usually  a  fall  from  a  height,  or 


4()2  Ay    AMI'JilCAy    'IllXT-llOOK    OF   SlUdEliY. 

forcible  twisting  of  the  foot.  The  varieties  are  very  numerous :  they  niay  be 
grouped  as  forward,  backward,  outward  and  foi'ward,  itnvard  and  forward, 
and  by  rotation.  In  the  first  four  groups  more  or  less  rotation  of  the  astragalus 
about  either  of  its  axes  is  frequently  associated. 

Outward  and  Forward. — This  is  the  most  frequent  form.  The  head  of 
the  ;istr:iu;ilus  rests  on  tlic  outer  cuneiform  and  the  cuboid  bones,  or  even  on 
the  fifth  metatarsal,  and  its  ])Osterior  ])art  is  still  in  contact  Avith  the  articular 
surface  of  the  tibia.  The  foot  is  adducted  and  inverted,  the  external  malleolus 
prominent.  If  the  dislocation  is  compound,  the  head  of  the  astragalus  presents 
in  the  wound.  Reduction  in  cases  not  complicated  by  rotation  of  the  astra- 
galus is  sometimes  very  easy  by  traction  downward  on  the  foot  and  pressure 
backward  on  the  head  of  the  astragalus. 

Inward  and  Forward. — The  astragalus  lies  in  front  of  or  below  the 
internal  malleolus,  its  head  well  depressed  toward  the  sole ;  the  foot  is  abducted 
and  everted.  Sometimes  the  head  passes  beyond  the  tendon  of  the  tibialis 
anticus,  which  then  tightly  embraces  its  neck  and  prevents  reduction. 

Forward. — Only  a  very  few  cases,  presenting  no  common  features,  have 
been  reported. 

Backward. — The  displacement  may  be  directly  backward,  or  backward 
and  to  either  side.  Stimson  has  collected  IG  cases,  in  7  of  which  the  bone 
was  broken  at  the  neck  and  only  the  posterior  fragment  was  dislocated.  The 
body  of  the  astragalus  can  be  felt  behind  the  ankle,  and  the  absence  of  its  head 
from  its  normal  position  may  be  recognized.  In  3  of  the  reported  cases  per- 
sistent flexion  of  the  terminal  phalanx  of  the  great  toe  was  present.  Reduction 
was  effected  in  only  one-third  of  the  simple  cases. 

Dislocation  by  Rotation. — Only  those  cases  are  here  considered  in 
which  the  astragalus  remains  in  its  mortise.  The  rotation  may  take  place 
about  the  vertical  or  transverse  axis  (and  it  is  then  associated  with  more  or  less 
dislocation  forward  and  inward,  so  that  the  separation  from  this  class  is  arbi- 
trary), or  about  the  antero-posterior  axis,  without  other  displacement.  Four 
cases  of  the  latter  kind  have  been  observed  and  verified  by  direct  examination, 
either  post-mortem  or  during  operation  ;  in  three  of  them  the  u])|)er  surface  of 
the  astragalus  was  directed  outward  ;  in  one  the  bone  was  turned  completely 
over,  180  degrees. 

DISLOCATIONS    OF    THE   TARSUS   AND    METATARSUS. 

Dislocations  of  one  or  more  of  the  other  tarsal  and  of  the  metatarsal 
bones  have  been  observed — namely,  of  the  medio-tarsal  joint,  of  every  tarsal 
bone  separately  except  the  outer  cuneiform,  and  of  the  metatarsal  bones  sep- 
arately and  in  various  combinations.  The  metatarsus  as  a  whole  has  been  dis- 
located in  each  of  the  four  principal  directions. 


DISEASES    AM>    IXJinJi:s    OF   LYMPHATICS.  MW 

CHAPTER    IX. 

DISEASES  AND  INJURIES  OF  LYMPHATICS. 

GENERAL  CONSIDERATIONS. 

The  lymphatic  vessels  pervade  every  tissue  and  organ  in  the  body:  the 
delicacy  and  transparency  of  their  walls  and  the  very  close  adhesion  of  these 
walls  to  surrounding  tissues  render  it  impossible  to  identify  them  under  ordinary 
circumstances.  In  their  anatomy  and  general  properties,  however,  they  bear  a 
close  resemblance  to  the  veins,  and  the  results  of  injuries  to  them  and  the  dis- 
eases to  which  they  are  subject  are  analogous  to  those  of  the  venous  system. 
By  reason  of  their  function  as  absorbents  they  are  the  great  agents  of  the  intro- 
duction into  the  general  circulation  of  the  products  of  local  septic  infection. 
From  their  open  mouths  during  the  first  hours  following  the  receipt  of  a  wound 
comes  much  of  the  serous  flow  to  dispose  of  which  drainage  is  necessary,  and 
some  of  which,  doubtless,  later  plays  an  important  part  in  facilitating  the  active 
cell-changes  upon  which  the  hesiling  process  depends.  All  wounds  involve 
lymphatics,  but  under  ordinary  conditions  these  vessels  call  for  no  special  atten- 
tion from  the  surgeon. .  Their  walls  collapse  and  become  closed  by  the  plastic 
exudate  that  is  formed  for  the  purpose  of  general  repair.  The  superficial 
lymphatic  plexuses  of  the  skin  are  not  only  exceedingly  numerous,  but  are  also 
so  superficially  placed  that  they  are  readily  influenced  by  antiseptic  solutions 
applied  to  the  surface  of  the  skin ;  hence  the  value  of  external  antiseptic 
lotions  and  fomentations  in  inflammation  of  the  superficial  lymphatics  and  of 
the  somewhat  deeper  vessels  into  which  they  immediately  empty,  and  the 
caution,  likewise,  with  w^hich  solutions  which  may  be  toxic,  as  carbolic  acid 
and  corrosive  sublimate,  should  be  applied  for  any  length  of  time  to  extensive 
surfaces  of  skin.  Any  consideration  of  the  aflections  of  the  lymphatics  will 
include  those  of  the  lymphatic  glands,  Avhich  are  scattered  along  their  course 
and  form  a  part  of  the  lymphatic  system.  In  explanation  of  the  greater  fre- 
quency of  aff"ections  of  the  lymphatic  glands  in  youth,  it  must  be  remembered 
that  the  quantity  of  lymph  in  circulation  is  greater  then  than  in  later  years, 
and  that  the  lymphatic  glands  are,  during  that  period  of  life,  more  largely 
developed  and  more  active.  Figs.  196-200  show  the  lymphatic  glands  ac- 
cording to  the  careful  researches  of  Leaf.  They  should  be  consulted  in  con- 
nection with  operations  in  the  neck,  the  axill?e.  and  the  groin. 

INJURIES  OF  LYMPHATICS. 

Rupture  of  the  Thoracic  Duct. — This  main  lymph-duct,  although  so 
much  protected  by  its  anatomical  position,  may  nevertheless,  under  excep- 
tional circumstances,  be  w^ounded  or  ruptured.  Of  17  such  cases  collated  by 
Kirchner,  2  Avere  due  to  contusions  of  the  chest ;  1  each  to  a  puncture,  a  cut, 
and  a  shot  wound ;  3  to  erosion  from  suppuration.  In  the  remaining  cases 
the  account  failed  to  assign  a  definite  cause.  The  wound  in  these  cases 
resulted  in  chylothorax  in  nine  instances ;  in  chylous  ascites  in  six  in- 
stances ;  in  one  (doubtful)  in  exudation  into  the  mediastinum ;  while  the 
remaining  case  was  an  instance  of  operative  injury  of  the  duct  near  its 
mouth.  In  a  case  reported  by  Krabbel,  the  patient  on  the  fifth  day  after 
being  run  over  by  an  empty  coal-car  died  from  sufi'ocation  due  to  an  efi'u- 
sion  into  the  right  pleural  cavity,  which  on  post-mortem  examination  was 
found  to  be  chyle  and  to  have  come  from  a  rent  in  the  thoracic  duct  opposite 


464 


^^V  AMERICAN    TEXT-BOOK    OF  SURGERY. 


the  ninth  dorsal  vertebra,  ^vhich  had  been  transversely  fractinod.  In  one  of 
Kirchner's  eases  a  girl  of  nine  years  had  been  violently  j>ushed  against  a  win- 
dow-sill, striking  the  front  of  her  chest  opposite  the  third  rib;  a  gradual  and 
increasing  dyspnea  developed  after  some  days,  with  signs  of  pleural  effusion, 


KiG.  190. 


Lhit  edge  of  skin 
Submaxillary 
salivary  glaml 


Inferior  cunstricto 

Omo-hyoid- 

!>terno-thyroi(t 

Internal  jugular  i-ein 

Sterno-hyoiil 

Sterno-masfni'l—/^ 


Cltirirlf 


Smnll  occipital  nerte 


'osterior  belly  of  digastric 
lylo-hyoid 

(turiculiir  nerve 


r  anguli  scapulx 


accessory  nerre 
apezius 

ftrending  branches  of 
cervical  plexus 


^'^ 


Lymphatic  Glands  f>f  the  Head  and  Neck  (after  Leaf). 

which  on  aspiration  proved  to  be  chyle ;  relief  followed  the  aspiration,  but 
dyspnea  again  became  marked  after  some  days ;  a  proposed  repetition  of  the 
aspiration  was  deferred  on  account  of  a  spontaneous  improvement  which  then 
took  place  ;  the  dyspnea  subsided,  the  signs  of  effusion  gradually  disappeared, 

A  Fio.  197. 


The  dotted  line  indicates'i 
junction  of  Scarpa's  fas- 
cia with  fascia  lata. 


Saphenous      ^^■ 
opening—^ 


Femoral  vein 

Long  saphenous 

rein 
Fascia  lata 


Superficial 
fasciii 

Ant.  femonil 

cutaneous 

vein 


Long  saphenous 
rein 


Lymphatic  (Hands  of  the  Groin  :  a,  superficial  glands  ;  b,  deep  glands  (after  Leaf). 

and  ultimately  full  health  returned.  Two  American  cases  have  recently  been 
reported  (Eyer,  1891 ;  Manley,  1894).  In  the  first  a  young  man  suffered 
a  severe  S(|ueeze  of  his  thorax,  having  been  caught  between  a  railroad-car 
and  an  engine.     No  bones  were  broken,   and  for  some   days   a   traumatic 


1)Isi-:asI':.s  and  injuries  of  lAWfriiATics. 


465 


pneumonia  of  the  rio;ht  lung  Avas  the  chii'f  apparent  result  of  tlie  injury; 
on  the  seventeenth  day,  however,  a  fluctuating  swelling  was  detected  in  the 


Fi(i.  lys. 

f<kin  reflected 
PcctoraiiK  major 
Central  (jriiKp  of  (iliituls 


Cilihnl'iC  rein 


Central  (Superficial)  Lymphatic  filaiuK  ot  tin    \xilla  lafttr  I  eaf) 

right  inguinal  region,  which  on  being  opened  gave  exit  to  much  offensive 

Fi<i.  199. 


Oino-hyoid 

Clavicle 

SHbclaTius 

Sitxpenaort/  ligament 

Pccfuralis  minor 
Axillary  fascia 


Clavicular  porliov  of 
pectorulin  major 

Infernal  portion  of 
pectorulis  major 


Subscapular  Lymphatic  Glands  in  Section  (after  Leaf). 

gas  and  a  foul  feculent  discharge.    After  two  or  three  days  this  discharge  lost 

Fig.  200. 


Cephalic 

Axilla 


Glands  snrrou ndi 
subscapular 

Latissimns  dor 
Teres  maj 

Biceps 


■s—Pectoralis  minor 
Pectoralis  major 

^uhscapularis 
'^erratus  magmcs 


rectonil  (Dn.]))  L\mj  li  Uil  (  1  iiid^  (after  Leaf) 

its  offensiveness  and  became  opaque  and  milky :  rapid  emaciation  followed, 
resulting  in  death  on  the  thirty-eighth  day  from  the  original  injury.     Post- 
so 


466  AN   AMERICAN    TEXT- HOOK    OF  SlJUaEI!Y. 

mortem  examination  revealed  a  rupture  of  the  tlioraeic  duet  at  the  point  ^vhere 
it  passes  through  the  aortic  opening  of  the  diaphragm  ;  the  escaping  chyle  had 
burrowed  behind  the  peritoneum  and  had  become  superficial  at  the  groin  ;  in 
addition  to  this,  some  of  tlie  chyle  had  become  diverted  above  the  diaj)hragm 
and  had  dissected  up  the  pleura  from  the  posterior  chest-\vall  on  the  right  side 
so  as  to  form  a  post-})leural  cavity,  lilled  with  chyle,  extending  up  as  high  as  the 
apex  of  the  thorax.  In  the  second  case  the  escaping  chyle  likewise  burrowed 
behind  the  peritoneum  and  ])resented  a  superficial  swelling  at  the  groin  which 
was  incised,  and  gave  vent  for  ten  days  to  an  abundant  chylous  discharge.  The 
discharge  then  ceased,  and  the  conijdete  recovery  of  the  patient  followed. 

There  are  no  symptoms  indicative  of  this  rare  injury  until  a  sufficient  accu- 
mulation of  the  escaping  chyle  has  occurred  to  call  for  its  evacuation  surgically. 
The  character  of  the  evacuated  fluid  is  the  first  indication  that  a  wound  of  the 
thoracic  duct  has  occurred.  According  to  the  location  of  the  wound,  the  effused 
fluid  may  find  its  Avay  into  the  peritoneal  cavity  or  into  the  connective  tissue 
behind  the  peritoneum,  into  the  pleural  cavity  or  into  the  connective  tissue 
behind  the  pleura,  or  into  the  posterior  mediastinum.  The  particular  symptoms 
which  the  eftusion  will  provoke  nmst  depend  upon  its  location  and  extent. 
Rapid  emaciation  wall  result  from  the  inanition  due  to  the  failure  of  the  chyle- 
current  to  reach  its  destination. 

Death  from  inanition  is  to  be  expected  after  rupture  of  the  thoracic  duct. 
The  case  already  cited  Avhich  recovered  shows,  however,  that  exceptions  may 
occur,  possibly  due  to  the  existence  in  a  particular  instance  of  a  double  duct 
or  other  al)normality  whereby  a  collateral  circulation  is  possible.  Experiments 
on  animals  show  that  small  recent  wounds  of  the  thoracic  duct  may  heal  spon- 
taneously and  quickly. 

A  wound  of  the  thoracic  duct  is  beyond  surgical  treatment.  When, 
however,  such  a  wound  is  demonstrated  or  suspected,  the  suggestion  of  Agnew 
is  eminently  rational  that,  instead  of  feeding  the  patient,  no  food  should  be 
given,  in  order  that  the  walls  of  the  duct  may  remain  as  much  as  possible  in  a 
state  of  collapse,  and  thus  favor  any  attempt  Avhich  nature  may  make  toward 
closing  the  opening.  Meanwhile,  the  possibility  of  introducing  milk  directly 
into  the  venous  circulation  suggests  its  utility  as  a  method  of  nourishment 
during  the  period  that  must  intervene  before  the  ordinary  processes  of  diges- 
tion and  absorption  can  be  resumed. 

The  thoracic  duct  may  be  wounded  near  its  termination  at  the  base  of 
the  left  side  of  the  neck  in  the  course  of  operations  for  the  removal  of  deep- 
seated  growths  in  that  region,  especially  Avhen,  as  is  sometimes  the  case, 
irregular  terminal  branches  reach  somewhat  high  into  the  neck.  Keen  has 
reported  four  instances  of  this  accident.  In  two  of  these  cases  the  fluid  that 
exuded  was  unmistakably  chyle;  in  the  other  two  it  was  serous  in  charac- 
ter, but  in  all  its  abundance  was  great,  and  such  as  to  make  it  extremely 
probable,  even  in  the  latter  cases,  that  its  source  was  the  thoracic  duct.  In 
two  of  the  cases  the  flow  was  controlled  by  a  tampon,  in  one  by  a  pressure 
forceps,  and  in  one  by  a  suture.  Three  of  these  cases  recovered,  having  sus- 
tained no  detriment  from  the  injury  to  the  thoracic  duct.  One  died,  but 
its  fatal  result  was  not  especially  influenced  by  the  Avound  of  the  duct. 

Lymphangitis. — Certain  areas  of  lymi)hatic  radicles,  or  the  larger  con- 
tinuous lymphatic  trunks,  may  become  inflamed  as  the  result  of  retention 
within  them  of  irritants.  To  the  first  form  the  term  reticular  h/mpJiangitis, 
to  the  second  the  term  tubular  lymphangitis,  as  proposed  by  Bellamy,  may 
well  be  applied.  In  the  vast  majority  of  cases  the  irritants  in  question  con- 
sist of  septic  material  absorbed  from  an  infected  wound. 


DISEASES   AND    lyJUIilES    OF  LYMPHATICS.  467 

Reticnhtr  b/)iij)han(/itis  is  seen  in  many  cases  of  circumscribed  skin  inflam- 
mation attended  with'inore  or  less  oedema.  It  is  present  in  the  condition 
described  as  '^  erysipeloid  "  by  Rosen])ach,  a  term  applied  by  that  investigator 
to  certain  patches  of  superficial  skin  inflammation  Avhich  slowly  spread  from  a 
point  of  primary  infection,  usually  on  the  fingers,  the  point  originally  aff'ected 
returning  to  a  condition  of  health,  while  the  inflammation  extends  at  the 
periphery,  until  at  the  end  of  from  one  to  three  weeks  the  disease  has 
exhausted  itself  and  entirely  disappears,  having  possibly  extended  over  the 
back  of  the  hands  as  far  as  to  the  wrist.  Rosenbach  found  the  cause 
of  this  affection  to  be  the  invasion  of  the  lymphatics  by  a  specific  thread- 
formin^^  spore-bearing  micro-organism  derived  from  decomposing  animal 
matterf  Ordinary  erysipelas  presents  a  typical  form  of  reticular  lymphangitis 
in  which  the  inflammation  is  produced  by  the  invasion  of  the  lymphatic  chan- 
nels by  the  streptococcus  of  erysipelas.  (See  Erysipelas,  p.  66.)  In  the  rapidly- 
extendin<T  inflammations  which  attend  certain  poisoned  wounds  the  infection 
is  propa<nited  along  the  lymphatics,  which  share  in  the  general  inflammatory 
condition  that  prevails,  'both  types  of  lymphangitis  being  present  m  a 
marked  degree.  A  lymphangitis  of  less  virulence  often  develops  in  connection 
with  injuries  of  hands  or  feet  that  are  neglected  and  subjected  to  motion  and 
irritation,  or  with  scratches  and  abrasions  that  are  brought  into  contact  with 
decomposing  material.  This  inflammation  may  at  first  be  limited  to  a  small 
area  of  the'immediately  contiguous  lymphatic  rootlets ;  if  still  further  aggra- 
vated, the  larger  trunks  leading  away  from  the  part  become  involved,  and 
when  seated  iS  the  skin  are  seen  as  red  and  tender  streaks  running  in  the 
direction  of  the  lymph-current. 

Tubular  lymphangitis  is  invariably  the  result  of  the  entrance  mto  the 
affected  duct  of  bacteria  and  bacterial  products  of  more  than  usual  viru- 
lence. Long  before  the  agency  of  pathogenic  micro-organisms  in  its  pro- 
duction was  "recognized,  the  affection  was  appreciated  as  of  serious  import 
and  demanding  active  treatment  to  subdue  it.  The  entrance  of  septic  mate- 
rial into  lymphatic  channels  must  always  attend  infected  wounds,  but  it  is 
exceptional  that  a  spreading  inflammation  of  these  channels  results.  A  pre- 
viously existing  state  of  general  debility  upon  the  part  of  the  patient  predis- 
poses to  it.  Frequent  irritation  of  the  infected  wound  and  the  confinement 
of  septic  secretions  in  it  are  often  exciting  causes.  The  infection  of  trivial 
wounds,  as  a  prick  or  scratch,  with  virulent  septic  material,  as  in  dissection- 
wounds  and  snake-bites,  not  infrequently  causes  it.  Cases  have  been  recorded 
in  which  the  bathing  of  the  hands,  without  any  wound  of  the  skin,  m  putrid 
fluid  for  some  time  has  been  followed  by  lymphangitis.  The  tender  and  some- 
what cord-like  minute  red  streak  that  is  formed  by  the  inflamed  lymphatic 
vessel  results  from  the  blocking  up  of  its  lumen  by  a  coagulated  exudate  infil- 
trating also  the  ensheathing  connective  tissue  which  shares  in  the  inflammation, 
this  attendant  cellulitis  being  of  variable  extent  and  intensity  according  to  the 
intensity  of  the  primary  lymphatic  irritation. 

To  the  ordinary  inflammatory  swelling  of  the  affected  part  a  certain  amount 
of  oedema  is  added  from  the  'interruption  of  the  lymph-current  along  the 
thrombosed  lymph-vessels.  The  extent  and  persistence  of  this  oedema  will 
depend  upon  'the  number  of  the  lymphatic  trunks  involved  and  the  freedom 
of  the  anastomosing  communications. 

Inflammation  of  the  glands  into  which  the  affected  lymphatics  empty 
speedily  ensues  upon  a  primary  lymphangitis.  For  the  production  of  glandular 
trouble'  it  is  by  no  means  ne'ces'sary  that  any  extensive  inflammation  of  the 
ducts  leadintr  ifrom  the  seat  of  infection  to  the  gland  should  exist,  for  infective 


40S  AX   AMERICAN    TEXT-JiOOK    OF   SURGERY. 

matorial  is  often  carried  tlirou<rh  the  lyiiii»liaties  without  ])ro(luciiig  any  reac- 
tion until  it  has  become  arrested  in  a  <^hind,  wliere  its  irritative  effects  are  devel- 
o|)ed.  LikcAvise  a  second  <rrou|)  of  ^dands  may  heconie  involved  by  transmission 
of  infection  from  the  first,  without  any  disturbance  of  the  connecting'  ducts. 

Symptoms  and  Course. — In  addition  to  the  local  signs  of  lymphatic 
inflammation  that  have  already  been  described  there  are  present  constitutional 
conditions  dependent  upon  the  extent  and  severity  of  the  septic  infection. 
Rigors  are  not  unconnnon.  Fever,  usually  marked,  but  of  variable  severity, 
develops.  The  more  aggravated  cases  ra[)idly  display  the  effects  of  jjrofound 
septicemia.  "When  the  source  of  irritation  is  less  virulent  and  is  transient  or 
is  overcome  by  treatment,  the  inflammatory  reaction  soon  subsides,  the  exu- 
date liquefies  and  is  absorbed,  and  the  affected  vessels  readily  return  to  their 
normal  state.  If  pyogenic  organisms  in  sufficient  number  and  activity  have 
formed  a  part  of  the  infecting  virus,  suppuration  along  the  course  of  the 
inflamed  vessels  or  in  the  glands  into  -which  they  empty  results.  In  this  pro- 
cess of  suppuration  the  surrounding  connective  tissue  becomes  invaded,  result- 
ing in  abscesses.  This  is  true  both  of  gland  suppuration  and  of  suppuration 
along  the  course  of  the  vessels  themselves. 

Diagnosis. — Superficial  lymphangitis  is  not  likely  to  fail  of  recognition. 
The  tender  red  streaks  indicative  of  the  tubular  variety  are  pathognomonic ;  the 
diffuse  redness  of  the  reticular  variety,  with  its  attendant  sui)erficial  ccdema 
and  its  pain,  and  the  general  fever,  distinguish  it  from  ordinary  erythema  or 
dermatitis.  Some  cellulitis  accompanies  all  lymphangitis,  and  some  lymphan- 
gitis, on  the  other  hand,  attends  all  cellulitis.  Which  is  the  preponderating 
element  may  sometimes  be  a  matter  of  uncertainty.  Practically,  however, 
the  question  is  an  unimportant  one.  Phlebitis  is  closely  related  to  lymphangitis 
in  its  symptoms,  but  a  thrombosed  vein  forms  a  deeper-seated,  coarser  cord 
than  a  similarly  affected  lymph-vessel,  the  cutaneous  redness  is  not  so  vivid, 
the  pdin  is  less  acute,  the  general  fever  is  not  so  intenFc,  and  the  tendency 
to  glandular  involvement  is  less.  Inflammation  of  the  deep  lymphatics  is  not 
easily  differentiated  from  ordinary  cellulitis.  If  in  a  case  of  deep-seated 
inflammation  there  is  early  involvement  of  the  neighboring  lymphatic  glands ; 
if  lymphatic  oedema  can  be  detected ;  if  patches  of  superficial  reticular  lymph- 
angitis appear  at  points  of  anastomosis  with  deeper  trunks, — the  existence 
of  inflammation  of  the  deep  lymphatics  can  be  assumed. 

Prognosis. — The  course  of  a  lymphangitis  will  depend  upon  the  virulence 
the  amount,  and  the  persistence  of  the  infective  cause,  and  the  constitutional 
vigor  of  the  patient.  The  milder  attacks  upon  the  withdrawal  of  the  cause 
and  the  institution  of  proper  treatment  speedily  subside;  when  suppuration 
has  occurred  it  may  be  limited  in  amount,  and  upon  the  evacuation  of  the 
abscess  or  abscesses  a  steady  return  to  health  ensues.  In  the  more  virulent 
forms  successive  groups  of  glands  may  become  involved  and  suppurate  ;  exten- 
sive abscesses  develop ;  septic  absorption,  with  or  without  the  formation  of 
metastatic  abscesses  in  distant  parts,  imperils  life  ;  and  if  recovery  finally  takes 
place,  it  is  after  a  prolonged  illness ;  not  rarely  death  from  exhaustion  is  the 
inevitable  end.  In  a  certain  class  of  cases  lymphangitis  assumes  an  insidious 
and  chronic  form,  affecting  large  areas  of  vessels  and  ])ro(lucing  such  Avide- 
spread  obliteration  of  them  as  to  block  up  permanently  the  flow  of  lymph  fnmi 
a  considerable  territory  and  to  entail  a  permanent  lymphocdema  of  the  affected 
part.     (See  Elephantiasis  or  Lymphocdema.) 

Treatment. — The  recognition  of  the  septic  cause  of  the  lymphatic  inflam- 
mation at  once  gives  direction  to  the  treatment  that  is  to  be  employed.  Prompt 
and  thorough  disinfection  of  the  original  wound  from  which  the  infection  has 


i>isi:asi:s  axd  injuries  of  lymphatics.  469 

proceeded  should  be  done.  The  aftected  limb  should  be  put  at  rest  and  elevated. 
Tension,  wherever  present,  should  be  relieved  l)y  free  incision,  without  waiting 
for  suppuration  to  take  place.  The  whole  aftected  territory  should  be  covered 
with  compresses  kept  wet  with  a  1 :  2000  acjueous  solution  of  corrosive  sublimate 
until  the  inflammation  has  fully  subsided.  All  foci  of  suppuration  should  be 
freely  incised,  evacuated,  disinfected,  and  drained.  The  constitutional  treat- 
ment must  be  conducted  in  accordance  with  the  general  principles  of  support 
and  elimination.  Pain  may  recjuire  opiates,  but,  as  a  rule,  all  the  secretions 
should  be  promoted.  Stimulants  and  nutrients  should  be  fireely  administered 
in  the  more  severe  cases.  Persistent  oedema  remaining  after  the  subsidence 
of  the  inflammation  is  to  be  overcome  by  bandaging  and  massage. 

Lymphadenitis. — Lymphatic  glands  are  prone  to  inflammation.  Their 
function  as  reservoirs,  to  which  the  lymphatics  hurry  whatever  material  they 
gather,  renders  them  certain  to  become  places  of  arrest  for  whatever  irritants 
may  have  gained  access  to  the  lymphatic  circulation.  The  extent  to  Avhich  they 
become  involved  in  attacks  of  lymphangitis  has  been  mentioned  in  the  preced- 
ing paragraphs,  as  well  as  the  fact  that  they  are  aff"ected  by  absorption  from  sep- 
tic wounds  Avithout  involvement  of  the  trunks  that  transmit  the  septic  matter. 
The  amount  of  inflammatory  reaction  which  they  display  may  be  of  every  grade 
from  a  slight  transient  tumefaction  and  tenderness  to  a  rapid  necrosis  and  sup- 
puration, or  to  chronic  enlargement  and  induration — according  to  the  character 
of  the  irritant  acting  upon  the  gland  and  to  the  local  and  general  resisting 
power  of  the  individual.  Syphilis,  tuberculosis,  carcinoma,  glanders,  are  all 
characterized  by  specific  glandular  inflammation,  for  the  peculiarities  of  which 
reference  must  be  made  to  the  sections  devoted  to  these  several  alfections. 

Exposure  to  cold  and  over-exertion  are  often  accessory  causes  of  ordinary 
gland  inflammation.  They  act  as  local  depressants,  favoring  the  activity  of 
infective  organisms  that  otherwise  Avould  have  been  inert.  A  state  of  general 
debility  predisposes  to  glandular  inflammation.  The  glands  of  the  neck,  axilla, 
and  groin  are  more  frequently  affected  than  those  of  other  localities,  which  is 
the  natural  result  of  the  many  sources  of  infection  continually  arising  through 
affections  of  the  mouth,  throat,  and  extremities. 

The  degree  of  inflammation  excited  often  falls  short  of  suppuration,  in 
which  case  either  complete  resolution  and  rapid  return  to  the  normal  state 
occur,  or,  what  is  by  no  means  uncommon,  some  induration  and  enlargement 
of  the  gland  persists  for  some  time.  Suppuration  is  a  very  common  event. 
In  cases  of  adenitis  of  sufficient  intensity  to  entail  suppuration,  the  surround- 
ing connective  tissue  usually  becomes  involved  in  the  inflammation  and  sup- 
puration, and  the  resulting  abscess  when  opened  displays  a  pus-cavity  in  the 
connective  tissue  enclosing  the  more  or  less  thoroughly  destroyed  gland. 

Symptoms. — Pain,  heat,  and  swelling  are  the  characteristics  of  an  inflamed 
gland.  The  swelling  is  nodular,  and  may  be  either  well  defined  or  diffused, 
according  to  the  amount  of  periadenitis.  The  degree  of  heat  will  depend  upon 
the  intensity  of  the  congestion.  The  location  of  the  gland  and  the  looseness  of 
the  tissue  in  which  it  is  imbedded  will  largely  determine  the  amount  of  pain 
attending  the  attack,  although  tenderness  on  pressure  is  always  present.  The 
constitutional  reaction  is  likew^ise  variable ;  in  the  more  acute  attacks  consider- 
able pyrexia  is  developed,  with  rigors  on  the  occurrence  of  suppuration. 

Distinct  fluctuation  may  not  be  discernible  for  some  time  even  after  suppu- 
ration has  begun,  since  the  gland  which  is  breaking  down  is  likely  to  present 
more  than  one  focus  of  suppuration,  and  for  this  reason  w  ill  give  at  first  only  a 
boggy  feeling  to  the  touch.  This,  again,  will  be  rendered  indistinct  by  the  peri- 
glandular congestion.     If  the  surgeon  waits  to  obtain  well-defined  fluctuation 


470  AX   AMERICAX    TEXT-BOOK    OF  SURGERY. 

before  deciding  that  suppuration  has  occurred,  lie  will  find  it  only  alter  conj^id- 
erable  destruction  of  tissue  has  taken  place. 

Treatment. — The  sources  of  infection  should  be  removed  or  receive  ade- 
quate antiseptic  treatment  if  possible.  The  part  in  -which  the  gland  is  located 
should  be  kept  at  rest  and  free  from  irritation.  From  the  onset  of  the  glandular 
symptoms  cold  should  be  kept  apj)lied  if  practicable.  Injections  of  five  to  ten 
minims  of  a  3  per  cent,  solution  of  carbolic  acid  into  the  substance  of  the 
inflamed  gland,  if  made  early,  may  suffice  to  prevent  suppuration.  If  from  any 
cause  it  seems  best  to  encourage  suppuration,  warm  fomentations  may  be  kept 
applied.  When  pus  has  formed,  the  pus-cavity  should  be  freely  incised,  all 
necrotic  tissue  should  be  scraped  away,  and  the  cavity  after  having  been 
cleansed  should  be  stuffed  with  iodoform  gauze.  On  the  third  day  this  tam- 
pon should  be  removed.  In  many  cases  healthy  granulating  surfaces  will 
already  have  formed,  the  adhesion  of  which  may  now  be  secured  by  the  appli- 
cation of  an  absorbent  compress.  In  other  cases  a  more  prolonged  use  of  the 
iodoform  tampon  may  be  recjuired  before  the  desired  healing  surface  of  the 
cavity  is  produced.  If  sinuses  have  formed,  they  must  be  followed  up,  opened 
freely,  and  treated  in  the  same  way  as  the  original  cavity.  If  the  healing  pro- 
cess is  sluggish,  free  applications  of  naphthaline  and  Peruvian  balsam  will  serve 
to  stimulate  it,  due  attention  being  paid  to  the  general  health. 

Chronic  Adenitis  is,  with  rare  exceptions,  either  tubercular  or  syphilitic 
in  its  nature.  In  the  exceptional  cases  not  referable  to  these  specific  causes 
nor  beloncrino;  to  the  malignant  degenerations,  inunctions  of  iodine,  blisters, 
and  compression  will  be  of  service.  Interstitial  injections  of  a  few  minniis  of 
tincture  of  iodine,  or  of  alcohol  alone,  will  promote  absorption.  If  the  mass 
resists  these  measures  and  its  presence  is  a  cause  of  functional  disability  or  a 
serious  disfigurement,  it  may  be  excised.  Very  extensive  operations  are  now 
often  practised  in  the  removal  of  tubercular  glands,  especially  in  the  neck,  and 
with  great  advantage.  The  operation  should  be  very  thorough.  Every  gland 
that  can  be  found  should  be  removed.  The  wound,  if  made  antiseptically, 
usually  heals  in  a  short  time,  even  in  the  most  serious  cases.  Every  measure 
calculated  to  promote  the  general  health  should  be  resorted  to,  in  addition  to 
the  local  means  named. 

Lymphangiectasi?  and  Lymphangioma. — The  lymphatic  vessels,  like 
their  congeners  the  veins,  are  subject  to  dilatations  and  varicosities,  which  may 
be  of  every  degree  and  extent.  To  such  dilatations  in  general  the  term 
lymphancfiectasiH  is  applied,  but  when  these  dilatations  by  their  size,  their 
confluence,  or  their  aggregation  form  distinct  tumors,  the  term  lymphangioma 
may  be  substituted  (Fig.  201). 

Dilatations  of  the  cutaneous  lymph-radicles  may  be  recognized  as  soft  trans- 
parent sacs  or  vesicles  filled  with  lymph,  situated  manifestly  in  the  substance 
of  the  skin,  and  not  on  its  surface.  They  occur  most  frecjuently  on  the  inside 
of  the  thigh,  on  the  genitals,  and  on  the  anterior  wall  of  the  abdomen,  localities 
rich  in  superficial  lymphatic  plexuses.  They  are  usually  superficial  outcrop})ings 
of  a  deeper,  more  extensive  chain  of  lymphatic  dilatations  due  to  obstructive 
changes  in  distant  trunks.  Rupture  of  these  vesicles  is  not  infrequent,  and 
is  liable  to  be  followed  by  a  flow  of  lymjdi  of  variable  amount  and  duration. 
This  is  known  as  Lymphorrhagia. 

Rupture  of  a  dilated  lymphatic  along  the  urinary  tract  and  the  consequent 
lymphorrhagia  produce  Chyluria — an  intermittent  accumulation  of  chylous 
lymph  in  the  urinary  bladder.  Similarly  the  tunica  vaginalis  testis  may  be 
the  seat  of  a  lymphorrhagia,  and  Chylocele  result. 

A  group  of  dilated  lymphatic  radicles  may  be  present  in  the  shape  of  many 


DISEASES   AM>    IXJURIES    OF  LYMPHATICS. 


■171 


closely-aggregated  vesicles  of  varying  size;  or  if  the  enlargement  extends  along 
the  course  of  the  ducts,  cylindrical  and  tortuous  cords,  Avith  nodular  swellings 


Fk; 

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Lymiiliaiigiiinia  Circumscriptum  i'>riginal 


at  the  site  of  the  valve,  are  produced.  The  two  varieties  may  coexist ;  or  still 
greater  dilatation  at  various  points  may  have  taken  place,  so  that  the  varicos- 
ities are  converted  into  cystic  tumors.  Such  varicose  swellings  in  the  inguinal 
region  may  be  confounded  Avith  hernia.  Ectasi?e  or  dilatations  of  the  blood- 
vessels may  coexist  with  those  of  the  lymphatics,  producing  a  tumor  of  mixed 
character.  Such  mixed  growths  have  been  noted  in  the  tongue,  producing  an 
enlargement  of  it  known  as  Macroglossia,  and  in  the  lips,  Macrocheilia. 

Etiology. — In  a  large  proportion  of  cases  of  lymphatic  dilatation  the  con- 
dition is  congenital  in  its  origin  ;  it  may  be  due  to  an  essential  vice  of  develop- 
ment of  unknown  character,  or  more  likely  to  obstructions  to  the  lymph-stream 
of  a  mechanical  or  an  inflammatory  nature  arising  during  embryonic  life. 
In  the  acquired  variety  inflammation  and  thrombosis  are  the  chief  agents  Avhich 
are  active  in  the  production  of  the  condition,  the  direct  result  being  dilatation 
of  the  radicles  and  of  the  primary  channels,  with  lymph-stasis  and  oedema  of 
the  tissues  within  the  area  from  which  the  narrowed  or  occluded  vessels  are 
supplied.  Occlusion  may  also  result  from  cicatricial  contraction,  from  the  pres- 
ence of  tumors,  and  from  the  blocking  up  of  the  lymphatic  channels  by  tuber- 
cular or  cancerous  material.  The  presence  in  certain  lymphatic  vessels  of  a 
minute  parasitic  worm,  the  filaria  sanguinis  hominis,  has  been  demonstrated  to 
be  the  cause  of  lymph-thrombosis  and  inflammation  in  a  large  class  of  cases 
most  frequently  occurring  in  tropical  regions. 

Causes  and  Symptoms. — The  cystic  and  tubular  enlargements  of  the 
lymphatics  which  have  been  described  are  observable  only  when  they  are  situ- 
ated superficially  or  when  they  form  circumscribed  swellings  that  are  distinguish- 
able as  distinct  tumors.  A  very  marked  and  surgically  important  series  of 
symptoms  may  arise  Avhen  in  the  substance  of  a  limb  or  part  there  is  a  diffused 
dilatation  with  lymph-stasis.  Such  a  condition  results  when  there  is  obstruc- 
tion of  so  large  a  number  of  the  ducts  converging  to  the  root  of  the  extremity 
or  part  that  but  little  relief  through  collateral  trunks  is  possible.     The  affected 


472 


AN   AMHIUCAX    TKXr-JiOOK    OF   sriidKRy 


part  becomes  swollen  by  a  lianl,  compact,  luawiiy  tedi'iiia.  Lymphoedema, 
which  is  not  readily  reducible  either  l)y  position  or  pressure.  Attacks  of  diffuse 
lymphangitis  are  prone  to  recur,  each  successive  attack  causing  an  aggravation 
of  the  local  condition.  Thickening  and  induration  of  the  skin  and  connective 
tissue  take  jdace.  Dilatation  and  niultii)lication  of  the  blood-vessels  keep 
pace  with  the  general  connective-tissue  hypertrophy.  The  muscles  waste.  In 
the  more  advanced  and  aggravated  cases  of  this  class  an  enormous  deformity 
results;  the  skin  becomes  coarse  and  hypertrophied,  with  a  tendency  to  eczema 
and  seborrhea ;  papillary  excrescences  are  numerous  and  the  development  of 
ulcers  is  frequent ;  the  swollen  limb  presents  lobulated  masses  heaped  up  at 
different  parts,  separated  from  one  another  by  deep  sulci,  which  are  especially 
marked  at  the  flexures  of  the  joints.  If  the  scrotum  is  the  part  aff'ected — a  not 
uncommon  occurrence — it  may  form  a  huge  tumor  reaching  bblow  the  knees  or 
even  to  the  ground.  This  constitutes  the  disease  known  as  Elephantiasis 
Arabum.  While  it  is  more  common  in  certain  intertropical  countries  (Bar- 
badoes,  India,  Cayenne,  etc.),  where  its  frequent  dependence  upon  the  presence 
in  the  lymphatics  of  the  filaria  sanguinis  hominis  has  been  demonstrated,  occa- 
sional instances  of  it  are  met  with  in  all  climates.  The  accompanying  illustra- 
tion (Fig.  202)  shows  the  condition  of  the  limb  of  a  girl  of  twenty-one  years 
of  age,  the  subject  of  lymphoedema,  five  years  after  the  inception  of  the  dis- 
ease.    The  changes  in  the  limb  were  as  yet  moderate.     The  photograph  from 


Fig.  202. 


Lymphitdeinu  of  left  leg  live  years  after  its  ouset  (original). 

which  the  cut  was  made  was  taken  in  187o.  At  the  present  time,  seven- 
teen years  later,  the  case  presents  the  typical  condition  of  the  worst  form  of 
elephantiasis.  Repeated  attacks  of  lymphangitis  have  occurred  during  this 
period,  each  producing  an  aggravation  of  the  previous  condition.  The  leg 
below  the  knee  has  become  enormously  deformed  by  the  production  of  the  ele- 
phantoid  masses;  the  outer  side  of  the  thigh  remains  healthy,  but  the  skin  of 
the  inner  side  has  developed  so  as  to  form  a  very  large  and  pendent  lobulated 


DJSEA.'SES  AM)    ISJClilKS    OF    LYMI'HATICS. 


47;] 


Fig.  '20.3. 


nia^^  A  similar  eon.liticn  has  bo^un  to  develop  in  the  other  k-g,  uhieh  now 
i.  about  in  the  fon<liti()n  of  the  first  as  shown  in  the  figure.  Fig.  203  show.s 
an  example  of  tlir  ehan-es   produced  by  this  disease  in  its  most  aggravated 

form.  ,  .     ,        1  1  ^ 

Treatment.— Circumscribed  dilatations  and  isolated  cystic  enlargements 

m?v  be  extirpated  with  the  knife.  In  the  diftu.sed  dilatations  and  a'dema  due 
to'  persi«.tent  obstructive  causes,  in  cases  in  which  collateral  channels  may  in 
time  become  sufficieiitlv  <leveloped  to  relieve  the  stasis,  relief  will  be  given  by 
massa'^e,  elastic  baiulagini:,  and  support  in  an  elevated  position.  In  the 
absence  of  the  possible  relief  of  the  stasis  all  such  attempts  will  be  fruitless. 
Ligation  of  the  main  artery  of  supply  of  the  limb  in  a  few  recorded  cases  has 
been  followed  bv  rapid  improvement.  In  others  no  benefit  has  resulted.  A 
resort  to  it  wouhl  be  justifiable  when  other  means  had  foiled.  A\  hen  the  dis- 
ease is  confined  to  an"  extremity  and  causes  serious  disability,  amputation  may 
be  done.  Similar  tumors  involving  the  genitals  should  be  excised.  In  the  lat- 
ter cla.ss  of  cases  attempts  should  be  made  to  preserve  the  penis  and  testas  by 
dissecting  them  out  of  the  hypertropiiied  mass  in  which  they  are  imbedded. 
The  chief  difficulty  attending  the  ablation 
of  the  growths  is  the  prevention  of  hemor- 
rhage ;  but  this  has  been  greatly  fiicilitated 
by  the  use  of  the  elastic  bandage  for  con- 
stricting its  base. 

Lymphadenoma. — Under  this  head 
are  to  be  classed  lymph-gland  tumors,  in 
which  the  essential  change  is  purely  a 
hyperplasia  of  normal  gland  elements. 
Simple  overgrowths  aff"ecting  one  or  per- 
haps two  or  three  adjacent  glands,  with- 
out a  tendency  to  local  degeneration  or  the 
development  of  constitutional  cachexia, 
have  been  described,  but  it  is  probable 
that  in  most  of  such  cases,  if  not  in  all, 
either  foci  of  tubercular  infection  would 
be  found  in  them,  if  a  sufficiently  thor- 
ough examination  Avere  made,  or  they 
would  in  time  show^  themselves  to  be  the 
precursors  of  a  more  generalized  process. 
Enlargement  of  lymphatic  glands  con- 
sisting of  hyperplasia  of  the  normal  struc- 
ture is  an  important  element  of  leukemia. 
Single  glands  may  attain  the  size  of  a 
man's  fist  in  this  disease,  and  sometimes 
all  the  lymph-glands  of  the  body  beconae 
involved.  Associated  with  the  lymphatic 
tumors  are  enlargements  of  other  glands, 
notably  the  spleen,  thymus,  and  liver. 
Changes  in  the  marrow  of  the  bones  ac- 
company these  glandular  changes.  The 
resulting  alteration  in  the  blood — namely, 
the  great  incvease  of  the  white  corpuscles 
and  the  diminution  of  the  red — affords  a 
certain  means  of  identifying  this  form  of  glandular  disease,  which  has  a  place 
more  properly  in  internal  medicine  than  as  a  surgical  aff'ection. 


Lymphoedema  in  its  Later  Stage  (original). 


474  J.V  A.UERICAX    TEXT- HOOK    OF  SURGERY. 

Malkixaxt  Lymphoma. — Differing  from  these  trlantlular  tumors  of  leuke- 
mia chiefly  in  the  absence  of  the  blood-changes  are  the  cases  of  diff'use  gland- 
ular enlargement  to  which  the  term  Malignant  Lymphoma  (Tlodgkhi's  dis- 
ease, Pseudn-Uukemia)  is  applicable  (PI.  IX.  Fig.  2).  In  this  aftection  there  first 
appears  a  moderate  painless  swelling  of  one  or  more  glan<ls.  most  fre(juently 
in  the  neck,  more  rarely  in  the  axilla,  groin,  or  mediastinum.  After  a  time 
other  glands  enlarge,  until  great  tumors  may  result,  producing  much  dishgure- 
ment.  For  a  time  no  disturbance  of  the  general  health  is  observed.  The 
glands,  if  removed,  show  simply  great  hyperplasia  of  the  normal  elements. 
Gradually  groups  of  glands  in  other  parts  of  the  body  become  similarly 
enlarged,  until  finally  almost  all  the  glands  of  tlie  body  are  affected.  Some 
enlargement  of  the  spleen  may  now  be  discernible,  but  it  is  not  constant. 
Coincident  with  this  generalization  of  the  swellings  the  health  begins  to  suffer; 
emaciation  declares  itself;  progressive  anemia  develops,  which,  unless  death 
from  some  accidental  complication  occurs,  becomes  extreme ;  dropsies  arise ; 
diarrhea  sets  in ;  and  finally  collapse  and  death  terminate  the  case. 

The  etiology  of  malignant  lymphoma  is  totally  unknown.  It  attacks 
young  adults  most  frequently.  During  its  early  history  it  is  impossible  to 
distinguish  it  with  certainty.  The  element  of  time  is  required  to  develop  its 
malignancy.  When  the  swellings  have  become  generalized  and  the  constitu- 
tional symptoms  have  declared  themselves,  the  diagnosis  is  plain.  The  cha- 
racteristics of  the  glands  of  lymphoma  are  these :  they  preserve  their  proper 
shape ;  they  do  not  soften  and  degenerate,  as  do  tubercular  glands ;  they  do 
not  become  fused  together  or  adherent  to  surrounding  parts  by  inflammatory 
adhesions ;  they  have  a  certain  elasticity  when  compressed,  different  from  the 
board-like  hardness  of  unsoftened  tubercular  glands. 

The  prognosis  is  hopeless.  Its  course  varies  in  its  rapidity,  usually 
extending  over  about  one  year,  although  a  more  prolonged  course  is  not  infre- 
quent. Pressure  of  the  enlarged  glands  upon  the  trachea,  oesophagus,  or 
important  nerve-trunks  may  precipitate  the  fatal  termination. 

Treatment. — There  is  little  to  be  gained  from  surgical  interference  except 
when  pressure-symptoms  call  for  relief.  The  internal  use  of  arsenic,  com- 
bined with  its  parenchymatous  injection,  has  appeared  to  exercise  a  favorable 
effect  on  the  disease  in  some  cases ;  in  others  it  has  been  inert.  It  should  be 
tried  in  all  cases,  and  pushed  to  the  maximum  of  toleration.  Its  administration 
should  be  persevered  in  for  a  long  period,  and  resumed  whenever  evidences  of 
rencAved  glandular  hyperplasia  appear. 

Sarcoma  of  Lymphatic  Glands,  Lympho-Sakcoma. — A  lymphatic  gland 
mav  be  the  seat  of  a  primary  sarcoma.  In  the  early  history  of  such  a  tumor 
it  will  be  impossible  to  distinguish  it  positively  from  other  varieties  of  glandular 
hypertrophy.  As  it  continues  to  develop  it  will,  after  a  time,  display  its  special 
malignant  features  as  it  involves  the  adjacent  tissues  and  becomes  attended  by 
secondary  deposits  in  various  internal  organs,  as  the  lungs,  liver,  kidneys,  brain, 
and  bones.  (See  the  chapter  on  Sarcoma.) 

Treatment. — Soon  after  its  development,  if  not  already  veiy  large,  it 
should  be  thoroughly  extirpated,  the  incision  going  wide  of  the  gland.  If  it 
returns,  amputation  should  immediately  be  done  if  the  tumor  be  on  an 
extremity. 


DISEASES    OF    THE  SKIN   AM)    ITS   APPENDAGES.        475 

CHAPTER    X. 

SURGICAL  DISEASES  OF  THE  SKIN   AND  ITS  APPENDAGES. 

Co.MEDO. — This  is  a  disease  of  the  sebaceous  glands  occurring  chiefly 
about  the  face,  neck,  chest,  and  back,  resulting  from  accumulation  of  the  altered 
sebum,  producing  small  yellowish  or  Avhitish  elevations  marked  by  a  central 
black  spot,  due  to  staining  by  dirt  of  that  portion  of  the  retained  secretion 
occupying  the  orifice  of  tlie  duct.  Pressure  "will  express  a  small  plug  of 
inspissated  sebum  mingled  with  epithelial  cells,  popularly  called  a  "worm." 
Partly  due  to  idiosyncrasy,  and  usually  a  disease  of  puberty,  it  is  apt  to  coin- 
cide with  dyspepsia  and  constipation,  and  in  young  women  with  chlorosis  and 
menstrual  irregularities. 

Treatment. — Frequent  bathing  with  hot  water  and  stimulating  ointments 
rubbed  in  at  night  (such  as  sulph.  prsecip.  3j  to  ung.  aquae  rosie  5j),  or  Aveak 
alkaline  ointments  (such  as  borax,  grs.  xx  to  .5J),  may  be  tried.  To  remove 
the  comedones  apply  night  and  morning  the  following  paste — aceti  3ij,  glyceringe 
jiij,  kaolini  giv, — after  which  gentle  pressure  by  a  watch-key  applied  over  the 
spots  will  dislodge  the  plugs. 

Milium. — This  appears  as  small,  rounded,  pearly,  superficial  elevations  in 
the  skin,  occurring  chiefly  on  the  face  and  genitals  ;  they  are  not  painful,  and  re- 
sult from  the  accumulation  of  sebum  from  obliteration  of  a  small  secondary  duct. 

Treatment. — Each  elevation  must  be  opened,  the  cheesy  matter  squeezed 
out,  and  the  interior  touched  with  tincture  of  iodine  or  a  nitrate-of-silver  point. 

Sebaceous  Cysts  or  Wens. — These  form  variously-sized  firm  or  somcAvhat 
soft,  rounded  tumors,  usually  seated  in  the  skin  or  subcutaneous  tissue  of  the 
scalp,  face,  back,  or  scrotum,  although  they  occur  elsewhere.  The  superjacent 
integument  is  unaltered.  If  injured  they  may  inflame  and  ulcerate,  or,  in  the 
old,  degenerate  into  epithelioma.  Although  usually  originating  from  obstruction 
of  a  duct,  they  often  have  no  opening,  but  at  times  one  persists,  admitting  a 
small  probe.     Their  contents  are  cheesy  or  milky,  and  are  often  fetid. 

Treatment. — Excision  should  be  performed  either  by  carefully  dissecting 
out  every  particle  of  the  cyst,  or,  after  transfixing  this  and  the  overlying  skin, 
seizing  and  tearing  out  each  half  of  the  cyst-wall  with  a  pair  of  forceps. 

MoLLUSCUM  CoNTAGiosuM  vel  EpiTHELiALE  is  characterized  by  small, 
semiglobular,  or  conical,  whitish,  sometimes  translucent  elevations,  from  the 
size  of  a  pin's  head  to  that  of  a  pea,  with  a  central  dark  spot  or  depression, 
which  is  the  aperture  of  a  duct.  They  occur  chiefly  upon  the  eyelids,  cheeks, 
chin,  neck,  breast,  and  genitalia,  and  are  not  painful,  although  terminating  by 
disintegration  and  sloughing  of  the  masses.  The  question  of  contagiousness 
is  still  a  mooted  point.  It  is  liable  to  be  confounded  with  molluscum  fibrosum, 
but  may  be  distinguished  from  it  by  the  absence  of  the  central  black  opening 
in  this  latter  aff"ection  and  the  more  general  dissemination. 

Treatment. — Thorough  inunctions  with  white  precipitate  or  sulphur  oint- 
ment will  sometimes  suffice ;  if  not,  each  tumor  should  be  opened,  its  contents 
squeezed  out,  and  the  cavity  cauterized  with  nitrate  of  silver. 

Dermatitis  Venenata. — Tincture  of  arnica  and  the  wearing  of  garments 
colored  by  aniline  dyes  containing  arsenic  will  sometimes  produce  dermatitis, 
but  it  usually  results  from  the  rhus  venenata  or  rhus  toxicodendron.  Owing 
to  the  volatility  of  the  poison,  actual  contact  with  the  plants  is  not  necessary. 


47(j  AJV  AMKlilCAX    TF.XT-IIOOK    OF   sriidEnV. 

After  a  iew  hours  or  c-vcii  days  of  iiu-uhatioii,  in  cliildrcii  trt'tfiilncss  or  sli;^bt 
fever  may  be  noticed,  but  ordinarily  the  h>cal  symptoms  first  appear — viz.  heat 
and  iteliing,  probably  of  the  face  and  hands,  with  surface  redness  and  some 
subcutaneous  oedema.  Eczematous  vesicles  now  appear,  usually  first  between 
the  fintjers ;  next  the  genitals  are  apt  to  be  attacked  in  the  male,  wlience  the 
eruption  may  spread  to  other  parts.  The  infiame<l  portions  of  the  skin  are 
intensely  red,  somewhat  ocdematous,  and  covered  by  groups  of  i)apules  or  vesicles, 
these  latter  being  often  confluent,  while  from  scattered  excoriations  a  clear, 
yellowish,  gummy  fluid  exudes,  forming  a  soft  crust  on  drying.  The  eyelids, 
lips,  nose,  ears,  and  genitals  are  sometimes  enormously  swollen,  and  exude 
large  quantities  of  serum.  Sometimes  the  constitution  sympathizes,  as  is  shown 
by  fever,  coated  tongue,  and  constipation.  The  burning,  stinging  pain  is 
occasionally  so  severe  as  to  deprive  the  patient  of  sleep,  when  anodynes  will 
be  required.  The  disease  remains  at  its  height  for  several  days,  but  usually 
in  a  week  the  acute  symptoms  have  subsided,  although  the  disease  may  recur 
from  time  to  time. 

The  diagnosis,  especially  from  erysipelas,  nmst  depend  on  the  history  of 
exposure,  on  the  appearance  of  the  vesicles  first  between  the  fingers,  next  on 
the  dorsum  of  the  fingers  and  hands,  finally  on  the  palms ;  the  eruption  is  more 
scattered  than  in  eczema ;  the  vesicles  usually  do  not  pass  through  the  papular 
stage,  as  is  common  in  eczema,  but  often  spring  directly  from  the  skin.  The 
disease  is  not  contagious,  although  in  recent  cases  the  poison  itself  may  be  con- 
veyed from  person  to  person  or  to  other  parts  of  the  same  individual,  as  from  the 
hands  to  the  genitals. 

Treatment. — Cloths  kept  wet  with  black-wash,  provided  the  extent  of  sur- 
face be  not  too  great,  or  w  ith  weak  solutions  of  sulphate  of  zinc,  or  fluid  extract 
of  grindelia  robusta  in  the  proportion  of  3ij-3iv  to  the  pint  of  water,  keeping 
the  cloths  just  damp  with  the  solution,  are  very  useful ;  for  the  face,  when  the 
patient  cannot  remain  confined  to  the  house,  equal  parts  of  starch  and  precipi- 
tated carbonate  of  zinc  may  be  dusted  over  the  parts. 

Furuncle,  or  Boil. — This  is  a  disease,  probably  due  to  mi<'robic  infec- 
tion, in  which  one  or  more  small,  circumscribed,  acuminated,  dusky-red,  firm, 
painful  spots  form  in  the  skin,  the  result  of  localized  inflammation,  the  cen- 
tral portion  of  skin  dying,  forming  a  slough  or  "core"  around  which  suppu- 
ration takes  place,  ending  in  the  separation  of  the  "core,"  the  subsidence  of 
the  inflanmiation,  and  the  healing  of  tlie  cavitv  bv  granulation.  The  matu- 
ration  of  each  boil  takes  about  a  week  or  ten  days :  sometimes  no  suppuration 
occurs,  when  the  condition  is  called  a  "  blind  boil."  The  pain  is  throbbing, 
and  often  quite  severe  until  suppuration  and  loosening  of  the  slough  have 
occurred,  when  it  subsides.  Although  any  portion  of  the  integument  may  be 
attacked,  the  face,  ears,  neck,  back,  axilla,  buttocks.  ])erineum,  scrotum,  labia, 
and  legs  are  the  favorite  sites;  the  nearest  lyni])h-glands  may  become  enlarged, 
and  sometimes  constitutional  disturbance  results.  Ei-i-oneous  hygiene  and  diet 
even  in  the  robust,  overwork,  nervous  depression,  impro])er  food,  irregularity 
of  the  bodily  functions,  and  certain  atmospheric  conditions  prevalent  in  spring 
and  autumn  are  predisposing  causes.  The  diff"erences  from  carbuncle,  with 
which  alone  a  boil  is  likely  to  be  confounded,  will  become  clear  when  the  for- 
mer disease  is  described. 

Treatment. — The  cause  should  be  ascertained  and  removed.  The  diet 
must  be  regulated  and  varied.  Exercise  in  the  open  air,  (juinine.  iron,  and 
strychnine  are  useful  in  debilitated  patients.  Arsenic,  with  or  without  iron,  is 
at  times  of  benefit.  The  sulphite  or  hyposulphite  of  sodium,  grs.  xv-xxx 
■every  three  hours,  sulphide  of  calcium,  \  gr.  every  two  or  three  hours,  and 


J )  IS  i:  ASKS    OF    THE   SKIN    A  A  J)    ITS   A  I'/'hWDA  (,' h'S.        nlJ 

projior  (loses  of  sulphur  iiitorniilly  have  been  thouiiht  to  do  good  at  times,  but 
there  is  no  speeifie.  When  a  hair  oceupies  the  center  of  the  boil  its  avulsion; 
will  sometimes  abort  the  furuncle.  Locally  a.  10  per  cent,  salicylic-acid  oint- 
ment, or  ichthyol  combined  Avith  an  erjual  (piantity  of  collodion,  -will  prove  bene- 
ficial. White  has  reported  a  series  of  cases  of  furunculosis  in  which  the  obstinate 
recurrence  of  boils  was  arrested  by  the  administration  of  bichloride  of  mercury 
in  full  doses.  It  is  possible  that  this  acts  through  its  bactericidal  properties, 
the  origin  of  the  condition  being  perhaps  microbic. 

Carbuncle. — This  is  a  circumscrilx-d,  deep-seated  inflammation  of  the  skin 
and  subcutaneous  tissue,  terminating  in  a  slough.  Constitutional  disturbance  is 
usually  marked,  the  disease  being  ushered  in  by  a  chill  followed  by  fever.  The 
skin  becomes  hot,  painful,  and  dusky  red,  and  a  flattened,  fairly  circumscribed 
inflammatory  induration  of  the  subcutaneous  tissue  forms;  the  pain  is  usually 
burning.  Steadily  progressing  and  extending,  until  it  may  be  from  three  to  six 
inches  in  diameter,  by  the  end  of  from  ten  days  to  two  weeks  the  mass  begins  to 
soften,  and  the  skin  ulcerates  at  numerous  points,  which  are  usually  filled  with 
yellow  sloughs,  whence  issues  sanious  pus.  The  sieve-like  appearance  pre- 
sented by  the  skin  surface,  due  according  to  Warren  to  pus  in  the  column9& 
adiposjB,  is  characteristic,  but  in  most  large  carbuncles  the  overlying  integu- 
ment sloughs  away  sooner  or  later,  leaving  a  large,  slowly-healing  ulcer. 
Carbuncle  lasts  for  from  four  to  six  weeks,  is  usually  single,  and  its  favorite 
sites  are  the  back  of  the  neck,  shoulders,  back,  and  buttocks :  it  is  especially 
dangerous  Avhen  occurring  on  the  scalp,  abdomen,  and  upper  lip ;  in  these 
locations,  occurring  as  it  does  in  the  young,  it  runs  an  acute  course  and  is 
apt  to  terminate  fatally  from  pyemia.  It  is  a  serious  disease  when  extensive 
and  attacking  the  elderly,  especially  if  complicated  Avith  Bright's  disease  or 
diabetes,  wdiich  latter  affection  stands  in  a  causative  relation  to  it.  The  causes, 
other  than  diabetes,  are  probably  the  same  as  those  of  boil.  The  possibility 
of  microbic  origin  should  be  remembered.  The  size,  flatness,  multiple  points 
of  suppuration,  and  extensive  slough  distinguish  carbuncle  from  furuncle. 

Treatment. — Large  amounts  of  easily  digestible,  nourishing  food  should 
be  given,  but  stimulants  only  when  distinctly  indicated.  Quinine  and  tincture 
of  iron  in  large  doses,  with  anodynes  to  procure  rest,  are  requisite.  Diff"erent 
plans  of  local  treatment  may  be  adopted :  one,  of  doubtful  utility,  is  compres- 
sion by  the  concentric  application  of  adhesive  straps,  limiting  the  spread  of  the 
inflammatory  exudates  and  seeming  to  lessen  the  destruction  of  cellular  tissue ; 
another  and  far  better  plan  is  applicable  even  in  the  early  stages,  before  the 
skin  is  seriously  damaged,  and  consists  in  making  under  anesthesia  multiple 
crucial  incisions  or  one  long  incision — after  freezing  the  parts  to  render  them 
friable — and  thoroughly  curetting  away  all  dead  or  dying  cellular  tissue,  care- 
fully disinfecting,  suturing,  and  draining,  as  in  an  incised  Avound.  This  is  done 
upon  the  theory  that  the  spread  of  the  disease  is  due  to  the  micro-organisms 
flourishing  in  the  sloughs.  Or  warm  moist  antiseptic  dressings  covered  Avith 
oiled  silk,  early  removal  of  loose  sloughs,  and  the  free  use  of  iodoform  may  be 
employed,  but  poultices  should  be  avoided. 

Burns  and  Scalds. — These  two  classes  of  injuries  may  be  conveniently 
discussed  together.  Scalds  are  apt  to  be  more  extensive,  because  the  clothing 
diff'uses  the  fluid  over  a  greater  area  and  the  hairs  remain,  Avhile  in  burns 
these  are  destroyed  and  the  tissues  are  often  more  deeply  involved  ;  the  efl"ects 
of  concentrated  acids  and  alkalies  resemble  burns  rather  than  scalds.  The 
old  classification  of  Dupuy tren  needs  revision  since  the  introduction  of  modern 
methods  of  Avound-dressing,  so  far  as  prognosis  goes,  although  if  asepsis  is  not 
secured  and  maintained,  in  the  more  severe  cases  the  old  rules  will  still  hold 


478  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

good  :  moreover,  the  ability  rui»iill_v  to  remove  the  drain  of  free  sujijmration 
and  relieve  pain  by  Thiersch's  method  of  skin-grafting  lessens  the  secondary 
mortality  of  extensive  burns  or  scalds.  For  practical  purposes  only  three 
classes  of  burns  and  scalds  need  be  made,  viz. :  (1)  those  presenting  ervthema- 
tous  inflammation  of  the  skin  without  vesication  ;  (2)  those  in  -which  the  inflam- 
mation of  the  skin  results  in  the  formation  of  vesicles  and  bullae ;  (3)  those  in 
■which  partial  or  complete  carbonization  of  the  part  results,  or  in  which  from  the 
secondary  effects  of  inflammation  more  or  less  extensive  and  deep  sloughs  form. 

Deatii,  when  it  occurs,  results  early  fi-om  shock  ;  after  reaction,  from  con- 
gestion of  internal  organs  produced  by  reflex  vaso-motor  paresis,  or  from  these 
congestions  going  on  to  actual  inflammation  of  the  pulmonary  or  gastro-intes- 
tinal  mucous  membrane,  of  the  serous  membranes,  etc. ;  after  suppuration  is 
established,  exhaustion,  erysipelas,  pyemia,  septicemia,  and  tetanus  may  end 
life.  (Edema  of  the  glottis  from  scalds  of  the  mouth  is  a  very  fatal  complica- 
tion, while  perforating  ulcer  of  the  duodenum  sometimes  occurs. 

The  prognosis  depends  upon  the  extent  and  depth  of  the  injury;  thus 
mere  reddening  of  two-thirds  of  the  cutaneous  surface  will  almost  inevitably 
result  in  death,  Avhile  destruction  of  one-third  of  the  skin  will  probablv  pro- 
duce the  same  result ;  yet  most  burns  of  the  first  and  second  classes  of  the 
extent  commonly  met  with  in  practice  will  recover ;  in  burns  of  the  third 
class  the  region  affected,  the  depth  to  which  the  tissues  are  destroyed,  the 
age,  sex,  and  previous  health  of  the  patient,  Avill  determine  the  result ;  thus 
even  slight  burns  of  the  third  degree  may  be  fatal  to  the  young  or  old. 

Symptoms. — These  are  local  and  constitutional.  The  local  vary  with  the 
depth  of  the  injury,  from  mere  reddening  and  swelling,  up  through  vesication, 
excoriation,  and  partial  destruction,  to  charring.  The  pain  may  be  of  every 
grade,  from  moderate  burning  up  to  intense  agony,  the  most  painful  variety  of 
burns  being  that  in  which  the  outer  layers  of  the  skin  are  destroyed,  exposing 
the  nerve-endings,  less  pain  being  complained  of  when  total  destruction  of  the 
skin  has  taken  place.  The  constitutional  symptoms  vary  from  slight  fever  in 
burns  of  the  first  class  to  profound  shock  in  the  deeper  forms,  followed  by  reac- 
tion, and  this  succeeded  by  congestion  or  inflammation  of  the  viscera.  Thus 
death  may  result  from  cerebral  coma ;  later,  the  exhaustion  incident  to  sup- 
puration, pain,  or  hemorrhage,  with  the  inflammation  of  the  kidneys  or 
nervous  centers  liable  to  set  in  at  this  stage,  is  apt  to  carry  off  the  patient. 

Local  Treatment. — In  slight  or  moderate  burns  and  sunburn  nothing 
else  relieves  the  [)ain  so  well  as  wrapping  the  part  in  clotlis  wet  with  a  saturated 
solution  of  bicarbonate  of  sodium  or  ordinary  ''baking  soda,"  or  a  weak  dilu- 
tion. 1  :  8,  of  phenol  sodique. 

In  severe  burns  remove  the  clothing  with  great  care,  lest  the  cuticle  be  torn 
off;  relieve  the  tension  in  the  blisters  by  pricking  them  with  a  needle;  avoid 
exposure  to  cold  during  the  removal  of  the  clothing  and  during  the  after-dress- 
ing ;  disinfect  the  parts  with  warm  boric  acid  or  boro-salicylic  lotions;  dress  the 
parts  so  as  to  exclude  the  air  and  keep  them  antiseptic  by  boric  acid,  iodoform — 
in  reasonable  amounts — oil  of  eucalyptus,  or  other  non-poisonous  drugs,  and  by 
enveloping  the  parts  in  cotton  rendered  aseptic  by  prolonged  heating.  Swath- 
ing the  parts  in  gauze  wet  with  aseptic  normal  salt  solution  is  an  excelic-nt 
dressing.  Subsei|uent  dressing  should  be  done  only  when  absolutely  necessary 
on  account  of  the  })ain.  the  sloughs  being  carefully  removed  or  trimmed  away, 
and  the  most  unirritative  germicidal  solutions  employed  for  cleansing  the  sur- 
faces. Where  destruction  of  tissue  has  occurred,  splints,  elastic  traction,  and 
position  must  be  employed  to  prevent  or  overcome  cicatricial  contraction, 
while  early  attention  must  be  paid  to  the  condition  of  the  granulations,  with 


DISEASES    OE    THE  SKIN  AND   ITS   APPENDAGES.       479 

free  skin-grafting — either  from  human  sources  or  from  the  lower  animals — 
after  Thiersch's  method.  ^Veak  solutions  of  copper  sulphate,  or  of  chloral, 
grs.  X  Cc/  5J,  to  stimulate  the  formation  of  granulations,  and  repression  of  the 
same  by  the  solid  nitrate  of  silver  and  pressure  when  Habhy  or  redundant,  will 
suffice  in  many  cases  to  ensure  healing,  and  should  precede  the  skin-grafting. 

Constitutional  Treatment. — If  shock  is  severe,  stimulants,  such  as 
ammonia  and  alcohol,  with  warm  coverings,  hot  bottles,  etc.,  and  opium  inter- 
nally, should  be  used  ;  later,  fluid  nourishment,  regulation  of  the  bowels  and  of 
the  cutaneous  and  renal  secretions,  with  iron,  (juinine,  and  treatment  calculated 
to  su])p()rt  tlie  system  under  the  drain  of  ])rolonged  suppuration,  and  treating 
■  such  comjdications  as  pneumonia,  pleurisy,  peritonitis,  enteritis,  or  hemorrhage 
on  general  principles,  constitute  all  that  can  be  done. 

The  scars  resulting  from  burns  and  scalds  are  almost  certain  to  contract  more 
or  less  for  a  long  time  afterward,  and  produce  in  bad  cases  most  terrible  deform- 
ities. These  are  to  be  prevented  as  far  as  possible  by  position,  splints,  active 
and  passive  motion,  etc.,  and  later  by  operative  measures.  (See  Orthopedic 
Surgery,  Surgery  of  the  Face,  and  Plastic  Surgery.) 

LiGiiTNiXG-STROKE. — Instantaneous  death  or  only  temporary  unconscious- 
ness may  result.  Sometimes  superficial  or  deep  burns,  or  paralysis  of  the  spe- 
cial nerves  or  of  those  of  general  sensation  and  motion,  may  be  occasioned. 

Treatment. — The  application  of  external  warmth,  artificial  respiration, 
and  stimulants  are  indicated  during  the  stage  of  shock  ;  later,  galvanism  and 
strychnia  internally  may  aid  in  the  restoration  of  the  paral}' zed  nerves.  The 
local  lesions  must  be  treated  in  the  same  manner  as  burns  of  the  same  class. 

Frost-bite. — This  term  is  used  to  designate  the  local  results  of  cold,  the 
destructive  eifects  being  either  direct  or  more  usually  indirect  from  inflamma- 
tion. The  depressing  eff'ect  of  cold  upon  the  circulation  of  the  part  is  such 
that  this  ceases,  and  the  part  may  be  actually  frozen.  With  due  care  the  vital- 
ity may  yet  be  restored ;  but  even  when  actual  congelation  of  the  part  has  not 
occurred,  unskilful  treatment  will  determine  gangrene. 

Symptoms. — First  numbness  and  tingling,  then  loss  of  power,  usually 
commencing  in  the  fingers  and  toes,  and  a  sense  of  weight,  are  complained 
of;  finally,  absolute  loss  of  sensation  is  noted,  and  the  parts  are  bleached, 
"white,  and  icy  cold  to  the  touch.  Those  parts  which  are  hopelessW  frozen,  at 
first  white,  cold,  and  insensible,  after  reaction  either  become  swollen  and  dis- 
colored, or  may  shrivel  up  and  contract.  Gangrene  does  not  usually  set  in  for 
some  little  time,  it  being  not  unusual  for  the  parts  to  look  quite  well  for  some 
days,  then  to  become  discolored,  bluish,  next  dark-blue,  and  finally  black.  A 
line  of  demarcation  forms,  evidenced  by  inflammation  in  the  contiguous  living 
tissues,  and  then  a  line  of  separation — i.  e.  ulceration — sets  in,  resulting  event- 
ually in  the  separation  of  the  dead  tissues. 

Treatment. — As  the  result  to  be  dreaded  is  partial  or  total  death  of  tis- 
sues the  vitality  of  which  has  been  seriously  lowered  by  cold,  and  as  undue 
reaction  will  either  determine  the  immediate  death  of  the  parts  or  give  rise  to 
such  a  degree  of  inflammation  as  will  destroy  them  by  the  compression  exerted 
by  the  exudates  upon  the  feeble  circulation,  the  indication  is  clear — viz.  grad- 
ually to  induce  a  return  of  the  heat-producing  power  of  the  parts.  The  tran- 
sition must  be  slowly  progressive ;  thus,  gently  rubbing  the  parts  with  snow  or 
employing  friction  Avhile  they  are  immersed  in  iced  water  is  advisable,  this  being 
done  in  a  room  where  the  temperature  is  low ;  even  the  warmth  of  the  bed  has 
been  known  to  set  up  inflammation,  which  tends,  as  has  been  shown,  to  run  on 
into  gangrene.  Of  course  anything  like  approach  to  a  fire  must  be  avoided. 
As  soon  as  the  general  bodily  temperature  and  that  of  the  part  have  become  about 


480  AX  AMKincAX   ri:xr-r>()(>K  of  scuuKin'. 

normal,  .stimulating  friction  with  soap-linimcnt,  alcoliol,  and  water  or  s])irit  of 
camphor,  -with  elevation  of  the  parts,  should  be  tried,  after  which,  the  air  of 
the  room  havinf;  been  gradually  Avarmed,  exposure  to  the  air  for  a  time  is  advis- 
able ;  then  cover  the  parts  with  cotton :  as  reaction  progresses,  stimulants  and 
warm  drinks  may  be  cautiously  administered.  If  excessive  reaction  takes 
place,  evaporating  lotions  of  equal  parts  of  alcohol  and  water  are  indicated. 
Should  gangrene  set  in,  the  treatment  must  be  such  as  is  proper  for  this 
condition. 

CoNSTiTUTioxAL  EFFECTS  OF  CoLD. — This  is  first  stimulating,  the  circula- 
tion being  increased  in  force  and  frequency :  then  pain  and  uneasiness  super- 
vene :  general  numbness  and  coldness,  with  drowsiness,  inducing  an  almost 
irresistible  desire  to  sleep,  are  finally  experienced,  which  if  yielded  to  means 
death  from  congestion  of  the  viscera,  the  slowing  respiration  and  failing  nervou? 
power  and  circulation  making  up  a  complexus  of  symptoms  like  those  of 
apoplexy.  Sudden  chilling  produces  death  by  cerebral  anemia,  slow  prolonged 
exposure  to  cold  kills  by  cerebral  congestion,  Avhile  sudden  exposure  to  warmth 
produces  a  fatal  result  from  embolism  :  partial  freezing  usually  causes  fatal 
congestion  or  sometimes  anemia,  both  induced  by  capillary  embolism. 

Treatment. — In  addition  to  the  local  means  advised  to  prevent  sudden 
reaction,  artificial  respiration  should  be  tried,  and  the  temperature  of  the  apart- 
ment must  be  raised  even  more  gradually  than  when  dealing  merely  with  a 
frozen  member. 

Chilblain  or  Pernio. — This  results  from  the  sudden  application  of  cold 
to  any  exposed  part,  as  the  nose,  ears,  lips,  fingers,  or  toes,  of  debilitated  per- 
sons. Moderate  exposure  to  dry  cold,  or  even  to  cold,  damp  air,  followed  by 
the  sudden  increase  of  temperature  induced  by  approach  to  the  fire,  is  a  pro- 
lific cause  of  the  slighter  forms,  especially  in  children  and  those  with  feeble 
circulation. 

Symptoms. — These  may  be  only  a  slight  degree  of  redness,  swelling, 
heat,  and  itchiui:,  which  subside  almost  Avithout  treatment :  or  a  more  severe 
condition  may  exist,  marked  by  considerable  swelling,  such  deep  congestion  as 
often  to  produce  a  bluish  tinge  of  the  skin  and  very  annoying  heat,  pain,  and 
itching.  Although  usually  a  favorable  termination  is  to  be  expected,  cases 
occur  where  the  inflammation  runs  higher,  and  vesicles  form,  which  rupture 
and  leave  obstinate  ulcerations.  If  neglected,  these  ulcers  may  degenerate 
into  foul  sores,  even  the  bones  becoming  bared  and  carious  ;  but  such  results 
are  decidedly  exceptional,  the  variety  characterized  by  slight  local  conges- 
tion, tenderness,  and  itching  being  that  usually  seen. 

Treatment. — This  should  be  prophylactic  as  well  as  curative.  Persons 
once  attacked  are  liable  to  relapses  upon  slight  provocation.  Warm  woollen 
socks,  gloves,  and  proper  muflSers  for  the  ears  and  face  should  be  worn.  As 
a  feeble  circulation  favors  pernio,  frictions  of  the  parts  to  stimulate  the  circula- 
tion, Avith  general  tonics,  are  advisable.  Avoid  any  sudden  a]iproach  to  the 
fire  after  exposure  to  cold.  In  mild  acute  chilblains  gentle  frictions  with  snow 
and  the  application  of  iced  Avater,  with  rest  and  the  use  of  lead-Avater  and  laud- 
anum, usually  suflSce.  In  the  more  chronic  forms,  when  the  skin  is  unbroken, 
stimulant  and  astringent  applications  to  the  locally  sluggish  circulation,  such 
as  tincture  of  iodine,  alcohol,  camphorated  soap-liniment,  oil  of  turpentine,  oil 
of  peppermint  pure  or  diluted  up  to  even  six  parts  of  glycerin,  and  numerous 
other  similar  applications,  have  all  been  successfully  employed ;  in  especially 
chronic  or  recurring  cases  the  constant  galvanic  current  has  proved  serviceable. 
AVhen  ulcers  form  they  must  be  treated  upon  general  principles. 

Callosities. — These  are  flattened,  irregular,  translucent,  yclloAvish,  dense 


DISEASES    OF    THE   SKJX   AND    ITS   APPEND  AGES.        481 

thickenings  of  the  cuticle,  ■which  are  developed  by  prolonged  pressure  and  fric- 
tion, and  are  usually  seated  over  bony  prominences.  According  to  their  situa- 
tion and  cause  their  appearance  varies ;  thus  various  mechanical  trades  will 
show  thickenings  on  the  hands  differing  in  situation  and  appearance.  The 
soles  and  sides  of  the  feet  are  common  situations.  So  long  as  the  exciting 
cause  persists,  the  thickening  will  remain,  but  usually  when  this  has  ceased  to 
act  for  a  considerable  time  they  gradually  disappear,  either  exfoliating  en  masse 
or  more  gradually  desciuamating.  The  only  troubles  to  which  they  give  rise, 
beyond  slight  diminution  in  sensibility  and  freedom  of  movement  of  the  parts, 
are  the  tendency  to  form  fissures  over  the  flexures  of  the  joints,  and  the  occa- 
sional excitation  of  pain,  heat,  and  suppurative  inflammation  from  irritation 
of  the  subjacent  tissues. 

Treatment. — Except  in  the  event  of  the  last  two  contingencies,  treatment 
is  rarely  needed.  For  fissures  the  application  of  softening  ointments,  as  diachy- 
lon spread  upon  lint,  unirritating  warm  antiseptic  washes  or  fomentations,  and 
quiet  of  the  parts  if  the  cracks  be  deep,  secured  by  firm  coaptating  strapping 
with  adhesive  plaster,  are  usually  sufficient ;  if  abscess  forms,  treat  it  as  such. 

Clavus,  or  Corn. — A  corn  is  a  circular,  flattened,  hemispherical,  circum- 
scribed thickening  of  the  horny  layer  of  the  epidermis,  extending  in  the  form 
of  a  cone  below  the  normal  level  of  the  corium,  constant  pressure  having  pro- 
duced some  localized  absorption  of  this  structure.  Corns  result  from  pres- 
sure or  friction  either  of  the  shoes  or  of  adjacent  surfaces,  as  those  of  con- 
tiguous toes ;  in  the  latter  situations,  from  the  constant  moisture,  the  usually 
yellow,  horny,  epithelial  masses  being  substituted  by  soft,  whitish  collections 
of  epithelium  (soft  corns),  which,  being  removed,  leave  a  slightly  elevated  margin 
of  white,  sodden  cuticle  with  a  central  reddened  depression — i.  e.  the  deepest 
layers  of  the  epidermis — through  which  is  seen  the  congested  corium.  Pressure 
always  produces  pain  by  driving  the  conical  mass  of  epithelium  down  upon  the 
sensitive  corium,  while,*^  from  constant  irritation,  inflammation  and  even  sup- 
puration are  not  uncommon. 

Treatment. — Since  pressure  from  improperly-shaped  shoes  is  the  usual 
cause,  these  must  be  improved  in  form,  pressure  must  be  taken  off"  by  felt  rings, 
and  after  prolonged  soaking  in  warm  water  containing  washing-soda  the  outer 
layers  of  the  corn  should  be  gently  scraped  away  with  a  sharp  knife — this  is 
better  than  digging  them  out  with  the  point ;  the  tender  surface  should  be  pro- 
tected by  a  little  patch  of  salicylic  rubber  plaster.  Or  the  reverse  process  may 
be  employed — i.  e.  hardening  "^by  applications  of  tincture  of  iodine  or  nitrate 
of  silver  at  night,  and  in  the  morning  removing  with  the  knife  the  hardened 
tissue.  The  following  prescription,  painted  on  at  night  and  scraped  off  in  the 
morning,  is  excellent : 

I^  Acid,  salicylici,  3iss  ; 

Ext.  cannabis  indicse,  grs.  x  ; 

Collodii,  Ij. 
M.    Sig. — Paint  on  daily. 

Soft  corns  should  have  the  softened  epithelium  gently  removed,  and  be 
desiccated  by  keeping  the  surfaces  separated,  at  the  same  time  removing 
pressure  by  proper  disposition  of  pads  of  absorbent  cotton,  preceded  by  free 
dusting  with  equal  parts  of  boric  acid  and  oxide  of  zinc.  Inflamed  corns 
must  be  treated  by  rest,  and  warm,  moist  antiseptic  dressings,  the  pns  being 
let  out  when  formed,  remembering  that  in  the  old,  in  whom  senile  vascular 
changes  have  occurred,  erysipelas  and  gangrene  not  infrequently  result  from 
trimming  a  corn  too  closely. 

31 


482  ^.V  AMERICAN   TEXT-BOOK   OF  SURGERY. 

IIoRXS  (CoHNU  Cutaneim).—  TLesc  are  solid,  wrinkled,  dry,  hypertropliic 
outgrowths  of  the  skin  ;  they  may  be  twisted,  elongated,  flattened,  or  miisli- 
room-shaped,  and  are  brownish-yellow,  gray,  or  black  in  color.  They  varv 
from  the  size  of  a  mustard-seed  to  several  inches  in  length,  may  be  single  or 
more  rarely  midtiple,  have  flattened  or  concave  bases  attached  to  normal  or 
inflamed  skin,  and,  while  found  on  any  part  of  the  body,  are  most  common 
upon  the  face.  Elderly  persons  are  most  liable  to  this  affection,  the  young 
being  rarely  attacked.  Of  slow  growth,  and  painless  uidess  injured,  tbev 
sometimes  drop  off.  a  new  horn  sj)ringing  from  the  shallow  ulcerated  base.  In 
structure  they  consist  of  hyperplasia  and  cornification  of  the  epidermic  cells, 
with  hypertrophy  of  the  papilhe  ;  or,  again,  they  may  spring  from  the  interior 
of  a  sebaceous  gland,  an  old  ulcerated  sebaceous  evst  being  often  their  starting- 
point.  Warty  growths  may  also  be  the  origin  of  horns,  and  the  bases  of  all 
forms  may  undergo  epitheliomatous  degeneration. 

Treatment. — <.)wincr  to  their  tendency  to  re-form,  the  base  from  which 
they  spring  must  be  freely  dissected  out.  or  destroyed  by  chloride  of  zinc, 
caustic  potassa.   or  the  thermo-cautery. 

Warts  (\'erruc.e). — Warts  are  circumscribed,  elevated  hypertrophies  of 
both  the  papillary  and  epidermic  layers  of  the  skin.  The  common  variety  (  V. 
vulgaris)  most  commonly  appears  upon  the  hands  of  children,  but  may  occur 
on  other  parts  and  at  anv  age.  forming  flattened  or  seiniglobular  projections, 
varying  in  size  from  that  of  a  pin-head  to  half  an  inch  in  diameter.  Primarily 
of  the  same  color  as  the  surrounding  skin,  they  become  darker  and  harder  after 
a  time,  and  the  elongated  papillse,  covered  Avith  cornified  epithelial  cells  at  first, 
may  become  partially  denuded  of  these  and  present  the  appearance  of  a  numbej 
of  projecting  points,  with  a  circuravallation  of  thickened  cuticle:  this  is  popu- 
larly termed  a  "seed-wart."'  Warts  may  be  single  or  multiple,  may  rapidly 
attain  their  full  size,  may  last  indefinitely  or  spontaneously  disappear  at  any 
stage,  and  are  not  contagious :  if  picked  or  wounded,  they  bleed  freely,  being 
often  very  vascular.  The  filiform  wart,  occurring  in  narrow  lines  along  the 
free  edges  of  the  nails  or  elsewhere  in  patches,  is  formed  by  excessive  elonga- 
tion of  the  papillae,  without  the  surrounding  epidermic  rim  of  the  ordinary 
form.  The  flat  wart  (  J \  plana)  is  never  much  raised  above  the  surface,  retains 
its  outer  layer  of  epidermis,  and  therefore  possesses  a  smooth  surface.  Warts 
may  occur  upon  the  scalp  singly  or  in  small  numbers,  and  consist  of  numerous 
projections,  compressed  at  their  bases,  but  standing  out  at  the  j>eriphery;  they 
are  often  very  vascular.  Anatomically  they  consist  of  hyperplasia  of  the 
papillae,  of  the  blood-vessels,  and  of  both  the  rete  and  the  horny  layer  of  the 
epidermis.  A  form  a])pearing  congenitally,  or  even  later  in  life,  apt  to  be 
pigmented  and  to  become  hairy,  is  called  ncerns  verrucosus.  When  such  pig- 
mented hairy  growths  occupy  considerable  portions  of  the  surface  and  coincide 
with  the  courses  of  important  cutaneous  nerves,  they  are  called  papilloma 
neurotieum.  and  cause  great  disfigurement. 

Treatment. — Painting  the  growths  with  the  juice  of  the  milk-weed,  with 
tincture  of  iodine,  or  with  a  solution  of  perchloride  of  iron,  or  applying  moistened 
powdered  chloride  of  ammonium,  will  often  cause  their  disappearance.  If  these 
means  fail,  or  if  time  is  an  element,  free  painting  with  bichloride  of  mercury,  gr. 
XXX  to  fej  of  collodion,  touching  once  or  twice  with  one  of  the  strong  mineral 
acids,  or  repeated  applications  of  glacial  acetic  acid,  may  be  resorted  to :  care 
must  be  exercised  when  employing  any  of  these  agents  over  superficial  joints, 
lest  they  penetrate  too  deeply.  Excision  by  the  knife,  snipping  them  off  with 
curved  scissors,  or  curetting  them  away  when  soft,  is  of  course  the  quickest 
means  of  removing  warts.    Hypodermatic  injections  of  cocaine  will  avoid  pain. 


DLSEASLS    OF    THE   SKJX   AXD    ITS   APPEyDAGES.        483 

DISEASES  OF  THE   NAILS. 

Although  chronic  inflammatory  aft'ections  of  the  neighboring  skin  often  pro- 
duce changes  in  the  form,  color,  and  thickness  of  the  nails,  these  so  rarely  call 
for  surgical  interference  that  they  will  not  be  described  here. 

lii'PEiiTRui'HY. — This  Can  result  only  from  hyperplasia  of  the  papillae  of  the 
matrix,  the  thickening  of  the  nail  occurring  at  the  base,  front,  lateral  edges,  or 
over  its  whole  extent,  according  to  the  parts  diseased.  The  nail  may  be  evenly 
thickened  or  variousl}'  curved  or  twisted,  Avhile  its  structure  becomes  brittle, 
opaque,  and  discolored.  Removal  of  the  most  projecting  portions  of  the  nail 
will  reveal  the  papillae  elevated  far  above  the  normal  level  of  the  matrix.  The 
change  is  slow,  progressive,  and  when  pronounced  is  usually  permanent.  The 
causes  are  not  well  understood :  pressure,  however,  seems  to  be  an  exciting 
cause,  this  being  more  efficient  in  the  nails  of  the  toes,  especially  those  of  the 
great  and  little  toes.  The  old,  whose  epithelial  structures  tend  to  overgrowth, 
are  more  liable  to  hypertrophy  of  the  nails  than  the  young.  "When  attacking 
the  fingers,  beyond  the  blunting  of  the  tactile  sensibility  and  the  deformity,  no 
special  trouble  arises,  unless  painful  cracks  form  from  the  splitting  of  the  brittle 
nails.  When  aff"ecting  the  feet,  however,  it  is  difficult  for  the  patient  to  wear 
shoes,  the  pressure  leading  to  inflammation  of  the  adjacent  soft  parts.  It  is 
thousht  that  mere  abnormal  broadening  of  the  nail  is  one  of  the  causes  of 
"ingrowing  toe-nail." 

Treatment. — When  the  deformity  seriously  interferes  with  the  appearance 
or  use  of  the  foot,  the  nails  must  be  reduced  to  normal  dimensions  by  strong 
scissors,  with  the  knife  or  a  fine  saw,  removing  at  the  same  time  as  deeply  as 
possible  the  elongated  papilla?,  which  may  be  cut  across  during  the  operation, 
and  then  cauterizing  with  perchloride  of  iron.  When  lateral  hypertrophy 
without  thickening  or  incurvation  is  present,  before  inflammation  has  been 
excited,  frequent  trimming  of  the  anterior  margins  and  corners  of  the  nail  has 
been  recommended.  When  actual  ulceration  of  the  lateral  fold  has  occurred, 
removal  of  an  elliptical  portion  of  the  hypertrophied  fold,  suturing  of  the 
wound,  removal  of  a  strip  of  nail,  including  the  matrix  underlying  it,  followed 
by  the  use  of  wide-toed  shoes,  are  the  measures  best  adapted  to  cure  the  dis- 
ease. Thinning  the  nail  by  scraping  a  groove  with  a  piece  of  glass,  and  pack- 
ing a  little  cotton  beneath  the  buried  edge  of  the  nail,  if  persevered  in,  aided 
by  repression  of  the  granulations  by  dusting  with  nitrate  of  lead,  touching  with 
nitrate  of  silver,  etc.,  will  eventuate  in  the  cure  of  a  certain  number  of  cases. 

Inflammatiox  of  the  Matrix  (Onychia). — As  a  result  of  traumatism 
in  unhealthy  individuals  inflammation  and  suppuration  sometimes  occur  at  the 
»"00t  of  a  finger-nail  and  in  the  contiguous  portion  of  matrix  ("run-around"), 
and  often  stubbornly  continue  unless  the  loosened,  sharp  edge  of  the  buried 
nail  be  carefully  trimmed  away  from  time  to  time  and  a  little  iodoform  cotton 
be  emplo3'ed  to  press  back  the  inflamed  tissues.  From  lateral  hypertrophy 
of  a  toe-nail  the  .sharp  lateral  edge  of  the  nail  becomes  imbedded  in  the  lateral 
fold,  or  from  improper  lateral  compression  of  the  toes  the  same  portion  of  soft 
tissues  is  forced  up  against  the  margin  of  the  nail,  in  either  case  causing 
inflammation,  suppuration,  and  ulceration,  resulting  in  the  formation  of  red, 
exuberant,  excessively  painful  granulations,  constituting  the  condition  called 
ingrowing  toe-nail,  though  more  correctly,  in  most  instances,  it  should  be 
termed  "up-growing  pulp."  Sometimes  both  edges,  or  even  the  whole  matrix, 
become  involved,  producing  pain  on  any  movement  of  the  member.  When 
inflammation  and  ulceration  of  the  whole  matrix  occur,  especially  where  a 
finger  is  involved,  the  condition  is  termed  "onychia  maligna:"  it  attacks 
only  those  in  depressed  health. 


484 


AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 


Treatment. — The  treatment  suggested  for  hypertrophy  of  the  nail  is 
indicated  for  all  inflaniination  of  the  matrix,  so  far  as  removal  of  the  portion 
of  nail  producing  irritation  is  concerned,  but  in  onychia  maligna  the  whole 
nail  usually  requires  removal  under  anesthesia,  with  destruction  of  the  matrix 
by  caustics,  or,  better,  dressing  with  powdered  nitrate  of  lead  or  iodoform,  and 
the  internal  administration  of  iodide  of  iron,  cod-liver  oil,  etc. 

TUMORS  OF  CICATRICES. 

Hypertrophied  Scars. — Commonly  these  are  masses  of  dense  fibrous 
tissue  resulting  from  prolonged  cicatrization  due  to  extensive  losses  of  sub- 
stance. Hypertrophied  scars  assume  a  nodular,  stellate,  and  reticular  band  or 
bridle  form,  either  by  the  time  cicatrization  is  completed  or  shortly  afterward 
from  further  contraction  ;  or,  again,  long  subse^iuently  to  the  healing,  appa- 
rently normal,  non-elevated  sears  take  on  this  hypertrophic  process,  resulting 
in  the  formation  of  tumors  presenting  the  most  varied  appearance.  No  cause 
can  be  assigned  for  these  secondary  fibroid  alterations  of  scars,  which  some- 
times attack  those  resulting  from  small  linear  incisions.  The  condition  diifers 
from  keloid  chiefly  in  the  disarrangement  of  the  component  bundles  of  fibrous 
tissue  and  the  entire  absence  of  the  papillary  layer  of  the  skin.  The  vascular 
supply,  free  at  the  outset,  diminishes  as  the  scar  contracts. 

Treatment. — Excision,  followed  by  a  plastic  operation,  is  all  that  can  be 
recommended,  and  that  for  exceptional  cases  only,  because  the  resultant  scarring 
will  ofnecessitybegreaterthanthatoftheoriginal  trouble,  and  too  often  the  new 
cicatrix  undergoes  hypertrophy ;  doubtless  some  of  the  cases  are  closely  allied  to, 
if  not  a  variety  of,  keloid.  In  some  cases  reported  by  White  thyroid  extract 
seems  to  have  done  some  good. 

¥\c..  204. 


ill  (uriginal). 


Keloid. — This  is  a  connective-tissue  neoplasm  arising  in  a  scar,  and  may 
develop  single  or  multiple  tumors  (Fig.  204). 

Symptoms. — Commencing  usually  as  a  small  elevated  nodule,  as  it  slowly 
enlarges  it  tends  to  assume  an  elongated  oval  form  with  irregularly  radiating, 
well-defined  projections,  presenting  a  rude  resomlilance  to  a  crab  ;  or,  again,  it 
may  affect  a  linear  form.  The  growth — generally  devoid  of  hair — is  a  smooth, 
firm,  elastic,  pale-red,  elevated,  cicatrix-like  mass,  usually  painless,  but  some- 


DISEASES    OF   THE  SKIN  AND   ITS  APPENDAGES.        485 

times,  especially  on  ])ressurc,  the  reverse  ;  more  rarely  itching  is  complained  of. 
Its  favorite  site  is  over  the  sternum,  but  it  is  met  with  over  the  mammae,  on 
the  neck,  ears,  arms,  and  elsewhere.  In  those  rare  instances  where  it  becomes 
inflamed,  keloid  may  present  a  temporary  appearance  of  malij^nancy,  but  this 
condition  usually  subsides  spontaneously.  The  course  may  be  either  rapid 
or  slow,  but,  having  reached  a  certain  point,  a  keloid  is  apt  to  remain  sta- 
tionary for  a  time  or  for  life,  although  it  sometimes  disappears.  Although  it 
is  stated  that  keloid  can  arise  spontaneously,  it  usually  starts  from  some  trauma 
of  the  skin,  as  the  scars  of  burns,  cuts,  floggings,  or  the  perforations  in  the 
lobes  of  the  ears  for  ear-rings.  The  colored  race  is  decidedly  more  liable  to  the 
development  of  keloid  than  the  white.  Microscopically,  the  growth  consists 
of  dense  fibrous  tissues  involving  the  corium  and  extending  especially  along 
the  adventitious  tissue  of  the  vessels. 

Prognosis. — Although,  as  has  been  stated,  keloid  sometimes  disappears, 
the  outlook  is  not  very  favorable ;  temporary  arrest  in  growth  may  continue 
for  years,  yet  the  groAvths  may  again  enlarge. 

Diagnosis. — This  is  easy,  the  only  condition  with  which  it  can  be  con- 
founded being  a  simple  cicatrix,  which  difliers  in  color,  outline,  elevation,  and 
consistence ;  moreover,  scars  do  not  increase  in  size. 

Treatment. — This  is  unsatisfactory.  Removal  by  the  knife  or  caustics 
should  never  be  undertaken  while  the  growth  is  enlarging ;  if  any  caustic  is 
used,  the  best  is  potassa  fusa.  Repeated  scarifications  (see  Lupus)  or  multiple 
electrolytic  punctures  may  succeed.  Anodyne  liniments  or  morphine  hypoder- 
matically  may  be  required  to  relieve  pain.  Thyroid  extract  has  been  tried 
with  success  in  a  few  cases. 

LUPUS. 

As  lupus  vulgaris  is  the  variety  of  chief  interest  to  the  surgeon,  lupus  erythe- 
matosus will  be  merely  incidentally  described  under  the  head  of  differential  diag- 
nosis. Lupus  vulgaris  is  a  chronic  new-cell  growth,  due  to  the  bacillus  tubercu- 
losis, which  forms  variously-sized  reddish  or  brownish  masses  consisting  of  an 
aggregation  of  papules  or  tubercles,  the  usual  termination  being  ulceration  fol- 
lowed by  cicatrization. 

Symptoms. — The  disease  commonly  begins  in  youth  as  small,  yellowish  or 
reddish-brown  points  beneath  the  skin,  which  increase  and  coalesce,  forming 
irregular  roundish  or  serpiginous,  ill-defined  patches  ;  papules  usually  form  and 
enlarge  until  they  become  tubercles ;  the  lesions  vary  from  the  size  of  a  pin- 
head  to  that  of  a  pea,  and  are  covered  with  ill-formed  epidermis.  They  may 
be  either  firm  or  soft,  and  are  painless.  One  of  two  changes  follows :  viz. 
retrogression  by  absorption  of  the  lesions  takes  place,  leaving  a  thin  cica- 
tricial tissue  covered  with  desquamating  epithelium ;  or  ulcerative  destruction 
of  the  infiltrated  skin  occurs,  with  subsequent  cicatrization,  producing  much 
disfigurement.  While  the  limbs  and  trunk  may  be  attacked,  the  nose,  cheeks, 
and  ears  are  the  favorite  sites  ;  it  destroys  the  nasal  and  palpebral  cartilages,  and 
even  the  eye  when  attacking  the  face,  sometimes  also  extending  into  the  mouth. 
The  extremities  are  frequently  attacked,  especially  the  fingers,  the  disease  then 
often  resulting  in  serious  deformity.  It  is  never  congenital,  is  rarely  heredi- 
tary, is  uncommon  among  native  Americans,  and  usually  attacks  only  debili- 
tated, underfed  persons  of  the  lower  classes. 

Diagnosis. — Syphilitic  lesions  most  closely  resemble  those  of  lupus,  and 
the  distinction  must  depend  chiefly  on  the  history,  in  conjunction  with  the  fol- 
lowing facts  :  lupous  ulcers  are  relatively  superficial  and  less  extensive ;  syphi- 
litic ulcers  are  deep,  excavated,  and  extensive  ;  the  numerous  spots  of  ulceration 
in  lupus  tend  to  become  confluent ;  syphilitic  ulcers  usually  remain  distinct,  and, 


486  A.X   AMERICAN    TEXT- HOOK    OF  SUliaEi:)'. 

moreover,  liave  sharply-defined  inar;_nns;  tin-  secretions  of  lupous  ulcers  are 
thin,  brownish,  scanty,  and  inodorous,  while  those  of  syjdiilitic  ulcers  are  thick, 
often  greenish,  abundant,  and  offensive  ;  lu])Ous  ulceration  is  slow,  taking  years 
to  reach  the  same  size  that  a  syphilitic  ulcer  would  attain  in  the  same  number 
of  weeks;  the  lupous  scar  is  yellowish,  liard.  and  distorted;  that  of  syphilis  is 
smooth,  thin,  whitish,  and  small  compared  to  the  extent  of  the  original  ulcera- 
tion;  finally,  a  history  of  other  syphilitic  manifestations  is  often  obtainable  in 
syphilitic  ulceration.  (See  p.  lt>3.)  Lu|)us  erythematosus  usually  appears  after 
puberty,  beginning  as  an  erythema ;  the  orifices  of  the  sebaceous  glands  are 
often  gaping  and  distended  with  hardened  sebum  ;  ulceration  never  occurs, 
and  after  the  disease  disappears  a  cicatricial  appearance  of  the  skin  is  left. 
Epithelioma  is  more  localized,  is  painful  and  circumscribed  ;  induration  exists ; 
epithelial  ulceration  usually  extends  from  one  point,  while  that  of  lupus  has  a 
multiple  origin  ;  finally,  epithelioma  is  rarely  a  disease  of  youth. 

Prognosis. — If  limited,  the  prognosis  is  fair,  but  when  the  disease  is  ex- 
tensive it  is  very  stubborn  and  results  in  marked  scarring  and  deformity. 

Treatment. — In  the  early  stages  thyroid  extract  and  cod-liver  oil,  com- 
bined w  ith  iodine  and  phosphorus,  should  be  fiithfully  tried.  Avith  stimulating 
absorbent  applications,  such  as  e(|ual  parts  of  tincture  of  iodine  and  glyce- 
rin, mercurial  plaster,  tar  ointment,  or  the  ointment  of  red  iodide  of  mercury. 
Repeated  linear  scarification,  making  numerous  parallel  cuts  which  must  be 
crossed  at  various  angles  by  others  similarly  disposed,  is  often  very  successful, 
leaving  eventually  a  healthy  scar ;  or  the  galvano-cautery  may  be  employed 
under  anesthesia.  When  milder  measures  fail,  recourse  must  be  had  to  caustics, 
of  which  chloride  of  zinc  and  pyrogallic  acid  are  the  best.  Caustic  potassa,  in 
stick  form,  should  be  bored  into  the  diseased  parts,  and  be  promptly  neutral- 
ized by  dilute  acetic  acid  or  vinegar.  The  papular  and  tubercular  masses  can 
sometimes  be  successfully  treated  by  Avorking  a  stick  of  nitrate  of  silver  into 
them,  while  the  patches  should  be  repeatedly  painted  over  with  a  saturated 
solution  of  the  same :  this  is  said  not  to  leave  scars.  One  dram  of  pyrogallic 
acid  to  the  ounce  of  ointment,  applied  thickly  on  lint  twice  daily,  often  does 
well.  Freezing  the  parts  with  rhigolene  or  ether  and  curetting  with  small, 
sharp  curettes,  supplemented  by  applications  of  pyrogallic  acid,  is  an  excellent 
measure ;  or  still  better  the  patient  may  be  etherized  and  thorough  erasion  of 
the  patches  be  done  with  the  sharp  spoon.  AVhere  the  patches  are  of  suitable 
size  and  in  a  favorable  position,  excision  is  proper.  Koch's  lymph,  especially 
in  the  modified  form,  has  seemed  to  be  of  more  service  in  lupus  than  in  any 
other  form  of  tuberculosis. 

PERFORATiNa  Ulcer  OF  THE  FooT. — This  is  often  a  misnomer,  no  true 
ulcer  being  present,  but  an  opening  communicating  Avith  a  sinus,  the  orifice 
being  perhaps  surrounded  Avith  granulations,  and  the  neighboring  skin  only 
slightly  inflamed ;  sometimes,  hoAvever,  the  skin  is  extensively  ulcerated :  the 
opening  may  be  in  the  center  of  a  corn.  The  usual  position  is  over  the  meta- 
tarso-phalangeal  joint  of  the  great  or  the  little  toe,  although  other  parts  may  be 
aflfected  and  several  points  at  the  same  time ;  one  or  sometimes  both  feet  may 
be  attacked.  The  discharge  is  generally  slight  and  sanious,  and  the  opening 
is  found  by  probing  to  be  the  orifice  of  a  sinus  leading  doAvn  to  diseased  bone. 
There  is  marked  insensibility  of  the  diseased  part,  and  a  varying  amount  of 
anesthesia  exists  over  an  irregular  area,  extending  sometimes  to  just  beloAv  the 
knee;  the  toes  are  especially  anesthetic.  The  local  temperature  is  usually 
reduced ;  during  the  early  stages  abnormally  free  SAveating  occurs,  and  later, 
owing  to  organic  changes  in  the  tendons,  distortion  of  the  toes  follows :  the  nails 
areyelloAv,  cracked,  and  tAvisted  laterally.  Increasedepithelial  formation  occurs 
upon  the  sole  and  dorsum  of  the  foot,  Avhile  the  hairs  and  the  depth  of  color  of 


/>/,s7.AlX/vV    OF    THE  SKIN  AND    ITS   APPENDAGES. 


487 


the  skin  are  increased.  Dissections  show  the  foot  to  he  traversed  by  sinuses 
eadi  "  o  ctrious  bone,  inflamed  buvsa>,  and  opened  jomts  w.tli  eroded  carti- 
a'e  "  These  ehan^es  result  from  thickening  of  the  endoneuruun  with  com- 
pre  ion  and  destruction  of  the  sensory  nerve-fibers.  ^^^-^--^  ;;\  ';J7^^i 
injurin-  a  peripheral  nerve  may  cause  perforating  ulcer,  or  the  neivc  lesion 

"^y^ioLi^^nuf  is  doubtful,  owing  to  the  liability  to  recurrence  from 
the  persisteuc-e  of  the  nerve  lesions,  even  if  healing  should  occur  after  re  t 

Treatment.-In  its  early  stages  prolonged  rest  m  bed,  or  even  the  use  of 
an  art'hml  limb  attached  to  the  bent  knee,  will  often  secure  temporary  heal- 
ii?;  but  1  most  cases,  as  soon  as  the  member  is  used  again  the  sore  recurs. 
Exci  ion  of  the  ulcer  is  useless,  nothing  short  of  a  Syme  or  a  P-ogoff  amput^^ 
Son  availing.  These  measures  are  usually  successful,  for,  a  though  the  whole 
an  thetic  ai^ea  is  not  removed,  experience  shows  that  the  ^^- ;!  ^f^^^^  ^^^^^ 
■Mo  to  be-u-  the  pressure  without  ulceration  ;  occasionally  amputation  beloNv  the 
k^es^nist?  beyond  which  point  the  anesthesia  probably  never  extends. 
Ch  pa  It  hLs  reported  five  cases  in  which  entire  recovery  resu  ted  after  stretch- 
in  t  plantar  nerves  below  the  internal  malleolus,  and  no  failures.  If  further 
experience  demonstrates  its  efficacy,  this  should  be  the  operation  of  choice. 
MALIGNANT  DISEASES  OF  THE  SKIN. 

Epithelioma  may  be  either  superficial  or  deep-seated,  the  former  appear- 
inff  as  small  yellowish-red  papules  or  flattened  aggregations  of  the  same,  situ- 
ated in  the  upper  layers  of  the  skin,  which  eventually  crack  or  become  excori- 
ated, giving  vent  to  a  scanty  watery  or  viscid  secretion  drying  into  thin  brownish 
c  us  s^;  the^patch  enlarges  by  additions  to  its  periphery,  and  finally  breaks  down 
into  a  supeiificial,  spreading,  rounded  or  irregular  ulcer  ^^^^^^rder  usually  e^^^ 
vated  into  a  "pearly  ridge,"  although  this  may  be  leve  with  the  ^1^^^,  with  a 
sloping  or  sharply  defined  edge:  the  base  is  infiltrated  hard,  bleeds  readdy, 
and  secretes  a  scanty  viscid  fluid.  Pain  is  rarely  complained  of,  and  involve- 
ment  of  the  Ivmphatic  glands  seldom  occurs.  Unless  the  disease  develops  into 
the  infiltrating  variety,  the  ulcer  when  once  formed  remains  almost  unchanged 

in  extent  for  a  long  time.  ,  n  ■  ^  r        ■ «+ 

Rodent  UlceI,  a  variety  of  epithelioma,  m  this  superficial  form  is  most 
frequently  situated  at  the  inner  canthus  or  upon  the  side  of  the  nose,  it  is 
a  disease  of  late  adult  life.  It  commences  as  a  thickening  of  the  skin  which 
continues  to  extend  as  a  flattened  nodule,  and,  becoming  centrally  abraded, 
degenerates  into  an  ulcer,  at  first  of  a  rounded  form,  later  irregular  m  out- 
line. The  base  and  margins  are  indurated,  the  latter  being  somewhat  abrupt 
or  rounded,  firm,  and  slightly  elevated.  The  surface  of  the  uIcct  is  smooth 
or  slicrhtly  granular,  glossy,  dry  and  of  a  pinkish-red  color.  Progressing 
slowly  and  attended  with  but  little  pain,  although  cicatrization  may  occur  at 
spots:  the  disease  is  never  spontaneously  arrested,  everything  in  its  course 
being  destroyed,  including  the  bones,  until  the  orbits,  nose  and  mouth  may 
form  one  crater-like  opening;  in  advanced  cases  severe  hemorrhage  from 
ulceration  of  large  vessels  is  not  uncommon. 

Deep-seated  Epithelioma  begins  as  a  small  reddish  tubercle  or  warty 
growth  involving  the  whole  skin  and  subcutaneous  tissue,  with  an  indurated, 
fnfi  trated  base  ^ usually  within  a  few  months,  from  failing  ^l^tn-n  ulcera- 
tion begins  at  the  older  portions,  producing  an  irregular  ulcer  with  a  foul,  bleed- 
incr,  indurated  base.  Pain  is  often  severe,  lymphatic  mvolvemen  occuis 
soSner  or  later,  and  death  results  from  exhaustion  due  to  pam,  discharge,  and 
septic  absorption.  The  most  common  sites  are  the  lips,  tongue,  nose,  eyelids, 
forehead,  scalp,  penis  and  scrotum,  and  labia.     Chronic  ulcers,  old  cicatrices 


488  AN  AMERJCAX    TEXT- HOOK    OF   SVRGERY. 

which  have  hecome  irritated,  and  psoriasis  may  all  degenerate  into  epithelioma, 
and  chronic  irritations,  such  as  those  caused  by  a  jagged  tooth,  by  pruritus  ani, 
etc..  may  give  rise  to  the  disease. 

Diagnosis. — This  must  depend  upon  the  points  already  given,  upon  the 
rapid  growth  iiml  early  ulceration  of"  a  flattened  tubercle  or  wart,  induration 
of  the  base  of  the  ulcer,  age  over  forty  years,  and  involvement  of  the  lymphatics. 

The  treatment  is  free  removal,  including  an  area  of  healthy  tissue.  The 
knife,  galvano-cautery,  or  caustics  such  as  potassa  fusa  or  pyrogallic  acid,  after 
freezing  and  curetting,  may  be  employed. 

Carcinoma. — This  occurs  in  three  forms  :  1.  The  lenticular  or  scirrhous 
fonn  commences  as  slowly-growing,  smooth,  shiny,  brownish-red,  flat,  dissemi- 
nated papules  or  tubercles,  which  later  become  confluent ;  these  are  painful, 
ulcerate,  involve  the  lymphatics,  and  recur  after  removal,  finally  destroying  life. 
2.  The  tuberous  form  occurs  as  firm,  hard,  flattened,  raised,  rounded,  or  oval 
nodular  masses,  varying  in  size  from  that  of  a  pea  to  an  inch  or  more  in  diame- 
ter, involving  the  skin  and  the  underlying  tissue.  They  are  dull  red,  multiple, 
discrete,  or  confluent,  and  terminate  by  ulceration,  lymphatic  infection,  and 
death.  3,  Melanotic  carcinoma  commences  as  small,  multiple,  rounded  or 
oval,  soft  or  moderately  firm  papules,  finally  becoming  confluent.  They  are 
brownish,  purplish,  or  black,  ulcerate,  often  forming  gangrenous  fungating 
ulcers,  involve  the  lymphatics,  and  eventually  cause  death  :  this  variety  usu- 
ally commences  in  a  mole  or  pigmented  wart  on  the  hands  or  feet  during  early 
adult  or  middle  life. 

Cancerous  ulcers  differ  from  simple  ulcers  as  follows  :  The  malignant  ulcer 
is  excavated,  with  elevated,  everted,  knobby,  sinuous  margins.  The  base  is 
nodular,  infiltrated,  and  therefore  fixed,  often  readily  bleeds  when  touched, 
is  granular,  livid,  or  covered  with  yellowish  or  grayish  sloughs,  and  e.xudes  a 
profuse  offensive  ichorous  or  sanious  discharge,  which  usually  excoriates  the 
surrounding  skin.  The  ulcer  tends  to  spread  continuously  in  extent  and 
depth,  involving  all  the  tissues,  even  bone,  in  its  path.  The  breaking  down 
is  preceded  by  a  nodular  irregular  infiltration  of  the  tissues  and  skin,  the 
latter  often  presenting  a  livid-red  or  violaceous,  glazed  appearance.  Here 
and  there  nodular  or  tubercular  cancerous  infiltrations  are  often  seen,  situated 
some  distance  from  the  ulcer,  with  comparatively  or — to  the  eye — absolutely 
normal  skin  intervening.  Again,  much  of  the  surrounding  skin  may  be 
more  evenly  infiltrated  and  fixed  to  the  subjacent  parts,  presenting  the 
Avell  known  "  hog-skin  "  appearance. 

Treatment. — The  same  as  for  epithelioma. 

Sarcoma  occurs  as  small  single  or  multiple,  variously-sized  discrete  tuber- 
cles or  tumors,  which  may  or  may  not  be  pigmented.  Smooth,  firm,  elastic, 
slightly  tender  on  pressure,  the  non-pigmented  tumors  are  reddish.  ])uri)lish, 
or  brownish  red.  The  multiple  pigmented  sarcoma  is  described  as  invariably 
commencing  on  the  plantar  and  dorsal  surfaces  of  the  feet.  Sarcoma  occurs 
toward  middle  life  and  pursues  a  malignant  course.  Ulceration  of  sarcoma 
of  the  skin  does  not  usually  produce  much  destruction  of  ti.ssue.  "When 
involvinrr  the  deeper  parts  or  organs,  as  the  breast,  and  ulceration  occurs 
late,  secondarily  attacking  the  skin,  and  extends  rapidly,  the  ulcer  presents 
a  foul,  fungous  appearance,  the  margins  are  not  indurated  to  any  extent,  and 
the  discharges  are  abundant,  often  bloodv,  and  sometimes  offensive.  Free 
hemorrhage  is  not  uncommon. 

Treatment. — Fowler's  solution  diluted  with  two  parts  of  distilled  water, 
given  hypodermatically  twice  daily,  commencing  with  two  drops  and  increasing 
to  its  physiological  limit,  seems  to  be  the  only  remedy  which  has  proved  succes.s- 
ful.     Early  amputation  is  to  be  done  where  possible. 


BOOK  III. 

EEGIOJ^AL   SURGERY. 


CHAPTER  I. 

DISEASES  AND  INJURIES  OF  THE  HE.4D. 
I.— GENERAL  CONSIDERATIONS. 

Injuries  of  the  head  are  peculiarh-  important  from  the  fact  that  they  may 
not  be  limited  to  the  external  soft  parts  and  the  bones,  but  may  involve  the 
brain,  the  great  nervous  center  on  the  integrity  of  which  life  itself  depends.  The 
brain  is  well  protected  against  ordinary  injuries  by  moderate  violence.  Not 
only  is  the  head  covered  with  the  dense^  fibrous  scalp,  but  the  brain  is  further 
encased  and  defended  by  the  hard,  bony  skull,  which  is  practically  a  closed 
box,  the  thickness  of  which  varies  in  different  persons  and  in  different  regions. 
This  bony  case  is  arched  on  its  upper  surface,  so  that  blows  which  would 
otherwise  fracture  and  penetrate  the  skull  glance  from  this  curved  surface  and 
do  but  little  harm.  Moreover,  the  bones  are  distinctly  resilient  and  elastic, 
yielding  before  a  blow,  but  springing  back  to  their  former  position  without 
fracture  unless  the  violence  be  too  great.  Its  elasticity  of  course  diminishes 
from  youth  to  age.  It  is  made  up  also  of  a  number  of  bones  united  edgewise 
at  the"^  sutures,  which  to  some  extent  diminish  and  dissipate  the  violence  inflicted 
upon  the  skull,  although  a  fracture  often  crosses  the  sutures.  Moreover,  a 
blow  of  sufficient  violence  may  produce  a  fracture  either  at  the  point  where  it 
is  inflicted,  or,  occasionally,  though  rarely,  at  a  point  opposite  that  at  which 
the  blow  was  received.  This  last  form  of  fracture  is  called  fracture  by  contre- 
coup,  or  counter-stroke.  It  should  be  observed  that  injury  by  counter-stroke 
is  much  more  frequent  in  the  brain  than  in  the  skull.  There  are  a  number 
of  instances  on  record  where  a  blow  received  on  one  side  of  the  head  has  pro- 
duced laceration  of  the  brain,  and  even  of  the  middle  meningeal  artery,  on  the 
opposite  side.  It  will  be  seen,  therefore,  that  in  such  cases  if  an  operation  is 
done,  the  question  on  which  side  of  the  skull  it  shall  be  done  is  to  be  deter- 
mined by  localizing  brain  symptoms  rather  than  by  the  external  evidences 
of  injury. 

Inside  of  this  bony  case  lies  the  brain  surrounded  by  its  membranes,  and 
more  or  less  steadied  and  protected  by  a  small  amount  of  fluid  normally  exist- 
ing in  the  skull,  both  on  the  outside  of  the  convolutions  and  in  the  ventricles 
themselves.  Not  uncommonly  there  is  a  distinct  area  of  oedema  in  the  pia 
which  undoubtedly  acts  as  a  buffer  in  fending  off  a  blow,  but  in  spite  of  this  the 
brain  must  be  looked  upon  as  a  soft  mass  of  tissue  more  or  less  easily  lacerated 
by  commotion  or  shaking  from  blows  and  falls,  even  without  any  fracture  of 
the  bones. 

Both  the  brain  and  its  membranes  are  subject  to  inflammation,  which  is 
followed  by  irritation  and  later  by  exudation,  swelling,  and  pressure,  and  the 
exudate  cannot  escape  through  the  thick  skull  and  scalp  except  a  means  of 
4sy 


490  Ay   A^fERICAN   TEXT-llOOK    OF   SURGERY. 

exit  be  offerctl  l)y  the  surgeon.  Hence  the  frecjuent  need  for  trephining.  The 
pressure  of  this  e.xu(hite  may  be  relieved  to  some  extent  by  tlie  escape  of  some 
of  the  intracranial  bh)od  and  of  some  of  the  cerebro-spinal  fluid  into  the  spi- 
nal canal ;  but  if  the  pressure  increases,  the  functions  of  the  brain  must  be 
interfered  with  and  become  altered  or  even  abolished,  while  the  irritation  may 
cause  an  exaltation  of  function.  This  alteration  or  abolition  may  apply  to 
the  intellectual,  the  sensory,  or  the  motor  functions  of  the  brain,  so  that  there 
may  be  mania  or  coma,  hyperesthesia  or  anesthesia,  and  spasm  or  paresis  or 
paralysis. 

Moreover,  the  interference  with  function  may  be  general,  or  if  the  pressure 
be  local  the  alteration  or  abolition  of  function  will  be  local,  at  least  at  the 
beginning,  so  that  there  will  be  paresis  or  paralysis  of  an  arm  or  a  leg,  or 
of  half  the  face ;  alteration  or  abolition  of  speech,  either  sensory  or  motor ; 
hemianopsia  if  one  cuneus  be  involved ;  and,  if  there  be  inllannuation  of  or 
pressure  on  the  optic  nerves  or  tracts,  optic  neuritis  Avill  develop.  Sometimes 
the  alteration  will  be  obscure,  and  functional  rather  tlian  organic,  so  far  as  we 
can  discover,  and  will  produce  headache,  epilepsy,  or  insanity,  without  any 
perceptible  change  in  the  brain  substance.  When  pressure  is  produced  by  a 
blood-clot,  caused  by  a  blow  with  or  without  fracture,  and  followed  not 
uncommonly  by  a  cyst,  epilepsy  is  a  not  infrequent  sequel.  It  seems  also  to  be 
probable  that  the  scar  resulting  from  laceration  of  the  brain  tissue,  even  in 
simple  fracture  or  contusion,  may  be  followed  by  epilepsy. 

While  the  o;eneral  anatomical  facts  here  stated  have  been  of  course  long 
known,  yet  the  localization  of  function  in  various  parts  of  the  brain  has  been 
proved  and  accepted  only  in  the  last  thirty  years,  while  cerebral  surgery 
founded  upon  it  practically  began  only  in  1884.  Broca  in  France,  Goltz, 
Fritsch,  and  Ilitzig  in  Germany,  and  Ferrier  and  Horsley  in  England,  have 
done  the  principal  work  in  solving  the  neurological  ])roblem.  while  Macewen 
and  Horsley  in  England  have  created  a  new  department  in  surgery.  Fntil  a 
few  years  ago  the  skull  was  regarded  as  a  region  so  dangerous  that  Dante's 
motto  might  have  been  an  appropriate  warning :  "  Abandon  hope,  all  ye  who 
enter  here;"  and  though  there  were  occasional  accounts  of  extraordinary  and 
unexpected  recoveries  from  accident,  yet  purposeful  interference  with  the  1)rain 
and  its  membranes  was  never  to  be  thought  of  except  where  compound  fracture 
with  serious  brain  symptoms  made  it  absolutely  needful,  and  then  it  was  under- 
taken with  reluctance  and  fear.  This  was  due,  first,  to  our  ignorance  of  the 
localizing  value  of  the  different  parts  of  the  brain,  which  differ  from  one 
another  in  function  as  much  as  the  different  viscera  of  the  abdomen  inter  se  ; 
and  secondly,  to  our  ignorance  of  the  fact,  now  amply  proved,  that  if  we  em- 
ploy the  rigid  antiseptic  details  practised  by  Macewen,  and  fully  formulated 
by  Horsley  so  late  as  1886  and  1887,  we  can  invade  the  skull-cavity  with 
far  less  danger  than  was  formerly  thought  possible.  Inflammation  and  sup- 
puration should  rarely  follow,  provided  antiseptic  precautions  are  strictly  fol- 
lowed. These  precautions  are  given  in  detail  under  the  head  of  Technique. 
They  must  be  observed  to  the  letter  in  every  operation,  no  matter  how  slight, 
which  can  possibly  involve  the  brain-cavity. 

This  revelation  of  the  function  of  the  various  parts  of  the  brain,  and  the 
similar  revelation  of  the  operative  possibilities,  have  exercised  a  marked  influ- 
ence upon  recent  surgical  practice.  The  aim  of  the  present  text-book  will  be 
to  place  the  surgeon  abreast  of  the  most  recent  experience;  but,  where  treat- 
ment is  of  doubtful  or  as  yet  unproved  value,  a  proper  conservatism  will  be 
advocated;  for  it  must  still  be  recognized  that  any  o))eration  involving  the 
brain  is  a  very  serious  one  and  may  be  attended  with  danger  to  life. 


DISEASES   AND    lyjL'RIKS    OF    THE    HEAD. 


491 


II.— TOPOGRAPHY  OF  THE  BKAIN   IX   ITS  SURGICAL  RELATIONS. 

The  situation  ot"  the  chief  fissures  and  convolutions  of  the  brain,  and 
therefore  of  the  various  ascertained  cortical  centers,  has  of  late  assumed  the 
gre-itest  importance,  and  they  have  frequently  been  mapped  out  on  the  exterior 
of  the  skull  with  almost  absolute  accuracy,  without  any  other  guide  than  the 
rules  given  below.     Fig.  20o  shows  the  points  named  by  Broca  on  the  skull, 


Skull  showing  the  Points  named  by  Broca. 


Ai.  asterion  (junction  of  the  occipital,  parietal,  and  temporal  bones) ;  Basion,  middle  of  anterior  wall  of 
foramen  magnum ;  £,  bregma  (junction  of  the  sagittal  and  coronal  sutures) ;  G,  ophryon  (on  a  level 
with  the  superior  border  of  the  eyebrows,  and  corresponding  nearly  to  the  glabella,  the  smooth  swell- 
ing between  the  evebrows) ;  g,  gonion  (angle  of  the  lower  jaw) ;  /,  inion  (external  occipital  protuber- 
ance):  L,  lambda  "(junction  of  sagittal  and  lambdoidal  sutures) ;  N,  nasion  (junction  of  the  nasal  and 
frontal) ;  Ob,  obelion  (the  sagittal  suture  between  the  parietal  foramina) ;  P,  pterion  ^ point  of  junction 
of  great  wing  of  sphenoid  and  the  frontal,  parietal,  and  squamous  bones.  This  may  be  H-shaped  or 
K-shaped,  or  "  retourn^,"  in  which  the  frontal  and  temporal  just  touch) ;  S,  stephanion  (or,  better,  the 
superior  stephanion,  intersection  of  ridge  for  temporal  fascia  aud  coronal  suture) ;  S',  inferior  ste- 
phanion (intersection  of  ridge  for  temporal  muscle  and  coronal  suture). 

and  Figs.  206,  207,  and  208  show  the  chief  fissures  and  convolutions  of  the 
brain. 

The  fissure  of  Bichat  between  the  cerebrum  and  the  cerebellum  corre- 
sponds to  a  line  drawn  from  the  inion  to  each  external  auditory  meatus.  The 
median  fissure  between  the  two  hemispheres  is  slightly  to  the  right  of  the 
median  line,  the  left  hemisphere  in  right-handed  persons  being  slightly  larger 
than  the  right,  and  vice  versd  in  left-handed  persons.  The  two  lines  just 
given  also  correspond  respectively  to  the  lateral  and  superior  longitudinal 
sinuses. 

The  other  three  leading  fissures  which  it  is  important  to  be  able  to  locate 
on  the  exterior  of  the  skull  are,  1,  the  fissure  of  Rolando ;  2,  the  fissure  of 
Sylvius ;  and  3,  the  intraparietal  fissure ;  especially  the  first  two. 

1.  The  Fissure  of  Rolando  (Figs.  206,  c,  and  2<>7,  e),  as  Thane  has  shown, 
starts  from  a  point  which  lies  back  of  the  glabella  55.7  per  cent,  of  the  distance 
from  the  glabella  to  the  inion,  and  runs  downward  and  forward  at  an  angle  of 
67°,  its  average  length  being  3f  inches.  The  lower  third  of  the  fissure  changes 
to  a  somewhat  more  vertical  direction.     Practically,  the  fissure  of  Rolando 


492 


AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 


commences  half  an  inch  behind  the  mid-point  between  the  glabella  and  the 
inion.     Mr.  Horsley  states  that  in  a  head  with  a  cranial  index  of  75'  the  fissure 

Fifi.  2or,. 


s.  - 


— -P 


View  of  the  Brain  from  Above  (Ecker). 

A,  anterior  central  or  ascending  frontal  convolution ;  B,  posterior  central  or  ascendin?  parieUl  convo- 
lution ;  c.  central  fissure  or  fissure  of  Rolando  ;  cm,  calloso-marrinal  sulcus ;  F,  frontal  lobe  ;  / , ,  upper, 
F,,  middle,  F3,  lower  fronUl  convolution;  /,,  superior  frontal  sulcus ;  /,,  inferior  frontal  stJcus ;  /,, 
vertical  fissure  (sulcus  pr!ecentralis) ;  jp,  intraparietal  sulcus ;  O,  occipital  lobe;  o',  sulcus  occipitalis 
transversus;  0,,  first  occipital  convolution;  0.„  second  occipital  convolution ;  P,  parietal  lobe;  po, 
parieto-occipital  fissure;  Fy,  upper  or  postero-parietal  lobule:  P^,  lower  parietal  looule,  constituted 
oy  P-^<  gyrus  supramarginalis,  andiP2't  gyrus  angularis ;  S,  end  of  the  horizontal  branch  of  the  fissura 
Sylvii;  <,,  upper  temporal  fissure. 

runs  at  an  angle  of  69°,  the  angle  increasing  or  diminishing  one  degree  for 
every  two  degrees  of  increase  or  decrease  in  the  cranial  index.  In  all  ordinary 
cases,  however,  the  fixed  angle  of  67°  will  be  found  sufficient. 

Chienes  Method. — Mr.  Jolin  Chiene  of  Edinburgli  has  proposed  a  method 
of  fixing  the  position  and  length  of  the  Rolandic  fissure  which  is  at  once  sim- 
ple, ingenious,  and  always  available.  He  folds  a  square  piece  of  paper  once 
^Fig.  209,  ABCD).  on  the  diagonal  line  AC.  The  angle  BAG  is  then  evi- 
dently 45°.  The  angle  DAC  (45°)  is  then  halved  (22.5°)  by  folding  the 
paper  again  on  the  line  AE.  The  sum  of  the  angles  BAG  and  GAE  is 
evidently  67.5°,  which  is  near  enough  for  all  practical  purposes  to  the  angle 
of  the  fissur'i  of  Rolando.  The  side  AB  is  tlien  applied  to  the  middle  line 
of  the  head,  the  point  A  being  placed  half  an  inch  behind  the  mid-point 
between  the  glabella  and  the  inion,  when  the  line  AE  will  correspond  to  the 
fissure  of  Rolando. 

1  The  cranial  index  is  found  by  dividing  the  transverse  diameter  of  the  head  by  the  antero- 
posterior diameter. 


DISEASE,^   AND    INJURIES    OF    THE   HEAD. 

Fig.  207. 


49a 


Outer  Surface  of  the  Left  Hemisphere  (Ecker). 


A  antPrior  ppntral  or  ascending  frontal  convolution :  B,  posterior  central  or  ascending  parietal  convo- 
'  Intion  •  ^sulcus  centrX  of  fissure  cf  Rolando ;  cm,  termination  of  the  calloso-marginal  fissure  ;  F. 
frontal  lobe-  F  superior  F.  middle,  and  F3,  inferior  frontal  convolutions:  /„. superior,  and/,,  infe- 
rior f^onta^su^lcusT  °ucus  p^^^  ?p,  sulcus  intra-parietalis;  O,  occipital  lobe  ;  O,  first,  O,, 
second  O  third  ocdpifaconStions  ;  oi  sulcus  occipitalis  transversus ;  o„  su  cus  occipitalis  longi- 
?,Xaii?infS  P  EtaK^^^  po,  parieto-occipitaf fissure ;  P..  superior  parietal  or  postero-parie- 
tel  lobule  pT  inferior  parieta^^^^^^^^  P,.  gyrus  supramarginalis  ;  P^-F^us  annularis;  &  fis- 
sfirP  of  svl'vhis  «'  horizontal  S"  ascending  ramus  of  the  same ;  T,  temporo-sphenoidal  lobe ;  1  „  first. 
TrsecoDd.  TstVhiVd  tem^^^^                      coVolutions ;  t,,  first.  U,  second  temporo-sphenoidal flssurea. 


Fig.  208. 


Inner  Surface  of  Right  Hemisphere  (Ecker). 


-ispiii^iiiilSl^ 

l^me=-'o'"cuneu  "ff  ^arS\\a?lob^ 

Mdpito-t4mpomUs  lateralis  globulus  fusiformis) ;  T.„  gyrus  occipito-temporalis  medialis  (lobulus  liu- 

gualis) ;  U,  uncinate  gyrus. 


494 


AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 


The  length  of  the  fissure  being  ^l  inches,  Mr.  Cliiene  suggests  that 
every  man  who  has  seen  his  mother  measure  her  tape  on  her  right  fore- 
finger should  know  what  point  on  his  own  right  forefinger  corresponds  to 
3|  inches  in  length.      This  will  give  the  length  of  the  fissure  of  Rolando  on 

tlie  line  AE. 

Fio.  20y. 


V 

■T    -     1    - 

B 

l\\ 

/            / 

'           / 

1  \ 

V 

\ 

'^  1 

1      \ 

V        ,>      /            /o 

1 

Vv>:-\ 

/€ 

1 

\          y 

\ 

1 
1 

1 

\ 

\ 
\ 
\ 

\ 

1b 

e\ 

\ 

Chiene's  Method  (jf  Fixing  Position  of  Rolandic  Fissure  (original). 

Mr.  Horsley  has  devised  an  instrument  made  of  metal  or  of  two  strips 
of  parchment  paper,  as  shown  in  Fig.  210,  the  antero-posterior  arm  being 
14  inches  long,  and  the  lateral  arm  being  placed  at  an  angle  of  67°.  The 
scale  of  this  instrument  starts  from  the  zero  point  (half  an  inch  in  front 
of  the  lateral  arm),  and  runs  both  forward  and  backward.  To  determine 
the  fissure  of  Rolando,  place  the  antero-posterior  arm  in  the  middle  line 
in  such  a  position  that  the  glabella  and  the  inion  will  each  mark  the  same 
distance  from  the  zero  point  on  the  scale;  for  instance,  each  six  or  six  and 
a  half  or  seven  inches.  The  laternl  arm  will  then  correspond  to  the  fissure 
of  Rolando,  except  in  the  lower  third,  where,  as  already  stated,  the  fissure 

Fk;.  210. 

rTr,.^i.,.ii.ii.i..ii.^i.i.f.i,f,iT,i,p,,,r,i.r,i,r,i,F,i,i 


Horsley's  Cyrtonieter  (as  modified  by  Dr.  Morris  .1.  Lewis). 

becomes  slightly  more  vertical.  To  admit  of  its  use  on  both  sides  of  the 
skull  the  lateral  arm  should  be  made  reversible  right  and  left,  or  the  whole 
instrument  may  be  reversed  from  side  to  side  if  it  is  graduated  on  both 
sides.  In  children  below  nine  years  of  age  the  fissure  is  much  more  obliijue 
(even  down  to  02°),  and  lies  farther  forward  on  account  of  the  slighter 
development  of  their  frontal  lobes. 

Kriinlein  has  recently  proposed  a  .'dimple  and  accurate  method  of- locating 
the  fissures  of  the  brain  as  follows  (Fig.  211):  (1)  The  base-line.  ZJ/,  runs 
horizontally  at  the  lower  border  of  the  orbit  and  the  upjier  border  of  the 
auditory  meatus.  (2)  Parallel  with  this,  on  a  level  with  the  supra-orbital 
ridge,  another  horizontal  line  {KK')  is  drawn.     (3)  An  anterior  vertical  line 


DISEASES   AND    IXJ CRIES    OF    THE   HEAD. 


495 


{ZK)  is  drawn  from  the  middle  of  the  zygoma  to  the  supra-orbital  line. 
(4)  A  middle  vertical  line  is  drawn  from  the  articulation  of  the  lower  jaw  A, 
and  })roloiiged  to  R.  (5)  A  posterior  vertical  line  is  drawn  from  the  posterior 
])order  of  the  base  of  the  mastoid  [MK')  and  ])rolonged  to  1*.  the  middle  line 
of  the  skull.  (6)  Draw  a  line  from  K  to  I*.  Between  the  points  li  and  P'  it 
corresponds  to  the  fissure  of  lUjlando.  (7)  Bisect  the  angle  PKK'  by  the 
line  KS.     This  line  corresponds  to  the  fissure  of  Sylvius  from  its  bifurcation 

Fh;.  211. 


Supra-orbital  line  (upper  horizontal) 


Auriculo-orhital  line  (lower  horizontal^) 


Kronlein's  method  of  locating  the  fissures  of  Rolando  iHP')  and  of  Sylvius  (KS):  Kronlein's  points  of 
trephining  for  hemorrhage  from  the  middle  meningeal  (KK') :  and  von  Bergmann's  region  for  tre- 
phining for  abscess  of  the  temporo-sphenoidal  lobes  (AaK'M ). 


to  its  posterior  end.  The  point  K  is  over  the  bifurcation  of  the  fissure  of 
Sylvius.  K  and  K'  are  the  points  for  trephining  to  reach  the  anterior  and 
posterior  branches  of  the  middle  meningeal  artery.  The  method  applies 
equally  to  all  varieties  in  the  shape  of  the  head. 

The  importance  of  fixing  the  fissure  of  Rolando  will  be  especially  appre- 
ciated in  observing  the  motor  centers  which  cluster  around  this  bv  far  the 
most  important  of  the  cerebral  fissures. 

^  This  lower  or  '"  German  horizontal "  is  the  same  as  "  Reid's  base-line." 


496 


AN  AMERICAN    TEXT-BOOK    OF  SURGERY. 


FR 


POFi 


2.  The  Fissure  of  Sylvius  (Fig.  207,  S,  S',  S",  and  Fig.  212,  SF  and 
A). — To  fix  this  fissure,  draw  a  lino  from  EAP  (Fig.  212),  the  external  angu- 
lar process,   to    Ol'r,    by 
Fig.  •IVl.  the  siiortest  route  between 

these  points.  This  usually 
passes  at  about  haltan  inch 
above  the  meatus.  The 
fissure  of  Sylvius  begins 
one  and  one-eighth  inches 
posterior  to  the  exter- 
nal angular  process  on 
this  line,  and  from  this 
point  the  main  line  of  the 
posterior  branch  of  the 
fissure  of  Sylvius  (Fig. 
212,  SF)  runs  in  a  direct 
line  toward  the  parietal 
eminence,  PE.  The  as- 
cending or  anterior  limb 
of  the  fissure  corresponds 
closely  to  the  squamoso- 
sphenoidal  suture  in  its 
entire  length,  and  is  con- 
tinued upward  in  the  same 
line  for  half  an  inch  or 
more  (Fig.  212,  A).  The 
middle  meningeal  artery 
is  shown  in  the  same  fig- 
ure in  its  relation  to  the 
Sylvian  and  Kolandic  fis- 
sures. 

The  pre  -  central 
sulcus,  or,  as  it  is  often 
called,  the  vertical  sul- 
cus (Fig.  207,  P)  is  of 
great  importance,  as  it  limits  the  pre-Kolandic  convolution  anteriorly.  It  is 
sometimes  joined  by  the  inferior  frontal  sulcus  (Fig.  207,  /^).  It  runs  parallel 
to  and  just  behind  the  coronal  suture,  at  the  width  of  one  convolution  in  front 
of  the  fissure  of  Rolando.  Its  upper  end  does  not  extend  as  far  as  the  superior 
frontal  sulcus.  The  pre-Rolandic  or  ascending  frontal  convolution  bends  around 
the  lower  end  of  the  pre-contral  sulcus  forward  and  forms  a  crescentic  convo- 
lution which  lies  in  the  hollow  of  the  two  limbs  of  the  fissure  of  Sylvius  and 
is  continuous  anteriorly  with  the  third  frontal  convolution.  It  is  called  the 
operculum,  and  in  it,  especially  in  its  anterior  portion  (the  base  of  the  third 
frontal  convolution),  is  Broca's  center  for  speech. 

There  are  two  frontal  sulci,  the  superior  and  inferior,  which  divide  the 
frontal  lobe  into  three  convolutions:  the  superior,  middle,  and  inferior,  or  first, 
second,  and  third,  frontal  convolutions.  The  Hiipe7'ior  frontal  sulcus  (Figs. 
20()  and  207,  /^)  starts  from  the  pre-Rolandic  convolution  about  midway 
between  the  fissure  of  Rolando  and  the  line  of  the  pre-central  sulcus.  The 
inferior  frontal  sulcus  (Figs.  200  and  207,/^)  starts  from  the  vertical  sulcus 
and  runs  forward  parallel  Avith  the  superior  frontal  sulcus.  It  lies  about  on  a 
level  with  the  superior  temporal  ridge  or  superior  stcphanion  (Fig.  20"),  S). 


Head,  Skull,  and  Cerebral  Fissures  (adapted  from  Marshall 
by  Hare). 

B  corresponds  to  Broca's  convolution  :  EAP,  external  angular  pro- 
cess ;  FK,  fissure  of  Rolando  :  I  F,  inferior  frontal  sulcus  ;  TPF,  in- 
traparietal  sulcus  ;  MMA.  iniddli'  ineninKcal  artery  ;  OPr,  occipital 
protuberance;  PE,  parietal  eniiiii'ncf ;  POF,  parieto-occipitai  fis- 
sure :  SF,  Sylvian  lissure  :  A,  its  aseendiuK  limb  ;  TS,  tip  of  temporo- 
sphenoidal  lobe.  The  pterion  (to  tlie  left  of  B)  is  the  region  where 
three  sutures  meet,  viz.,  those  bounding  the  great  wing  of  the 
sphenoid  where  it  joins  the  frontal,  parietal,  and  temporal  bones. 


JJ/SJJASI'JS   AND    IX.nillF.S    OF    Till':    UFA  I). 


497 


Fig.  213. 


3.  The  Intraparietal  Fissure  (Figs.  20(5  and  207,  iij)  lies  posterior  to 
the  fissure  ot"  liulamlo,  and  is  the  posterior  boundary  of  the  motor  region.  It 
begins  opj)osite  the  junetion  of  the  nii(hlle  and  inferior  thirds  of  the  fissure  of 
Kohmdo.  I'assing  upAvard,  it  lies  midway  between  the  fissure  of  Rolando  and 
tile  parietal  boss.  It  then  diverges  from  the  fissure  of  Rolando  posteriorly, 
antl  thus  widens  the  upper  end  of  the  post-llolandic  convolution  to  such  an 
extent  that  the  upj)er  end  of  this  convolution  is  known  as  the  Hiqyerior  j)arietal 
Ivhuh'  (Figs.  20(),  207,  and  20^,  P").  In  the  middle  of  its  course  the  intraparietal 
fissure  runs  about  parallel  to  the  great  longitudinal  fissure  and  midway  between 
it  and  the  parietal  boss.  Farther  back  it  passes  by  the  parieto-occipital  fissure 
and  downward  and  backward  into  the  occipital  lobe.  Below  its  curve,  at  the 
ends  of  the  Sylvian  and  first  temporal  fissures  respectively  (S'  and  ^\  Fig.  207), 
are  the  supramarginal  (P,)  and  angular  (V^')  gyri.  Once  these  fissures  are 
determined  from  tlie  outside  of  the  skull  and  the  brain  exposed,  the  latter  can 
be  faradized,  and  the  exact  localization  of  the  motor  cortical  centers  can  be 
determined  by  the  movements  produced  by  faradization.  This  has  been  done 
in  a  number  of  cases  with  unexpected  accuracy. 

For  a  more  minute  localization  of  the  other  fissures  and  convolutions  of 
the  brain  the  reader  is  referred  to  the  American  edition  of  Gray's  Ar^atomy 
for  1887,  p.  681,  and  to  the  article  on  "  The  Surgery  of  the  Brain,"  Buck's 
Reference  Handbook  of  the  Medical  Sciences,  vol.  viii.  p.  201. 

Figs.  213  and  214  show  the  position  of  the  chief  motor  areas  in  the 
brain  of  the  monkey,  as  determined  by  Horsley  and  Schafer,  which  correspond 
closely,  as  has  frequently 
been  shown,  to  the  same 
cortical  centers  in  man. 
Roughly  speaking,  the 
upper  third  of  the  con- 
volutions in  front  of  and 
behind  the  fissure  of  Ro- 
lando corresponds  to  the 
center  for  the  movements 
of  the  leg ;  the  middle 
third  corresponds  to  those 
for  the  arm  (beginning 
at  the  upper  end  with  the 
shoulder  center,  the 
middle  part  the  elbow 
center,  and  the  lower 
the  hand  center).  In 
the  lower  third  lie  the 
face  center  and  the 
center  for  the  mouth  and  larynx.  The  centers  for  the  face,  leg,  and  trunk, 
it  will  be  noticed  in  Fig.  214,  are  largely  situated  on  the  median  surface  of 
the  hemispheres  as  well  as  on  their  external  surface.  Broca's  center  for 
speech  lies  just  in  front  of  the  end  of  the  fissure  of  Rolando,  and  in  the 
angle  formed  by  the  main  trunk  and  the  anterior  limb  of  the  fissure  of 
Sylvius. 

The  center  for  vision  is  situated  chiefly  in  the  cuneus  (Fig.  208,  Oz),  a 
lesion  of  which  produces  blindness  of  the  corresponding  (right  or  left)  half  of 
both  retinse.  The  supramarginal  and  angular  gyri  are  also  probably- 
concerned  to  some  extent  in  vision.  These  same  convolutions  (supramargi- 
nal and  angular)  are  the  seat  of  certain  mental   processes,  the  abolition  of 

32 


Motor  Areas  on  tlie  Outer  Surface  of  the  Brain  of  the  Monkey 
(Horsley  and  Schafer). 


498 


AX  AMKJilCAX    TEXT-liOOK    OF  SVlidERY. 


Motor  Areas  on  the  Median  Surface  of  tlie  Brain  of  the  Monkey 
(Horsley  and  Schafer). 


wliicli  piuducL'S  .sensory 
apliasia,  alexia,  agraphia, 
apraxia,  etc. ;  for  the  de- 
tails of  which  see  page 
r>4(j.  '{"lie  cfiitcr  for 
hearing  is  pi-oljably  sit- 
u:itc(l  in  the  luitldle  mikI 
jtosterior  |)arts  of  tiie 
first  tempore -sphe- 
noidal coiivolittioii  (Fig. 
:i')7,  T'j.  The  center  for 
smell  is  pi-obaldy  situ- 
ated in  the  uncus,  near 
the  lower  part  of  the 
hippocampus  major  (Fig. 
208,  U). 


III.— TECHNIQUE  OF  CEKEBRAL  OPERATIONS. 

We  owe  this  chiefly  to  Mr,  Horsley's  brilliant  papers.  It  is  always  of  the 
utmost  importance  that  the  head  should  be  shaved.  This  will  often  reveal 
scars,  etc.  hitherto  unsuspected,  and  no  definite  diagnosis  should  over  be  reached 
or  an  operation  determined  on  without  this  procedure.  The  fissures,  so  far 
as  is  necessary,  may  be  marked  out  on  the  shaven  scalp  by  means  of  an  aniline 
pencil,  which  is  itself  antiseptic.  Of  course,  after  being  shaved,  the  patient 
should  be  protected  against  catching  cold  by  a  silk  handkerchief  or  cap  around 
the  head.  The  day  before  the  operation  the  head  should  be  shaved  anew  if 
need  be,  scrubbed  with  soap  and  water,  next  cleaned  with  ether,  and  then 
covered  with  a  sublimate  dressing,  the  three  or  four  inner  layers  of  which  may 
be  wet  with  a  sublimate  solution  1 :  2000,  as  a  1  :  1000  solution  might  vesicate. 
This  dressing  should  be  retained  in  place  until  the  operation,  when  the  disin- 
fection should  be  repeated.  There  is  no  need  for  the  spray.  Of  course  all  the 
ordinary  operative  precautions  described  elsewhere,  as  to  the  thorough  cleansing 
of  the  finger-nails,  hands,  and  arms  of  the  operator  and  liis  assistants,  should  be 
carried  out  Avith  scrupulous  care. 

Ether  or  chloroform  may  1)0  used,  and  it  is  better  to  operate  with  the  patient 
in  the  seml-recumbent  position  rather  than  lying  flat,  in  order  to  diminish 
the  amount  of  hemorrhage.  It  is  important  to  mark  three  points  on  the  bone : 
viz.  the  place  at  which  the  center  pin  of  the  trephine  is  to  be  applied,  and 
the  upper  and  lower  ends  of  the  fissure  of  Rolando  at  points  just  outside  the 
flap,  in  order  that  the  fissure  may  be  recognized  after  the  flap  has  boon  raised. 
This  is  best  done  by  using  the  center  pin  taken  out  of  another  trephine,  by 
means  of  which  a  little  triangular  point  can  be  marked  on  the  bone,  using  the 
rongeur  forceps,  for  example,  as  a  hammer,  or  a  very  small  gouge  will  nick  the 
bone  sufficiently  to  enable  it  to  be  recognized. 

The  flap  to  be  raised  should  be  of  a  horseshoe  shape,  with  a  diameter  of 
about  three  inches.  As  a  rule,  the  base  of  the  flap  should  be  below,  on  account 
of  tlie  more  favorable  l)lood-supply.  The  flaj)  of  periosteum  should  be  raised 
with  the  scalp.  The  hemorrhage  is  best  controlled  by  seizing  the  edge  of  the 
flap  at  the  bleeding  points  with  hemostatic  forceps. 

The  trephine  opening,  Avith  rare  exceptions,  should  be  large,  not  less 
than  \\  inches.  Once  tlie  trephine  opening  is  made,  it  can  be  enlarged  by  the 
rongeur  forceps  (Fig.  216)  to  any  extent  desired.    Before  enlarging  it  the  dura 


J)Lsi:a.ses  axi)  ixjcuies  of  the  head. 


499 


slioiild  be  separated  from  the  bone  by  Ilorslcy's  diiral  separator  (Fig.  215), 
by  means  of  Avhieli  also  tlic  inner  surfaee  of  the  skull  can  be  explored,  and 
any  irregularities  detected,  two  inches  or  more  from  the  trephine  opening. 


Fkj.  '_'!"). 


Horsley's  Dural  Separator. 

Osteoplastic  Resection. — In  1889,  Wagner,  following  an  earlier 
suggestion  of  Woltt",  proposed  to  make  a  temporary  osteoplastic  resec- 
tion by  chiselling  loose  the  piece  of  bone  to  be  removed,  except  at  one 
portion  where  it  was  fractured  and  turned  back  on  the  scalp  as  a  hinge. 
The  scalp  is  incised  down  to  the  bone,  the  flap  not  being  loosened  from  it. 
By  mallet  and  chisel  the  bone  is  then  nearly  cut  through  at  every  point 
excepting  its  base,  the  separation  being  completed  by  an  osteotome.  It  is 
then  lifted  by  means  of  elevators,  the  base  being  fractured,  a  window,  so  to 


Fig.  216. 


Fig.  211 


Hopkins'  Rongeur  Forceps,  as  modified  by  Weir. 


Osteoplastic  Restction  of  SLull  b\  the  Wagner- 
WolU  Method  (Lsmarch  and  Kowalzig;. 


Fig.  218 


Keen's  Rongeur  Forceps 


speak,  being  opened  by  turning  back  the  flap  (Fig.  217).  By  this  means 
access  can  be  had  to  a  very  large  area  of  the  brain-cortex  ;  even  three,  four, 
or  five  inches  have  been  thus  exposed.  When  the  operation  is  terminated 
the  opening  is  closed  by  replacing  the  flap,  which  is  sutured  in  place  as  usual. 
In  chiselling  such  a  piece  loose  it  is  best  to  chisel  it  obliquely,  so  that  the 
opening  in  the  inner  table  will  be  a  little  smaller  than  that  in  the  outer,  the 
inner  table  thus  forming  a  shelf  on  which  the  flap  rests.      The  base  of  the 


500  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

llaj),  wliioh  serves  as  a  hinge,  should  alwavs  be  in  that  part  of  the  Ikip  having 
the  Largest  blood-suj)j)l\-. 

The  surgical  engine  with  a  special  drill,  an  electrical  motor  vith  a  saw, 
and  the  Gigli  -wire  saw  have  been  also  used  in  place  of  the  chisel. 

"  Trephining  "  in  the  remainder  of  this  chapter  >vill  be  used  in  the  sense 
of  opening  the  skull  to  obtain  access  to  its  interior,  irrespective  of  whether 
the  opening  is  made  by  the  trephine,  the  chisel,  or  any  other  means. 

As  a  rule,  the  dura  should  be  opened.  The  additional  danger  is  very 
slight,  and  the  additional  information  may  be  very  great.  With  rare  excep- 
tions, if  we  trephine  at  all  the  brain  itself  should  be  examined  by  sight  and 
touch.  The  opening  in  the  dura  is  best  made  parallel  with  the  edge  of  the 
bone  and  a  quarter  of  an  inch  away  from  its  margin.  Care  should  be  taken 
not  to  wound  the  large  and  troublesome  veins  of  the  brain  immediately 
beneath  the  dura.  This  can  best  be  avoided  by  lifting  the  dura  Avith  rat- 
toothed  forceps  while  making  the  first  incision  by  a  knife,  and  then  by  using  a 
blunt-pointed  pair  of  scissors. 

If  hemorrhage  occurs  from  any  branch  of  the  middle  meningeal,  it  may 
be  arrested  by  passing  a  ligature  through  the  dura  under  the  vessel  Ijy  means 
of  a  fine  semicircular  needle,  the  finest  Hagedorn  being  the  best.  For  check- 
ing hemorrhage  in  the  brain  the  chief  reliance  must  be  placed  on  catgut  (non- 
chromicized).  Some  of  the  larger  arteries  can  be  tied  directly,  but  in  many 
cases  it  is  better  with  the  fine  semicircular  Hagedorn  needle  to  pass  a  ligature 
through  the  brain  substance  and  around  the  vessel,  and  tie  it  with  great  gentle- 
ness, care  being  taken  to  see  that  the  traction  on  the  two  ends  of  the  ligature 
is  exactly  even,  in  order  not  to  tear  the  vessel.  The  knot  must  not  be  tied  too 
tightly,  or  it  will  cut  through  the  fragile  vessel.  Pressure  continued  for  a  few 
minutes  by  gauze  or  sponge  and  hot  water  at  105°  to  115°  will  often  serve  a 
good  purpose.  Sometimes,  especially  in  hemorrhage  from  the  sinuses,  the  hem- 
ostatic forceps  may  be  left  for  from  thirty-six  to  forty-eight  hours.  Usually, 
however,  pressure  upon  the  sinuses  or  plugging  them  is  the  best  means  of  con- 
trolling such  hemorrhage.  A  lateral  ligature  may  be  used  if  the  wound  is  small, 
or  the  entire  sinus  may  be  ligated  if  need  be. 

After  opening  the  dura  the  first  point  to  be  observed  is  whether  the  brain 
bulges  into  the  trephine  opening,  for  if  it  does  there  is  a  pathological  increase 
in  the  intracranial  pressure,  due  to  tumor,  abscess,  internal  hydrocephalus,  etc. 
Next  observe  the  color.  Lividity  or  a  yellowish  tinge  will  indicate  a  probable 
tumor  beneath  the  cortex.  An  old  laceration  will  usually  show  a  dirty  yel- 
lowish-brown. (Edema  of  the  membranes  is  not  uncommon,  even  to  such  an 
extent  as  in  great  measure  to  obscure  the  sulci  and  convolutions.  The  serum 
will  escape  on  nicking  the  membranes,  and  the  sulci  and  convolutions  may 
then  be  recognized.  Absence  of  pulsation  in  the  brain  usually  indicates  a 
large  tumor,  abscess,  or  cyst.  The  density  of  the  brain  can  best  be  deter- 
mined by  touch. 

If  the  brain  tissue  be  abnormal,  the  whole  abnormal  portion  ought  to  be 
removed.  In  doing  so  we  can  cut  much  more  freely  antero-posteriorly  than 
vertically  without  doing  damage,  as  in  the  vertical  direction  other  centers  than 
the  one  we  seek  are  more  quickly  encroached  upon  than  by  excision  antero- 
posteriorly.  (Compare  Fig.  213.)  When  the  brain  is  exposed,  if  we  wish 
to  recognize  any  motor  center  by  faradization,  no  antiseptics  should  be  used, 
as  they  all  dull  the  reaction  of  the  cortex  to  electricity,  but  only  sponges  or 
sterilized  gauze  wrung  out  of  hot  water.  For  faradization  of  the  brain  the 
ordinary  faradaic  battery  suffices.  The  current  should  not  be  too  strong,  lest 
it  do  harm  to  the  cortex.     A  current  sufficient  to  stimulate  the  thenar  muscles 


DISEASES  AND    IXJURIES    OF    THE  HEAD.  601 

is  that  usually  emijloyed.      A  doiilile  Ijraiii  olectroile*(Fig.  211t)  may  be  used 

Fui.  219. 


Double  Brain-electrode  (Keen). 


with  advantage.  The  points  should  be  sterilized  and  the  handle  wrapped  in 
antiseptic  gauze.  By  applying  the  electrodes  to  various  parts  of  the  cortex 
the  motor  centers  can  be  readily  determined  in  most  cases,  even  without 
opening  the  dura.  Notes  should  be  taken  of  the  phenomena  following  each 
application,  and  the  situation  of  the  points  stimulated  should  be  determined 
bv  exact  measurements.  A  stenographer  should  be  present  to  take  the  dic- 
tation of  the  observed  phenomena  rapidly  and  exactly.  As  a  rule,  it  is  better 
not  to  drain  after  cerebral  operations,  but  occasionally,  especially  in  cysts, 
drainage  is  a  matter  of  importance.  In  abscesses,  gunshot  wounds,  hemor- 
rhage, etc.  it  is  of  course  a  necessity.     Rubber  tubing  is  the  best  means. 

Not  uncommonly  the  hone  can  be  replaced.  Even  a  l|-inch  button  of  bone 
will  retain  its  vitality  and  re-establish  its  connection  with  the  skull  if  properly 
cared  for.  In  all  cases,  therefore,  where  there  is  a  possibility  of  the  replace- 
ment of  the  bone,  the  moment  it  is  removed  it  should  be  placed  in  a  bowl  con- 
taining a  1 :  2000  sublimate  solution,  and  the  bowl  be  placed  in  a  basin  of  hot 
water  the  temperature  of  which  is  kept  at  105°  to  100°  F.  This  should  be 
the  sole  care  of  one  assistant.  Instead  of  replacing  it  in  one  large  piece,  it 
may  be  bitten  into  small  pieces  by  bone  forceps.  The  pieces  bitten  away  by 
the  rongeur  forceps  may  be  similarly  utilized.  Sometimes  Senn's  decalcified 
ox-bone  can  be  better  used  than  the  bone  which  has  been  removed.  Of  course 
if  the  bone  be  diseased  or  very  compact,  or  it  be  desired  to  change  the  intra- 
cranial pressure,  as  in  cases  of  headache,  insanity,  etc.,  the  bone  should  not  be 
replaced.  In  this  case  a  small  disk  of  tin  can  be  advantageously  secured  to 
the  inside  of  a  skull-cap  to  protect  the  brain.  To  prevent  adhesion  of  the 
brain  disinfected  gold-foil  has  been  inserted.  Fraenkel  has  recently  filled  the 
opening  by  a  disinfected  celluloid  plate.  Kiinig  has  proposed  to  fill  the  gap 
of  an  old  fracture  by  chiselling  a  neighboring  piece  of  the  outer  table  away 
with  a  flap  of  scalp,  sliding  it  into  the  opening,  and  covering  the  wound  thus 
made  by  transplanting  skin  by  Thiersch's  method.  Instead  of  this, 
pieces  of  the  outer  table  of  the  neighboring  bone  may  be  chiselled 
away  and  scattered  thickly  over  the  dura.  They  are  held  in  place  by 
the  replaced  flap  of  scalp.  If  the  dura  has  been  removed,  and  it  is  still 
desired  to  replace  the  bone  in  one  large  piece,  this  may  be  perforated 
and  secured  to  tlie  under  surface  of  the  flap  by  catgut,  then  preferably 
chromicized. 

After  the  operation  on  the  brain  is  completed  the  dura  should  be  sutured 
by  interrupted  or  continuous  catgut  sutures  as  is  desired.  The  scalp  should  now 
be  replaced  and  secured  by  the  ordinary  interrupted  sutures,  and  an  abundant 
sublimate  dressing,  of  which  the  inner  lavers  may  be  again  Avet  with  a  solu- 
tion  of  the  strength  of  1  :  2000,  should  be  applied.  This  should  be  covered 
with  rubber  dam,  and  be  retained  in  place  by  a  bandage  and,  especially  in 
children  or  in  restless  adults,  by  a  night-cap.  As  soon  as  the  dressing  is 
moistened  to  its  margin  b}'  serous  or  bloody  discharge  the  wound  should  be 
redressed.  If  a  drainage-tube  has  been  used,  it  should  be  removed  at  the 
end  of  from  twenty-four  to  forty-eight  hours,  except  in  cases  of  abscess,  etc., 


502  AX  AMElilCAX    TEXT-IKJUK    OF  SURGERY. 

•when  it  .should  remain  for  some  days.  In  ease  no  drainage  has  been  provided, 
if  too  mueh  bh>od  and  serum  or  cerebro-sj)inal  fluid  aeeumulates  under  the 
flap,  as  shown  by  its  marked  bulging  and  possibly  by  paralysis,  the  uound- 
fluids  can  be  evacuated  by  inserting  a  probe  or  a  pair  of  forceps  between  two 
stitches.  As  a  rule,  by  the  fifth  or  sixth  day  about  half  the  stitches  may  be 
removed,  and  all  of  them  usually  by  the  seventh  or  eighth  day.  Absolute 
«|uietude,  both  of  mind  and  of  body,  should  be  insisted  upon,  esi)ecially  for 
the  first  week.  Xo  letters,  visitors,  or  other  causes  of  excitement  should  be 
allowed  for  some  time.  Though  sometimes  less  severe  restrictions  may  be 
required,  yet  this  course  should  be  enforced  for  two  weeks,  and  in  some  cases 
even  for  months,  after  the  operation. 

Operation  in  Two  Stages. — The  severe  shock  in  serious  operations  on 
the  l)rain  has  led  llor.-^k'y  and  other  surgeons  to  modify  the  procedure  by 
dividing  it  into  two  stages.  The  first  stao;e  consists  in  merely  effecting  an 
opening  into  the  skull.  This  is  then  closed  by  a  few  temporary  sutures. 
After  an  interval  of  from  three  to  six  days  the  wound  is  reopened  and 
the  operation  completed.  This  method  is  especially  applicable  to  opera- 
tions for  brain-tumors  and  occasionally  in  the  removal  of  the  Gasserian 
ganglion. 

Secondary  operations  are  not  uncommonly  recjuired  when  the  brain,  its 
membranes,  and  the  bone  will  all  be  adherent,  and  must  be  dissected  free  from 
one  another  with  great  care.  Some  of  the  brain  tissue  will  of  necessity  be  torn 
away,  and  more  or  less  pronounced  paresis  of  the  centers  corresponding  to  the 
interference  may  be  produced.  After  removal  of  a  motor  center  there  is  of 
course  entire  paralysis  of  the  part  supplied  by  this  center ;  and  the  pressure 
caused  by  the  blood-clot  which  accumulates  and  the  later  cell-proliferation  is 
apt  to  cause  widespread  paralysis,  amounting  even  to  a  hemiplegia.  After 
some  wxeks  this  invariably  disappears  to  a  greater  or  lesser  extent,  leaving, 
however,  the  affected  muscles,  it  may  be.  somewhat  paretic. 

If  any  portion  of  the  dura  has  been  removed,  and  especially  if  this 
is  followed  by  removal  of  the  brain  substance,  there  is  a  marked  tendency  to 
proliferation  of  the  cerebral  tissue,  with  danger  of  a  fungus  cerebri  forming. 
This  may  be  prevented  by  taking  a  bit  of  the  pericranium  from  the  under  sur- 
face of  the  scalp,  turning  the  osteogenetic  surface  upward,  and  attaching  it  to 
the  dura  by  interrupted  sutures.  The  pericranium  will  very  quickly  contract 
adhesions  to  the  dura,  and  the  gap  will  be  closed  (Keen). 

The  limits  of  operative  procedure  are  constanth'  being  enlarged. 
Once  the  skull  is  trephined,  we  can  explore  the  inner  surface  of  the  skull 
over  a  wide  area  by  the  dural  separator  or  probe.  If  the  dura  has  been 
opened,  the  finger  can  be  gently  inserted  between  the  brain  and  the  dura  and 
the  .surface  of  the  brain  explored  for  at  least  an  inch  all  around  the  opening 
in  the  dura.  The  brain  can  be  readily  depressed  by  the  finger  or  the  knife- 
handle  used  with  gentleness,  and  the  eye  can  see  for  an  inch  beyond  the  dural 
opening.  If  the  opening  be  toAvard  the  base  of  the  brain,  the  brain  may  be 
lifted  either  with  or  without  the  dura  and  the  base  of  the  skull  explored  for  a 
considerable  distance.  The  cerebellum  can  be  lifted  and  the  finger  and  the  eye 
can  reach  to  the  foramen  magnum.  The  sinuses  can  be  safely  uncovered  and 
separated  from  the  skull,  and  the  frontal  lobe  lifted  far  enough  to  discover  the 
anterior  clinoid  process,  while  laterally  the  surfaces  of  the  petrous  bone  can  be 
explored.  The  brain  can  be  punctured  almost  with  impunity,  especially  if  a 
blunt  instrument  like  a  grooved  director  be  used,  so  as  not  to  wound  the  large 
vessels,  and  the  ventricles  can  be  tapped. 


DISEASES   AND    IXJIRIES    OF    THE   HEAD.  503 


IV.— DISEASES  INVOLVING  THE  SCALP. 

1.  Inflammation  of  the  Scalp. — This  is  a  frequent  sequence  of  wounds, 
and  will  be  referred  to  later.  It  is  often  caused  by  the  poison  ivy  or  poison 
oak  and  by  erysij)t'las,  and  is  described  under  these  heads. 

II.  Tumors  of  the  Scalp. — 1.  The  most  frequent  of  all  are  the  Seba- 
ceous Tumors,  or  Wens.  The  pathology  of  these  tumors  will  be  found  in  the 
chapter  on  Tumors.  Their  diagnosis  is  easy.  They  are  frequently  multiple, 
are  of  slow  growth,  vary  in  size  from  that  of  a  pea  to  that  of  a  small  egg, 
are  painless,  and  have  an  elastic,  cystic  feel.  Occasionally,  especially  near  the 
angle  of  the  eye,  they  are  dermoid  in  character,  having  a  number  of  hairs  inter- 
mingled with  the  sebaceous  contents.      Sometimes  they  ulcerate. 

The  treatment  is  extirpation.  In  removing  them  it  is  not  necessary  to 
shave  the  scalp,  but  the  hair  should  be  neatly  parted  over  them,  all  grease 
removed  from  the  scalp,  which  is  next  thoroughly  disinfected  with  a  bichloride 
solution.  An  incision  is  then  made  down  to  the  wall  of  the  tumor,  when  it 
can  usually  be  enucleated  without  difficulty.  It  is  very  important  to  leave 
none  of  the  cyst-wall  behind,  or  the  tumor  will  be  reproduced.  A  simple 
bichloride  dressing  and  a  bandage  complete  the  operation.  Unless  the  tumor 
is  large,  neither  drainage  nor  sutures  are  necessary.  Usually  the  wound  will 
be  entirely  well  in  three  or  four  days. 

2.  Fatty  Tumors  occur  rarely  in  the  scalp,  and  are  very  difficult  to  diag- 
nosticate from  the  sebaceous,  as  they  resemble  them  in  almost  all  respects. 
They  are  apt,  however,  to  be  somewhat  flatter  and  less  globular,  and  also  to 
be  situated  more  deeply  than  the  sebaceous  tumors,  not  uncommonly  being 
next  the  pericranium.  An  error  in  diagnosis  is  of  no  importance,  however,  as 
the  treatment  is  identical — extirpation. 

3.  Congenital  Cysts  and  Fibromata  may  occasionally  occur  in  the 
scalp.  The  diagnosis  is  perfectly  clear,  and  the  treatment  equally  so — entire 
removal. 

4.  Warts  and  Horns  are  not  uncommon.  Horns  should  be  removed  by 
the  knife.  Warts,  when  they  are  inconspicuous  and  non-irritating,  may  be 
disregarded,  but  if  they  show  the  least  tendency  to  grow  they  should  be  removed 
by  the  knife,  as  they  sometimes  become  malignant. 

5.  Moles  are  a  local  hypertrophy  of  the  skin.  There  are  two  forms : 
first,  the  hairi/  mole,  covered  with  more  or  less  stiff,  bristle-like  hairs,  and 
without  discoloration  of  the  skin ;  and,  second,  the  pigmented  mole,  in  Avhich 
the  skin  is  discolored  and  of  a  brown  or  black  tint.  Sometimes  they  are  of 
sufficient  size  to  become  serious  disfigurements,  and  must  then  be  removed  by 
the  knife  after  local  anaesthesia  by  cocaine.  If  very  large,  sometimes  either 
transplantation  of  skin  or  a  plastic  operation  may  make  good  the  defect  pro- 
duced by  their  removal. 

6.  Pneumatocele,  or  a  tumor  filled  with  air,  is  very  rarely  met  with. 
Treves  states  that  only  ten  cases  are  on  record.  It  is  most  frequently  a  result 
of  spontaneous  atrophy  of  the  osseous  tissue  producing  a  communication  with 
the  mastoid  cells.  The  air  then  escapes  under  the  pericranium,  forming  a 
tumor  which  may  vary  in  size  up  to  that  of  a  pigeon's  egg.  It  is  painless, 
elastic,  smooth,  and  tympanitic  to  percussion.  Pressure  will  ordinarily  oblit- 
erate the  tumor.  The  treatment  is  usually  compression  after  emptying  the  sac 
of  its  air  by  pressure  or  by  the  needle  of  a  hypodermatic  syringe. 

III.  Arterial  Varix,  or  Cirsoid  Aneurysm. — This  is  a  peculiar  dila- 
tation of  the  arteries  resembling  the  varix  of  varicose  veins,  but  as  it  exists  in 
arteries  it  is  called  arterial  varix.     It  occurs  most  frequently  in  the  scalp  and 


504  AN   A. U /■:/,'/(■  A. \    TKXT-noOK    OF   SlltdKliV. 

the  liand.  The  arteries  becoiiu-  dihitrd,  the  uiiddlo  coat  es])ecially  underf^oing 
atrui)liy,  and  are  elongated  and  tortuous,  like  ordinary  varieosc  veins.  True 
aneurysmal  jmuches  as  large  as  the  last  joint  of  the  linger  or  tlnnnb  are  felt  at 
various  points.  The  whole  mass  pulsates  synchronously  uith  the  heart,  and  a 
marked  bruit  is  heard  with  the  stethoscope  (sec  P'ig.  ')•>). 

There  is  no  difficulty  in  making  the  diagnosis,  Imt  the  treatment  is 
much  less  satisfactory.  Ligation  of  one  or  both  carotid  arteries  has  been  done, 
but  only  occasionally  has  it  been  satisfactory.  Excision  has  occasionally  been 
resorted  to,  and  is  perhaps  the  best  method,  but  it  should  be  done  oidy  by  an 
experienced  surgeon,  as  it  is  apt  to  be  very  bloody  and  difficult.  Hypoder- 
matic injections  of  tincture  of  chloride  of  iron  and  of  pure  alcohol  have  both 
been  successful,  as  has  also  galvano-puncture.  Direct  ligation  all  around 
the  periphery  by  multiple  ligatures  tied  over  compresses  of  gauze  has  also 
proved  successful.  The  ligature  should  be  inserted  by  means  of  a  curved 
Hagedorn  needle,  and  should  go  all  the  way  to  the  bone,  in  order  to  include 
the  dilated  deep  branches.  Subcutaneous  ligature  has  been  tried,  the  so- 
called  Barwell's  scarless  method,  by  a  curved  needle  carrying  the  thread  from 
point  to  point,  being  inserted  anew  at  each  point  of  exit  and  carried  to  the 
next  point.  This  method  can  be  adapted  to  the  ligation  of  the  aneurysm  in 
sections,  or  if  small  the  entire  mass  can  be  secured  by  one  ligature.  If  not 
increasing  and  not  a  source  of  annoyance,  it  may  well  be  let  alone. 

IV.  Capillary  Varix,  Naevus,  or  Mother's  Mark. — These  are  of  two 
varieties  :  1.  One  made  up  of  capillary  vessels  of  good  size,  presenting  a  small, 
straivherry-like  tumor,  somewhat  elevated  above  the  skin.  Naevi  of  this  variety 
are  very  apt  to  increase  steadily  in  size  until  they  become  a  serious  danger 
from  hemorrhage.  They  should  be  removed  early  in  life,  especially  if  they 
show  any  tendency  to  enlarge  and  invade  the  surrounding  healthy  skin.  If 
they  are  small,  the  best  way  is  to  put  a  pin  underneath  them  and  strangulate 
them  by  means  of  a  silk  ligature,  tied  tightly  under  the  pin,  which  prevents 
its  slipping  off.  It  is  very  important  that '  the  whole  of  the  nsevus  shall  be 
included  in  the  ligature,  and  if  it  is  too  large  to  be  thus  included  by  the  liga- 
ture and  a  single  pin,  it  is  better  to  insert  two  pins  at  right  angles  to  each 
other ;  or  a  double  ligature  may  be  passed  under  a  single  pin,  each  half  of  the 
ligature  being  tied  separately.  Excision  will  sometimes  answer  the  purpose 
where  the  naevi  are  small.  When  very  large,  however,  they,  must  be  ligated 
in  sections. 

2.  The  Port-wine  Mark  is  a  naevus  with  very  small  capillary  vessels,  which 
very  rarely  tends  to  enlarge,  but  may  in  itself  be  a  serious  deformity  by  its 
color  and  its  original  large  size.  Its  name  describes  very  well  its  appearance. 
The  best  treatment  is  excision,  and,  as  the  tissues  of  the  face  are  very  elastic, 
such  a  naevus,  even  of  considerable  size,  may  easily  be  removed,  leaving  only 
a  linear  scar.  If  too  large  for  this  method,  it  may  sometimes  be  destroyed  by 
passing  through  its  substance  parallel  threads  of  silk  soaked  in  a  tincture  of 
chloride  of  iron  or  Monsel's  salt.  Or  the  nrevus  may  be  frozen  a  part  at  a 
time,  cross-hatched  with  a  cataract  needle  or  knife,  the  hemorrhage  arrested 
by  steady  pressure  with  blotting  paper,  this  process  being  repeated  from  time 
to  time.  This  is  practically  painless  and  leaves  no  appreciable  scar.  Escha- 
rotics  and  the  cautery  have  also  been  successfully  used.  None  of  these  methods, 
however,  is  as  good  as  excision,  since  most  of  them  leave  unsightly  scars. 

V.  Lupus,  the  tubercular  origin  of  which  is  noAV  certain,  is  not  so  frequent 
on  the  scalp  as  on  the  face.  It  is  a  persistent  ulcer,  following  tubercular 
infiltration  of  the  skin,  which  gra<lually  invades  the  surrounding  sound  struc- 
tures and  makes  wide  havoc.     If  small  it  may   be  excised:    Koch's  lymph 


DISEASES   AND    TXJURIES   OF    THE   HEAD.  505 

seems  to  have  luul  a  heneiirial  iiilluciice  in  a  muiiber  of  cases.      It  may  also 
be  cured  sometimes  by  t]iorouo;h  cauterization  by  ra(iuelin's  cautery. 

v.— DISEASKS    AND    M  A  LFOKM  AT(  »NS    I  N  VoLV  I  N( ;     llli:   SKIF.L. 

T.  Periostitis,  Ostitis,  Caries,  ami  Necrosis  all  occur  in  the  bones 
of  the  skull  as  elsewhere.  They  very  often  follow  injuries,  are  rarely  tuber- 
cular in  origin,  and  still  more  rarely  may  follow  typhoid  fever.  V>y  far  their 
commonest  cause  is  syphilis,  Avhich  may  make  extensive  ravages  and  destroy 
large  parts  of  the  skiill.  The  dura  seeins  in  these  cases  to  resist  with  singular 
power  the  extension  of  inllannnation  as  a  meningitis.  Lai-gc  portions  of 
necrosed  bone  may  lie  on  a  bed  of  granulations  sjjringing  front  the  dura,  the 
inllannnation  being  absolutely  local  and  without  any  tendency  toward  a  general 
meningitis.  There  will  usually  be  either  the  history  of  an  injury  or  the  plain 
history  of  constitutional  syphilis,  with  evidences  of  its  existence  in  other  parts 
of  the  body. 

The  treatment  of  all  these  conditions  is  the  same  as  elscAvhere.  If  pus 
accumulates,  it  must  be  evacuated  as  early  as  possible.  If  sinuses  form,  they 
must  be  opened  speedily  and  be  scraped  and  disinfected  thoroughly.  If  caries 
exists,  the  bone  must  be  laid  bare  and  all  carious  bone  removed  with  sharp 
spoon,  gouge,  and  chisel.  Necrosis  may  affect  only  the  outer  table  or  the  entire 
thickness  of  the  bone.  •  The  sequestrum  and  necrosed  fragments  must  be  en- 
tirely removed.  In  no  part  of  the  body  is  it  more  important  to  insist  on  fre- 
quent dressings,  absolute  cleanliness,  and  the  securing,  so  far  as  possible,  of  an 
aseptic  condition ;  otherwise  the  odor  becomes  almost  intolerable.  Corrosive 
sublimate,  carbolic  acid,  iodoform,  aristol,  peroxide  of  hydrogen,  and  pyoktanin 
are  all  of  use  in  attaining  these  ends. 

II.  Hypertrophy  of  the  Bones  of  the  Skull,  with  sclerosis  and  dis- 
appearance of  the  diploe,  is  a  not  uncommon  result  of  osteitis  deformans,  and 
especially  of  hereditary  syphilis,  but  usually  recjuires  no  treatment.  A  local 
and  sometimes  widely-spread  enormous  thickening  of  the  skull  occurs,  known 
as  leontiasis  ossium.  If  not  too  extensive,  it  is  to  be  removed  by  the 
chisel  and  rongeur.      Permanent  recovery  has  been  reported  in  several  cases. 

III.  Atrophy  of  the  Bones  of  the  Skull  is  often  seen  as  a  simple 
senile  change.  All  the  bones  of  the  skull  become  thin  and  light,  and  even  the 
base  of  the  skull  may  become  translucent  or  may  be  perforated  as  a  result  of 
the  gradual  thinning  and  absorption  of  the  bones.  When  occurring  in  early  life 
it  was  formerly  thought  to  be  especially  the  result  of  rickets,  but  later  researches 
have  shown  it  to  arise  more  commonly  from  hereditary  syphilis.  The  cranial 
bones  may  become  so  thin  that  they  will  crackle  like  parchment  under  very 
slight  pressure.  It  is  sometimes  called  craniotabes,  and  especially  affects  the 
occipital  bone.     A  similar  thinning  sometimes  occurs  from  brain-tumors. 

The  general  treatment  for  inherited  syphilis,  together  with  cod-liver  oil  and 
the  hypophosphites  of  lime  and  soda,  etc.,  will  sometimes  produce  speedy  and 
very  happy  recovery.  The  child  must  be  carefully  protected  from  blows,  falls, 
and  other  mechanical  injuries. 

lY.  Tumors  of  the  Skull. — 1.  Exostoses  sometimes  occur  as  a  result 
of  injury,  and  if  on  the  forehead  become  serious  deformities.  More  commonly 
they  are  the  result  of  syphilitic  gummata,  occurring  therefore  in  the  tertiary 
stage.  They  may  arise  on  either  the  outer  or  the  inner  surface  of  the  skull. 
If  external,"^ they  are  called  exostoses;  if  internal,  enostoses. 

The  treatment  is  that  for  syphilis  of  the  bones.  If  external  and  a  seri- 
ous annoyance,  they  may  be  removed  by  the  knife  and  chisel.  If  internal 
and  productive  of  any  serious  lesion  of  the  brain,  the  skull  should  be  trephined 


506  .l^V    AMKRK'AX    TKXT-noOK    OF  SURGERY. 

and  the  mass  removed.  The  diflRculty  lies  in  locating  the  tumor.  Not  uncom- 
monly the  development  on  the  inside  of  the  skull  corresponds  to  a  similar 
growth  on  the  outside.  Failing  this,  the  only  other  indication  of  the  internal 
tumor  is  the  localizing  symptoms  in  brain  disease  which  are  described  later. 

2.  Sarcoma  affects  the  bones  of  the  skull  in  all  of  its  three  forms,  round- 
celled,  >pi)idk'-celled,  and  giant-celled.  It  may  arise  in  the  periosteum,  the 
diploe,  or  the  dura.  If  it  develops  to  any  size,  it  is  accompanied  with  great 
deformity  and  in  all  cases  with  great  danger. 

The  only  proper  treatment  is  excision  by  tlie  knife,  chisel,  and  saw,  but 
this  is  usually  unavailing  in  preventing  relapses,  and  the  operation  itself 
involves  such' danger  as  often  to  be  fatal,  especially  when,  as  is  sometimes  the 
case,  the  superior  longitudinal  sinus  is  involved.  Except  in  very  favorable 
cases,  therefore,  as  a  rule  no  operation  should  be  attempted. 

Sarcoma  arising  from  the  dura  perforates  the  cranium  and  spreads  some- 
times widely  under  the  scalp,  and  finally  perforates  it  externally.  It  was  known 
to  the  older  writers  a.^  fungus  of  the  dura  mater.  The  diagnosis  is  best  made  by 
discovering  the  opening  in  the  bone  by  touch  and  by  the  evidences  of  pulsation 
of  the  mass,  its  partial  or  complete  reducibility,  generally  accompanied  with 
symptoms  of  pressure,  and  the  optic  neuritis  which  often  results  from  it.  It 
may  occasionally  be  removed,  but  will  always  recur,  and  is  a  fatal  disease. 

3.  Epithelioma  is  occasionally  seen,  and  is  to  be  treated  on  the  same  prin 
ciples  as  stated  under  Sarcoma. 

VI.— DISEASES   AND   MALFORMATIONS   INVOLVING  THE   BEAIN. 

I.  Meningocele,  encephalocele,  and  hydrencepbalocele  are  allied  malforma^ 
tions  of  the  brain  which  are  fortunately  not  common. 

1.  Meningocele  consists  in  the  protrusion  of  the  membranes  of  the  brain 
through  an  aperture  in  the  bones  of  the  skull,  the  sac  formed  by  the  membranes 
being  distended  to  a  greater  or  lesser  extent  by  fluid  which  is  extra-cerebral. 

2.  Encephalocele  consists  in  the  protrusion  of  a  portion  of  the  brain  itself, 
as  well  as  of  the  membranes,  usually  with  a  smaller  amount  of  fluid  in  it,  the 
fluid  again  being  external  to  the  brain  substance. 

3.  Hydrencephalocele  consists  in  the  protrusion  of  the  brain  substance 
itself  as  well  as  of  the  membranes,  but  in  this  case  the  interior  of  the  mass 
communicates  directly  with  the  ventricles,  and  is  often  filled  with  a  large 
amount  of  the  ventricular  fluid,  so  large  in  some  cases  that  the  layer  of  brain 
substance  enclosing  the  fluid  is  reduced  to  a  very  thin  film. 

All  three  forms  of  the  disease  arise  in  intra-uterine  life,  and  are  therefore 
congenital.  The  most  frequent  is  unfortunately  the  gravest  form — viz.  hydren- 
cephalocele— and  the  least  frequent  is  meningocele.  As  a  rule,  they  are  apt  to 
be  fatal  early  in  life.  Their  commonest  situation  is  first  in  the  median  line, 
especially  in  the  occipital  region ;  next,  the  fronto-nasal ;  and  lastly,  the  sides 
of  the  skull  or  about  the  base.  Of  93  cases  collected  by  Ilouel,  68  were  occip- 
ital, 16  fronto-nasal.  and  0  at  the  sides  and  base. 

Diagnosis. — They  have  been  mistaken  for  abscesses,  nsevi,  sebaceous  cysts, 
etc.  The  following  points  of  diagnosis  will  generally  enable  the  surgeon  to 
reach  a  proper  conclusion : 

All  of  them  are  congenital,  commonly  median,  and  especially  occipital 
in  position.  Meningocele  is  usually  cystic  in  its  feel,  is  translucent,  fluc- 
tuates, rarely  pulsates,  is  more  or  less  pedunculated,  generally  becomes  tense  in 
forced  expiration,  and  is  easily  reducible.  Encephalocele  is  usually  small,  is 
opaque,  does  not  fluctuate,  pulsates  distinctly,  has  a  wide  base,  becomes  more 
tense  in  forced  expiration,  and  symptoms  of  pressure  are  produced  on  attempt- 


DISEASES   AX  J)    IXJi'llIES    OF    THE   HEAD.  5U7 

ing  to  reduce  it.  JTj/ih'enccphalocele  is  generally  large,  is  lobiilated,  is  partially 
translucent,  fluctuates  distinctly,  pulsates  but  rarely,  is  usually  pedunculated,  is 
made  only  slightly  more  tense  in  forced  expiration,  and  is  not  reducible.  • 

All  three  forms  are  apt  to  be  combined  with  other  deformities,  and  paraly- 
sis often  accompanies  hydrencephalocele. 

Treatment. — As  a  rule,  hydrencephalocele  is  not  amenable  to  treatment. 
The  child,  fortunately,  dies  early.  The  other  two  forms  hold  out  more  hope, 
especially  if  they  are  small.  Sometimes  an  encephalocele  by  retrograde  devel- 
opment may  be  changed  into  a  meningocele,  and  occasionally  by  gradual 
concentric  ossification,  resembling  that  of  the  fontanelles,  the  bony  aperture  is 
lessened  and  may  even  be  closed.  The  intracranial  communication  with  the 
interior  of  the  sac  may  be  narrowed  and  finally  obliterated,  thus  partially  or 
completely  eS'ecting  a  spontaneous  cure.  Until  the  late  improvements  in  cere- 
bral surgery  nothing  was  usually  recommended  in  the  way  of  treatment,  cer- 
tainly not  unless  there  was  danger  of  rupture.  A  number  of  successful  cases 
of  excision,  however,  have  been  recently  reported,  and,  unless  the  size  of  the 
tumor  or  the  condition  of  the  patient  forbid,  this  should  be  attempted,  of  course 
with  all  the  antiseptic  care  bestowed  on  all  other  brain  operations.  Enough 
scalp  should  be  preserved  to  make  sufficient  flaps  to  close  the  opening.  If 
operation  be  thought  inadvisable,  electrolysis  may  be  used  as  a  substitute. 
Pressure  and  the  injection  of  Morton's  fluid  (iodine  gr.  x,  potass,  iodid.  gr. 
XXX,  glycerin  oj)  may  be  tried,  but  with  little  prospect  of  benefit. 

II.  Hydrocephalus,  or  dropsy  of  the  brain,  exists  in  two  forms:  1. 
Acute  hydrocephalus,  which  is  usually  the  result  of  meningitis,  especially 
of  tubercular  origin.  It  consists  in  an  accumulation  of  fluid  which  is  occasion- 
ally extra-ventricular,  but  more  commonly  is  in  the  ventricles  themselves.  There 
will  usually  be  headache,  fever,  more  or  less  stupor  or  delirium,  with  symptoms 
of  pressure,  producing  strabismus,  rigidity  of  the  muscles  of  the  neck,  twitch- 
ing of  the  muscles  of  the  face  or  of  the  extremities,  and  convulsions,  followed  by 
paresis  or  paralysis  of  one  or  more  members.  As  a  rule,  optic  neuritis  will  be 
present.  Generally  nothing  will  check  the  progress  of  the  disease.  Tapping 
of  the  ventricles  has  been  done  in  several  instances,  but  without  success  except 
in  one  non-tubercular  case  of  Mayo  Robson's.  Success  must  necessarily  be 
rare,  but  every  life  saved  is  one  rescued  from  otherwise  certain  death. 

2.  Chronic  hydrocephalus  is  entirely  different  in  its  origin  and  course. 
It  is  usually  congenital,  although  it  may  not  be  observed  until  some  months 
after  birth.  The  first  symptom  is  enlargement  of  the  cranium,  which  goes  on 
until  the  bones  become  separated  from  one  another.  The  protuberant  forehead 
gives  a  characteristically  strange  facial  expression.  The  child  very  rarely 
becomes  able  to  walk  or  to  talk.  The  sight  is  often  affected,  intelligence  is 
absent,  and  convulsions  are  common.  The  post-mortem  will  show  enormous 
distention  of  the  ventricles,  so  that  the  brain  consists  merely  of  a  soft  bag  of 
cerebral  substance  distended  with  cerebro-spinal  fluid.  Fortunately,  most  such 
defectives  die  early,  but  occasionally  they  live  even  to  adult  life. 

The  treatment  is  unsatisfactory  and  usually  unsuccessful.  Pressure  does 
but  little  good.  Tapping  has  been  done  by  two  different  methods.  First,  by  a 
fine  trocar  the  ventricle  has  been  punctured  through  the  widely-dilated  anterior 
fontanelle.  This  puncture  should  be  made  away  from  the  middle  line,  so  as  not 
to  puncture  the  superior  longitudinal  sinus.  Not  more  than  two  or  three  ounces 
of  the  fluid  should  be  evacuated,  for  the  removal  of  large  quantities,  and  very 
often  even  of  small  ones,  is  followed  by  convulsions  and  death.  Occasionally 
larger  quantities  have  been  removed  successfully.  In  this  case  pressure  must 
be  carefully  maintained  during  and  after  the  operation.      Second,  when  the 


508 


vkV    AMKIilCAy    TEXT- HOOK    OF   SURGERY. 


Vertical  Section  of  Base  of  Skull  immediately  to  the 
right  of  the  Merlian  Line:  'i,  basal  subarachnoid  cav- 
ity and  its  relation  to  the  cerebellum :  h.  fcjurth  ven- 
tricle; r,  site  of  trephine  aperture  !  Parkin). 


ossification  of  tlio  skull  is  complete,  ta|»])ing  tlie  lateral  ventricles  has  been 
donOi  but  so  far  with  but  a  single  success. 

Lumbar  Puncture. — Quincke  has  recently  proposed  the  tapping  of  the 
theca  of  the  lumbar  spinal  cord,  thus  draining  the  ventricles  at  a  distance, 

while  pressure  is  inadeontheskull. 
^^''       ■  The  theca  of  the  spinal  eord  may  be 

punctured  and  some  of  the  cerebro- 
spinal Huid  withdrawn  for  diagnos- 
tic or  therapeutic  purposes.  When 
a  patient  is  recumbent  the  cerebro- 
spinal Huid  is  under  a  pressure  of 
20  to  40  mm.  of  water  (Quincke), 
and  this  pressure  is  (juite  sufficient 
to  force  the  fluid  out  of  a  tube  which 
has  been  inserted.  The  lumbar  re- 
gion is  selected  for  puncture.  No 
anesthetic  is  re(juired.  The  pa- 
tient is  placed  upon  his  side.  The 
legs  are  drawn  up  and  the  back 
strongly  arched.  In  order  to  per- 
form the  operation  a  hollow  needle 
is  employed,  which  is  filled  with  a 
stilet.  The  fluid  is  caught  in  a  graduated  glass. "^  The  space  between  the 
second  and  third  lumbar  vertebrae  is  determined  and  the  lower  edge  of  the 
spinous  process  is  the  guide.  In  children  the  trocar  is  entered  in  the  middle 
line  directly  below  the  spinous  process,  the  point  of  the  needle  being  directed 
upward;  in  adults  the  instrument  is  entered  5  mm.  to  the  right  of  the  middle 
line,  but  is  made  to  enter  the  dura  in  the  middle  line. 

If  the  bone  is  struck,  the  needle  is  withdrawn  a  little  and  again  pushed 
upward  and  forward.  AVhen  the  instrument  enters  the  dural  sac  its  point 
can  be  moved  freely.  The  stilet  is  then  Avithdrawn.  As  soon  as  the  fluid 
begins  to  flow  the  rubber  tube  is  attached  to  the  needle  and  the  fluid  is 
caught  in  an  aseptic  glass  tube.  It  is  not  advisable  to  use  a  syringe  for 
suction  purposes. 

Lumbar  jjuncture  may  give  valuable  aid  to  diagnosis,  the  character  of  the 
fluid  being  altered,  the  (juantity  being  increased,  and  the  pressure  being  ex- 
aggerated. In  acute  inflammation  of  the  brain  and  in  brain  tumor  pressure 
is  greatly  increased.  In  cases  of  acute  inflammation  sugar  is  absent.  In 
brain  tumor  albumin  is  increased.  In  tubercular  or  septic  cases  the  fluid 
may  contain  micro-organisms.  If  there  is  any  obstruction  in  the  channel  of 
communication  between  the  fourth  and  the  third  ventricles,  the  diagnostic 
value  of  lumbar  puncture  is  impaired.  The  therapeutic  utility  of  this  oper- 
ation is  very  doubtful. 

Parkin  has  suggested  in  ]jlace  of  lumbar  puncture  to  substitute  jjuncture 
of  the  subarachnoid  space  under  the  cerebellum.  He  reports  4  cases  with  2 
recoveries,  and  Ord  and  ^Yaterhouse  record  another  recovery  from  an  almost 
certain  tubercular  meningitis.  The  occipital  bone  is  treidiined.  The  dura 
is  opened,  the  cerebellum  lifted,  and  the  subarachnoid  space  jMincturcd  by  a 
grooved  director  or  other  similar  instrument  (Fig.  220). 

VII.— INMriUKS   OF   THE    HEAD. 

I.  Cephalhematoma,  or  Caput  Succedaneum,  is  a  soft  tumor  usually 
in  the  parieto-occipital  region  in  new-born  e)iildren.    It  consists  of  an  accumu- 


DISEASES  AND  INJURIES  OF  THE  HEAD.  509 

lation  of  blood  and  seruiu  under  the  scalp,  the  result  especially  of  prolonged 
labors  and  consequent  mechanical  injury  to  the  scalp.  Generally  no  treat- 
nu'iit  is  necessary,  as  the  mass  is,  as  a  rule,  absorbed  within  a  few  days  after 

birth. 

II.  Wounds  of  the  Scalp. — These  differ  in  no  respect  from  wounds 
elsewhere  in  the  body,  excei)t  that  wounds  of  the  scalp  are  more  prone  to 
erysipelatous  inflammation  and  abscesses  than  wounds  of  the  skin  in  other  parts 
of  the  body,  unless  the  greatest  care  is  taken  in  their  proper  treatment. 

The  blood-supply  of  the  scalp  is  so  abundant  that  even  a  slight  pedicle  of 
attachment  is  suflicient  to  ensure  the  vitality  of  a  large  flap.  Hence  in  lace- 
rated wounds  an  attempt  should  be  made  to  save  most  of  the  torn  pieces  unless 
absolutely  detached.  In  any  Avounds,  except  very  small  ones,  in  order  to 
ensure  disinfection  the  scalp  should  be  shaved  over  a  very  Avide  area.  Even 
in  women  appearance  must  give  Avay  to  safety.  It  should  then  be  thoroughly 
disinfected  by  the  removal  of  all  dirt  and  other  foreign  matters  by  rubbing  in 
sweet  oil,  then  washing  well  with  soap  and  water,  following  this  by  a  thorough 
scrubbing  with  a  bichloride  solution  1 :  1000,  trimming  off  the  infected  edges 
if  the  wound  is  lac.erated,  and  lastly  by  accurate  suturing.  The  bleeding  vessels 
will  require  ligation  only  when  exceptionally  large,  provided  the  hemorrhage 
has  been  arrested  by  crushing  the  vessels  in  the  jaws  of  hemostatic  forceps. 
The  forceps  may  seize  the  entire  thickness  of  the  scalp  with  impunity.  If 
these  precautions  are  taken,  usually  no  drainage  will  be  necessary,  but  should 
there  be  necessity  for  it  a  few  strands  of  disinfected  horsehair  will  answer  the 
purpose.  These  should  be  removed  in  a  day  or  two.  Silkworm-gut  interrupted 
sutures  may  be  used.  A  large  sublimate  dressing  may  then  be  applied  and 
retained  in  place  by  an  ordinary  recurrent  bandage.  The  most  important 
point  in  such  Avounds  is  the  careful  and  Avide  disinfection.  They  Avill  then 
follow  the  usual  aseptic  course  of  other  wounds.  If  this  be  neglected,  even 
small  Avounds  have  a  large  reserve  of  danger. 

III.  Abscess  of  the  Scalp  is  first  a  consequence  of  inflammation,  often 
of  an  erysipelatous  character,  and  occasionally  it  is  a  sequel  of  typhoid  fever ; 
secondly,  it  is  a  sequel  of  contusions ;  and  thirdly,  it  often  follows  wounds  the 
edges  of  Avhich  have  been  closely  coaptated  without  sufficient  preliminary  dis- 
infection. Very  often  such  patients  are  first  treated  in  drug-stores,  where 
usually  a  very  elaborate  stellate  dressing  of  adhesive  plaster  is  put  on  Avithout 
any  attempt  at  disinfection.  All  such  dressings  should  be  removed  at  once 
and  the  wound  re-dressed  after  proper  disinfection. 

Abscess  is  accompanied  usually  with  pain  of  a  throbbing  character  and 
inflammation  of  the  scalp,  which  is  almost  ahvays  erysipelatous  in  appearance, 
though  it  may  not  be  caused  by  the  microbe  of  erysipelas.  Not  uncommonly 
there' is  marked  oedema  of  the  surrounding  parts,  which  if  it  extends  to  the 
eyelids  produces  blindness  mechanically  by  the  swelling  of  the  lids.  There  is 
almost  alwavs  pitting  on  pressure.  The  constitutional  symptoms  are  marked 
and  sometimes  verv  severe,  the  fever  running  high  and  being  accompanied  not 
infrequently  with  delirium.  The  chief  dangers  here  are  that  the  pus  may  bur- 
row widely;  if  under  the  aponeurosis  of  the  occipito-frontal  muscle  it  wdl  be 
limited  by  the  attachments  of  this  muscle  and  its  aponeurosis,  and  the  location 
of  the  effusion  can  thus  be  readily  diagnosticated ;  and  if  it  be  under  the  peri- 
cranium, and  sometimes  even  if  'it  be  more  superficial,  that  the  inflammation 
may  extend  to  the  brain  through  the  vascular  perforations  in  the  skull  and 
cause  meningitis.      Occasionally  it  may  produce  necrosis  of  the  bone. 

The  treatment  is  very  clear.  As  soon  as  the  abscess  is  diagnosticated 
a  free  incision  should  be  made  at  Avhat  will  be  the  most  dependent  point  in 


51 U  AN  AMERICAN  TEXT-BOOK  OF  SURGERY, 

the  recumbent  posture,  •\s\\\\  disinfection  of  the  wound  as  far  as  possible,  and 
drainage. 

1\ .  Contusions  of  the  Head  are  very  connnon  as  a  result  of  falls, 
blows,  etc.  TIk'V  may  l)e  slight  or  severe.  After  a  slight  contusion  the 
patient  is  more  or  less  stunned,  and  swelling  veiy  quickly  follows,  due  chiefly 
to  hemorrhage  under  the  scalp.  This  hemorrhage  is  very  apt  to  give  the 
impression  of  depressed  bone,  and  may  mislead  one  into  supposing  that  there 
is  a  fracture,  the  hard  ridge  on  the  curved  edge  of  the  swelling  being  mistaken 
for  the  edge  of  the  depression.  But  after  a  simple  contusion  this  ridge  is  ele- 
vated considerably  above  the  general  contour  of  the  head,  the  edges  are  rounded, 
and  pressure  will  not  uncommonly  cause  pitting.  If  there  be  fracture  with 
depression,  the  edge  is  usually  about  on  a  level  with  the  surrounding  skull  or 
below  it,  and  the  margin  is  sharper,  more  irregular,  and  less  circular. 

Ordinarily  pressure,  with  perhaps  some  cooling  lotion,  as  simple  tincture 
of  arnica  or  lead-water  and  laudanum,  will  cause  the  major  part  of  the  swell- 
ing to  disappear  within  twenty-four  hours.  Rather  rarely,  however,  abscess 
will  follow. 

If  the  contusion  be  somewhat  more  severe,  the  bone  may  become  involved, 
producing  sclerosis  as  a  result  of  the  chronic  inflammation,  or  if  the  blow  be 
sufficiently  severe  to  destroy  its  vitality  even  necrosis  may  follow,  although 
this  is  a  comparatively  rare  result.  Severer  contusions  may  involve  the  brain 
itself.      These  are  described  under  the  next  head. 

V.  Concussion  or  Laceration  of  the  Brain. — The  term  "concus- 
sion "  of  the  brain  is  an  unfortunate  one,  as  it  conveys  the  idea  of  a  functional 
rather  than  an  organic  lesion.  While  there  may  be  slight  injuries  of  the  brain 
that  mav  in  this  sense  be  properly  called  concussions,  it  is  far  better  to  consider 
concussion  as  usually  equivalent  to  laceration  of  the  brain  tissue. 

The  brain  may  be  injured  either  by  direct  or  by  indirect  force.  A  blow  on 
the  head  is  an  example  of  direct  force ;  an  instance  of  indirect  force  is  a  fall 
in  which  the  patient  lights  fully  upon  his  feet  or  sits  down  upon  his  buttocks. 
AVhat  happens  in  such  cases  is  best  explained  by  an  experiment  made  by 
Felizet.  lie  filled  a  skull  with  parafiine  and  dropped  it  on  the  floor.  On 
opening  the  head  no  fracture  was  found,  but  at  the  point  of  impact  the  bone 
had  been  driven  down  upon  the  paraffine  and  flattened  it,  and,  while  the  bone 
had  sprung  back  to  its  original  position  without  fracture,  the  flattening  of  the 
contents  remained.  Had  the  skull  been  living  and  filled  with  brain  tissue,  the 
same  depression  and  temporary  compression  of  the  brain  would  have  taken  place; 
and  we  can  scarcely  imagine  that  such  an  amount  of  mechanical  disturbance  of 
the  brain  can  occur  without  more  or  less  laceration  of  brain  tissue  and  rupture 
of  blood-vessels,  followed  by  some  slight  hemorrhage.  Moreover,  as  Duret  has 
showm,  the  wave  in  the  cerebro-s])inal  fluid  created  by  a  blow  produces  what  is 
often  its  maximum  effect  on  the  opposite  side  of  the  skull  from  the  point  struck, 
tearing  the  vessels  of  the  pia  and  the  cortex.  This  undoubtedly  explains 
injuries  of  the  brain  by  so-called  contreconp.  or  counter-stroke.  Miles  has 
shown  experimentally  that  at  the  point  of  impact  there  is  a  ''cone  of  depres- 
sion," accom])anied  by  a  "  cone  of  bulging  '"  at  the  opposite  })ole,  thus  con- 
firming Duret"s  observations.  If  the  cone  of  bulging  is  sufficiently  ample,  a 
fracture  may  be  produced. 

The  patient  who  has  received  such  an  injury,  if  it  be  slight,  will  perhaps 
lose  his  balance  and  fall,  become  pallid,  confused,  and  giddy,  and  may  be 
nauseated  and  even  vomit,  but  after  a  period  of  rest  he  will  gradually  recover. 
If,  however,  the  injury  be  more  severe,  there  may  be  grave  laceration  of  the 
brain  or  of  its  membranes,  or  of  Itoth.  and  the  patient  will  fall  and  lie  quietly, 


DISEASES   AND    IXJVIilES    OF    THE   HEAD.  oil 

with  a  feeble,  fluttering  heart,  cold,  clammy  skin,  and  apparently  be  uncon- 
scious, lie  can  usually,  however,  be  aroused  by  shouting  and  loud  (|uestioning, 
but  will  reply  in  monosyllabic  answers  or  unintelligible  sounds.  He  will  not 
be  paralyzed,  but  may  move  the  extremities,  which  will  not  have  lost  entirely 
their  sense  of  feeling.  Not  uncommonly  urine  and  feces  will  be  passed  invol- 
untarily. The  pupils  Avill  vary,  being  either  contracted  or  dilated  to  a  mode- 
rate extent,  and  possibly  unequally,  but,  as  a  rule,  they  will  react  to  light. 
Occasionally  convulsions  occur.  As  he  reacts  he  will  very  probably  vomit. 
Usually  within  twenty-four  hours  or  more  his  condition  as  to  consciousness 
will  become  better,  but  he  will  suffer  from  considerable  headache,  lassitude, 
and  indisposition  to  exertion.  After  partial  recovery,  and  sometimes  for  a 
long  period,  he  will  suffer  more  or  less  with  vertigo,  headache,  and  indisposi- 
tion to  mental  exertion.  Occasionally  more  serious  results  will  follow,  even 
after  a  long  interval,  and  abscess  of  the  brain  should  be  especially  watched  for. 
Sometimes  epilepsy  or  insanity  may  follow.  If  the  patient,  instead  of  recover- 
ing, grows  Avorse,  either  coma  will  set  in  or  the  symptoms  of  meningitis  or 
encephalitis  as  described  below. 

Prognosis. — The  uncertainty  as  to  the  degree  and  even  the  character 
of  the  cerebral  injury  should  make  us  especially  careful  as  to  prognosis  and 
treatment.  Any  contusion  which  has  been  severe  enough  to  produce  uncon- 
sciousness should  be  considered  a  serious  injury,  for  we  may  be  sure  that  there 
has  always  been  such  an  amount  of  laceration  as  to  make  serious  danger  a  pos- 
sibility and  often  a  probability. 

Treatment. — As  soon  as  possible  the  patient  should  be  placed  in  bed 
without  any  pillow,  and  his  body  surrounded  with  hot-water  bags  or  hot-water 
bottles  suitably  protected.  He  should  be  kept  quiet  and  as  free  from  the 
excitement  of  conversation  or  business  as  possible,  and  restful  sleep  should  be 
encouraged.  Aromatic  spirit  of  ammonia  during  the  period  of  shock  is  better 
than  alcohol,  for  the  excitement  of  alcohol,  which  is  quickly  felt  in  the  brain, 
should  be  avoided.  Hot  water  or  ice  water,  as  may  be  most  agreeable  to  the 
patient,  may  be  given.  A  careful  diet,  with  occasional  purgatives,  and  atten- 
tion to  the  general  hygiene  are  necessary  for  days  or  weeks. 

In  case  inflammation  of  the  brain  supervenes,  surgical  opinion  is  at  present 
somewhat  divided  as  to  the  proper  course  to  be  pursued.  Many  surgeons,  per- 
haps the  majority,  would  treat  it  as  an  Encephalitis  (see  p.  530)  and  not  tre- 
phine ;  others,  on  the  contrary,  believe  that  if  serious  symptoms  arise,  indi- 
cating intracranial  mischief,  especially  if  this  be  localized,  a  semicircular  flap 
of  scalp  should  be  raised  over  the  seat  of  the  injury  and  the  bone  inspected. 
If  an  unsuspected  fracture  is  discovered  and  the  symptoms  are  serious,  show- 
ing meningitis  or  encephalitis,  an  exploratory  trephining  should  be  done  and 
the  dura  opened.  Once  such  inflammation  with  its  attendant  proliferation  and 
exudation  has  begun,  it  is  essential  in  their  view  that  a  means  of  escape  for 
the  exudate  be  provided  before  the  inflammation  shall  have  proceeded  so  far  as 
the  production  of  dangerous  pressure  or  even  of  suppuration  itself.  In  other 
words,  they  would  treat  contusion  followed  by  symptoms  of  serious  intracranial 
mischief  precisely  as  they  would  treat  such  injuries  in  other  parts  of  the  bodv  ; 
always  remembering  that  in  the  brain  there  is  no  possible  means  of  escape  for 
the  hemorrhage  or  exudate  without  surgical  assistance,  because  of  the  bonv  case 
in  which  it  is  retained  ;  but  remembering  also  that  while  trephining  is  equivalent 
to  incision  down  to  the  injury  in  any  other  part  of  the  body,  yet  that  it  is 
always  a  grave  operation  and  never  to  be  undertaken  without  earnest  reflection 
and  good  reason. 

In  many  cases  of  severe  contusion  it  is  proper  immediately  (with  all  the 


512  AN  AMEUIfAX    TEXT-BOOK    OF  SUIiOKnY. 

antiseptic  precautions  so  often  insisted  on)  to  raise  a  liorseslioe-slia{)e(l  fla})  in 
order  to  determine  at  once  the  <[uestion  of  frac-ture,  as  the  swellini^  of  the 
scalp  if  this  be  thick  or  very  dense  makes  it  difficult  Avithout  such  an  incision 
to  ascertain  whether  fracture  exists  or  not.  The  objection  that  if  a  simple 
fracture  exists  by  such  an  incision  we  convert  it  into  a  compound  one  no  longer 
holds  good,  for  a  simple  incision  through  the  scalp  is  not  attended  with  grave 
danger  in  these  days  of  antiseptic  surgery,  and  the  very  slight  dangers  of  the 
wound  are  as  nothing  compared  to  a  certain  diagnosis  and  suitable  treatment. 

After  the  patient  has  recovered  from  a  severe  contusion  or  laceration  of  the 
brain  he  should  not  be  allowed  to  return  to  business  or  other  occupation  for  at 
least  a  numl)er  of  weeks,  or  even  for  a  longer  period ;  and  if  at  any  time  he 
shows  indications  of  hebetude  or  is  attacked  by  headache,  especially  if  accom- 
panied with  little  or  no  rise  of  temperature  or  even  a  somewhat  suljnormal  tem- 
perature, an  abscess  should  be  suspected  and  its  symptoms  watciied  for,  (See 
Abscess.) 

After  severe  concussion  of  the  brain  the  patient  sometimes  passes,  in  the 
course  of  a  few  hours  or  more,  into  a  peculiar  condition  well  termed  by  Mr. 
Erichsen  cerebral  irritahility.  Instead  of  recovering  consciousness,  he  is  apt 
to  lie  on  his  side,  w^ith  his  eyes  closed,  his  legs  drawn  up,  and  his  back  curved. 
The  pupils  are  contracted,  but  respond  to  light.  If  disturbed,  he  is  restless 
and  irritable  or  may  even  show  some  delirium.  He  may  answer  questions 
sometimes  in  a  vexed  way,  or  may  refuse  to  respond.  There  is  sometimes  no 
rise  of  temperature,  either  general  or  local,  and  it  may  even  be  subnormal. 
The  pulse  is  weak  and  slow.  Not  uncommonly  the  bowels  and  bladder  are 
evacuated  involuntarily,  though  sometimes  the  patient  will  indicate  his  wants. 
Recovery  Avill  usually  take  place  slowly,  with  no  recollection  of  his  condition 
or  conduct.  Occasionally,  however,  the  mental  faculties  will  not  recover. 
The  treatment  for  this  irritability  must  necessarily  be  a  symptomatic  one. 

VI.  Compression  of  the  Brain. — The  surgical  causes  of  compression 
of  the  brain  are  intracranial  hemovrliage,  tumor,  depressed  fracture,  foreign 
bodies,  and  the  products  of  inflammation.  Hemorrhage  and  inilammatory 
exudate  produce  the  symptoms  of  compression  almost  immediately  when  they 
are  sudden  and  severe,  but  if  the  blood  or  exudate  accumulate  gradually,  the 
compression  symptoms  will  arise  as  soon  as  the  amount  of  blood  or  pus  becomes 
large.  In  very  slight  but  steadily  increasing  hemorrhage  or  a  slowly-forming 
abscess  the  brain  accommodates  itself  for  a  time  to  the  gradually  increasing 
pressure.  Even  considerable  depression  of  the  bone  may  for  some  time  be 
followed  by  no  symptoms  of  compression. 

Symptoms. — In  compression  unconsciousness  is  complete.  The  patient 
lies  supine  and  does  not  move,  or  if  he  moves  it  will  be  an  occasional  restless 
change  of  place  of  an  arm  or  a  leg.  He  Avill  not  respond  to  any  questioning 
or  to  the  loudest  shouting  in  his  ear.  The  pupils  are  dilated  and  do  not 
respond  to  light,  the  breathing  is  slow  and  stertorous,  with  a  peculiar  jiuffing 
respiration,  due  to  expiratory  distention  of  the  cheeks  and  lips,  the  facial 
muscles  being  paralyzed.  The  skin  is  usually  hot  rather  than  cold,  and  is 
covered  with  a  profuse  perspiration.  The  pulse  is  slow,  full,  and  often 
irregular.  The  bladder  and  bowels  are,  as  a  rule,  paralyzed  :  hence  the  urine 
is  not  voided  until  the  bladder  becomes  over-full,  when  the  incontinence  of 
retention  sets  in.  Sometimes  the  Avhole  body  is  paralyzed,  though  hemiplegia 
is  more  common.  If  the  lesion  is  limited  and  not  too  large,  the  paralysis  will 
be  limited,  for  example,  to  a  monoplegia,  that  is  to  say,  paralysis  of  one  arm 
or  one  leg  or  one  side  of  the  face,  if  the  cause  of  the  compression  is  limited  to 
one  of  the  cortical  centers  supplying  these  regions.     The  significance  of  such 


DISEASES  AND    INJURIES    OF    THE   I  IK  A  I).  513 

a  localized  paralysis  is  extrcmelv  valuable  in  the  diagnosis  of  the  seat  of  the 
lesion;  and  if  the  paralysis  l)eiiins  in  (ine  j)art  of  the  l)ody  and  spreads  to  other 
parts,  the  cortical  centers  of  Avhich  are  adjacent  to  the  center  for  the  part 
first  paralyzed,  the  diagnosis  may  be  regarded  as  positive. 

If  the  cause  of  the  compression  is  hemorrhage  in  the  interior  of  the  brain 
— e.g.  from  the  lenticulo-striate  artery,  the  "artery  of  cerebral  hemorrhage" 
of  Charcot — unconsciousness  usually  occurs  instantaneously  or  almost  so.  If 
it  is  from  a  rupture  of  the  middle  meningeal  artery,  a  point  of  the  greatest 
importance  in  the  diagnosis  is  that  after  the  reception  of  the  blow  there  is 
a  period  of  consciousness  corresponding  to  the  period  of  time  necessary  for 
the  escape  of  a  sufficient  quantity  of  blood  to  produce  unconsciousness  from 
pressure.  If  a  small  branch  of  the  middle  meningeal  is  ruptui'ed,  the  period 
of  consciousness  may  be  comparatively  long,  even  several  hours,  occasionally 
a  day  or  more;  but  if  the  main  trunk  is  injured,  the  blood  pours  out  so 
rapidly  that  only  a  few  minutes  may  pass  before  unconsciousness  supervenes. 

If  caused  by  fracture  or  foreign  bodies,  the  symptoms  of  compression  usually 
follow  immediately  upon  the  reception  of  the  injury,  but  occasionally  they  may 
be  delayed  for  some  hours.  If  caused  by  inflammation  and  the  formation  of 
pus,  the  symptoms  of  course  will  develop  only  when  the  pus  accumulates  in 
sufficient  quantity  to  produce  serious  pressure.  This  development  of  pressure 
symptoms  in  these  cases  is  usually  gradual,  the  mental  dulness  deepening  into 
coma,  but  sometimes  it  is,  as  it  were,  by  a  sudden  explosion.  If  tumor  is  the 
cause,  the  brain  may  accommodate  itself  for  some  time  to  a  slowlv-crrowing 
tumor,  but  if  it  grows  rapidly  symptoms  of  compression  will  set  in  at  an  early 
date.     Optic  neuritis  will  generally  develop  at  an  earlier  or  later  date. 

Diagnosis. — The  principal  conditions  which  must  be  diagnosticated  from 
injuries  of  the  brain  producing  compression  are  alcoholic  intoxication,  opium- 
poisoning,  apoplexy,  and  uremia.  If  a  man  is  picked  up  in  the  street  by  the 
police  and  is  carried  to  a  hospital  without  any  previous  history,  the  surgeon 
must  be  on  his  guard  lest  he  mistake  any  one  of  these  four  conditions  for  a 
serious  injury  to  the  brain.  In  cerebral  injuries  there  will  usually  be  an  evi- 
dence of  the  accident  in  a  bruise  or  cut,  though  of  course  the  man  may  have 
fallen  when  intoxicated  or  have  been  suddenly  attacked  by  apoplexy  and  in 
falling  have  received  a  more  or  less  serious  wound.  In  intoxication  the  acci- 
dent will  usually  be  comparatively  slight.  Possibly  his  appearance,  giving 
evidence  of  intemperate  habits,  may  be  some  guide  to  diagnosis,  but  this  may 
easily  mislead  us.  His  breath  may  be  alcoholic,  but  it  must  be  remembered 
that  alcohol  may  have  been  given  to  the  man  to  revive  him  after  serious  brain 
injury.  A  drunken  man,  although  stupid,  is  not  unconscious,  nor  is  he  para- 
lyzed or  hemiplegic.  His  pupils  are  not  dilated  as  in  compression,  but  are  more 
commonly  contracted,  dilating  when  any  attempt  is  made  to  rouse  him.  The 
temperature  is  generally  subnormal. 

In  apoplexy  there  are  absolute  unconsciousness,  stertor,  and  hemiplegia  or 
complete  paralysis.  In  opium-poisoning  the  pupils  are  contracted  to  pin-points 
and  will  not  dilate,  and  there  is  no  paralysis.  In  uremia  paralysis  and  stertor 
are  absent,  unless  there  is  apoplexy,  and  there  is  apt  to  be  oedema  of  the  legs, 
and  if  the  urine  be  examined  there  will  be  found  undoubted  evidences  of 
albumin.  The  eye-ground  should  be  examined  in  all  cases,  as  it  may  throw 
considerable  light  on  the  nature  of  the  case.  If,  after  all,  the  case  is  doubtful, 
it  should  always  be  treated  as  one  of  cerebral  injury. 

Prognosis. — If  the  compression  is  caused  by  extravasated  blood,  the 
patient  has  a  fair  chance  of  recovery  after  trephining,  evacuation  of  the  clot, 
and  arrest  of  the  hemorrhage.     If  it  is  caused  by  depressed  fracture,  and  the 

3.3 


514  .l.V   A.}fK/!/<'AX    TEXT-BOOK'    OF  .SfJiC'EIi  V. 

proper  operative  relief  is  aflbrdeil.  his  chances  of  life  will  vary  with  the  de^^ree 
of  severity  of  the  injury.  In  cases  of  foreij^n  body  in  the  brain  the  j)rof];nosis, 
as  a  rule,  must  be  unfavorable;  and  the  same  may  be  said  nf  tumors  and 
inflammation  Avith  internal  hydrocej»halus. 

Treatment. — 'J'he  diairnosis  of  compression  havin<^  been  established,  the 
treatment  will  vary  with  the  cause.  If  it  is  from  hemorrhage,  the  treatment 
must  be  the  speedy  relief  of  the  jiressure  by  evacuation  of  the  clot  and  arrest 
of  further  bleeding  b}'  ligature,  as  mentioned  in  the  next  section.  If  it  is 
from  depressed  bone,  trephining  should  be  done  at  once  with  all  the  pre- 
cautions heretofore  described,  and  the  bone  elevated  or  removed  as  may  be 
found  necessary.  If  from  foreign  bodies,  these  .should  be  removed,  with  the 
limitations  stated  in  the  section  treating  of  that  lesion.  If  from  an  abscess 
in  the  brain,  trephining  should  be  done  and  the  abscess  evacuated  and  drained. 
(See  Abscess  of  the  Brain.)  If  serum  has  accumulated  either  in  the  ventricles 
or  in  the  subarachnoid  space,  trephining  should  be  done  and  the  exudate 
drained,  even  by  i)uncture  of  the  ventricles  if  necessary.  If  the  compression 
is  from  tumor,  the  tumor  should  be  removed  if  the  case  is  suita])le. 

In  all  cases  the  utmost  care  must  be  observed  as  to  the  later  treatment  by 
rest,  the  most  restricted  liquid  diet,  attention  to  the  bowels  and  bladder,  and  the 
general  precautions  mentioned  in  connection  with  Meningitis  and  Encephalitis. 

YII.  Intracranial  Hemorrhage. — This  may  be  either  spontaneous  or 
traumatic.  Tluxigh  there  is  at  least  one  case  of  apparently  spontaneous  rup- 
ture of  the  middle  meningeal  arteries,  yet  as  a  rule  spontaneous  hemorrhage  into 
the  brain  occui's  in  connection  with  the  lenticulo-striate  artery  distributed  to  the 
ganglia  at  the  base.  The  clot  usually  forms  either  in  these  ganglia  or  in  the 
white  substance  of  the  centrum  ovale,  and  produces  the  familiar  forms  of  apo- 
plexy, the  consideration  of  which  belongs  to  medicine  rather  than  to  surgery. 
Richardiere  has  shown  that  one  of  the  most  frequent  causes  of  the  death  of  new- 
born children  very  shortly  after  delivery  is  meningeal  hemorrhage  from  the  rup- 
ture of  the  vessels  at  the  moment  of  birth  as  a  result  of  traumatism  to  the  foetal 
head  in  its  passage  through  the  pelvis. 

HemorrJiage  from  Traumatism  may  occur  in  three  positions:  it  may  be 
(a)  extradural,  that  is,  between  the  dura  mater  and  the  bones ;  {h)  subdural, 
that  is,  between  the  dura  and  the  brain ;  (c)  cerebral,  that  is,  into  the  brain 
tissue  itself. 

{a)  Extradural  Hemorrhage. — This  is  almost  always  caused  by  the  rup- 
ture of  the  middle  meningeal  artery  or  its  branches.  The  violence  which  may 
rupture  this  artery  is,  as  a  rule,  considerable,  although  it  may  be  so  slight  as  to 
leave  no  bruise.  Fracture  will  frequently  exist,  though  in  a  considerable  per- 
centage of  cases  there  may  be  no  fracture  whatever;  but  commonly  it  is  pres- 
ent, and  extends  not  only  over  the  vault,  but  also  to  the  base  of  the  skull.  It 
will  be  remembered  that  the  middle  meningeal  arises  from  the  internal  maxil- 
lary and  enters  the  cranium  at  the  foramen  spinosum,  quickly  dividing  into  an 
anterior  and  a  posterior  branch.  The  anterior  branch,  after  running  ii>  the 
groove  in  the  wing  of  the  sphenoid,  reaches  the  parietal  bone  at  its  anterior 
inferior  angle,  whence  it  passes  upward  toward  the  middle  line.  The  poste- 
rior branch,  after  running  over  the  posterior  part  of  the  sijuamous  portion 
of  the  temporal  bone,  also  reaches  the  parietal  bone.  The  main  trunk  of  the 
artery  is  rarely  ruptured ;  the  two  branches  are  far  more  frequently  the  site 
of  this  lesion  (Fig.  221). 

The  symptoms  of  such  hemorrhage  are  of  great  importance,  for  while 
formerly  in  these  cases  the  surgeon  stood  by  with  his  arms  folded  and  watched 
his  patient  die,  the  last  few  years  have  taught  us  that  a  large  proportion  of  such 


DISEASES    AXD    IXJrUIES    O/'    yv//-;    HEM). 


515 


Fig.  221. 


cases  inay  be  saved  by  pruiiij)t  interference.  The  accident  may  stun  the  patient 
and  niav  prochiee  a  brief"  jieriod  of  unconsciousness.  Fi"oni  this  he  recovers 
only  to  rehipse  anew  into  unconsciousness.  This  i>eriod  of  conariousucss 
between  the  acci(U'nt  and  the  appearance  of  the  persistent  coma  is  of  tlic  great- 
est importance  and  worth  all  the  other  symptoms  put  together.  It  is  due  to  the 
fact  that  a  certain  amount  of  time  must  elapse  before  the  quantity  of  blood 
which  escapes  is  sufficient  to  produce  unconsciousness  from  pressure.  If 
the  main  trunk  or  one  of  the  larger  branches  is  ruptured,  the  blood  escapes 
raj)idly,  and  this  period  of  consciousness  will  be  very  brief;  but  if  one  of  the 
smaller  branches  is  ruptured  the  interval 
may  be  one  of  hours  or  even  days  before 
a  sufficient  clot  accumulates  to  produce  it. 
The  possible  existence  of  this  interval  of 
consciousness  should  therefore  be  inijuired 
into  in  all  cases,  and  if  there  be  other 
signs  of  intracranial  hemorrhage  the  diag- 
nosis will  be  clear.  These  other  signs  may 
be,  (1)  Hemiplegia,  on  the  side  opposite  to 
the  hemorrhage.  The  hemorrhage,  AvliiK- 
usually  on  tlie  same  side  as  the  injury, 
may  take  place  upon  the  o])posite  side, 
in  which  case  the  hemiplegia  and  the 
wound  will  be  on  the  same  side.  More- 
over, the  paralysis  is  apt  to  be  progress- 
ive, extending  from  one  part  of  the  body 
to  another,  as  the  widening  clot  produces  pressure  on  one  cortical  center  after 
another.  For  instance,  the  clot  may  begin  over  the  face  center,  producing 
paralysis  of  the  face ;  then  it  extends  upward  to  the  arm  center,  and  the  arm 


Hemorrhage  from  the  Middle  Meningeal  Artery 
(Jacobson). 


Fig.  222. 


Site  of  Trephine  Opening  to  reach  Clot  in  Hemorrhage  from  Middle  Meningeal  Artery  (Kronlein) :  a,  b, 
horizontal  line  through  the  meatus :  c,  d,  on  a  line  with  the  eyebrows ;  e,  f,  vertical  line  3  to  4  cm 
behind  the  ext.  ang.  process ;  g,  h,  at  the  posterior  border  of  tlie  mastoid  process,  a,  the  point  to 
reach  the  anterior,  and  b,  the  posterior  branch  (Esmarch  and  Kowalzig). 

Avill  be  paralyzed;  and  finally,  as  it  reaches  the  leg  center,  the  leg  will  be  para- 
lyzed. Rarely  the  artery  may  be  ruptured  on  both  sides.  (2)  If  the  clot, 
instead  of  extending  upward,  gravitates  toward  the  base,  the  pupil  on  the 
side  of  the  clot  will  be  dilated  and  immobile,  and  if  on  the  left  side  aphasia 


516  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

will  appear.  (3)  The  pulse  becomes  frequent.  (4)  Respiration  is  slow  and 
stertorous.  (5)  The  temperature  Avill  probably  rise  to  101°  to  103°,  or  even 
104°  F.,  especially  on  the  side  opposite  the  clot.  (6)  In  a  compound  (espe- 
cially in  a  gunshot)  fracture,  with  a  perforation  of  the  skull  and  the  meninges, 
blood  may  escape  in  such  quantity  and  with  such  rapidity  as  continually  to 
force  the  l)rain-substance  out  of  the  wound. 

Treatment. — As  soon  as  the  diagnosis  is  well  established,  operative  treat- 
ment should  be  resorted  to  as  quickly  as  possible.  Wiesmann  has  best  shown 
the  importance  of  this,  for  of  147  cases  treated  expectantly,  131  (89.1  per 
cent.)  died,  while  of  110  cases  operated  on,  only  36  (-32.7  per  cent.)  died,  and 
in  the  majority  of  the  fatal  cases  the  extravasation  was  not  reached  and  the 
clot  therefore  not  removed.  In  operating  we  should  determine  the  question 
which  side  of  the  skull  should  be  trephined,  not  by  the  site  of  the  irijnry,  but 
by  the  localising  symptoms.  In  far  the  greater  number  of  cases,  as  shown  by 
Krbnlein,  the  clot  will  be  best  reached  by  trephining  one  inch  and  a  quarter  be- 
hind tlie  external  angular  process  at  the  level  of  the  upper  border  of  the  orbit 
(Fig.  222,  a).  If  the  clot  be  not  revealed  by  this  opening,  immediately  tre- 
phine again,  just  below  the  parietal  boss,  on  the  same  level  as  the  former  open- 
ing (Fig.  222,  B  ;  see  also  Fig.  211).  By  the  anterior  opening  the  main  trunk 
and  the  anterior  branch  of  the  middle  meningeal  artery  may  be  reached,  and 
by  the  posterior  opening  the  posterior  branch.  In  many  cases,  of  course,  it  is 
very  doubtful  which  branch  is  ru])tured  ;  hence  the  need  for  the  second  open- 
ing if  the  first  does  not  disclose  the  clot.  The  clot  should  now  be  removed, 
either  opening  being  enlarged,  if  need  be,  by  the  rongeur  forceps  in  order  to 
gain  access  to  it.  If  the  pupil  is  dilated,  and  evidence  given  therefore  that 
the  clot  is  gravitating  toward  the  base,  the  trephine  opening  should  be  made 
near  the  first  point,  but  about  half  an  inch  lower.  The  clot  should  be  scooped 
out  very  gently,  and  the  cavity  in  which  it  has  lain  should  be  well  washed  out 
with  sufiiciently  cooled  boiled  water.  If  the  artery  is  still  bleeding,  a  catgut 
ligature  should  be  passed  through  the  dura,  under  the  artery,  and  out  again 
through  the  dura  on  the  other  side  of  the  artery,  by  a  semicircular  Hagedorn 
tieedle,  and  the  artery  tied.  Drainage  should  be  carefully  provided,  and  the 
wound  then  treated  as  usual.  If  the  first  trephine  opening  does  not  answer 
well  for  drainage  in  the  recumbent  posture,  a  second  one  should  be  immedi- 
ately made. 

(b)  Subdural  Hemorrhage. — This  hemorrhage  will  occur  most  fre- 
quently as  a  result  of  dej)ressed  fracture  and  rupture  of  a  number  of  small 
vessels,  or  it  may  be  of  one  large  vessel  (especially  the  middle  cerebral),  the 
contents  of  which  pour  out  under  the  dura.  The  symptoms  will  be  much  the 
same  as  those  mentioned  in  connection  Avith  hemorrhage  from  the  middle  menin- 
geal, and  at  present  there  are  no  means  of  distinguishing  between  hemorrhage 
from  the  middle  meningeal  and  that  from  the  middle  cerebral.  It  is,  however, 
of  no  great  pi-actical  importance  to  distinguish  between  them,  for  the  treat- 
ment is  the  same.  The  anterior  trephine  opening  before  referred  to,  especially 
if  enlarged  upward  and  backward,  will  give  access  to  the  middle  cerebral,  and 
if  the  evidences  point  to  intracranial  hemorrhage,  and  on  trephining  no  clot  is 
found  under  the  bone,  the  dura  should  be  opened  and  the  clot  searched  for  on 
the  surface  of  the  brain  itself,  following  the  direction  of  the  fissure  of  Sylvius, 
in  which  the  middle  cerebral  lies.  If  this  be  the  source  of  the  hemorrhage, 
the  bleeding  point  must  be  found  and  the  artery  ligated.  More  commonly, 
however,  subdural  hemorrhage  is  caused  by  the  rupture  of  a  number  of  vessels 
under  a  depressed  fracture,  and  the  consequences,  unless  the  case  is  properly 
treated,  are  most  deplorable.     Not  uncommonly  the  patient  will  die  as  a  result 


DISEASES   AXD    IXJLIIIES    OF    THE    HEAD.  oil 

of  the  injury  to  tlie  brain  ;  but  sliould  he  recover  the  course  of  events  is  usually 
as  follows :  The  clot,  having  produced  more  or  less  extensive  paralysis,  is  grad- 
ually absorbed,  but  the  brain  may  not  expand  to  its  former  position,  being  per- 
manently depressed,  for  the  site  of  the  injury  is  sometimes  occupied  by  spongy 
connective  tissue  the  meshes  of  -which  are  filled  with  cerebro-spinal  fluid,  resem- 
bling a  series  of  cysts.  The  paralysis  will  gradually  lessen  and  may  almost 
entirely  disappear.  Aft^r  a  varying  interval,  from  a  fcAV  months  up  to  two  or 
three  years,  the  patient  may,  however,  become  subject  to  epileptic  or  other 
cerebral  disturbances,  and  if  so  he  will  lead  a  miserable  existence  so  long  as 
he  may  live.  The  importance,  therefore,  of  evacuating  the  clot,  removing 
the  pressure,  and  thus  preventing  the  disastrous  later  effects,  is  evident. 
Hence  all  cases  of  marked  and  localized  depressed  fracture  should  be  tre- 
phined, the  bone  lifted,  and  the  clot  evacuated  and  treated  as  has  been 
described. 

Hemorrhage  from  Pachymeningitis  Interna. — A  few^  cases  have  been 
reported  of  subdural  hemorrhage  from  pachymeningitis  interna.  These  are 
amenable  to  the  same  treatment,  by  trephining,  evacuation,  and  drainage. 
Even  so  long  as  two  months  after  the  accident  Ceci  has  been  able  to  rescue 
his  patient  from  a  condition  of  complete  coma  and  palsy,  with  almost  total 
restoration  of  function.- 

((?)  Hemorrhage  into  the  Brain  Substance. — Severe  traumatism 
may  rupture  the  vessels  in  the  interior  of  the  cerebrum,  and  even  produce 
hemorrhage  into  the  ventricles.  The  symptoms  in  this  case  will  resemble 
those  of  ordinary  apoplexy  in  every  respect  except  the  cause.  The  diag- 
nosis is  based  upon  this  resemblance  and  this  difference.  As  a  rule,  little  can 
be  done  in  such  cases,  for  the  injury  to  the  brain  substance  is  generally  so 
extensive  that  even  if  the  clot  be  evacuated  the  patient  will  usually  die  from 
the  injury. 

{d)  Wounds  of  the  Sinuses  of  the  Brain. — Occasionally  in  ope- 
rations, but  more  commonly  from  severe  and  usually  compound  fracture,  the 
superior  longitudinal  or  the  lateral  sinuses  of  the  brain  may  be  injured.  It  is 
always  a  serious  and  often  a  fatal  accident.  The  blood  pours  out  so  furiously 
that  the  patient  may  die  in  a  few  minutes  from  the  shock  of  the  injui-y ;  for 
undoubtedly  rapid  loss  of  blood  from  the  brain  itself  is  more  fatal  than  the 
loss  of  an  equal  amount  of  blood  from  any  other  part  of  the  body.  Hence 
all  operations  in  the  neighborhood  of  the  sinuses  should  be  conducted  with 
great  care.  If  necessary  to  trephine  in  their  neighborhood,  the  edge  of 
the  trephine  should  be  at  such  a  distance  as  to  be  perfectly  safe.  With  the 
.dural  separator  or  a  grooved  director  or  probe,  and  then  the  finger,  the  dura 
may  be  separated  and  the  sinus  entirely  detached  from  the  skull ;  and  then  the 
original  trephine  opening  can  be  safely  enlarged  at  will  by  the  rongeur  forceps. 
If  necessary,  a  portion  of  the  sinus  may  be  removed  by  first  exposing  it  in  the 
manner  indicated,  and  then  ligating  it  on  both  sides  of  the  proposed  incision. 
Should  the  sinus  be  ruptured  either  in  an  operation  or  by  a  fracture,  the  hem- 
orrhage usually  can  be  controlled  by  instant  packing  with  iodoform  gauze. 
Sometimes  the  margins  can  be  seized  by  one  or  more  pairs  of  hemostatic  for- 
ceps, which  may  be  removed  on  the  second  or  third  day.  Of  course  great  care 
should  be  taken  lest  they  be  displaced  in  the  tossing  of  the  head  by  the  patient. 
Lateral  ligature  and  suture  of  the  sinuses  have  also  been  employed. 


518  ^l^V   AMERICAN   TEXT-BOOK    OF  SURGERY. 


VIII.— FRACTURES  OF  THE  SKULL 

Fractures  of  the  skull  are  considered  with  injuries  of  the  head  rather  than 
■with  other  fractures,  for  the  reason  that  the  fracture  y^cr  se  is  of  comparatively 
small  moment.  My  far  the  most  important  factor  in  such  injuries  is  the  injury 
to  the  brain  or  to  its  membranes,  or  to  both.  A  violence  that  will  break  the 
bones  of  the  head  is  such  that,  even  thou<:h  there  is  no  depression,  very  often 
the  brain  itself  suffers  serious  injury  ;  and  if  fragments  are  depressed  or  broken 
off  and  driven  into  the  brain,  the  injury  becomes  even  more  severe  and  often 
fatal.  The  treatment  of  such  fractures,  therefore,  is  based  on  the  injury,  either 
actual  or  possible,  to  the  brain  itself,  rather  than  on  the  injury  to  the  skull. 
The  history  of  such  fractures  and  of  their  treatment  is  almost  like  that  of 
abdominal  diseases  and  injuries.  The  hesitation  to  interfere  Avhich  })revailed 
in  the  past  has  been  happily  replaced  by  positive  action  of  the  most  radical 
character,  so  that  the  treatment  of  such  fractures  has  been  almost  entirely 
changed  within  the  last  ten  years.  The  danger  is  now  perhaps  in  the  opposite 
direction — that  surgeons  may  go  too  far  and  do  harm  rather  than  good  by  a 
rash  interference  instead  of  a  wise  conservatism. 

Fractures  of  the  skull  are  very  frequent  as  a  result  of  falls,  blows,  either 
from  falling  bodies  or  in  personal  encounters,  and  similar  accidents.  They  are 
often  extensive  and  involve  wide  areas  of  the  skull  in  multiple  fractures  ;  or,  on 
the  contrary,  they  may  be  limited  to  a  very  small  area,  as  in  punctured  frac- 
tures made,  for  instance,  by  a  knife-blade  or  a  nail,  in  which,  as  a  rule,  there 
lurks  even  more  danger  than  in  the  more  extensive  fractures,  because  they  are 
so  apt  to  be  improperly  treated.  The  same  varieties  that  are  found  in  frac- 
tures elsewhere  obtain  in  the  skull.  The  fracture  may  be  either  simple  or 
compound.  If  simple,  the  fracture  in  the  bone  does  not  communicate  with  the 
external  air ;  if  compound,  it  does,  usually  through  the  lacerated  scalp.  But 
attention  is  especially  called  to  the  fact  that  a  fracture  of  the  skull  which 
extends  into  the  nose,  ear,  or  mouth  is  just  as  truly  compound  as  a  fracture  of 
the  vault,  and  even  more  dangerous,  because  the  feet  that  it  is  a  compound 
fracture,  and  therefore  liable  to  infection,  is  so  often  overlooked.  Such  frac- 
tures, again,  may  be  impacted.  They  may  also  be  partial ;  that  is,  the  outer 
table  may  not  be  broken,  yet  fragments  may  have  been  broken  off  from  the 
inner  table,  wounding  either  the  meninges  or  the  brain  itself. 

Fractures  of  the  skull  are  best  discriminated  by  their  position  as  fractures 
of  the  vault  and  fractures  of  the  base  of  the  skull.  Fractures  of  the  vault  are 
usually  the  result  of  direct  violence,  while  fractures  of  the  base  result  either 
from  the  extension  of  fractures  of  the  vault  from  the  side  to  the  base  of  the 
skull,  or  from  indirect  violence,  such  as  a  fall  in  which  the  person  may  alight 
upon  the  feet  or  the  buttocks,  in  which  case  the  blow  is  delivered  through  the 
spinal  column,  and  sometimes  even  a  fall  on  the  vertex,  in  which,  either  with 
or  without  fracture  of  the  vault,  the  base  is  fractured  in  a  similar  manner  by 
the  Aveight  of  the  body.  The  base  has  also  been  fractured  l)y  violence  received 
through  the  lower  jawbone,  the  condyles  having  even  been  forced  within  the 
cavity  of  the  skull. 

Fracture  of  the  skull  sometimes,  but  very  rarely,  occurs  at  a  point  opposite 
that  at  which  the  blow  is  received.  This  is  called  fracture  by  cantre-conp,  or 
counter-stroke.  Rupture  of  the  meningeal  vessels  and  of  the  brain  itself 
certainly  does  take  place  at  such  a  point  not  uncommonly,  and  its  mechanism 
has  already  been  explained  (p.  510). 


FRACTURES  OF  THE  SKULL. 


Plate  XI IL 


1.  Linear  fracture  of  vault  of  skull.       2.  Depressed  fracture  of  vault  (from  within).       3.  Depressed 

fracture  of  vault  (from  without). 


DISEASES   AND    INJURIES    OF    THE   HEAD.  519 


1.  FRACTURE  OF  THE  VAULT. 

This  may  be  a  mere  fissure,  like  a  crack  in  a  cliina  plate  (PI.  XIIT,  Fig.  1). 
The  fissure  may  not  he  limited  to  one  bone,  but  may  cross  a  suture  and  extend 
quite  widely.  When  compound,  such  a  fracture  may  catch  dirt  or  even  a  single 
hair,  which,  unless  it  is  removed  and  the  part  disinfected,  may  become  a  source 
of  serious  or  even  fatal  infection.  Instead  of  a  fissure  the  bones  may  be  broken 
into  several  pieces,  a  comminuted  fracture,  either  with  or  without  depression  of 
the  fraixnients  (PI.  XIII,  Figs.  2  and  3).  If  depression  takes  place,  there  is  usu- 
ally a  funnel-like  hollow.  There  is  no  separation  of  the  fragments,  save  what 
has  been  produced  mechanically,  for  there  are  no  muscles  inserted  on  the  skull 
to  cause  displacements  similar  to  those  which  occur  with  most  other  fractures. 

Symptoms. — If  the  fracture  be  a  fissure,  it  can.usually  only  be  suspected, 
but  may  possibly  be  recognized  in  some  cases  by  a  "cracked-pot''  sound. 
This  may  be  elicited  by  percussion,  best  with,  but  sometimes  even  with- 
out, a  stethoscope.  It  may  be  heard  by  the  surgeon  or  by  the  bystanders, 
or  may  be  perceived  only  by  the  patient  himself.  The  same  curious  sound 
may  be  similarly  elicited  in  hydrocephalus  with  beginning  separation  of  the 
bones.  If  the  fracture  is  much  depressed,  however,  the  depression,  as  a 
rule,  may  be  easily  felt  by  the  finger.  Care  must  be  taken  not  to  mistake  for 
a  fracture  the  circular  effusion  of  blood  which  is  so  common  after  contusion. 
If  there  has  been  any  destruction  of  the  scalp,  it  is  very  possible  to  mistake  an 
old  depressed  scar  from  this  loss  of  tissue  for  an  old  depressed  fracture  of  the 
skull.  Occasionally  there  may  be  rupture  of  the  dura  even  with  simple  frac- 
ture, and  the  cerebro-spinal  fluid  escaping  under  the  scalp  Avill  cause  a  partially 
translucent,  pulsating  swelling,  which  becomes  tense,  especially  with  expiratory 
efforts  such  as  sneezing,  coughing,  etc.  It  is  a  very  rare  but  a  positive  sign 
of  fracture.      Still  more  rarely  the  fluid  may  come  from  the  ventricles. 

If  the  fracture  be  compound,  its  extent  can  be  determined  both  by  eye  and 
by  touch,  but  care  must  be  taken  not  to  mistake  the  ordinary  sutures,  and  espe- 
cially those  of  the  Wormian  bones  or  a  slit  in  the  pericranium,  for  linear  frac- 
ture. The  dark  line  of  blood  which  marks  a  fissured  fracture  cannot  be 
sponged  or  washed  away,  while  the  coagulated  blood  in  an  unbroken  suture 
can  be  readily  removed.  This  is  a  valuable  means  of  differential  diagnosis. 
The  tooth-like  character  of  the  sutures  is  also  a  valuable  aid.  If  cerebro- 
spinal fluid  or  brain  tissue  escape,  the  evidence  of  course  will  be  positive. 

Fracture  of  the  inner  table  alone,  which  is  very  rare,  can  also  only  be  sus- 
pected, but  if  there  have  been  marked  violence  followed  by  symptoms  of  intra- 
cranial irritation  or  inflammation,  the  possibility  that  such  an  injury  has  occurred 
is  increased;  and  if  the  symptoms  be  of  localizing  value — for  instance,  if  there 
be  a  palsy  of  speech  or  of  the  right  arm,  or  both  of  these  symptoms,  and  if  the 
blow  have  been  received  above  and  in  front  of  the  left  ear — the  possibility  will 
become  strong  enough  to  warrant  immediate  operative  interference. 

The  prognosis  depends  almost  entirely  on  the  amount  of  injury  done  to 
the  brain  rather  than  to  the  bone.  As  to  the  fracture  itself,  repair  will  take  place, 
and  the  amount  of  callus  thrown  out  in  the  skull  is,  fortunately,  but  little. 
Were  it  great,  pressure  on  the  brain  would  be  the  rule  even  in  simple  fissurea 
fractures.  If  the  fracture  be  compound,  with  loss  of  any  fragments  of  bone, 
the  loss  will  not  usually  be  made  good  by  new  bone,  but  by  fibrous  tissue 

Treatment. — The  conservative  treatment  of  the  last  seventy-five  years, 
which  inculcated  rest,  antiphlogistics,  sedatives,  cold,  and  watching  and  Avaiting 
until  the  patient  recovered  or  died,  is  curiously  preceded  and  followed  by  a  bold 
and  active  interference.     Even  pre-historic  trephining,  which  was  largely  praC" 


520  AX  AMi:in(A.\  Ti: XT- HOOK  or  sruarjiY. 

tiscd  as  a  religious  rite,  niust  liave  been  comparatively  liarniless,  judging  from 
the  large  lunuher  of  skulls  discovered  -with  trephine  openings  healed  before 
death.  Prior  to  the  earlier  part  of  the  nineteenth  century  the  trepliine  was 
very  frequently  used:  it  is  said  that  Chadborn  trci)hined  Philip  of  Nassau 
for  epilepsy  twenty-seven  times,  and  instances  of  even  a  far  larger  number 
of  o])erations  on  a  single  individual  are  known.  The  use  of  the  trephine, 
however,  was  gradually  abandoned,  and  for  the  last  three-quarters  of  a  century, 
almost  disappeared  until  modern  methods  made  the  operative  surgery  of  the 
brain  so  much  safer  that  a  return  to  frequent  trephining  and  other  similar  ope- 
rative interference  has  been  a  very  notable  fact  within  the  last  few  years. 
Especially  is  this  true  since  jNIacewen  and  Horsley  have  established  the  proper 
technicjue  of  such  operations.  At  present,  therefore,  trej)hining  with  a  view 
to  the  relief  of  innnediate  symj)tonis,  and  also  quite  as  much  for  the  ])reven- 
tion  of  later  ill  effects,  is  not  only  justifiable,  but  in  many  cases  is  demanded. 

There  are  two  forms  of  danger  from  such  fractures :.  (1)  the  immediate 
dangers,  which  are  first  the  injury  to  the  brain,  and  secondly  septic  inflamma- 
tion ;  and  (2)  the  later  dangers  of  severe  continuous  heachiche  or  of  epilepsy 
and  insanity,  which  are  worse  than  death.  For  instance,  even  in  a  case  of 
simple  fracture  there  may  have  been  a  rupture  of  the  dura  and  more  or  less 
laceration  of  the  brain  tissue,  Avith  effusion  of  a  large  or  a  small  clot.  If  the 
clot  be  small,  it  will  be  absorbed  before  long,  and  healing  of  both  the  brain 
and  the  dura  will  take  place  by  the  ordinary  cicatricial  tissue  of  a  lacerated 
wound.  The  skull,  if  it  have  been  depressed,  may  even  recover  its  vaulted 
contour  (especially  in  children),  but  the  scars  which  remain  in  the  brain  and 
dura  are  sometimes  remotely  the  cause  of  epilepsy,  insanity,  and  other  compli- 
cations of  like  character.  Such  a  fracture,  especially  if  compound  and  the 
result  of  a  localized  violence,  may  be  attended  with  a  clot,  producing  all  the 
symptoms  of  compression  of  the  brain.  This  clot  and  the  brain  tissue  more 
or  less  intermingled  with  it  may  gradually  be  absorbed,  but  the  brain  is  some- 
times left  permanently  depressed,  witli  spongy  connective  tissue,  the  meshes  of 
which  are  filled  with  cerebro-spinal  fluid;  this  sort  of  multiple  cyst  may  keep 
up  the  palsy  originally  produced  by  the  clot,  and  epilepsy,  insanity,  and  other 
serious  consequences  may  follow  even  if  the  patient  recovers.  The  journals 
of  the  last  few  years  have  recorded  a  number  of  such  cases,  and  the  lesson  to 
be  derived  from  them  is  a  most  important  and  practical  one.  The  doubt  often 
expressed  as  to  the  wisdom  of  converting  a  closed  fracture  into  an  open  one  by 
an  incision  into  the  scalp  has  little  weight,  provided  the  surgeon  observes  the 
modern  antiseptic  precautions,  without  which  methods  no  surgeon  should  touch 
a  fracture  of  the  skull. 

Moreover,  it  is  important  to  observe  the  great  difference  that  should  attend 
the  treatment  in  cases  in  whicli  a  sinqde  fracture  occupies  a  limited  area  as  a 
result  of  a  localized  violence — e.  g.  a  blow  from  a  hammer,  and  one  in  Avhich 
the  "bursting"  force  of  a  diffused  injury  produces  long  fissures  in  the  bone 
and  widespread  injury  to  the  brain.  In  tlie  former  such  an  exploratory 
incision  may  be  entirely  proper,  in  the  latter  in  most  instances  it  would  be 
inadvisable. 

If  tlie  fracture  of  tJievauU  be  simple,  ivitliout  depression  and  without  cere- 
bral symptoms,  or  if  moderate  cerebral  symptoms  have  been  ptresent,  but  are 
abating,  or  if  a  fracture  be  only  suspected,  the  case  should  be  treated  expect- 
antly, but  if  any  serious  symptoms  of  intracranial  mischief  arise  trephining 
should  be  done.  In  simple  fracture  with  marked  depression  immediate  jire- 
ventive  trephining  should  be  done,  even  if  there  be  no  signs  of  encephalic 
mischief.    Any  violence  sufficient  to  break  a  bone  and  depress  it,  there  is  good 


DISEASES  AND   INJURIES   OF   THE  HEAD.  521 

reason  to  believe,  may  have  lacerated  the  brain  substance  and  probably  the 
dura,  aiul  may  be  follo\ved  either  by  speedy  infUunmation  or  later  in  many 
cases  by  epilepsy,  etc.  if  the  depression  remain.  It  is,  however,  but  just  to 
add  that  many  surgeons  still  reject  trephining  until  some  symptoms  of  a  lesion 
of  the  brain  have  manifested  themselves. 

In  all  compound  fractures  of  the  skull  it  is  far  better  to  shave  the  entire 
scalp  rather  than  a  small  area,  as  is  so  often  done.  The  removal  of  the  hair 
even  from  a  nu^derate  area  becomes  very  conspicuous,  and  it  is  better,  even 
from  an  esthetic  ])oint  of  view,  that  the  entire  head  should  be  shaved,  so  that 
the  new  crop  of  hair  shall  be  of  a  uniform  length  all  over  the  head.  More 
than  this,  it  is  impossible  to  observe  rigid  asepsis  without  wide  shaving,  which 
thus  becomes  obligatory,  even  in  women. 

Compound  fractures  should  always  be  explored  by  a  large  incision  in  the 
scalp.  If  the  fracture  be  a  mere  linear  fissure,  it  must  be  most  carefully 
disinfected,  and  if  it  be  impregnated  with  dirt  or  even  if  a  single  hair  be 
caught  in  it,  the  outer  table  must  be  carefully  chiselled  away,  turning  the 
fissure  into  a  V-shaped  groove.  The  reason  for  this  is  that  the  danger  lies  far 
more  in  the  probable  infection  than  in  the  mere  fissured  fracture.  If  much 
depression  exist  even  without  symptoms  showing  that  serious  injury  to  the 
brain  has  been  done,  trephining  should  be  done  at  once.  It  is  still  more 
strongly  indicated  if  there  be  localizing  symptoms  which  point  to  an  injury  of 
any  of  "^the  cortical  centers  Avithin  easy  reach,  Avhether  the  fracture  be  simple 
or  compound. 

Punctured  tvounds  of  the  brain  are  of  course  always  compound  fractures 
of  the  most  fatal  kind.  In  these  the  rule  has  long  been  absolute  to  trephine 
whether  there  be  any  brain  symptoms  or  not. 

If  the  surgeon  sees  that  symptoms  of  intracranial  mischief,  such  as  local 
paralysis,  epileptic  seizures,  beginning  choked  disks,  etc.,  arise  in  any  case  of 
fracture  of  the  skull,  even  after  a  considerable  interval,  his  proper  course  is 
immediate  operation.  The  longer  the  operation  is  delayed,  the  longer  the 
"epileptic  habit"  has  had  a  chance  to  form  and  the  organic  changes  in  the 
brain  to  become  fixed,  the  less  the  probability  of  benefit  from  any  operation. 
If,  however,  as  in  a  case  reported  by  Horsley,  an  old  depressed  compound 
comminuted  fracture  with  laceration  of  the  brain  tissue,  which  caused  in  the 
first  thirteen  days  of  the  patient's  stay  in  hospital  2870  fits,  could  be  cured 
by  the  removal  of  the  scar  tissue,  we  should  not  be  deterred  from  attempting  to 
relieve  even  the  apparently  most  hopeless  cases. 

To  sura  up  the  matter,  in  any  fracture  of  the  vault,  simple  or  compound, 
in  which  there  are  symptoms  of  intracranial  mischief  it  is  proper  to  incise  the 
scalp  and  trephine.  If  there  are  no  symptoms  pointing  to  intracranial  mis- 
chief, but  there  is  marked  localized  depression  from  which  we  should  infer  the 
probability  of  either  immediate  or  remote  ill  consequences,  we  should  trephine. 
In  all  cases  of  punctured  fracture  the  rule  is  absolute  to  trephine,  open  the  dura, 
and  disinfect.  If,  however,  in  a  simple  fracture  there  be  no  decided  depres- 
sion and  no  brain  symptoms,  the  expectant  plan  may  be  pursued ;  but  if  the 
fracture  be  compound,  it  must  be  carefully  disinfected,  as  has  been  described. 

In  giving  these  directions  to  operate  it  is  of  course  understood  that  not 
only  is  the  bone  to  be  trephined,  but  if  there  is  any  reason  whatever  the  dura 
must  be  incised  and  the  brain  inspected.  Any  further  steps  must  depend  on 
what  is  found.  In  81  cases  of  compound  fracture  of  the  skull  treated,  as  above 
described,  by  primary  trephining  the  mortality  was  1.23  per  cent.,  while  in  12 
cases  treated  secondarily  the  mortality  was  33.5  per  cent.  (Wagner).  That  is 
to  say,  later  trephining,  which  should  have  been  done  at  the  time  of  the  acci- 


522  AX  A  ME  RICA  X   TEXT-BOOK   OF  SURGERY. 

(lent,  caused  an  initial  mortality  nearly  thirty  times  as  great  as  simple  primary 
trephining,  to  say  nothing  of  later  dangers. 

2.  FRACTURES  OF  THE   BASE. 

As  has  been  already  stated,  fractures  of  the  base  (PI.  XIY,  Fig.  1)  cither 
result  from  the  extension  of  fractures  of  the  vault  to  the  base,  or  arise  from 
indirect  violence  received  through  the  spinal  column  or  rarely  through  the 
lower  jaw. 

In  addition  to  these  cases  a  punctured  fracture  of  the  base  may  take  place 
through  four  cavities  at  the  base  of  the  skull,  the  orbit,  the  nose,  and  the 
mouth,  or  a  fissured  fracture  of  the  ear.  It  is  not  very  uncommon  to  see 
fractures  of  the  base,  with  wound  of  the  brain,  caused  by  umbrellas,  canes, 
knives,  small  sticks  of  wood,  etc.,  which  enter  the  orbit  above  the  eyeball  or 
gain  access  through  the  nose  by  piercing  the  cribriform  plate  of  the  ethmoid, 
while  gunshot  fractures  are  often  the  result  of  attempts  at  suicide  by  dis- 
charging a  pistol  into  the  mouth.      All  invite  infection  from  without. 

The  fracture  of  the  base  may  exist  either  in  the  anterior,  middle,  or  pos- 
terior fossa  of  the  base  of  the  skull,  the  middle  fossa  suffering  most  frequently. 
Often  more  than  one  fossa  is  involved.  Fracture  of  the  posterior  fossa  has 
double  the  fatality  of  fracture  of  the  other  two. 

The  symptoms  of  fracture  of  the  base  are  usually  inferential,  depending 
on  the  violence  of  the  blow,  and  not  uncommonly  on  our  ability  to  detect 
extensive  fracture  of  the  vault  probably  extending  to  the  base.  In  fractures 
through  the  orbit  or  other  of  the  cavities  just  mentioned  the  evidence  may  be 
very  clear,  but,  on  the  other  hand,  it  may  be  very  difficult  to  arrive  at  a  posi- 
tive conclusion.  Not  a  few  cases  have  occurred  in  which  a  thrust  into  the  nose 
has  produced  severe  bleeding,  but  in  which  the  evidence  of  puncture  of  the 
base  of  the  skull  and  injury  to  the  brain  has  been  very  doubtful.  This  is 
equallv  true  of  the  orbit,  where  a  slight  wound  may  be  hidden  in  the  folds  of  the 
upper  lid.  Large  splinters  of  wood  which  have  entered  the  cranial  cavity  either 
through  the  orbit  or  through  the  nose  have  been  discovered  at  post-mortem 
examinations,  their  presence  having  been  unsuspected  during  life.  Of  course 
the  escape  of  brain  substance  through  the  ear,  mouth,  nose,  or  orbit  is  posi- 
tive evidence.  In  fracture  through  the  nose  and  mouth  there  may  be  vomit- 
ing of  blood  which  has  been  swallowed. 

The  commonest  sign  of  fracture  of  the  base,  especially  in  the  middle 
fossa,  is  the  escape  of  blood  or  cerebro-spinal  fluid  from  the  ear.  Sometimes 
there  will  be  bleeding  from  the  ear,  followed  by  the  ordinary  serous  discharge 
from  a  Avound,  which  may  exist  without  any  fracture  of  the  base,  but  this 
bleedinrr  will  usuallv  continue  for  onlv  a  short  time.  Lonji-continued  bleed- 
ing,  or,  still  more,  the  continuous  discharge  of  a  watery  fluid,  from  the  ear,  if 
abundant,  and  especially  if  it  is  aff"ected  by  the  position  of  the  head  and  is 
increased  by  any  violent  expiratory  effort,  such  as  sneezing,  coughing,  blow- 
ing the  nose,  etc.,  is  almost  positive  evidence  of  such  fracture,  and  especially 
if  the  watery  fluid  possess  the  chemical  characteristics  described  below  (p.  505). 
The  patient  may  be  directed  to  make  these  expiratory  efforts  with  a  view 
to  testing  the  result.  But  in  order  that  there  shall  be  the  escape  of  blood  or 
cerebro-spinal  fluid  from  the  ear  externally,  the  drumhead  itself  must  also 
have  been  ruptured.  The  fact,  therefore,  must  not  be  overlooked  that  there 
may  exist  fracture  of  the  base  without  the  escape  of  blood  or  cerebro-spinal 
fluid,  on  account  of  non-rupture  of  the  drumhead.  These  fractures,  however, 
are  still  compound,  because  they  communicate  with  the  external  air  through 
the  Eustachian  tube  and  the  naso-pharynx,  and  their  danger  is  all  the  greater 


FRACTURES  OF  THE  SKULL. 


Plate  XIV. 


1.  Fracture  of  base  of  skull,       2.  Gunsbot  fracture  of  lower  jaw  and  cranium. 


J)LsJ':a<sl\s  a.xj)  ixjiuiks  of  Tin-:  head.  wi?y 

because  of"  their  insidious  character.  Another  evidence  of"  fracture  ol"  the  base 
is  paralysis  of  the  cranial  nerves,  especially  of  the  optic,  facial,  and  auditory 
nerves.  Deafness  and  facial  palsy,  therefore,  are  very  significant  of  fracture 
of  the  petrous  bone,  and  if  either  or  both  of  them  accompany  discharge  of 
fluid  from  the  ear  and  other  evidences  of  fracture  of  the  base,  the  diagnosis  is 
assured.  Optic  neuritis  also  sometimes  occurs,  especially  in  fracture  of  the 
posterior  fossa  (Battle).  Its  advent  is  usually  not  till  toward  the  end  of  the 
first  week,  and  may  be  delayed  even  till  three  or  four  weeks  have  passed. 

When  the  orbital  plate  of  the  frontal  bone  has  been  fractured,  even  with- 
out puncture,  there  is  another  symptom  of  considerable  value — namely,  after 
a  day  or  two  blood  will  appear  first  under  the  conjunctiva  of  the  ball  of 
the  eye,  and  later  in  the  lids.  In  fracture  of  the  posterior  fossa,  which  is 
especially  fraught  with  danger,  the  mastoid  region  should  be  examined  for 
ecchymosis.  This  is  easily  overlooked,  as  its  existence  is  often  hidden  by  the 
ear,  the  pillow,  and  the  hair.  As  shown  by  Battle,  it  appears  first  anterior  to 
the  tip  of  the  mastoid  process,  usually  some  time  after  the  reception  of  the 
injury,  and  spreads  chiefly  upward  and  backward  with  a  crescentic  border. 
The  reason  for  these  peculiarities  is  that  the  blood  cannot  reach  the  skin  below 
the  occiput  on  account  of  the  dense  cervical  fascia,  but  follows  the  muscular 
planes  sidewise,  first  reaching  the  surface  anterior  to  the  tip  of  the  mastoid  by 
the  loose  tissue  around  the  posterior  auricular  artery. 

The  temperature  during  the  shock  following  the  injury  is  subnormal. 
This  is  succeeded  by  a  rise  to  100°  or  101°  F.,  followed  often  by  a  second  fall 
somewhat  below  the  normal.  It  will  then  remain  subnormal  or  rise  to  the 
normal.  If  the  temperature  rises  to  any  notable  degree,  we  may  suspect  sup- 
puration and  meningitis.  If  soon  after  the  initial  fall  it  rises  quickly  to  102° 
or  in  some  cases  106°,  108°,  or  even  110°,  we  may  be  sure  there  has  been 
some  serious  laceration  of  the  brain,  with  almost  certainly  a  fatal  issue. 

The  prognosis  in  fracture  of  the  base  had  always  been  an  unfavorable 
one  until  of  late  years.  The  danger  of  infection  was  especially  great,  because 
the  points  through  which  septic  infection  may  penetrate  are  hidden,  and  there- 
fore were  generally  overlooked.  These  sources  of  infection  are  chiefly,  as  has 
been  pointed  out,  the  ear,  mouth,  nose,  and  orbit  (if  punctured) ;  all  of  them 
are  more  or  less  inaccessible,  difficult  to  disinfect,  and  likely  to  be  overlooked. 
But  the  last  few  years  have  seen  immense  improvement  in  our  methods  of  treat- 
ing such  fractures.  The  urgent  necessity  for  disinfection  of  these  dangerous 
cavities  has  been  recognized,  and  as  a  result  fractures  of  the  base  are  much, 
more  amenable  to  treatment  and  their  danger  has  been  greatly  reduced.  A 
sudden,  and  especially  a  high,  rise  of  temperature,  as  has  just  been  stated,  is 
a  most  unfavorable  symptom. 

Treatment. — In  case  of  fracture  of  the  base  the  fluid  which  escapes  from 
the  ear,  nose,  etc.  ought  to  be  collected,  and  examined  to  determine  whether  it 
be  cerebro-spinal  fluid.  If  it  be,  it  Avill  contain  a  small  amount  of  albumin  and 
a  large  amount  of  chlorides,  and  will  sometimes  give  the  reaction  for  sugar  with 
Fehling's  test.  Next  the  cavity  or  cavities  involved  must  be  carefully  disin- 
fected. The  ear  should  first  be  mechanically  cleansed  of  w^ax,  dirt,  blood-clot, 
etc.,  and  then  should  be  most  carefully  disinfected  by  a  stream  of  warm  sub- 
limate solution,  1  :  2000,  or  hydrogen  peroxide,  till  it  is  absolutely  clean.  It 
may  then  be  filled  with  sublimated  cotton,  iodoform  gauze,  or  some  similar  dis- 
infectant, and  a  sublimate  dressing  be  applied  externally.  In  the  orbit  the 
same  rule  must  be  carried  out,  and  if  the  fracture  be  a  punctured  one,  carry- 
ing infection  into  the  brain,  the  wound  must  be  enlarged  and  thoroughly  dis- 
infected ;  as  a  rule  it  is  best  to  trephine  or  remove  by  the  gouge  and  chisel 


o24  .l.V   AMKlllVAy    TEXT-liOOK    OF  Sl'RiiKRY. 

sufficient  of  the  roof  of  the  orbit  to  inspect  the  duni  and  l)rain  itself  if  need 
be,  and  then  after  liaving  disinfected  the  parts  to  drain  them. 

In  the  nose  and  mouth  this  proceeding  nnist  be  modified,  inasnnich  as  cor- 
rosive-sublimate solution  would  be  dangerous  from  the  jjussibility  of  its  being 
swallowed.  The  parts,  however,  should  be  thoroughly  washed  with  water  as 
hot  as  can  be  borne,  and  then  with  a  boric  acid  s^jlution.  which  in  the  mouth 
must  be  fre([uently  repeated  by  gargling,  and  in  the  nose  by  Thudichum's 
douche  or  bv  spraying.  The  nose  should  then  be  lightly  packed  with  subli- 
mate gauze'or  sublimate  cotton,  which  will  not  only  sterilize  the  air  that  may 
enter  by  the  anterior  nares,  but  also,  by  obstructing  the  passage  of  the  air 
through  the  nose,  tend  to  prevent  infection  by  the  posterior  nares.  Iodoform 
or  boric  acid  may  be  insufflated  into  the  naso-pharynx,  and  thus  reach  the 
orifice  of  the  Eustachian  tube.  Of  course  it  is  recognized  that  the  nose  and 
mouth  cannot  be  made  absolutely  aseptic,  but  only  approximately  so.  But 
even  this  partial  asepsis  has  resulted  most  hopefully  in  treatment.  In  rare 
cases  drainage-tubes  may  be  inserted  into  the  cranial  cavity  through  the  nos- 
trils, if  need  be  by  puncture  of  the  cribriform  plate.  Similarly,  for  draining 
the  middle  fossa  the  skull  may  be  trephined  above  and  behind  the  auditory 
meatus.  Thoroughness  of  disinfection  and  of  drainage  must  be  an  absolute 
rule.  To  attain  these  ends  the  operative  interference  may  have  to  be  consider- 
able, but  they  must  be  attained  at  whatever  cost.  If  a  fracture  of  the  base  is 
extensive,  the  head  may  be  shaved  and  a  plaster  cap  applied  so  as  to  immobilize 
the  fragments.  Of  course  the  utmost  quiet  both  physical  and  mental  is  neces- 
sary, with  restricted  diet,  attention  to  bladder  and  bowels,  and  treatment  by 
drugs  to  combat  the  symptoms  as  they  arise. 

IX.   WOUNDS  OF  THE  BRAIN. 

These  are  produced  by  severe  falls,  by  kicks,  by  the  penetration  of  knives, 
nails,  swords,  bayonets,  rifle-balls,  etc.,  and  may  be  received  either  on  the 
vault  or  sides  of  the  cranium  or  through  the  orbit,  nose,  or  mouth.  With 
the  exception  of  such  wounds  in  children  through  the  open  fontanelles.  or  jios- 
siblv  in  adults  through  a  large  parietal  foramen,  they  are  necessarily  accom- 
panied by  fracture  of  the  skull.  In  many  cases  they  are  punctured  fractures 
of  the  most  dangerous  kind.  They  must  all  be  more  or  less  septic  in  character, 
with  laceration  of  the  brain  substance  by  the  vulnerating  instrument,  with  not 
uncommonly  fragments  of  bone,  hair,  cap,  etc.  carried  into  the  brain,  and  they 
are  always  attended  by  more  or  less  severe  hemorrhage.  Recovery  after  a 
severe  wound  of  the  brain  sometimes  follows  almost  miraculously ;  as,  for  instance, 
in  a  recent  case  where  a  would-be  suicide  deliberately  drove  four  nails  through 
the  skull  into  the  brain,  one  being  driven  through  the  occipital  bone.  Knife 
wounds  have  been  repeatedly  recovered  from,  the  blade  of  the  knife  having 
remained  in  the  brain  for  many  days  or  even  years.  Not  uncommonly  pistol- 
balls  have  remained  in  the  brain  for  years  before  producing  any  serious  symp- 
toms, and  sometimes  the  foreign  body  has  been  discovered  only  at  the  post- 
mortem, no  symptoms  whatever  having  arisen.  The  celebrated  Vermont 
'*  tamping-iron  ctise,"  in  which  a  patient  recovered  after  being  wounde<l  by  a 
tamping-iron  which  passed  entirely  through  the  brain  from  below  upward,  is 
too  well  known  to  require  repetition  in  detail.  Loss  of  brain  substance  is  by 
no  means  invariably  fatal,  although  of  course  always  serious. 

The  symptoms  in  such  cases  are  occasionally  surprisingly  slight  and  long 
delayed,  but  more  commonly  are  immediate  and  severe  and  in  proportion  to  the 
extent  of  the  injury  received.     Usually,  even  if  the  injury  be  moderate,  head- 


DISEASES  AA^n   INJURIES    OF   THE   HEAD.  525 

aclie  soon  sets  in,  with  all  the  symptoms  of  a  developed  encej)halitis,  followed, 
if  not  soon  relieved,  by  coma  and  death.  Very  often  there  may  be  localizing 
symptoms  of  the  greatest  value  Avhicli  will  enalde  us  to  discover  an  otherwise 
hidden  injury.  For  instance,  if  a  knife-ldade  have  penetrated  the  speech 
center  above  and  in  front  of  the  left  ear,  and  have  been  broken  off  and  hidden 
by  the  scalp  and  hair,  the  motor  aphasia  which  follows  will  guide  us  to  the 
region  where  we  should  search  for  the  injury.  If  word-blindness  or  apraxia 
occur,  the  injury  will  be  more  apt  to  be  above  and  behind  the  ear;  if  there 
be  hemianopsia,  the  region  of  the  cuneus  should  be  examined ;  while  palsy  of 
the  face,  arm,  or  leg  will  point  to  their  respective  cortical  centers  as  the  prob- 
able site  of  the  injury.  In  all  such  cases  the  entire  head  should  be  shaved,  in 
order  that  the  surface  of  the  scalp  may  be  examined  with  minute  care.  The 
vulnerating  body  also,  if  possible,  should  be  examined,  to  see  whether  any  part 
has  been  broken  off  and  possibly  left  in  the  brain,  and  the  evidence  of  eye- 
witnesses to  the  accident  is  alw-ays  to  be  carefully  weighed.  In  all  cases  which 
may  involve  a  trial  at  court  or  a  coroner's  inquest  careful  notes  should  be  made 
at  the  time.  The  question  of  foreign  bodies  in  the  brain  will  be  treated  presently. 
Treatment. — The  head  should  be  shaved,  and  then  Avith  the  greatest 
care  the  parts  should  be  made  as  aseptic  as  possible,  and  all  foreign  bodies  on 
the  outside  should  be  washed  away  or  removed  with  forceps.  Foreign  bodies, 
fragments  of  bone,  etc.  which  have  been  driven  into  the  brain  should  all  be 
removed  and  the  depressed  bone  elevated ;  the  cavity  in  the  brain  should  also 
be  disinfected.  Hemorrhage  should  be  arrested  by  ligature,  by  hot  water,  or 
by  pressure.  The  dura,  if  not  lacerated  beyond  repair,  should  be  sutured,  and 
possibly  its  place  may  be  supplied  by  a  bit  of  the  pericranium.  Drainage 
should  be  provided,  best  by  rubber  tubing,  and  then  the  flap  of  scalp  should 
be  replaced  and  sutured,  and  an  ample  sublimate  dressing  applied.  The  after- 
treatment  before  indicated  should  be  carried  out.  Secondary  abscess  will  be 
very  apt  to  follow  in  many  cases,  and  should  be  watched  for,  and  the  pus  evac- 
uated as  soon  as  possible. 

X.  GUNSHOT   WOUNDS   OF   THE   HEAD. 

These  are  frequently  more  sei'ious  than  they  appear  to  be  at  first.  A 
glancing  rifle-ball,  and  still  more  a  larger  shot,  impinges  with  such  force 
that  while  only  the  scalp  may  seem  to  ha-ve  been  injured,  in  reality  the 
bone  may  have  received  sufficient  injury  to  produce  necrosis,  and  even  the  brain 
and  its  membranes  may  be  or  may  become  involved.  The  outer  table  may  be 
only  fissured,  or,  if  it  apparently  have  escaped,  a  fragment  of  the  inner  table 
may  have  been  broken  off.  The  scalp  not  uncommonly  sloughs  to  a  consider- 
able extent.  In  other  cases  the  most  frightful  and  extensive  injuries  of  the 
brain  and  the  skull  ma}'  be  produced,  as  is  shown  on  Plate  XIV  (Fig.  2). 

Gunshot  wounds  directly  involving  the  brain  may  be  either  perforating  or 
penetrating.  A  penetrating  w'ound  is  one  in  which  the  missile  enters  and  doe? 
not  emerge,  and  a  perforating  wound  is  one  in  which  it  passes  entirely  through 
the  head.  The  injury  to  the  skull  or  brain  may  vary  from  a  comparatively  slight 
wound  to  one  which  inflicts  immense  and  widespread  injury  both  to  the  skull 
and  to  its  contents.  The  difference  between  the  wound  of  entrance  and  the^ 
wound  of  exit  is  apt  to  be  far  more  marked  in  the  skull  than  in  the  soft 
parts.  At  the  wound  of  entrance  the  aperture  in  the  external  table  may  be 
no  larger  than  the  ball  itself,  or  may  even  have  been  reduced  to  a  simple 
slit,  whereas  the  inner  table  may  be  quite  extensively  fractured.  At  the 
wound  of  exit  the  reverse  is  true.     The  outer  table  will  be  more  extensively 


526 


.l.V   AMKIUCAy    TEXT- BOOK   OF  SURGERY. 


Vui. 


fractured  than  tlie  inner,  and  in  addition  the  entire  ajierturc  at  the  wound 
of  exit,  as  the  ball  strikes  on  the  concave  surface  of  the  skull,  is  ajit  to  be 
much  larger  than  the  wound  of  entrance  (Fig.  2i!8). 

The  symptoms  are  very  much  the 
same  as  those  in  any  other  wound  of  the 
brain,  with  the  exception  that,  owing  to 
the  widespread  injury,  there  is  less  prob- 
ability of  limited  localizing  symptoms, 
though  these  may  exist. 

Treatment. — The  recent  advance  in 
cerebral  surgery  again  has  materially 
changed  our  treatment  of  such  wounds. 
The  difference  between  the  modern  treat- 
ment of  gunshot  wounds  of  the  brain  and 
the  older  methods  is  due  to  the  applica- 
tion of  antiseptic  methods  and  the  con- 
sequent boldness  with  which  we  inter- 
fere, to  the  use  of  the  aluminium  gravity 
probe,  and  to  our  knowledge  of  the  facts 
that  drainage  of  the  brain  is  not  only 
feasible  but  essential,  and  that  for  the 
pur])0se  both  of  searching  for  the  bullet 
and  of  removing  it  we  should  often  make 
a  counter-opening  by  the  trephine.  The 
details  of  the  treatment  may  be  stated 
briefly  as  follows:  (1)  Shave  and  disin- 
fect the  entire  scalp.  (2)  Disinfect  the 
entire  track  of  the  wound  from  the  wound  of  entrance  to  the  wound  of  exit,  if 
onf  be  present,  or  to  the  certain  or  probable  site  of  the  ball  if  there  be  no  wound 
of  exit.  (8)  If  there  be  any  serious  hemorrhage,  the  wound  of  entrance  or  the 
wound  of  exit  or  both  must  be  freely  enlarged  by  the  rongeur  forceps  or  the 
trephine,  and  the  vessels  secured  by  ligature,  or  occasionally  the  hemorrhage 
may  be  arrested  by  pressure  or  by  hemostatic  forceps.  (4)  The  bullet  or  other 
missile  must  be  removed  if  possible.  For  this  purpose,  if  necessary,  a  counter 
trephine  opening  must  be  made.  (5)  Free  drainage  must  be  secured,  again  if 
need  be  by  a  counter-opening.  For  this  purpose  the  drainage-tube  may  have 
to  traverse  the  entire  brain.  (6)  Apply  antiseptic  dressings,  and  continue  the 
subsequent  treatment  on  the  principles  already  laid  down.  Most  of  the  points 
above  enunciated  have  already  been  considered,  but  some  re(iuire  a  few  words. 
The  removal  of  tlie  hall  has  always  been  one  of  the  principal  difliculties  in 
gunshot  wounds.  Fluhrer  has  introduced  a  probe  of  great  value  (Fig.  224  j,  made 


Perforating  Gunshot  Wound  of  the  Brain,  in- 
volving the  cuneus  and  i)roducing  hemian- 
opsia. Tlie  wound  of  entrance  is  marked  by 
a  small  linear  sear  below  and  to  the  right  oi" 
the  wound  of  exit,  wliieh  produced  the  large 
excavated  scar  (Thomson  and  Keen). 


Fig.  -224. 


Fluhrer's  Aluminium  Gravity  Probe  (natural  size,  except  the  length,  which  is  IJ  inches). 


of  aluminium,  with  large  conical  ends  of  different  sizes.  The  material  is  so 
light  that  if  the  head  be  so  placed  that  the  track  of  the  ball  is  vertical,  the 
probe  if  allowed  to  enter  by  its  own  weight  will  not  produce  a  false  passage, 
but  will  follow  the  track  of  the  ball.  If  the  ball  is  near  the  wound  of 
entrance,  it  may  be  extracted  through  this  Avound,  but  if  it  has  penetrated  so 
far  as  to  be  more  accessible  from  the  opjiosite  side  of  the  skull,  a  counter- 
opening  should  be  made  at  the  point  at  which  the  probe  would  emerge  if  it 


DISEASES  AND    ISJLRIES    OF    THE   HEAD. 


52; 


were  carried  througli  the  head.  It  is  iin|)ortaiit,  tliorffore,  in  using  the  probe 
to  measure  its  length,  and  when  the  probe  has  readied  the  ball  to  measure  the 
protruding  portion,  which  will  give  us  the  dejtth  at  which  the  ball  lies  from  the 
Avouud  of  entrance.      Then,  pushing  the  probe  farther  on  just  to  the  counter- 


FiG.  22o. 


Fig.  212,  A,  B.— Method  of  Determining  the  Point  lor  Counter-trephining:  a,  the  protruding  end  of  the 
probe  ;  6.  its  axis  continued  to  the  counter-point  d ;  c,  similar  lines  all  converging  to  d,  the  place  for 
the  counter-opening.  These  lines  are  fixed  by  regarding  the  skull  in  various  planes  :  first  from  above, 
then  in  front,  etc.,  and  following  the  line  of  the  protruding  part  of  the  probe  to  the  opposite  side  of 
the  slcuU  (Bryant). 

opening,  and  again  measuring  the  part  which  protrudes  from  the  wound  of 
entrance,  we  ascertain  the  depth  at  which  the  ball  lies  from  the  counter-opening. 
Two  strands  of  antiseptic  silk  are  now  attached  to  the  extremities  of  the  probe 
and  are  drawn  through  the  wound  by  the  withdrawal  of  the  probe.  To  one 
of  these  strands  a  No.  9  (French)  gum  catheter  is  attached.  This  must  be 
jiew  and  well  disinfected,  especially  in  the  interior,  and  made  rigid  by  a  disin- 


528  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

fected  straight  stylet.  A  ])air  of  forcoj)S  is  now  tethered  to  the  eatlieter  by  a 
loop  of  silk  around  one  of  its  arms,  and  the  ball  is  searched  for  at  its  known 
de])th,  first  above,  then  l)elow,  to  the  ri^rht  and  to  the  left  of  the  catheter 
guide.  The  forceps  should  not  be  swept  around  the  catheter,  but  should  be 
withdrawn  and  reintroduced  for  each  search.  The  object  of  this  is,  of  course, 
to  avoid  unnecessary  injury  of  brain  substance.  The  ball,  if  found,  having 
been  removed,  the  second  strand  of  silk  is  utilized  to  draw  a  drainage-tube 
directly  through  the  wound.  In  Fluhrer's  remarkable  case  the  ball  entered 
the  forehead,  struck  the  occiput,  and  rebounded  in  a  track  determined  first  by 
the  natural  angle  of  reflection  and  secondly  by  the  influence  of  gravity.  He 
made  a  counter-opening,  and  found  the  wound  made  in  the  meninges  by  the 
ball  on  striking  the  inner  surface  of  the  occiput,  and  from  this  as  a  new  point 
of  departure  made  another  search  in  the  manner  above  indicated,  with  the 
result  not  only  of  removing  the  ball,  but  also  of  saving  his  patient. 

Dr.  Girdner  has  devised  a  very  ingenious  instrument  which  may  aid  in 
locating  the  ball,  viz.  the  "  telephone  probe."  One  end  of  the  probe  is  attached 
to  a  telephone  receiver  which  is  held  to  the  ear.  The  other  cord  attached 
to  the  telephone  receiver  has  a  metal  handle  which  is  moistened  and 
placed  in  the  patient's  closed  hand  or  against  some  other  part  of  his 
bare  skin.  If  the  probe  touches  the  ball,  a  grating  sound  peculiar  to  the 
contact  of  the  probe  with  a  metallic  substance  is  heard  through  the  tele- 
phone receiver.  By  means  of  the  .T-rays  a  ball  within  the  cranium  may 
now  be  accurately  located.  To  accomplish  this  two  skiagraphs  must  be 
taken,  one  in  the  antero-posterior  plane  and  a  second  at  right  angles 
to  this.  Formerly  balls  lodged  in  the  brain  were  allowed  to  remain  unless 
they  were  quite  superficial  and  readily  found.  The  idea  was  that  any  med- 
dlincr  with  the  brain  with  a  view  to  the  removal  of  foreijxn  bodies  was  unwar- 
ranted.  Modern  brain  surgery  has  changed  all  this.  Antiseptic  disturbance 
of  the  brain,  though  of  course  to  be  deprecated  unless  essential,  we  now  know 
is  not  so  dangerous  as  the  retention  of  the  foreign  body.  Wharton  has  shown 
by  an  analysis  of  316  cases  of  foreign  bodies  lodged  in  the  brain,  occurring 
even  in  the  pre-antiseptic  days,  that  in  106  in  which  removal  was  eff'ected  34 
(32  per  cent.)  were  fatal ;  whereas  in  210  cases  in  which  the  missile  was 
not  removed  122  (58.1  per  cent.)  died,  and  of  those  who  recovered  10  suc- 
cumbed ultimately  from  the  effects  of  the  retention  of  the  missile,  and  many 
others  suffered  from  epilepsy  and  other  physical  and  mental  troubles.  Brad- 
ford and  Smith  have  analyzed  89  recent  cases  of  similar  Avounds  of  the  brain, 
with  a  mortality  of  33.3  per  cent,  following  removal  of  the  ball,  and  54  per 
cent,  when  the  ball  Avas  not  removed.  If  the  bullet  cannot  be  found  by  the 
wound  of  entrance  without  undue  interference  with  the  brain,  thorough  disin- 
fection of  the  wound  should  be  made,  followed  by  drainage  by  a  rubber  tube 
reaching  the  entire  'depth  of  the  wound.  If  a  counter-opening  have  been 
made,  disinfection  and  through-and-through  drainage  should  be  employed. 
The  head  should  then  be  placed  so  as  to  favor  drainage,  the  wound  covered 
with  antiseptic  dressings,  and  the  after-treatment  carried  out  as  before. 

XI.— FOREIGN  BODIES  IN  THE  BRAIN. 

The  treatment  of  foreign  bodies  in  the  brain  has  already  been  practically 
considered  under  the  head  of  Compound  Fracture  and  especially  under  that 
of  AVounds  and  Gunshot  Wounds,  and  the  reader  is  referred  to  these  subjects. 

XII.— FUNGUS  CEREBRI,   OR  HERNIA   CEREBRI. 
The  former  is  the  better  term,  as  there  is  not  commonly  a  true  hernia  of 
the  brain.     It  is  usually  a  growth  from  connective  tissue  (the  neuroglia),  and 


DISEASES   AND    INJURIES    OF    THE   HEAD. 


529 


ravel V  contains  much  true  brain  substance  (F.g.  22b).  lungus  cerebri,  of 
course,  cannot  take  place  unless  the  dura  has  been  opened,  and  in  fact  even  in 
this  case  it  is  not  likely  to  occur  unless  the  brain  substance  itselt  has  been 
Avounded.  Sei)tic  Avounds  by  their  failure  to  close  early  involve  far  greater 
Fk;.  22ii.  Fig.  227. 


Removal  of  a  Large  Fibroma  from  the  Brain 
(original):  fungus  cerebri  soon  after  ope- 
ration 


Depression  in  tlie  Head,  seven  years  after  ope- 
ration (same  ease  as  Fig.  226;  original). 


dan<Ter  of  fungus  cerebri  than  the  aseptic  wounds  of  modern  surgery,  which 
close  by  immediate  union,  because  the  neuroglia  is  softened  and  the  intra- 
cranial  pressure   is   markedly  increased.       Hence   trephining  ^^  /^o^%™ 
modern   precautions   involves   but   little   danger  of  such  a  growth.      Jiven 
if  the  dura  has  been  opened,  if  it  be  closed  either  by  interrupted  or  by 
continuous   sutures    there   will   be   scarcely   any   risk     but  the  moment  that 
any  brain  substance  is  removed  the  general  risk  of  the  operation,  and  the 
especial  risk  of  fungus  cerebri,  are  very  much  increased.     If,  therefore,  in  any 
operation  it  is  necessary  to  remove  any  of  the  dura,  and  still  more  if  any  of  the 
brain  substance  is  removed,  the  suggestion  made  by  Keen  may  be  carried 
out,  that  a  piece  of  the  pericranium  should  be  entirely  detached  from  the 
under  surface  of  the  flap  of  scalp,  turned  upside  down  so  that  the  osteogenetic 
surface  shall  be  uppermost,  and  secured  to  the  dura  by  a  few  mterrup  ed  sutures. 
Such  a  piece  of  the  pericranium  will  retain  its  vitality  and  close  the  opening 
which  otherwise  would  exist  in  the  dura,  and  thus  prevent  a  fungus  cerebri.     A 
fungus  cerebri  is  usually  more  or  less  rounded  and  its  surface  lobulated,  ot  a 
grayish  dirty-white  appearance,  and  soft  to  the  touch  ;  it  produces  no  pam,  and 
may  pulsate  with  the  heart.     It  is  often  the  site  of  moderate  or  considerable 
discharge,  and  there  may  be  escape  of  cerebro-spmal  fluid  even  from  the  mte^ 
ri^r  of  the  ventricles.     It  is  apt  also  to  bleed.     The  intelligence  of  the  patient 
frequently  remains  good.     The  diagnosis,   of  course,   is  easy. 

Treatment.-As  a  rule,  the  best  treatment  is  to  let  the  fungus  alone  or 
to  dress  it  once  or  twice  daily  with  simple  antiseptic  dressings.  If  it  heals 
slowly  skin-o-rafting  may  be  resorted  to.  Pressure  by  sponges  or  by  dressing, 
though  sometimes  useful,  is  often  followed  by  symptoms  of  mti-acranial  pres- 
sure or  by  convulsions,  and  then  has  to  be  abandoned.  If  cut  off"  by  the  knite 
or  destroyed  by  the  cautery,  it  almost  always  sprouts  anew.  It  is  a  cunous  tact 
that  as  soon  as  such  a  fungus  has  cicatrized  there  is  a  sudden  subsidence,  so 
that  instead  of  a  bulging  mass  of  tissue  there  is  a  marked  depression,  which 
is  always  permanent,  and  may  be  even  one  and  a  half  inches  deep.  (See 
Figs  223  and  227.)  The  latter  shows  the  result  seven  years  J^^er  removal 
of  a  large  brain-tumor  followed  by  the  fungus  cerebri  shown  mJ^ig.^-b. 
An  important  lesson  can  be  taught  by  such  a  depression  m  the  brain 
If  the  patient  lies  down,  or  even  bends  over,  the  hollow  is  immediately 


630  AN  AMERICAN   TEXT- HOOK    OF  SURGERY. 

effaced.  So  too  in  violent  expiratory  efforts,  such  as  sneezing  and  couf^liing, 
the  same  effect  will  be  ])roduced.  Such  a  case  shows  very  clearly  the  rapid 
chan<i;es  effected  in  the  intracranial  circulation  and  the  cerebro-spinal  fluid 
either  by  position  or  by  violent  expiratory  efforts.  Q^his  explains  why  when 
suffering  from  headache  we  walk  on  tiptoe  in  order  to  avoid  any  shock  to  the 
brain,  anil  also  why  it  is  unwise  to  do  any  operation  for  cataract  or  other  opera- 
tion involving  an  incision  into  the  ball  of  tlie  eye  when  there  exists  cough 
from  bronchitis  or  other  similar  cause. 

XIII.— INFLAMMATION  OF  THE    BRAIN   AND    MEMBRANES    FROM   TRAUMATISM. 

Various  terms  are  used  to  indicate  inflammation  of  different  parts  of  the 
brain  and  its  membranes.  The  terms  encephalitis  and  eet'ebritis  are  used  indif- 
ferently for  inflammation  of  the  cerebrum,  and  cereheUitis  is  occasionally  used 
for  inflammation  limited  to  the  cerebellum.  3Ie)ii)i</ifis  means  inflammation  of 
the  meninges  of  the  l)rain,  and  arnchnitiH  inflammation  of  the  arachnoid  itself. 
Two  forms  of  meningitis  also  may  be  distinguished  pathologically:  pacht/men- 
ingitis,  or  inflammation  of  the  hard  membrane  or  dura,  and  leptomeninf/itis,  or 
inflammation  of  the  arachnoid  and  pia  considered  as  one.  The  differential 
diagnosis  between  these  two  forms  can  be  made  only  on  the  post-mortem  table; 
clinically  they  cannot  be  distinguished.  Moreover,  inflammation  of  the  brain, 
of  the  pia  and  arachnoid,  or  of  the  dura  is  sure  sooner  or  later  to  extend  to 
either  or  both  of  the  others,  and  the  consecjuence  in  any  form  may  l)e  the  pro- 
duction of  suppuration,  abscess,  effusion  into  the  ventricles,  and  softening  of 
the  cerebral  tissue  if  the  brain  itself  is  involved. 

Causes. — These  are  usually  traumatic,  such  as  contusions  or  laceration? 
of  the  brain,  fracture  of  the  skull,  etc.  Caries  and  necrosis  of  the  bones  of 
the  skull,  and  occasionally  pyemia,  may  also  be  the  starting-point  of  such 
inflammation.  Caries  and  necrosis  of  small  portions  of  the  skull  not  infre- 
quently may  cause  a  localized  and  limited  meningitis,  which  is  far  less  danger- 
ous than  the  diffused  form  resulting  from  contusions  or  similar  traunuitisms  which 
shake  the  brain  as  a  whole  and  are  followed  by  the  most  intense  forms  of  dif- 
fused inflammation.  Very  often  a  piece  of  necrosed  bone  will  lose  its  vitality, 
either  from  localized  injury  or  from  syphilis,  and  its  removal  ■will  disclose  a 
layer  of  granulation-tissue  under  it  extending  somewhat  beyond  the  layer  of 
necrotic  bone ;  yet  in  this  case  the  rest  of  the  membranes  and  the  brain  itself 
may  entirely  escape. 

Meningitis  and  encephalitis  are  either  chronic  or  acute,  and  it  is  necessary 
to  distinguish  the  two  forms.  Encephalitis  will  be  used  as  a  type  of  all  these 
forms  of  inflammation. 

1.  Acute  Encephalitis. — Symptoms. — These  usually  arise  within  a 
day  or  two  after  the  injury,  and  with  distinct  symj)t()ms,  such  as  pain  in  the 
head,  which  is  apt  to  be  general,  photophobia,  intolerance  of  noise,  and  rapidly 
rising  fever  until  the  temperature  is  103°  or  104°,  with  flushed  face,  full,  bound- 
ing pulse,  contracted  pupils,  and  a  rise  of  surface  temperature  at  the  site  of 
the  injury.  The  bowels  will  be  constipated  and  the  patient  sleejdess  and  rest- 
less. Delirium  is  apt  to  set  in  early,  with  twitching  and  strabismus,  followed 
by  drowsiness  which  deepens  into  coma,  and  as  the  symptoms  deepen  there 
will  be  paralysis  with  involuntary  evacuation  of  urine  and  feces,  and  the 
patient  will  die  in  a  typhoid  state.  The  ophthalmoscope  will  rarely  show- 
choked  disk.  At  the  post-mortem  the  dura  will  be  found  inflamed  and  red- 
dened, the  arachnoid  usually  whitish  and  opalescent,  and  if  the  inflammation 
have  progressed  far  enough  the  hemisi)heres  will  be  covered  with  a  greenish- 
yellow  layer  of  pus.     The  brain  substance  itself  will  be  softened  and  vascular, 


DLSEASKS   AN  J)    JXJURIES    OF    TlIK   HEAD.  531 

and  verv  likely  :i  layer  of  pus  will  lie  at  the  base  of  the  brain.  The  ventri- 
cles Avill  be  iilled  with  turbid  serum. 

It  is  very  important  to  distinguish  between  such  inflammation  of  the 
brain  and  uremic  coma.  In  uremia  the  fundus  of  the  eye  will  probably  show 
patches  of  albuminuric  retinitis,  while  the  urine  will  contain  albumin  and 
tube-casts,  and  there  will  be  very  likely  coexisting  (jcdema,  especially  about 
the  ankles  and  the  face.  Not  uncommonly  also  there  may  be  chills  at  the 
beginning  of  the  suppurative  process  in  encephalitis,  which  are  generally 
absent  in  uremia. 

Treatment. — The  patient  should  be  placed  in  a  (juiet,  dark  room,  Avith 
the  head  raised  and  the  entire  scalp  shaved.  The  bowels  should  be  quickly 
purged,  but  not  innnoderately,  lest  tiie  patient  be  weakened  by  it  as  well 
as  by  the  physical  efforts  necessitated  by  such  purgation.  The  bladder 
should  be  carefully  looked  after,  and  retention  of  urine  relieved  by  the  cath- 
eter. Cold  should  be  applied  to  the  head,  either  by  an  ice-bag  or  by  a  coil 
of  tubing  for  cold  water.  Occasionally,  but  not  often,  bleeding  from  the  arm 
may  be  of  value,  but  if  so  it  will  ])e  only  in  the  robust  and  at  the  beginning 
of  the  attack.  Leeching  or  wet  cups  applied  to  the  mastoid  region  and  nape 
of  the  neck  are  better,  as  they  directly  withdraw  venous  blood  from  the  lat- 
eral sinus  through  depletion  of  the  radicles  of  the  mastoid  veins.  Large 
doses  of  bromide,  up  to  100  grains,  or  even  more,  per  diem,  aconite,  calomel 
guarded  by  opium  up  to  the  point  of  beginning  ptyalism,  and  hj^pnotics,  such 
as  hydrobromate  of  hyoscine,  chloral,  paraldehyde,  etc.,  should  be  given  to 
procure  sleep.  In  the  early  stages  alcohol  in  any  form  is  to  be  avoided,  as  an 
additional  excitant,  but  in  the  later  stages,  when  exhaustion  and  especially  the 
typhoid  state  develop,  it  may  be  of  value.  In  the  stage  of  exudation,  when 
pressure  symptoms  begin,  blisters  to  the  nape  of  the  neck  and  occasionally  to 
the  scalp,  with  mercury  and  iodide  of  potassium,  are  the  best  remedies,  if  any 
remedies  can  be  said  to  be  best  in  a  disease  which  is  so  often  hopeless  from  the 
start.  Should  the  patient  recover,  as  he  occasionally  will,  the  most  careful 
after-treatment  is  essential.  Convalescence  must  be  conducted  very  watchfully 
as  to  diet,  exercise,  and  occupation.  No  physical  exertion,  even  of  the  mild- 
est character,  should  be  allowed  until  the  convalescence  is  well  established. 
Absolutely  no  mental  effort  should  be  allowed,  especially  that  involving  any 
excitement,  worry,  or  over-study,  for  many  weeks,  or,  better  still,  months, 
after  the  attack. 

2.  Chronic  Encephalitis. — The  causes  of  chronic  encephalitis  are  the 
same  as  those  of  acute,  but  usually  the  initial  traumatism  is  less  severe  and 
the  inflammation  follows  after  a  longer  interval,  but  it  is  always  much  more  apt 
to  result  in  the  formation  of  pus,  either  extradural,  subdural,  or  cerebral.  Dis- 
tinct accumulations  of  pus  will  be  considered  under  the  head  of  Abscess. 

Symptoms. — The  patient  ha's  received  probably  a  blow  on  the  head, 
followed  by  the  lighter  symptoms  already  described  under  Contusion.  From 
these  he  will  recover  more  or  less  rapidly,  and  will  apparently  be  again  a  well 
man ;  but  days,  weeks,  or  even  months,  after  the  injury  he  will  begin  to  suffer 
with  vague  symptoms  of  cerebral  trouble,  especially  headache,  which  very  fre- 
quently will  be  localized  at  or  about  the  site  of  the  injury.  He  will  be  unable 
to  attend  to  business  or  study  for  any  length  of  time.  There  will  be  more  or 
less  mental  dulness  and  irritability  of  temper.  Without  any  change  in  his 
acuteness  of  vision,  if  the  eyes  are  examined  choked  disk  will  be  found.  Not 
long  afterward  there  will  very  likely  be  a  chill,  followed  by  a  localized  paresis 
or  paralysis,  and  if  the  case  terminate  fatally  the  drow^siness  will  deepen  into 
coma,  and  he  will  die  with  the  same  symptoms  as  those  of  acute  encephalitis. 


532  .LV  AMERICAN    TEXT-BOOK    OF  SURGERY. 

Treatment. — The  same  care  should  be  giveu  to  the  patient  as  before 
in  the  matter  of  mental  quietude,  physical  rest,  diet,  moderate  purgation, 
and  watching  the  bladder  if  necessary.  Blisters  to  the  back  of  the  neck  and 
cold  to  the  head  are  useful.  Internally  calomel  and  opium  in  the  earlier 
stages,  and  mercury  and  iodide  of  potassium  in  the  later,  will  ])e  found  most 
useful.  Care  must  be  taken  not  to  confound  the  dulness  caused  by  the  opium 
with  the  coma  which  may  arise  in  the  course  of  the  disease,  and,  conversely, 
the  coma  must  not  be  mistaken  for  opium  narcosis.  If  the  patient  recover, 
the  same  Avatchful  after-treatment  that  has  been  above  described  must  be  strin- 
gently carried  out.  No  one  has  better  described  the  need  for  such  rest  after  any 
concussion  or  inflammation  of  the  brain  than  Mr.  Hilton,  in  Lecture  III.  of 
his  book  Rest  and  Pain. 

3.  Operative  Interference  in  Meningitis  and  Encephalitis. — Very 
naturally,  in  view  of  the  boldness  of  modern  cerebral  surgery,  the  question 
will  arise  whether  operative  interference  will  not  give  a  better  chance  for 
relief  than  the  treatment  above  indicated.  As  yet,  it  is  too  early  to  be  dog- 
matic on  this  point,  for  there  is  little  experience  to  guide  us.  But  as  inflam- 
mation in  the  brain  as  in  other  parts  of  the  body  is  followed  by  exudation  and 
suppuration,  and  this  exudate  or  pus,  not  being  able  to  escape,  produces  rapid 
tissue-changes  and  symptoms  of  pressure,  and  as  the  bony  skull  cannot  be 
perforated  by  the  serum  or  pus,  and  so  allow  it  to  escape  and  relieve  the 
pressure,  as  is  the  case  in  the  soft  parts,  it  seems  reasonable  that  we  should 
interfere  surgically  and  afford  a  means  of  escape  for  the  exudate  l)y  trephining, 
opening  the  dura,  and  draining.  All  surgeons  would  be  agreed  upon  the  pro- 
priety of  this  treatment  when  there  is  localized  suppuration,  but  there  is  still 
a  difference  of  opinion  as  to  its  propriety  in  the  early  stages  when  the  exudate 
is  only  serous.  It  is,  however,  possible  that  just  as  when  exudation  or  sup- 
puration occurs  under  the  dense  periosteum,  we  incise  it  and  give  exit  to  the 
fluid  ;  and  when  increased  intraocular  pressure  occurs,  an  incision  relieves  it 
and  saves  the  eye ;  or  in  an  orchitis  an  incision  relieves  the  pain  and  saves  the 
testicle ;  so  in  inflammation  of  the  brain  future  experience  may  show  that  it 
will  be  wise  to  trephine  for  drainage  of  the  effused  fluids  before  they  have 
gone  on  to  the  stage  of  suppuration  or  abscess  and  done  irreparable  damage  to 
the  brain.  In  that  case  we  shall  be  able  hereafter  to  cope  with  the  dangers 
of  cerebral  inflammation  far  better  than  we  have  been  in  the  past,  and  our 
mortality  records  Avill  be  immensely  improved.  Very  little  has  been  done  in 
this  direction,  however,  and  hence  these  views   are  put  forward  tentatively. 

Mr.  Horsley  has  already  urged  this  course  of  treatment,  and  very  prop- 
erly his  opinion  carries  great  weight.  In  cases  of  chronic  encephalitis  prob- 
ably such  operative  interference  will  be  more  likely  to  be  followed  by  .«uccess 
than  in  the  acute  form,  for  in  chronic  encephalitis  the  symptoms  often  indicate 
localized  pressure  on  a  single  cortical  center  or  on  more  than  one  neighboring 
center.  In  this  case  the  indications  Avould  be  clearly  in  favor  of  trephining, 
incising  the  dura,  or,  it  may  be,  puncturing  it,  with  a  view  to  the  relief  of  the 
pressure.  AVhether  acute  or  chronic,  those  cases  afford  the  greatest  probabil- 
ities of  cure  in  which  there  is  evidence  of  localized  rather  than  diffused,  and 
especially  of  basilar,  inflammation,  and  in  Avhich  tlii^re  is  a  local  production  of 
serum  or  of  pus.  One  remarkable  acute  case  has  been  reported  by  Mr.  A.  E. 
Barker,  in  which  there  is  reason  to  believe  that  he  evacuated  an  ounce  of  odor- 
less pus  from  the  fissure  of  Sylvius,  Avith  good  result.  While  a  single  case  like 
this  does  not  establish  a  rule,  it  at  least  suggests  a  possibility  Avhich  must  be  taken 
into  account  and  acted  upon,  especially  in  so  fatal  a  disorder.  In  any  such  ope- 
ration Ave  must  be  guided  absolutely  by  our  present  knoAvledge  of  the  localizing 


DLSEAUKS   AXI>    IXJClllKH    OF    THE   HEAD.  533 

more  doubttul. 

XIV.-ABSCESS  OF  THE  BRAIN. 
^        ^o      Npnrlv  50  per  cent,  of  the  cases  of  abscess  of  the  brain  arise 

simple  fracture  it  a  splintei    is   uiukc  contusion, 

^^r^fnot  e'^^Vrrbl'vtr^^^^^^^^  rLveryappa 

^vhich  ^^^y^'^^J\f^;^^;'Jf'' Weeks  or  months  after  such  an  injury   and 
rently  may  have  taken  place.      ^^^^'  "       .       ,  f  ^i.^  y^r^in  has  been 

:,"  ^^rer^k^L^n-TmerHrron  hS  'epted  *e  cse  of  a  boy  fifteen 

tt^fwhJr:;?'d  ateveve  Mow  on  ^^it^^^t^t^ :^^. 

from  a  pair  of  tongs,     ihree  days  alter  ^^^'^  ^  ^  ^j^    g^^j^e 

set  in.  beginning  in  the  rigU  arm  and  ^P^'^f  ^^^^  *Xrton  t^^^^^^^        him,  not 

'''"bII's  sucTam-:i  rnd'tXmatic  cases,  cevebral  abscess  sometimes  follows 

Besides  ^"'^  ™^',  ™  ulcerative  endocarditis,  and  in  pyemia  mul- 

?rp^rabtres°oVtt  S  ^oVurcommomy  exist.     Occasionally  tubercular 

"^'p^thor^ioarinatomy—The  site  of  the  abscess  may  be  between  the 

X^duJIl-^btsfSl  ^^e  no  means 

°^'  -nrilJ:tfht tt^c^^rS  =i  Ti-s  .-ally  situat^  ^^ 
site  of  the  injury,  to  which  we  ■^l'^^^^  ^^^^'^t,^l^JT\^ -^o^^-^ 
as  already  stated,  -^f  ™^\™/"tinT  aused  by  the  TacerTtion  of  the  brain, 
on  the  opposite  side  of  the  head,  being  "^"f  ^  7^°°      ,  ^^  determined 

as  already  explained,  by  contre-coup.  Its  f  "»^'  ;'™£  ^^,t„  ^^  for 
much  mo^e  by  the  loc^Mng  sympt^^^^^^^^^  ,^ifH\hrabLls:  wTi/ Brocas 
instance  m  a  case  repoUed  bj  J  Tnflrio'r  frontal  at  its  posterior  end-and  the 
convolution— that  is,  tne  miru  ui  lu  ohsppss  will  vary,  from  a  cavity 

cicatrix  was  on  the  forehead      The  size  ^^^^^^^^^^  of  the 

containing  a  dram  or  two  of  pus  up  to  ^^^^^J^  ^^^°».^^J'°,gP    ^here  it  is 


result. 


534  .l.V   AMEIUVAX    TKXT-BOOK    OF  .SL'UaFli  V. 

Symptoms. — Those  may  be  divided  into  three  classes:  (1)  tliose  due  to 
tlie  sii)>j)urative  process;  {-)  tliose  due  to  pressure;  (•])  the  focal  or  localizing 
syiujitoins. 

(1)  Si/mptons  due  to  tJic  ,Su/>j)uratii'c  J'roccss. — Usually  a  rise  of"  temper- 
ature is  significant  of  suppuration  in  other  parts  of  the  body,  but  it  is  espe- 
cially noteworthy  that  in  cerebral  abscess  the  temperature,  as  a  rule,  is  either 
normal  or  subnormal,  even  when  the  other  symptoms  indicate  tlie  gravest  peril. 
Occasionally  there  will  be  an  initial  rise,  followed  by  a  fall  to  normal  or 
below  it,  and  then  toward  the  end  of  the  disease  there  will  be  another  rise, 
often  accom])anied  by  delirium,  and  the  temperature  again  subsides,  only  to 
rise  after  an  interval  if  life  is  sufficiently  prolonged.  The  local  temperature 
over  the  abscess,  it  is  stated,  rises,  even  if  the  general  body  temperature  be 
subnormal.  If,  therefore,  in  any  case  following  a  traumatism  symptoms  of 
serious  intracranial  jiressure  set  in,  w^ith  the  botly  temperature  normal  or  sub- 
normal while  the  local  temperature  rises  and  the  pulse  is  slow,  the  first  thought 
of  the  surgeon  should  be  that  he  has  to  deal  probably  Avith  abscess  of  the 
brain.  A  chill  not  uncommonly  occurs,  but  may  be  absent.  Of  course  ano- 
rexia, vomiting,  general  malaise,  etc.  are  present.  Somerville  has  stated  that 
when  there  is  pus  in  the  brain  the  urinary  chlorides  Avill  be  below  normal  and 
the  phosphates  will  be  above. 

(2)  Sjjmptoms  due  to  Pressure. — Headache  is  one  of  the  most  important, 
and  is  almost  always  present,  and  not  infrecjuently  of  a  severe  character,  so  that 
the  patient  will  moan  constantly.  Should  the  temperature  rise  the  headache  is 
often  aggravated,  and  sometimes  is  located  distinctly  over  the  lesion,  but  very 
commonly  it  is  first  general  and  then  focal.  The  pulse  is  always  slow,  and  may 
even  fall  to  80  or  40.  Respiration  is  often  of  the  Cheyne-Stokes  type.  The 
mind  soon  becomes  clouded,  and  the  dulness  gradually  deepens  into  coma,  and 
the  bowels  and  bladder  are  evacuated  involuntarily.  Epileptoid  convulsions 
often  occur,  but  if  the  abscess  arises  from  ear  disease  and  is  situated  in  the 
temporo-sphenoidal  lobe,  the  patient  may  be  free  from  them.  Sensation 
is  not  usually  impaired  to  any  extent.  Choked  disk  may  be  present 
or  absent,  and  may  be  unilateral  or  bilateral.  If  bilateral,  it  is  commonly 
more  marked  on  the  same  side  as  the  abscess,  though  occasionally  this  is 
reversed.  Sometimes  ptosis  may  be  present,  and  occasionally  the  entire  third 
nerve  is  paralyzed,  while  the  sixth  escapes,  though  this  is  sometimes  reversed. 
The  pupil  on  the  side  of  the  lesion  is  usually  dilated  and  more  or  less  immo- 
bile. The  patient's  general  condition  fluctuates  remarkably  as  to  these  symp- 
toms of  pressure,  giving  us  hope  sometimes  of  spontaneous  recovery,  and  then 
becoming  worse  than  before. 

If  the  abscess  is  cerebellar.^  the  diagnosis  is  even  more  obscure.  There 
may  be  occipital  headache  and  muscular  rigidity  of  the  neck.  If  it  be  in  the 
middle  lobe,  there  will  be  muscular  incoordination,  and  especially  a  drunken, 
unsteady  gait.  Vertigo  and  vomiting  are  fre([uent  and  persistent.  There  will 
sometimes  be  tenderness  on  pressure  and  pain  on  percussion  over  the  cerebel- 
lum.    Choked  disk  is  commonly  absent. 

(3)  Foc(d  or  Localizing  Si/mptoms. — If  the  abscess  is  situated  in  the  left 
temporo-sphenoidal  lobe,  it  may  press  on  Broca's  convolution,  and  this  will  pro- 
duce motor  aphasia.  If  it  involve  or  press  upon  the  lower  part  of  the  Rolandic 
motor  region,  it  will  produce  paresis  or  paralysis  of  the  opposite  side  of  the  face, 
followed  by  paresis  or  paralysis  of  the  arm,  and  finally  of  the  leg  as  the  pus 
creeps  upward  in  the  motor  region.  Sometimes  there  will  be  distinct  squint, 
from  paralysis  of  the  sixth  nerve.  Should  the  abscess  arise  in  the  frontal  lobe 
from  contusion  or  fracture  of  this  region  or  from  nasal  disease,  localizing  symp- 


DISEASES   AXD    IXJl'IUES    OF    THE    HEAD.  535 

toms  are  apt  to  be  absent,  since  the  frontal  lobe  is  a  latent  region ;  and  the 
same  statement  applies  to  the  occipital  lobe  unless  the  abscess  involves  the 
cuneus,  when  hemianopsia  of  the  same  half — that  is,  right  or  left — of  each  ret- 
ina will  follow.  If  the  angular  or  su|)ramarginal  gyrus  is  involved,  there  may 
be  monocular  Argyll-Kobertson  jnipil,'  as  pointed  out  by  Oliver.  The 
local  temperature  of  the  two  sides  of  the  head  should  be  taken,  though  it 
must  be  interpreted  with  care ;  and  it  must  be  remembered  that  the  left  side 
is  normally  of  a  slightly  higher  temperature  than  the  right.  Pressure  on  the 
skull  and  percussion,  like  the  local  temperature,  may  be  of  value,  but  must 
not  bo  relied  u|>on  absolutely.  Ferrier  states  that  pain  which  is  not  sponta- 
neously complained  of,  but  is  elicited  by  percussion,  is  of  greater  value  than 
mere  tenderness  on  pressure.  As  a  means  of  diagnosis  between  cerebral  and 
cerebellar  abscess  this  is  of  some  value  so  long  as  the  mental  condition  of  the 
patient  is  sufficiently  clear. 

Differential  Diagnosis. — 1.  Meningitis. — Meningitis  and  abscess  are 
very  often  extremely  difficult  to  differentiate,  but  we  may  be  helped  in  the  diag- 
nosis by  the  fact  that  meningitis  is  apt  to  develop  Avithin  the  first  three  or  four 
days,  whereas  an  abscess  does  not  usually  form  earlier  than  the  end  of  the  first 
week.  In  meningitis  also  there  are  apt  to  be  early  dulness,  deepening  into  coma 
and  actual  delirium,  photophobia,  and  contraction  of  the  pupils,  with  high  gen- 
eral temperature  and  marked  rigidity  of  the  cervical  muscles. 

2.  Mastoid  Disease,  following  suppurative  disease  of  the  middle  ear,  some- 
times occasions  serious  cerebral  disorder  Avithout  abscess.  Trephining  the 
mastoid,  which  should  generally  be  done  at  an  early  stage,  will  eliminate  this 
as  a  factor  in  the  problem.  Mastoid  disease  will  ordinarily  be  accompanied 
with  swelling,  oedema,  and  pain  in  the  mastoid  region.  It  must  be  remem- 
bered also  that  a  cerebral  abscess  and  mastoid  disease  often  coexist. 

3.  Extradural  Abscess  may  be  distinguished  from  cerebral  abscess  by  the 
symptoms  given  later. 

4.  Thrombosis  of  the  Lateral  Sinus  and  Pyemia. — Commonly  the  internal 
jugular  vein,  as  well  as  the  lateral  sinus,  will  be  invaded  by  the  thrombus, 
and  will  be  hard  and  cord-like,  and  the  veins  of  the  face  are  apt  to  be  swollen. 
Pressure  and  percussion  over  the  lateral  sinus  will  be  painful.  The  tempera- 
ture will  fluctuate  violently,  rising  far  above  the  normal,  and  there  will  be 
rigors,  sweating,  and  general  prostration,  and  eventually  suppuration  in  the 
joints,  Avith  pyemic  symptoms  referable  to  the  lungs  and  liver.  Usually  also 
the  intellect  is  much  clearer  than  in  abscess,  at  least  in  the  early  stages. 

5.  Tumor. — A  tumor  is  ordinarily  slow  in  its  growth,  and  often  attended 
with  distinct  localizing  symptoms  at  a  comparatively  early  stage,  Avhile  abscess 
usually  pursues  a  much  more  rapid  course.  There  are  in  abscess  commonly  the 
history  and  often  the  evidence  of  distinct  injury  or  of  disease  of  the  ear  or  nose. 
Choked  disk  is  almost  ahvays  present  in  tumor,  and  is  generally  double  and 
much  more  frequent  than  in  abscess.  Moreover,  abscess  is  far  more  com- 
mon in  the  temporo-sphenoidal  lobe  or  in  the  cerebellum,  especially  from  ear 
disease,  while  tumor  is  rare  in  these  situations.  In  other  parts  of  the  brain,  on 
the  contrary,  tumor  is  more  common  than  {ibscess.  The  temperature  is  not  apt 
to  rise  in  tumor,  but  should  there  be  any  marked  and  rapid  fluctuation,  and 
especially  any  prolonged  subnormal  temperature,  it  would  be  strong  evidence 
of  abscess  ;  if  the  patient  is  syphilitic,  he  is  more  apt  to  have  tumor  than  abscess. 

^  The  Argyll-Eobertson  pupil  is  one  which  is  more  or  less  contracted,  but  the  iris  does  not 
contract  when  light  is  thrown  upon  the  retina,  although  it  varies  with  accommodation  and  con- 
vergence. If  this  peculiarity  exists  in  one  eye  only,  it  is  called  monocular  Arg}dl-Robertson 
pupil. 


536  .l.V  AMERICAN    TEXT-BOOK    OF  SURGERY. 

Treatment. — A  few  early  attempts  to  evacuate  an  abscess  of  the  brain,  by 
Dupuytrtn.  I)etnioM.  an<l  others,  are  on  record,  but  it  is  only  since  cerebral 
localization  has  enabled  us  to  diagnosticate  with  comparative  accuracy  the  lo- 
cation of  an  abscess,  and  within  the  last  few  years,  since  cerebral  sur;:ery  has 
advanced  with  such  rapid  strides,  that  surgeons  have  been  emboldened  to  inter- 
fere in  an  operative  way  in  cases  of  such  abscess,  and  in  very  many  instances 
with  the  happiest  results.  When  the  abscess  is  located,  the  head  should  be 
shaved  and  disinfected,  as  already  describerl.  If  the  localizing  symptoms 
point  to  the  region  of  the  scar,  we  should  trephine  at  that  point,  but  if  they 
indicate  another  region  we  should  always  trephine  in  accordance  with  the 
doctrines  of  cerebral  localization  rather  than  by  the  indication  or  the  history  of 
the  lesion.  Of  course  if  there  be  a  fistula  discharging  pus,  we  should  trephine 
at  the  mouth  of  the  fistula  and  follow  it  up  to  the  abscess. 

The  dura  having  been  opened,  if  there  be  an  abscess  the  brain  substance 
will  probably  bulge  markedly  through  the  opening.  The  normal  pulsations 
of  the  brain  will  be  absent.  For  exploration  the  grooved  director  is  the  best 
instrument  to  use.  The  hypodermatic  needle  and  the  knife  have  been  used, 
but  there  is  considerable  danger  of  wounding  the  vessels,  whereas  the  grooved 
director  is  safe  in  this  respect,  and  as  soon  as  the  abscess  is  reached  it  will 
allow  the  pus  to  flow  through  its  groove.  The  director  should  be  forced  gently 
and  carefullv  straight  forward  into  the  brain  in  the  probable  direction  of  the 
abscess,  and  may  be  safely  introduced  to  the  depth  of  two  to  two  and  a  half 
inches  if  the  abscess  be  not  reached  more  superficially.  If  the  abscess  be  not 
reached,  the  director  should  be  withdrawn  exactly  in  the  line  in  which  it 
entered,  and  the  brain  similarly  punctured  in  another  direction.  As  soon 
as  the  abscess-cavity  is  reached,  the  knife  should  be  used  to  open  the  abscess, 
and  the  opening  may  be  enlarged  by  a  pair  of  hemostatic  forceps,  introduced 
closed  and  drawn  out  expanded  to  a  reasonable  degree,  so  as  to  aflbrd  a  free 
opening  for  the  pus.  The  granulation-tissue  lining  the  walls  of  the  abscess- 
cavitv  should  then  be  removed  by  the  sharp  spoon,  care  being  taken  not  to  do 
unnecessary  damage  to  the  neighboring  parts  of  the  brain.  The  cavity  should 
next  be  very  crentlv  washed  out.  best  with  a  horic  acid  solution,  and  a  drain- 
af^e  tube  inserted.  '  This  should  be  either  of  rubber  or  of  silver.  A  buttonhole 
opening  should  be  made  in  the  scalp  through  which  the  tube  may  emerge,  and 
the  tube  should  be  secured  to  the  scalp  by  a  silk  thread.  The  bone  should  not 
be  replaced.  If  the  abscess  is  large  and  the  first  trephine  opening  does  not 
drain  it  well  in  the  recumbent  posture,  a  second  opening  should  be  made,  and 
the  tube  may  pass  through  this  or  through  both  openings.  An  abundant  sub- 
limate dressing  should  then  be  applied.  After  two  or  three  days  the  drainage 
tube  may  be  gradually  shortened  until  it  can  be  dispensed  with.  Should  there 
be  reaccumulation  of  pus  after  apparent  healing,  the  wound  must  be  reopened, 
the  pus  evacuated,  and  the  cavity  washed  out  and  treated  as  before.  Some- 
times such  reaccumulation  will  occur  two  or  three  years  after  the  first  abscess. 

If  the  first  trephine  opening  does  not  disclose  any  abscess,  and  it  is  possible 
that  one  mav  exist  at  another  point,  a  second,  and  if  need  be  a  third,  trephine 
opening  should  be  made  at  the  possible  point  of  suppuration.  The  dangers  of 
additional  trephining  are  nothing  as  compared  with  the  dangers  of  an  abscess, 
which  is  necessarily  fatal  unless  evacuated. 

In  cerebellar  abscess  the  upper  edge  of  the  trephine  should  be  well  below 
a  line  from  the  inion  to  the  external  auditory  meatus  (the  line  of  the  lateral 
sinus),  and  midway  between  the  tip  of  the  mastoid  and  the  inion.  The  gouge 
may  often  replace' the  trephine  to  advantage,  especially  in  children.  It  must 
be  remembered  that  the  skull  is  thin  and  quickly  penetrated  in  this  region. 


DISEASES   A  XI)    INJURIES    OF    THE   HEAD.  537 

The  rongeur  may  be  used  to  enlarge  the  opening  if  need  be.  The  flap  in  the 
dura  shouUl  have  its  base  upward,  to  guard  the  sinus.  The  grooved  director 
may  be  used  again  to  penetrate  the  cerebellum,  and  even  should  the  abscess 
exist  on  the  opposite  side  of  the  cerebellum,  it  may  be  reached  by  an  oblique 
puncture,  care  being  taken  not  to  injure  the  superior  vermiform  process. 

XV.— DISEASES  OF  THE  BRAIN  ARISING  FROM  SUPPURATIVE  DISEASE  OF  THE  EAR. 

If  Ave  look  at  the  base  of  the  skull  on  the  inside,  we  will  be  struck  by  the 
position  of  the  petrous  bone  as  a  boundary-line  between  the  middle  and  poste- 
rior fossaj  of  the  skull.  The  upper  edge  forms  a  sort  of  watershed,  with  a 
moderate  declivity  in  front  toward  the  middle  fossa,  in  which  lies  the  temporo- 
sphenoidal  lobe,  and  a  sheer  declivity  at  the  l)ack  toward  the  posterior  fossa,  in 
which  lies  the  cerebellum.  The  wall  of  bone  between  the  tympanum  and  the 
middle  fossa  especially  is  very  thin,  and  we  can  easily  understand,  on  noting 
the  anatomical  relation  of  the  temporo-sphenoidal  lobe  and  the  cerebellum  to 
the  petrous  bone,  how^  disease  of  the  ear  may  readily  break  through  the  thin 
osseous  barrier  and  produce  inflammation  of  the  meninges,  thrombosis  of  the 
petrosal  or  lateral  sinus,  and  involvement  of  either  the  temporo-sphenoidal  lobe 
or  the  cerebellum  itself.  This  explains  the  frequency  of  cerebral  disease  as  a 
result  of  disease  of  the  ear. 

Barker  estimates  that  there  are  not  far  from  2000  deaths  annually  from  ear 
disease  in  Great  Britain,  with  a  population  of  but  little  more  than  one-half  that 
of  the  United  States.  Of  all  these  a  very  large  proportion  are  caused  by  cere- 
bral disorder  resulting  from  ear  disease.  Of  43,730  cases  of  ear  disease  tabu- 
lated by  Biirkner,  66.9  per  cent,  were  disease  of  the  middle  ear,  and  20  per 
<;ent.  were  suppurative  middle-ear  disease.  Four-fifths  of  these  were  chronic, 
among  which  are  to  be  sought  the  greater  number  of  brain  lesions.  We  are 
very  apt  to  imagine  that  the  excessively  fetid  discharges  which  often  accompany 
■ear  disease  are  far  more  dangerous  than  those  without  such  odor ;  but  Rohrer 
has  shown  that  the  non-fetid  discharges  are  the  causes  of  the  most  dangerous 
■cerebral  sequels,  since  fetor  is  due  to  bacilli  which  are  not  pathogenic,  but 
merely  saphrophytic.  Therefore  the  presence  or  absence  of  odor  in  the  dis- 
•charge  is  no  test  of  its  danger.  Of  all  the  discharges,  the  inspissated  pus 
that  is  found  in  the  ear  in  many  cases  is  the  most  dangerous,  being  filled  with 
pathogenic  micro-organisms. 

Primary  acute  inflammation  of  the  ear  rarely  causes  cerebral  trouble:  it  is 
in  the  chronic  cases  that  the  danger  lurks.  In  these,  the  mucous  membrane 
being  destroyed,  the  bone  is  bare  and  often  carious  and  the  seat  of  septic  dis- 
charges and  also  of  septic  foci.  Hence  if  we  attack  an  ear  the  seat  of  such 
chronic  discharge,  and  possibly  of  such  inspissated  pus  and  septic  foci,  we 
should  be  very  careful  to  do  it  thoroughly  and  Avith  the  strictest  antisepsis,  or 
we  may  light  up  new  and  dangerous  septic  processes,  giving  to  the  inactive 
micro-organisms  ncAv  life  by  the  moisture  supplied  to  them  by  opening  the  ves- 
sels and  lymph-channels,  and  spreading  them  by  breaking  down  the  barriers  to 
their  introduction  into  the  system. 

It  is  a  curious  fact  that  aural  disease  may  produce  an  abscess  an  inch  or 
more  from  the  inferior  surface  of  the  brain,  the  intervening  cortex  remaining 
perfectly  normal.  This  may  occur,  according  to  Barker,  in  one  of  two  ways : 
•either  a  thrombus  may  extend  into  the  lateral  or  the  petrosal  sinus,  and  from 
this  through  the  veins  that  empty  into  the  interior  of  the  brain,  especially  as 
these  veins  have  no  valves ;  or,  secondly,  the  blood-current  may  be  reversed  in 
these  veins  by  reason  of  the  thrombus. 


538  J-V  AMi:i!i(AX  Ti:xr-Ji()()k'  of  sriKiKUV. 

Aural  ilist-ase  may  causr  ineiiingitis,  jiljlcljitis,  throiuljo.sis  of  the  lateral  and 
petrosal  sinuses,  extradural  abscess,  or  cerebral  or  cerebellar  abscess.  Of 
these,  meninfritis,  pyemia,  and  abscess  are  the  most  frecjuent. 

I.  The  Meningitis  from  aural  disease  differs  in  no  respect  from  that  aris- 
ing from  other  causes,  except  that  it  is  more  likely  to  be  localized  and  may  be 
more  fre<iuently  relieved  by  operation,  as  has  already  been  indicated  under 
that  head. 

II.  Cerebral  Abscesses  from  Ear  Disease  are  almost  always  situated 
in  the  teniporo-spliLUoidal  hjbe  between  two  vertical  lines,  of  which  the  anterior 
is  drawn  through  the  tragus,  and  the  posterior  two  inches  back  of  the  tragus. 
Nine-tenths  of  them  lie  in  a  region  covered  by  a  circle  of  one  inch  and  a 
quarter  radius,  the  center  of  which  is  one  inch  and  a  fjuarter  above  and  behind 
the  meatus.  This  is  well  named  by  Barker  the  '"dangerous  region."  They 
may  be  encapsulated  or  diffused.  In  other  respects  they  do  not  difTer  from  the 
cerebral  abscesses  already  described. 

Diagnosis. — The  ear  discharge  from  which  they  arise  is  almost  always 
chronic,  and  may  have  existed  for  years.  While  the  general  health  is  good, 
there  may  be  a  sudden  cessation  of  the  discharge,  with  a  rise  of  temperature, 
nausea  and  vomiting,  and  a  dull  ache  in  tlie  mastoid  region,  the  temples,  and 
the  neck  ;  the  pulse  becomes  frequent,  the  tongue  foul,  and  very  often  there 
is  diarrhea ;  that  is  to  say,  the  symptoms  of  acute  septic  infection  are  engrafted 
on  the  existing  chronic  saprogenic  sup])uration.  The  headache  and  tender- 
ness are  often  general  or  frontal,  and  not  located  at  the  site  of  the  lesion.  The 
temperature  after  the  initial  rise  is  again  subnormal,  and  is  in  especial  con- 
trast to  that  of  pyemia,  with  its  acute  fluctuations,  which  bear  no  relation  Xo- 
the  ordinary  morning  fall  and  evening  rise,  or  to  the  presence  or  absence  of  dis- 
charge, and  may  be  accompanied  with  rigors.  It  is  again  in  contrast  to  the  high 
temperature  of  meningitis,  which  has  not  the  abrupt  oscillations  of  pyemic  tem- 
perature. The  intellect  is  dull  and  sluggish  and  deepens  into  coma.  The  bowels 
are  apt  to  be  constipated,  the  breath  fetid,  and  the  skin  muddy,  and  there  is- 
marked  emaciation.  Optic  neuritis,  if  present,  is  of  value,  but  is  often  absent. 
Convulsive  twitchings  or  paralysis  are  of  great  value,  if  present,  by  their  local- 
izing indications.     The  state  of  the  pupil  is  not  commonly  to  be  relied  upon. 

Treatment  of  Abscess  from  Ear  Disease. — The  treatment  of  abscess 
arising  from  ear  disease  is  the  same  in  princi])le  as  that  of  cerebral  abscess  in 
any  other  region  or  from  any  other  cause.  Prevention  of  the  cerebral  disease 
is  vastly  better  than  treatment  after  its  onset.  Hence  if  after  chronic  ear  dis- 
ease persistent  headache,  vomiting,  and  mental  dulness,  without  rise  of  tem- 
perature, occur,  the  mastoid  should  be  opened  as  indicated  below.  Not  seldom 
this  will  avoid  the  later  necessity  for  graver  operations.  If,  however,  when  first 
seen  the  intracranial  symptoms  have  already  arisen  and  the  mastoid  process  has 
not  already  been  opene<l,  with  few  if  any  exceptions  the  first  step  should  be 
to  open  the  mastoid  and  thoroughly  wash  it  out.  In  doing  this  as  practised  by 
Horsley  and  Barker  a  vertical  curved  incision  should  be  made  a  ipiarter  of 
an  inch  behind  the  meatus  in  the  axis  of  the  mastoid  from  its  base  to  its  tip, 
about  two  inches  in  length,  the  ear  being  drawn  well  forward.  The  mastoid 
antrum  and  cells  should  then  all  be  thoroughly  laid  open  by  the  gouge  and 
chisel,  and  the  posterior  wall  of  the  meatus  be  chiselled  away  to  the  cavity 
of  the  middle  ear  (Fig.  228).  All  the  inspissated  pus  which  is  often  found 
both  in  the  mastoid  antrum  and  in  the  mastoid  cells,  and  which  cannot  begot 
rid  of  by  simple  syringing,  should  be  removed  by  a  small  sharp  spoon  or  a 
gouge  and  chisel,  care  being  taken  not  to  wound  the  lateral  sinus.  In  order 
to  reach  the  antrum  the  opening  is  best  made  from  one-third  to  one-half  of  an 


DISEASES   AND    INJURIES    OF    THE   HEAD. 


539 


inch  boliind  and  the  sanic  distance  above  the  center  of  the  meatus  (Fig.  221),  x  ). 
T(t  find  the  mastoid  antrum  Macewen  has  directed  attention  to  the  value  of 


Opening  the  Mastoid  Antrum  (Esmarch  and  Kowalzig). 

the   "  suprameatal  triaiigle  "  which  is  formed  by  the  posterior  root  of  the 
zygoma   above    (dotted    line.  Fig.  230), 

the  upper  and  posterior  segment  of  the  ^'^^-  230. 

osseous  external  meatus  in  front  (broken 
line,  Fig.  230),  and  an  imaginary  nearly 
perpendicular  line  uniting  these  two 
(short  nearly  vertical  line.  Fig.  230). 
Within  this  triangle  and  toward  its 
base  the  opening  into  the  mastoid  an- 
trum   may   be   made  with    safety.     The 


A,  A,  Reid's  Base  Line :  fi,  the  meatus ;  c,  the  point  for  tre- 
phining to  reach  an  abscess  in  the  temporo-sphenoidal 
lobe  or  to  puncture  the  lateral  ventricle  1'4  inches  back 
of  the  meatus  and  1'4  inches  above  Reid's  base  line ; 
i",  the  mastoid  vein  ;  o,  the  point  for  trephining  to  reach 
an  abscess  in  the  cerebellum  ;  v,  the  point  for  trephin- 
ing the  mastoid  antrum  (Barker). 


Surface  Guides  for  the  Sigmoid  Sinus  and 
the  Suprameatal  Triangle  (Macewen): 
artificial  lines  drawn  upon  the  skull  in- 
dicating the  following:  (1)  The  short 
vertical  line  from  the  posterior  border 
of  the  external  auditory  meatus  to  the 
posterior  root  of  the  zygoma  marks  the 
base  of  the  suprameatal  triangle  (a) ;  the 
broken  line  indicates  the  anterior  border 
of  the  suprameatal  triangle,  its  base  being 
the  dotted  line  marking  a  part  of  the  root 
of  the  zygoma.  This  broken  line  also  in- 
dicates the  course  of  the  fiicial  nerve. 
(2)  The  second  vertical  line,  extending 
from  parieto-squanio-mastoid  junction 
to  tip  of  mastoid ;  the  upper  two-thirds 
of  its  length  indicates  the  position  of  the 
sigmoid  sinus.  (3)  The  oblique  line  pass- 
ing from  asterion  to  upper  limit  of  ex- 
ternal auditory  meatus  indicates  the  pos- 
terior two-thirds  of  the  sigmoid  sinus 
from  its  commencement  to  its  knee. 


perforation  is  made  slightly  forward  to  avoid  opening  the  sigmoid  sinus  (the 
curved  part  of  the  lateral  sinus  in  the  mastoid  portion  of  the  temporal  bone, 


640  AN  AMKlili'AX    'JllXT-JiOOK    OF  sriiGKIiY. 

Fi".  22H).  When  the  surtroon  luis  pcnt'trated  to  tlic  depth  of  half  an  inch, 
he  must  be  eareful  not  to  injure  the  facial  nerve,  the  cour.se  of  which  is  indi- 
cated by  the  broken  line  in  Fig.  280.  To  avoid  this  he  should  "  keep  close 
to  the  floor  of  the  middle  fossa  and  nearer  the  posterior  border  of  the  ojicning, 
toward  the  posterior  superior  angle  of  the  suprameatal  triangle  "'  (Macewen). 
The  near  approach  to  the  nerve  is  often  preceded  by  twitching  of  the  facial 
muscles.  The  face  should  therefore  be  exposed,  and  an  assistant  be  re- 
(juested  to  observe  any  such  phenomenon. 

Of  course  the  external  meatus  should  also  be  well  cleansed  antiseptically. 
There  is  no  objection  here  to  the  use  of  the  1  :  1000  sublimate  solution, 
which,  however,  should  not  be  used  in  washing  out  the  cavity  of  the  cerebral 
abscess  itself.  After  having  cleansed  the  ear  it  is  well  to  inject  the  cavity 
with  an  emulsion  of  iodoform  and  to  apply  boric-acid  fomentations,  which  are 
to  be  freiiuently  changed. 

Should  this  not  relieve  the  symptoms  very  speedily,  we  must  search  for 
the  abscess  itself,  which  will  probably  lie  in  the  "'dangerous  region."  The 
best  point  to  apply  the  trephine  is  one  and  a  quarter  inches  behind  and  the 
same  distance  above  the  external  auditory  meatus  (Fig.  229.  <■).  One  great 
advantage  of  this  position  is  that  it  is  far  enough  away  from  the  ear  to  avoid 
septic  infection  from  any  aural  discharge  in  case  no  abscess  is  present.  It  is 
better  to  use  for  the  exploratory  operation  a  small  trephine,  one-quarter  or 
one-half  inch,  enlarging  the  opening,  if  need  be,  with  the  rongeur  forceps 
or  by  a  larger  trephine. 

The  dura  having  been  opened  by  a  simple  crucial  incision,  the  grooved 
director  should  be  inserted  downward,  forward,  and  inward  in  the  direction  of 
the  opposite  wing  of  the  nose,  as  this  is  the  axis  of  the  temporo-sphenoidal 
lobe.  Should  the  abscess  not  be  reached,  punctures  may  be  made  in  other 
somewhat  similar  directions,  and  the  cavity  when  found  should  be  treated  in 
the  manner  already  described.  Sometimes  pus  in  the  groove  for  the  lateral 
sinus  will  ooze  out  through  the  opening  for  the  mastoid  vein  (Fig.  229,  i),  which 
should  be  examined  by  turning  back  the  scalp  sufficiently  to  expose  it.  If 
found,  of  course  the  groove  must  be  opened  and  the  pus  evacuated.  The 
groove  for  the  lateral  sinus  can  safely  be  exposed  to  a  large  extent  by  means 
of  the  rongeur,  gouge,  and  chisel.  Of  course  great  care  must  be  taken  not  to 
wound  the  sinus,  but  should  it  be  wounded  it  can  be  plugged  and  the  hemor- 
rhage, as  a  rule,  readily  controlled.  Whenever  it  is  necessary  to  expose  the 
sinus,  strips  of  gauze  for  plugging  it  should  be  within  easy  reach.  In  some 
cases  it  is  desirable  to  open  it  deliberately.     (See  p.  541.) 

III.  Cerebellar  Abscess. — Abscess  of  the  cerebellum  sometimes  arises 
in  connection  with  ear  disease.  It  is  usually  situated  in  the  anterior  part  of  the 
lateral  lobes  where  these  are  in  contact  with  the  petrous  bone  and  the  groove 
for  the  lateral  sinus. 

The  general  diagnosis  for  such  an  abscess  is  based  on  the  same  symptoms 
as  that  of  cerebral  abscess,  except  that  the  temperature  may  be  high  from  com- 
plications, and  choked  disk  is,  as  a  rule,  absent.  Tenderness  over  the  cerebel- 
lum, especially  on  percussion,  and  occipital  headache  if  present,  are  both  of  value, 
but  our  mean's  of  positive  diagnosis  for  cerebellar  abscess  are  at  present  lamenta- 
bly deficient.  The  point  at  which  to  trephine,  as  already  indicated  (Fig.  229,  o), 
is  midway  between  the  tip  of  the  mastoid  and  the  inion,  and  well  below  a  line 
drawn  from  the  meatus  to  the  inion.  which  line  corresponds  to  the  lateral  sinus; 
or,  in  general  terms,  an  inch  and  a  half  behind  the  meatus  and  one  inch  below 
Reid's  base  line — a  line  drawn  from  the  lower  border  of  the  orbit  through 
the  middle  of  the  external  auditory  meatus  (Fig.  229,  a,  a).     The  surgeon 


DISEASES   AXP    IXJVRIES    OF    THE   HEAD.  541 

must  reraembor  that  the  occipital  bone  is  very  thin.     A  gouge  may  often 

'■^■''Tbc  treaS'enTof  the  abscess  when  once  fo«n<l  is  the  same  as  that  of 
cereb'al  ^^'^^  1"  punctunng  the  cevebeUum  care  must  be  taken  not  to 

"J'lV  •  Exr;Sdt;;'A;sc:ss'iT;rbscess  tb„„ing  between  the  ,lu,,  ana  the 
-^\;:^qni^'t:^JXS.cereb*r^^^^^^ 

Di-es^ure  are  sometimes  seen  in  extradural  abscess. 

^Treatment  -If  the  mastoid  has  not  already  been  opened,  it  f  ould  be 

"^Zt^  q4  -^en   of  cou.e  not  to  -™a  the  latera  srnus.^  K  a 

^^^^ious  bone  rem^ov.^,  -^^^f,  r^S  nS'the  diagnosis  was  only 

Hoffman  gives  -  'f  ^^^°/^/^tIf  we     d  agnosticated  durin=g  life,  of  which 

r'eXXr-opSot^ri:  hamiy  necessary  to  comment  upon  such 

Statistics.  .  .       ,  ^tf^ral  Sinus. — Until  recent- 

V.  PyetT^la  and  Throt^bosis  o      he  L  t  ^^^  ^^^^ 

:t:n?ryX:rtto^]elnrth\rsu,;geonssL^iIhe^^^^^^^^^^^^ 

toms  and  with  its  treatment,  especutlly  ^'°<='^f ';,;°!' j^f  "°^„Ve  i^^    pvemia 

rinrCthe  curved  j^nion tf  th^  lateral  s.nus  running  in  the  groove  of  the 

"-s::^~:Tb^ii^t.bh.d.^^ 

soon  softens  -'l  -JX^tty  become  detacb-ed  and  pass  into  the  lungs ;  or  the 


542  .l.V    AMlJilVAX    TEXT-llOOK    OF   .SL'L'd K/H'. 

Tlie  symptoms  uill  be  a  prt'coding  history  of  chronic  otorrhea,  followed 
by  headache  aiid  luiin  in  the  region  of  the  sinus,  vomiting,  distinct  and 
repeated  rigors,  followed  by  profuse  sweating,  violent  oscillations  of  tempera- 
ture, tenderness  and  local  oedema  over  or  behind  the  mastoid,  and  all  the 
ordinary  sym|>toms  of  pyemia.  As  the  clot  usually  extends  both  in  the 
course  of  the  lateral  sinus  and  soon  into  the  iiiterjial  jugular  vein,  there  will 
be  tenderness  over  the  course  of  the  lateral  sinus — that  is.  in  a  line  Irom  the 
external  auditory  meatus  to  the  inion — and  also  in  the  neck  over  the  course 
of  the  internal  jugular  vein,  which  may  feel  like  a  tense,  tender  cord  or  may 
even  have  been  destroyed.      Choked  disk  will  very  likely  be  present. 

The  treatment  should  be  prompt  and  positive.  First,  the  mastoid  should 
be  opened  and  cleansed.  If  the  internal  jugular  vein  is  involved,  it  should 
then  be  exposed  in  the  neck,  and  the  vein  should  be  followed  down  until  a 
point  below  the  thrombus  is  reached,  which  can  usually  be  determined  by 
touch  with  comparative  ease.  The  vein  should  next  be  ligated,  to  prevent 
extension  of  the  septic  thrombus  downward  to  the  heart  and  lungs,  and  it 
should  then  be  washed  out  and  made  as  aseptic  as  possible.  Next  the  sinus 
should  be  exposed,  and  if  there  be  any  pus  in  the  groove  for  the  sinus,  it 
should  be  washed  away.  If  the  sinus  be  thrombosed,  it  must  l)e  opened  and 
thoroughly  cleansed  even  to  the  torcular  Herophili.  Should  it  not  be  closed 
by  the  clot,  and  hemorrhage  be  very  free,  this  may  be  controlled  by  instan- 
taneous plugging  with  strips  of  iodoform-gauze,  which  should  be  ready  at 
hand.  Although  from  the  nature  of  the  case  perfect  asepsis  cannot  be  ob- 
tained, yet  the  results  have  been  such  as  highly  to  commend  the  treatment. 
Recovery  has  taken  place  in  56  out  of  84  cases — 6G.7  per  cent. — that  have 
been  operated  on  and  reported.  Without  operation  death  is  almost  inevit- 
able. Hence  every  case  should  be  submitted  to  operation  the  moment  the 
diagnosis  is  established. 

The  petrosal  sinuses  may  also  be  thrombosed,  but  without  local  symptoms 
to  guide  ur-. 

Sometimes  the  cavernous  sinus  is  thrombosed,  rarely  from  disease  of  the 
ear,  but  more  frequently  from  infective  inflammation  about  the  orbit,  the 
jaws,  or  the  throat.  If  so,  there  Avill  be  hyperemia  of  the  retinal  veins  and 
oedema  in  the  region  of  the  frontal  vein  and  in  the  eyelids,  with  exophthal- 
mos from  retrobulbar  oedema.  The  opposite  eye  is  often  in  turn  aftected 
from  extension  of  the  thrombus  to  the  opposite  side.  There  may  also  be 
neuralgia  of  the  first  division  of  the  fifth  nerve  and  paresis  or  paralysis  of 
the  muscles  supplied  by  the  motor  oculi  (third),  the  abducens  (sixth),  or  the 
pathetic  (fourth)  nerve,  all  of  which  run  in  the  sinus. 

The  treatment  of  these  latter  forms  of  sinus-thrombosis  and  of  pyemia 
from  ear  disease,  without  thrombosis,  must  unfortunately  be  limited  to  the 
general  treatment  of  pyemia. 

XVI.— SURGERY   OF   THE   L.\TERAL  VENTRICLES. 

Until  a  few  years  ago  it  Avas  supposed  that  any  injury  involving  the  lateral 
ventricles  was  necessarily  fatal.  This,  however,  is  disproved  by  a  number  of 
cases  in  which  the  lateral  ventricles  have  been  opened  by  injury,  such  as  simple 
fracture  of  the  skull,  of  which  there  are  at  least  o  ca.ses  reported  in^children, 
of  whom  3  recovered.  In  addition  to  these  there  are  also  recorded  7  cases  of 
compound  fracture  with  secondary  implication  of  the  ventricles,  4  of  which 
recovered,  and  2  of  primary  rupture  of  the  ventricles  by  compound  fracture, 
both  of  which  recovered.     Sometimes  also  in  cases  of  fungus  cerebri  a  com- 


DISEASES   A XI)    IXJllilKS    OF    THE    HEAD. 


543 


iiiiinieation  is  established  -with  the  hiteral  ventricles,  followed  by  continuous 
discharge  of  corebro-spinal  fluid  from  the  ventricles,  in  which  recovery  has 
taken  place.  Besides  this,  Keen  has  shown  that  puncture  of  the  lateral  ven- 
tricles through  the  brain  substance  can  be  done  accurately,  and  that  a  drainage- 
tube  mav  be  introduced  into  the  ventricles  and  remain  several  weeks  without 
inflammation  of  the  brain  or  its  meml)ranes,  and  that  even  irrigation  of  the 
ventricular  cavities  from  side  to  side  after  bilateral  tre}»hining  can  be  done 
without  discomfort  to  the  patient.  In  very  many  modern  cases  the  ventricles 
have  been  successfully  tapped  as  a  deliberate  procedure.  Therefore  in  fract- 
ure involving  the  ventricles  we  should  not  infer  that  the  patient  must  die  and 
that  we  must  do  nothing,  but  should  treat  the  case  on  the  same  antise})tic 
principles  and  by  the  same  methods  that  we  should  emi)loy  had  the  ventricle 
not  been  invaded,  and  with  a  very  reasonable  hope  of  recovery. 

If  the  ventricles  are  to  be  tapped,  the  lateral  route  is  the  best.     A  half-inch 
trephine  opening  should  be  made  one  and  a  quarter  inches  behind  the  external 

Fig.  231. 


Puncture  of  the  Lateral  Ventricle  by  the  Lateral  Route  at  A  (Keen). 


auditory  meatus  and  the  same  distance  above  Reid's  base  line  (Fig.  231,  A). 
Then  the  grooved  director  or  a  small  tube  (caliber  No.  5  of  the  French  cathe- 
ter scale  or  a  little  larger)  should  be  thrust  carefully  and  steadily  into  the 
brain  in  the  direction  of  a  point  H  vertically  two  and  a  half  to  three  inches 
above  the  opposite  meatus.  If  the  lateral  ventricle  be  of  normal  dimensions, 
it  will  be  reached  at  a  depth  of  two  to  two  and  a  quarter  inches,  but  if  dis- 
tended it  will  be  reached  at  a  less  depth.  The  entry  into  the  ventricle  will 
be  recognized  by  the  instant  diminution  of  resistance  and  by  the  escape  of 
cerebro-spinal  fluid.  Drainage  may  then  be  eff"ected,  either  by  inserting  a 
small  bundle  of  horsehair  doubled  like  a  hairpin,  wdth  the  rounded  ends 
inserted  first,  and  passed  through  the  tube,  or  by  carrying  a  rubber  drainage- 
tube  of  the  same  size  into  the  ventricle. 

The  operation  has  been  done  several  times  for  chronic  hydrocephalus, 
without,  however,  up  to  the  present  time,  a  single  cure ;  but  in  acute  hydro- 


544  AN  AMERICAN    TEXT-BOOK    OE  SURGERY. 

eeplialiis  the  result  lins  been  slij^litly  more  j)roinising.  ^Ir.  Mayo  Hobsoii 
has  reported  one  case  in  which  undoubtedly  life  was  saved.  Dennis  has 
reported  one  case  of  evacuation  of  a  clot  in  the  lateral  ventricles,  but  the 
laceration  of  the  brain  was  such  that  the  patient  died  soon  afterward.  A 
number  of  successful  cases  of  operation  for  increased  intracranial  pressure 
have  been  reported. 

Of  course  if  the  ventricles  are  tapped  the  asepsis  should  be  absolute,  or 
the  result  will  necessarily  be  fatal. 


XVII.— INTRACRANIAL  TUMORS. 

I.  Their  cause  cannot,  as  a  rule,  be  determined.  Occasionally  they  arise 
from  injury  ;  in  which  case  they  are  apt  to  be  sarcomata,  although  they  may  be 
fibromata  or  other  varieties  of  tumor.  Sometimes  they  are  parasitic  in  origin, 
from  the  echinococcus  or  from  the  ray  fungus  (actinomycosis),  and  tumors  of 
both  of  these  varieties  have  been  operated  on  successfully.  Much  more  fre- 
quently, however,  they  arise  from  no  assignable  cause.  Hale  White  and  Bern- 
hardt have  gathered  the  statistics  of  580  tumors,  which  are  tabulated  by  Seguin 
and  Weir,  as  follows : 

Number.  Per  cent. 

Nature  of  tumor  not  stated 133  22.9 

Tubercular  tumors 137  23.0 

Glioraata 76  13.0 

San'omata  (including  cysto-sarcomata) 75  13.0 

Hydatids,  cysticerci,  and  echinococci 30  5.0 

Cysts 27  4.6 

Carcinomata . 24  4.0 

Gummata 21  3.6 

Glio-sarcomata 14  2.2 

Mvxomata  (including  myxo-sarcoraata) 12  2.0 

Ostenmata 6  +1.0 

Neuromata 4  — 1.0 

Psammomata 4  — 1.0 

Papillomata 4  — 1.0 

Filjromata 3 

Cholesteatomata 2 

Lipomata 2 

Erectile  or  vascular  tumors 2 

Dermoid  cysts 2 

Enchondromata 1 

Lympliomata 1_ 

Cases 580 

On  looking  at  this  table  we  see  that  the  number  of  tubercular  tumors  exceeds 
twofold  that  of  tumors  produced  by  any  other  one  cause.  The  sarcomata  and 
gliomata,  which  are  practically  all  sarcomata,  taken  together  slightly  exceed 
tubercular  tumors.  Of  the  580  tumors  in  this  table,  the  nature  of  447  was 
known.  The  tubercular  and  these  two  kinds  of  sarcomata  numbered  288, 
leavinf',  therefore,  only  159  for  all  the  other  known  kinds  of  tumor.  Tuber- 
cular tumors  are  most  frequent  in  early  life.  Three-fourths  of  them  occur 
before  the  twentieth  year,  and  one-half  before  the  tenth,  according  to  Gowers. 
On  the  contrary,  the  various  forms  of  cancer,  including  sarcoma,  are  more 
common  from  twenty  to  forty  years  of  age. 

II.  Location. — Of  687  intracranial  tumors  tabulated  by  Gowers,  297 
were  situated  in  the  cerebral  hemispheres,  excluding  the  central  ganglia,  179 
in  the  cerebellum,  59  in  the  pons,  48  in  the  central  ganglia,  31  in  the  medulla, 
13  in  the  corpora  quadrigemina,  and  10  in  the  crura  cerebri.  Starr  found  96 
tumors  of  the  cerebellum  in  300  cases  of  intracranial  tumors  in  children  only. 


DISEASES   AM)    I XJ CRIES    OF    THE    HEAD. 


545 


ITT  Infiltration.— Some  tumors  are  definitely  limited  either  by  a  distinct 
TN-all  as  in  a  wcll-.kHned  cvst ;  in  others,  as  in  a  fil.roma  or  an  osteoma  the 
limits  of  the  tumor,  though"  without  any  such  wall,  are  definite  and  abrupt ;  but 
mali-nant,  and  to  a  less  extent  tubercular,  growths  of  the  brain,  as  of  othei- 
nartrof  the  bodv,  are  more  apt  to  infiltrate  the  surrounding  tissues  without 
inv  wcll-<lefined  margins.  This,  however,  is  not  always  the  case.  When 
infiltration  exists,  the  need  for  removal  of  more  tissue  than  that  which  constitutes 
the  tumor  itself  is  very  apparent.     The  probability  of  recurrence  is  also  much 

greater  in  such  cases.  •    -i       j.     ^i,  c 

IV    The  symptoms  of  tumor  are  in  many  respects  similar  to  those  ot 

other  lesions.     They  niav  be  caused  either  by  irritation  or  destruction  of  the 

cerebral  substance  or  by" pressure  upon  the  brain.     They  are  either  diffused  or 

localized.  ,  ^.^.         ,      ^ 

1  Headache  is,  as  a  rule,  early,  constant,  and  severe.  V\  hen  the  tumor 
is  superficial  the  headache  is  apt  to  correspond  to  the  site  of  the  disease. 
While,  like  all  the  other  symptoms  of  tumor,  it  may  be  absent,  yet  m  the 
great  majority  of  cases  it  is  present,  and  is  usually  one  of  the  most  annoying 
and  painful  symptoms.  As  a  rule  it  is  diffused,  but  even  if  it  is  localized  we 
must  not  depend  upon  it  too  much  as  an  indication  of  the  site  of  the  tumor. 

2.  Pain  is  almost  -always  present,  and  may  either  be  spontaneous  or  be 
evoked  by  pressure  or  percussion.  As  a  localizing  symptom,  pam,  like  head- 
ache, is  not  of  great  value.  Pain,  however,  which  is  not  spontaneously  com- 
plained of,  but  \  produced  by  percussion,  is  of  more  value  than  spontaneous 
pain  or  pain  upon  pressure. 

3.  Vertigo  is  a  common  symptom,  although  not  constant,  but  is  more 
marked  probably  in  cerebellar  tumors  than  in  cerebral.  If  the  tumor  is  in 
the  cerebellum,  the  vertigo  is  apt  to  be  present  in  the  recumbent  posture  as 

well  as  in  the  erect.  . ,      , ,        .  -r>  v.    i 

4.  Vomiting,  if  cerebral  in  origin,  is  of  considerable  value.  Uy  cerebral 
vomitin.'  is  meant  that  variety  Avhich  has  no  relation  either  to  the  ingestion 
of  food°or  to  a  furred  tongue,  constipation,  diarrhea,  or  other  evidences  of 

disturbed  digestion.  ■      c      ra  •     ^ 

5  Epileptic  convulsions  usually  set  in  as  soon  as  the  tumor  is  ot  sutfacient 
size  to  produce  pressure.  They  are  often  general  in  their  distribution  but 
occasionally  they  are  localized,  and  if  so  they  are  of  great  value ;  for  if  the 
attack  begins  always  in  the  same  arm  or  on  the  same  side  of  the  face  or  m  the 
same  le«',''they  point  with  reasonable  accuracy  to  the  location  of  the  tumor. 

6.  Another  of  the  pressure  symptoms  is  choked  disk,  which  in  tumor  is 
nearly  always  double.  It  sets  in'^probably  as  soon  as  the  tumor  has  reached 
any  size,  but  while  its  existence  is  of  value,  as  indicating  the  presence  of  a 
tumor,  it  gives  no  indication  of  the  position,  character,  or  size  of  the  tumor. 
If  it  be  m'onocular— that  is,  in  one  eye  only— the  tumor  is  most  likely  to  be 
in  the  opposite  hemisphere,  but  if  optic  neuritis  and  choked  disk  exist  m  both 
eves,  as  is  almost  always  the  case,  the  site  of  the  lesion  is  probably  the  side  on 
w'hich  the  least  swelling  occurs  ;  and  this  may  be  especially  inferred  if  the  other 
symptoms  point  in  the  same  direction.  Strange  to  say,  it  does  not  interfere  with 
the  acuity  of  vision  until  secondary  atrophy  of  the  nerve  has  taken  place. 

7.  Other  Eye-sgmptoms.—PaiYesh  of  any  single  muscle  or  any  group  of 
muscles  f^eneral'ly  indicates  either  pressure  from  a  coarse  lesion  m  the  cortex 
which  supplies  this  muscle,  or  true  infiltration  of  pathogenic  material  into  the 
meshes  of  the  nerves  themselves.  Unless,  however,  associated  with  other  symp- 
toms, it  is  of  little  value.  Spasm  of  any  of  the  muscles  is  of  more  value  than 
paresis  or  paralysis,  and  indicates  more  positively  a  lesion  in  the  motor  centers 

35 


.54')  ^l.V    AMKIUi  AX    rEXr-liUOK    OF   SllidKin'. 

of  sufli  inusclos.  Homonymous  liomiaiiopsia  is  of  j^reat  value,  since  it  jrenerally 
indicates  a  lesion  of  the  cuneus  on  the  same  side.  'JMie  term  hemianopsia  denotes 
acontlition  in  which,  each  retina  bein^  divided  by  a  vertical  line  into  two  halves, 
the  rijxht  half  of  each  retina  is  insensil>le  to  vision,  and  therefore  objects  in  the 
left  half  of  the  visual  field  .ire  not  seen  ;  or.  r/Vv  vrrsd,  the  left  half  of  each 
retina  is  blind,  and  then  the  rinjht  half  of  each  visual  field  is  not  seen.  If  the 
riflht  cuneus  is  involved,  the  right  halves  of  the  retinae  will  be  blind  and  the 
left  halves  of  the  visual  fields  not  be  seen,  and  vice  versd. 

The  pupils  are  not  unconnnonly  unequally  dilated  or  contracted.  Their 
condition  is  of  little  value  in  pointing  out  tumor  in  contrast  with  any  other 
intracranial  disease. 

Focal  Symptoms. — 1.   Hemianopsia  has  already  been  mentioned. 

2.  Aphasia. — If  the  tumor  be  located  in  the  third  frontal  convolution,  on 
the  left  side  in  right-handed  persons,  and  on  the  right  side  in  left-handed  per- 
sons, as  a  rule,  motor  aphasia  will  be  marked. 

3.  Paresis  or  Paralysis. — If  the  tumor  be  located  so  as  to  press  directly 
upon  the  fiice  center,  arm  center,  or  leg  center,  or  if  it  be  even  some  distance 
from  these  and  yet  large  enough  to  exercise  distant  pressure  upon  them,  there 
may  be  paresis  of  the  arm  or  leg  or  even  a  partial  or  complete  hemiplegia. 

4.  Anesthesia. — Unless  the  internal  capsule  is  involved,  anesthesia  is  rare; 
yet  it  sometimes  does  occur.  Tumors  pressing  upon  the  olfactory  or  any  other 
nerve  or  involving  the  nucleus  of  any  nerve  or  nerves  will  produce  at  first 
irritation  and  afterward  destruction  of  the  function  of  such  nerve  or  nerves. 

Mental  Disturbances. — As  a  tumor  increases  in  size,  stupor,  and  finally 
coma,  almost  always  precede  death.  Earlier  in  the  history  of  the  disease,  how- 
ever, there  are  mental  disturbances,  such  as  hallucinations  and  delusions,  and 
in  most  cases  there  is  a  general  loss  of  mental  acuteness,  with  loss  of  memory 
and  more  or  less  childishness.  Resemblance  of  the  symptoms  to  hysteria 
should  not  lead  the  surgeon  to  overlook  a  possible  organic  disease.  Among 
other  mental  disturbances,  the  following  .should  be  mentioned : 

1.  Word-deafness,  or,  as  it  is  often  called,  sensory  or  amnesic  aphasia,  is 
the  loss  of  memory  of  the  sound  of  a  word.  For  instance,  a  spoken  word,  such 
as  "cat,"  would  not  convey  its  proper  meaning  to  the  patient.  AVord-deafness 
generally  indicates  a  lesion  in  the  posterior  half  of  the  first  temporal  convo- 
lution on  the  left  side. 

2.  Word-blindness,  alexia,  is  the  loss  of  memory  of  the  appearance  of  a 
written  or  printed  word.  For  instance,  again,  a  written  or  printed  word  "  cat  " 
would  be  unintelligible  to  the  patient.  This  defect  usually  indicates  disease 
of  the  lower  posterior  portion  of  the  parietal  lobe  on  the  left  side,  and  espe- 
cially the  angular  and  supramarginal  gyri. 

3.  Agraphia  is  the  loss  of  memory  of  the  muscular  movements  made  in 
writing,  so  that  the  patient  has  lost  the  faculty  of  writing,  though  he  still 
retains  control  of  the  muscles  involved  in  this  act.  It  usually  indicates  a 
lesion  beneath  the  motor  speech  center  (Broca's  convolution),  or  possibly  of 
the  posterior  part  of  the  second  frontal  convolution. 

4.  Again,  there  may  be  loss  of  perception  of  the  use.  odor,  color,  or  taste 
of  any  object  presented  to  the  mind.  This  general  symptom  is  often  termed 
apraxia,  and  of  course  has  as  many  varieties  as  there  are  avenues  by  which 
the  mind  may  be  reached ;  for  instance,  sight,  touch,  smell,  taste,  hearing 
for  language,  hearing  for  music,  etc.,  any  of  which  may  be  lost,  producing 
mind-blindness,  mind-deafness,  etc.  The  patient  in  mind-blindne.ss  will  be 
unable  to  recognize  an  object  by  sight,  but  may  still  be  able  to  recognize  it  by 
touch.     All  these  various  conditions  should  therefore  be  examined.     Apraxia 


DISEASKS    AM>    I^JUniES   OF    THE    HEAD.  547 

will  <;oiior;illy  iTidicatc  a  k'sioii   in  the  sii|)raiiiar;^inal   or  angular  gyrus  in  the 
left   lieniisj)lici('   in   rigjit-lianded  persons,  and   vice  vcrsd. 

V.  Diagnosis. — That  there  is  need  for  more  exact  means  of  diagnosis  is 
very  evident  when  Ave  rememher  that  in  a  numher  of  eases  an  operation  has 
been  undertaken  for  a  tumor  su])posed  to  he  loeated  at  a  certain  point,  without 
finding  the  tumor,  and  the  post-mortem  has  shown  either  that  the  tumor  existed 
elsew  here  or  that  there  was  no  tumor  Avhatever.  Time  is  enabling  us,  however, 
gradually  to  become  more  accurate  in  our  diagnosis.  There  are  six  questions 
(Weir  and  Seguin)  to  which,  if  possible,  we  must  obtain  answers  in  any  sus- 
picious case : 

1.  Doi's  a  Tumor  exist? — The  symptoms,  briefly  stated,  Avill  be  headache, 
pain,  possibly  vertigo,  cerebral  vomiting,  convulsions  either  general  or  local- 
ized, and  paresis  or  paralysis  to  a  greater  or  less  extent,  choked  disk,  possibly 
stupor  toward  the  end  of  certain  cases,  hemianopsia,  and  apraxia  or  aphasia, 
with  or  without  anesthesia.  While  all  these  will  not  be  present  in  any  one 
case,  if  there  be  a  reasonable  number  of  them  the  probabilities  of  tumor  will  be 
very  strong.  The  difterential  diagnosis  between  tumor  and  abscess  has  already 
been  given  on  page  535.  In  Bright's  disease,  and  sometimes  in  lead-poisoning, 
there  may  be  headache,  vomiting,  convulsions,  and  choked  disk,  but  the  exami- 
nation of  the  urine  and  the  usual  dropsy  in  Bright's  disease,  and  the  wrist-drop 
and  condition  of  the  gums  in  lead-poisoning,  together  Avith  other  symptoms  of 
both  disorders,  should  put  us  on  the  right  track. 

2.  What  is  the  Location  of  the  Tumor-  ? — This  question  must  be  answered 
by  the  localizing  symptoms  above  given,  if  they  exist :  for  it  must  be  remem- 
bered that  in  certain  parts  of  the  brain  a  tumor  may  exist  without  any  local- 
izing symptoms,  but  with  only  the  general  symptoms  of  headache,  vomiting, 
choked  disk,  and  convulsions.  These  latent  zones  are  especially  the  anterior 
portion  of  the  fi-ontal  lobes,  the  temporo-sphenoidal  lobe  except  on  the  left 
side  in  part,  a  considerable  part  of  the  parietal  and  occipital  lobes,  and  to 
some  extent  the  cerebellum.  Sometimes  even  a  very  large  tumor  may  exist 
and  give  no  signs  of  its  presence,  but  if  it  be  in  certain  localities  where  the 
centers  for  the  special  senses  are  located,  or  in  the  cortical  centers  for  motion, 
or  in  the  paths  of  distribution  of  the  nerves  from  these  centers,  we  may  be  able 
in  most  cases  to  locate  it  with  reasonable  accuracy.  If  in  the  history  a  num- 
ber of  centers  have  been  successively  involved,  this  fact  is  very  important,  as 
the  history  of  the  march  of  the  paralysis  or  the  irritation  is  of  the  greatest 
value  in  enabling  us  to  locate  the  tumor.  Rapidly-produced  blindness  is 
usually  due  to  tumors,  especially  in  the  cerebellum  or  pons,  which  obstruct 
the  veins  of  Galen  or  the  straight  sinus  or  the  iter  e  tertio  ad  quartum  ven- 
triculum,  and  so  produce  an  internal  hydrocephalus,  pressure  on  the  optic 
tract,  choked  disk,  and  later  blindness. 

3.  At  tvhat  Depth  does  the  Tumor  lie — that  is,  is  it  cortical  or  subcortical? 
— A  tumor  in  the  cortex  may  be  diagnosticated  possibly  by  tenderness  to  pres- 
sure over  the  area  of  the  tumor,  possibly  by  a  local  rise  of  temperature,  and 
also  by  considering  the  number  and  relations  of  the  centers  involved  by  the 
tumor  and  the  absence  of  anesthesia. 

4.  Is  the  Tumor  Single  or  Multiple  ? — As  a  rule,  if  multiple,  operation 
will  be  contraindicated ;  but  if  single,  its  removal  may  be  attempted  unless 
specially  contraindicated.  If  single,  the  localizing  symptoms  should  be  referred 
either  to  one  center  if  the  tumor  be  small,  or  to  several  adjacent  centers  if  it 
be  large.  If  the  centers  involved  are  multiple  and  far  apart,  the  probabilities 
are  against  a  single  tumor  and  in  favor  of  a  multiple ;  or  if  single,  the  tumor 
will  be  very  large. 


548  AN  AMERICAX    TKXT-llOOK    OF  SURdEIiY. 

5.  What  is  the  Size  of  the  Tumor. ^ — Tii  a  few  cases  this  lias  been  diag- 
nosticated. Tlie  tumor  is  probably  small  if  only  a  restricted  area  of  the 
brain  is  involved,  as  shown  by  a  limited  paresis  or  paralysis,  if  with  time  no 
adjacent  centers  have  become  involved,  and  if  tlie  symptoms  of  intracranial 
pressure  are  either  slight  or  absent.  A  large  tumor  can  be  diagnosticated  by 
the  involvement  of  a  large  numl)er  of  neighboring  centers  and  marked  symp- 
toms of  pressure.  Often  this  diagnosis,  however,  cannot  be  made  Ix'fore  ope- 
ration. Even  if  the  tumor  be  large  it  may  be  removed  succossfnlly.  Thus 
Horsley  has  removed  a  tumor  weighing  over  four  ounces,  and  Weir  and  Keen 
have  removed  two  others  but  little  short  of  this  weight ;  and  two  of  these  three 
patients  recovered.  We  should  therefore  hesitate  before  refusing  to  operate, 
even  if  the  tumor  be  probably  of  large  size,  liefusal  means  Avitli  practical 
certainty  a  fatal  termination.  Operation,  it  is  true,  may  be  followed  by  death, 
but  this  would  only  be  anticipating  by  a  little  time  the  natural  termination  of 
the  disease,  and  it  gives  the  only  hope.  If  the  tumor  is  found  to  be  too  large 
for  removal,  the  surgeon  will  of  course  terminate  the  operation,  and,  as  shown 
by  a  number  of  cases,  the  patient  may  be  decidedly  the  better  by  reason  of  the 
interference,  especially  from  the  relief  to  the  headache,  blindness,  vertigo,  and 
vomiting.  In  one  of  Ilorsley's  cases,  in  which  for  inoperable  cerebellar  tumor 
he  removed  half  of  the  occipital  bone,  the  relief  to  the  dyspnea,  headache,  and 
rotary  convulsions  Avas  so  great  that  the  patient  requested  the  removal  of  the 
other  half,  and  his  life  was  prolonged  for  two  years  in  relative  comfort. 

6.  WJiat  is  the  Nature  of  the  Tumor? — If  the  patient  has  suffered  from 
cancer,  tubercle,  or  syphilis  and  the  symptoms  of  intracranial  tumor  are  present, 
it  is  most  likely  that  the  cerebral  tumor  is  of  the  same  nature  as  the  disease 
already  existing  elsewhere.  We  can  always  make  a  guess  based  upon  the  facts 
that  before  twenty  years  of  age  tubercle  is  much  more  frequent  than  any  other 
disease,  and  that  betAveen  twenty  and  forty  glioma  and  sarcoma  are  more  fre- 
quent than  other  tumors ;  but  such  a  guess  is  hardly  one  upon  Avhich  Ave  should 
act.  Hale  White  and  A^on  Bergmann  have  both  opposed  operation  in  syphi- 
litic tumors,  but  the  vicAv  of  Seguin  is  tliat  if  the  antisyphilitic  treatment  has 
been  inefficient,  including  the  administration  of  increasing  doses  of  the  iodides 
up  to  half  an  ounce  a  day,  operation  should  be  attempted.  Horsley  limits  such 
trial  of  internal  remedies  to  six  weeks,  after  Avhich  he  Avould  proceed  to  opera- 
tion. A  gumma  Avhich  has  undergone  a  fibrous  change  and  has  resisted  such 
vigorous  specific  treatment  is  practically  a  permanent  tumor,  and  Avhether  it 
shall  be  attacked  or  not  must  be  determined  on  precisely  the  same  grounds  as 
any  other  tumor.  Tubercular  tumors  are  more  ajjt  to  be  multiple  than  any 
other  variety,  and  Ave  should  therefore  hesitate  someAvhat  more  as  to  them. 

VI.  Prognosis. — If  an  intracranial  tumor  be  not  operated  upon,  it  is 
almost  necessarily  a  fatal  disease,  Avith  the  exception  of  those  syphilitic  groAvths 
which  yield  to  the  iodides.  It  is  possible  that  life  may  be  very  much  prolonged 
in  some  fcAV  cases,  but  in  the  majority  a  feAv  months  or  a  year  or  tAvo  is  all  that 
can  be  expected.  Hence,  as  it  is  so  almost  uniformly  fatal,  and  as  operation 
has  given  very  fair  results,  it  is  proper  that  avc  should  operate,  unless  the 
multiplicity,  depth,  size,  etc.  present  positive  contraindications.  If  Ave  operate, 
the  prognosis  varies  much,  first  as  to  immediate  recovery,  and  secondly  as  to 
ultimate  recovery. 

1.  Ah  to  Immediate  Keeovery. — v.  Bergmann's  statistics  (1898)  include  "273 
operations  for  intracranial  tumors,  of  Avliich  l<il»  (<il.!>  ]ier  cent.)  recovered, 
and  104  (38.1  per  cent.)  died.  Of  these,  157  Avere  exjtloratory  or  ])alliative 
operations,  of  Avhich  82  (52.2  per  cent.)  recovered  and  75  (48.4  per  cent.) 
died.     The  chief  reason  for  the  fatality  of  this  last  condition  has  been  prob- 


niSF.ASES   A  XT)    IXJlliTES    OF    THF.    HEAD.  549 

ably  too  extensive  exploration  in  search  of  the  tumor  or  for  its  removal.  If 
no  tumor  is  found  after  cautious  search  by  knife,  grooved  director,  and  the 
gentlest  use  of  the  little  finger,  or  if,  being  found,  it  is  not  removable,  the 
operation  should  be  terminated  at  once,  especially  if  there  is  much  bulging, 
indicating  a  large  tuuu)r.  In  14  cases  in  which  trephining  was  done  for  the 
relief  of  the  increased  intracranial  ])ressure  caused  by  the  tumor,  recovery 
followed  in  all.  Probably  time,  by  perfecting  both  the  diagnosis  and  the 
operative  methods,  will  enable  us  to  improve  upon  these  results.  At  the 
same  time,  it  must  always  be  recognized  that  an  operation  for  cerebral  tumor 
is  a  very  serious  one,  not  to  be  undertaken  lightly  nor  Avithout  explaining  the 
entire  matter  carefully  at  least  to  the  family:  the  mental  condition  of  the 
patient  may  be  such  that  it  would  be  unwise  or  useless  to  explain  it  to 
him. 

Another  important  reason  for  the  mortality  has  been  the  delay  in  operating. 
Physicians,  who  almost  always  see  these  cases  first,  postpone  consulting  a  surgeon 
for  an  unreasonal)ly  long  time,  in  the  vain  hope  of  improvement.  It  cannot  be 
too  strongly  insisted  on  that  we  should  treat  tumors  of  the  brain  just  as  we  treat 
tumors  in  other  parts  of  the  body — as  a  rule,  remove  them  at  the  earliest  pos- 
sible moment.  In  the  brain  the  reasons  for  early  operation  are  even  more 
cogent,  for  the  soft  tissue  here  is  more  easily  injured,  it  cannot  escape  from 
pressure  as  do  the  soft  parts  not  enclosed  in  such  a  bony  case,  and  the  growth 
of  the  tumor  is  insidious  and  not  easily  perceived,  as  it  is  when  accessible  to 
the  eye  and  the  finger.  We  can  only  infer  its  growth  from  the  symptoms. 
When  a  tumor  is  diagnosticated  and  located  with  reasonable  certainty,  if  it  be 
probably  amenable  to  operation,  its  removal  by  operation  should  be  attempted 
as  soon  as  drugs  have  been  fairly  tried  and  proved  of  no  avail.  The  limit 
for  this  "fair  trial"  Horsley,  as  stated  above,  puts  at  six  weeks,  and  cer- 
tainly this  is  enough.  After  that  it  is  but  wasting  time  and  imperilling  life 
to  wait  longer.  .  Further  time  only  allows  of  increase  in  the  size  of  the  tumor, 
with  wider  infiltration  of  brain  tissue  or  wider  destruction  by  pressure,  and  the 
operative  dangers  and  difiiculties  increase  with  each  week  or  month  of  delay. 
If  the  tumor  is  not  removable,  the  opening  in  the  skull  should  not  be  closed 
by  replacing  the  bone.  This  partial  operation  will  often  be  an  immense  com- 
fort. In  tumors  of  the  cerebellum  operation  for  their  removal  has  been  followed 
by  a  fatal  result  in  15  cases  out  of  23.  Their  proximity  to  the  fourth  ven- 
tricle, the  tubercula  ({uadrigemina,  and  the  pons,  Avith  the  important  and  vital 
centers  lying  there,  makes  operations  in  such  cases  peculiarly  hazardous.  But 
great  relief  can  be  given  by  wide  removal  of  the  bone,  as  already  stated. 

2.  As  to  Ultimate  Result. — If  the  tumor  be  malignant,  it  will  return,  as  a 
rule.  In  tubercular  or  syphilitic  tumors  the  probability  of  a  permanent  cure  is 
good.  In  benign  growths  recurrence  is  not  to  be  expected.  In  estimating  the 
future  of  such  patients  it  must  be  remembered  that  the  tumor  during  its  growth 
has  done  a  certain  amount  of  damage,  just  as  a  bullet  that  has  lodged  has 
inflicted  a  certain  amount  of  injury  in  its  pathway  to  its  resting-place.  The 
removal  of  the  bullet  or  of  the  tumor  will  not  affect  the  damage  already  done. 
Hence  if  an  optic  neuritis,  for  instance,  has  continued  long  enough  to  be  fol- 
loAved  by  atrophy  of  the  optic  nerve,  it  is  hopeless  to  expect  that  the  blindness 
Avill  disappear,  though  vision  may  improve  greatly  even  if  the  tumor  has  existed 
for  years.  So  also  the  paralysis  of  an  arm  or  a  leg  from  pressure  on  its  center 
may  remain,  though  in  the  majority  of  cases  the  motor  function  has  been  to  a 
great  extent  restored.  If  the  epileptic  habit  has  been  formed,  the  removal  of 
the  tumor  will  probably  modify  and  may  possibly  cure  the  attacks,  but  they 
will  often  persist,  though  they  may  be  less  frequent  and  milder. 


550  AN   AMERICA. \    ri'.XT- IK K )k'    O/'   srL'(;i:i{Y. 

\\\.  Treatment. — When  it  has  been  decided  that  the  tumor  exists  in  a 
given  locality,  and  that  it  is  amenable  to  operation,  the  o))erative  proeedure 
may  be  very  briefly  descrii)ed. 

1.  A  large  semilunar  llaj)  is  made,  with  the  center  corresponding  to  the 
site  of  the  tumor.  2.  A  large  opening  from  two  to  four  inches  in  diameter 
is  made  in  the  skull,  the  best  method  being  by  a  large  osteoplastic  flap.  8. 
The  dura  should  be  opened.  4.  The  tumor,  having  ]>een  recognized, 
should  be  enucleated,  if  possible,  by  the  ii)igci-.  This  will  very  rarely  be 
practicable.  If  not,  the  knife,  the  scissors,  the  sharp  spoon,  or  the  handle 
of  an  ordinary  teaspoon  may  be  used  to  remove  it,  either  as  an  entire 
mass  or  piecemeal.  5.  If  the  tumor  be  subcortical,  an  incision  should  be 
made  in  the  brain  and  the  little  finger  inserted  Avith  great  gentleness  to 
recognize  the  resistance,  size,  etc.  of  the  tumor.  When  found  it  is  to  be 
removed  as  before  described.  6.  If  the  tumor  be  so  large  that  it  would  be 
unwise  to  remove  it,  the  operation  should  be  immediately  terminated  and  the 
dura  and  llap  secured,  the  bone  not  being  replaced.  7.  The  operation  is 
often  best  done  in  two  stages  (p.  502).  8.  The  method  of  dealing  with 
hemorrhage  and  the  other  steps  of  the  operation  differ  in  no  wise  from  those 
described  under  the  head  of  Techni((ue. 

XVIII.— EPILEPSY. 

From  a  surgical  point  of  view  cases  of  epilepsy  are  either  traumatic  or 
non-traumatic. 

I.  Epilepsy  following  Traumatism. — As  a  rule,  the  epileptic  attacks 
do  not  make  their  appearance  until  some  months  or  even  years  after  the  acci- 
dent, and  the  earlier  attacks  are  not  only  less  frequent  than  the  later  ones,  but 
are  often  unattended  at  first  by  loss  of  consciousness  (petit  mal),  and  only  after 
a  time  become  fully-developed  epileptic  attacks.  There  is  reason  to  believe 
that  even  slight  accidents  may  sometimes  produce  epilepsy,  presumably  through 
the  agency  of  a  cicatrix  in  the  dura  or  in  the  brain.  Very  often  in  such  cases 
there  will  be  lesions  of  motion  and  sometimes  of  sensibility,  perhaps  dating 
back  to  the  time  of  the  accident.  It  is  probable  also  that  if  after  compound 
fracture  any  portion  of  bone  remains  depressed,  it  may  irritate  the  underlying 
cortex  and  cause  epilepsy.  Similarly,  in  some  cases  apparently  by  reason 
simply  of  the  presence  of  the  resulting  cicatrix,  epilepsy  may  follow.  Hence 
one  argument  for  the  radical  treatment  of  such  injuries  at  the  time  they  are 
received,  as  has  been  advocated  in  preceding  pages.  The  numerous  cases 
reported  in  the  periodical  literature  of  the  last  few  years  constitute  a  very 
strong  reason  for  the  propriety  of  thus  interfering  in  the  way  of  prevention  of 
the  epilepsy,  rather  than  allowing  it  to  set  in  and  then  trying  to  remedy  it. 

Sometimes  the  cicatrix  in  the  scalp  is  tender  or  is  tlie  seat  of  radiating 
pains  and  sometimes  of  the  aura.  Pressure  on  it  may  produce  a  fit,  although 
most  frequently  it  will  not.  Very  rarely  there  will  arise  from  a  tramnatism  a 
sarcoma,  fibroma,  or  other  form"'  of  tumor  which  itself  will  cause  epilepsy. 
Apparently  mere  alteration  in  the  texture  of  the  cortical  tissue  from  fatty  or 
other  degenerative  changes  following  traumatism  may  itself  give  rise  to  the  epi- 
lepsy. Sir.  Ilorsley  especially  has  shown  not  only  that  such  brain  scars,  scars 
in  the  dura,  cysts,  fragments  of  bone,  etc.,  are  presumably  the  cause  of  such  epi- 
leptic attacks'  but  also  that  their  removal  has  resulted  in  relief  and  even  in  cure. 
In  cases  of  epilepsy  arising  from  traumatism,  if  the  trauma  is  .'^liown  by 
a  scar  or  by  evidence  of  injury  to  the  bone  without  a  scar,  the  injury  may 
be,  fir-st,  over  Avcll-known  centers,  motor  or  otherwise ;  or,  secondly,  it  may  lie 
over  the  so-called  latent  zones  of  the  brain. 


/>  AS  AM, SAW  A\/>    IX.JriilKS    OF    THE   HEAD.  551 

In  those  cases  in  •\vliicli  tlic  lesion  lies  over  well-hiotvn  centers  and  the 
ei>/Ic/>f/i!  Jit  is  limited  to  the  viKscles  corresjxmditiji  to  these  motor  centers, 
the  inference  is  that  they  stand  in  tlie  relation  of  cause  and  effect.  But 
it  must  always  lie  remenihered  that  the  irritation  of  the  scar  in  the  scalp 
is  sometimes  sufficient  to  cause  the  epileptic  attacks,  and  hence,  as  a  rule,  the 
proper  course  of  procedure  is  to  prepare  for  a  complete  trephining  with  the 
same  minute  care  that  has  heretofore  been  described  as  necessary  in  cerebral 
operations;  l)ut  if  an  exploratory  incision  exposing  the  bone  under  the  scar 
shows  no  injury  sufficient  to  make  us  think  the  brain  is  certainly  injured,  ■\ve 
should  limit  the  operation  to  the  excision  of  the  scar.  Especially  Avill  this  be 
proper  if  the  scar  be  the  site  of  tenderness  on  pressure  and  of  the  epileptic 
aura,  or  if  pressure  on  the  scar  produce  a  distinct  fit.  In  a  moderato  number 
of  cases  now  reported  in  which  there  existed  no  fracture  of  the  bono,  but  only 
a  sear  in  the  scalp,  the  excision  of  the  scar  has  been  followed  by  cure. 

Moreover,  we  must  remember  such  cases  as  the  one  related  by  Briggs,  in 
which  a  girl  had  both  an  old  depressed  fracture  of  the  skull  and  necrosis  of 
the  tibia.  He  very  wisely  first  operated  on  the  tibia,  and  after  five  years 
the  fits  had  not  recurred,  showing  that  their  origin  was  not  in  the  depressed 
fracture  of  the  skull,  Avhich  prima  facie  was  the  probable  cause,  but  in  the 
irritation  of  the  tibial  disease.  We  should  not,  however,  be  too  hopeful  if  the 
fits  cease  immediately  after  the  excision  of  the  scar  or  after  any  other  ope- 
ration. It  is  a  strange  fact,  to  which  White  has  recently  called  renew^ed  and 
especial  attention,  that  any  operation,  even  though  trivial,  is  apt  to  cause  the 
cessation  of  the  fits  for  weeks  or  months ;  and  hence  after  removal  of  the  scar 
we  cannot  be  certain  that  the  epilepsy  is  cured  until  at  least  three  years  have 
elapsed  without  the  return  of  the  attacks.  The  surgeons  of  the  largest  expe- 
rience are  probably  the  most  cautious  in  drawing  too  favorable  conclusions. 

If  excision  of  the  sear  does  not  cure  the  patient,  and  the  scar  lies  over  the 
motor  center  which  corresponds  to  the  initial  muscular  spasm,  and  still  more 
if  there  is  evidence  of  any  depression  of  the  skull  or  of  an  old  compound 
fracture,  a  second  operation  should  be  done  and  the  patient  be  trephined. 
The  lesion  rarely  will  be  a  splintering  of  the  inner  table,  sometimes  with  a 
depressed  fragment  of  bone ;  sometimes  a  cyst  following  a  blood-clot,  or  not 
uncommonly  simply  a  brain  scar,  with  generally  a  corresponding  cicatrix  in 
the  dura.  Occasionally,  hoAvever,  nothing  more  than  thickening  and  eburna- 
tion  of  the  bones  of  the  skull  will  be  found. 

After  trephining  the  skull,  the  dura  should  always  be  opened,  even 
though  it  be  sound,  in  order  to  inspect  the  brain.  If  there  be  a  scar  in  the 
dura,  it  must  be  excised,  and  if  there  be  one  in  the  brain,  it  should  also  be 
excised  down  to  the  white  tissue.  In  such  cases  it  is  of  the  utmost  importance 
to  remember  that  all  the  damaged  brain  tissue  must  be  removed.  It  is  better 
even  to  trench  somewhat  upon  apparently  healthy  brain  tissue,  for  the  removal 
of  a  little  more  tissue  than  is  necessary  is  preferable  to  the  opposite  error  of 
removinof  less  than  is  necessary,  with  possible  retention  of  the  epileptic  fits. 
In  effecting  this  removal  it  is  important  also  to  remember  that  we  can  extend 
our  incisions  in  the  antero-posterior  direction  much  more  freely  than  we  can  in 
the  vertical  direction,  for  extension  in  the  vertical  direction  means  involve- 
ment of  other  motor  centers,  whereas  extension  antero-posteriorly  will  prob- 
ably merely  add  to  the  completeness  of  the  removal  of  the  injured  center.  It 
is  not,  as  a  rule,  necessary  to  go  deeper  than  the  gray  substance,  unless  we 
find  evidence  of  a  scar  or  other  lesion  at  a  greater  depth.  Care  must  be 
taken  to  arrest  the  hemorrhage,  as  has  been  already  mentioned  in  the  section 
on  Technique,  the  ligature  being  the  chief  reliance,  and  pressure  and  hot 


552  -l.V   J.l//;A'/r.i.V    THXT-ltnOK    OF   srUdFUY. 

water  coming  next  in  efficiency.  Lai<re  veins  should  be  lijrated  before 
division,  or,  better  still,  should  be  avoided,  as  is  often  possible,  by  going 
around  them  or  by  lifting  them  and  working  under  them.  If  any  of  the  dura 
has  been  removed,  its  place  should  be  supjilied.  as  has  been  suggested,  by  a 
bit  of  the  pericranium.  This  is  especially  important  in  cases  where  the  brain 
has  been  incised,  so  as  to  avoid  a  fungus  cerebri.  Drainage,  as  a  rule,  may 
be  omitted.  The  bone  should  not  be  replaced  if  it  would  probably  product 
pressure  on  the  brain.  (Otherwise  it  may  be  put  back,  not  only  the  large 
piece  removed  by  the  trei)hine,  V»ut  a  number  of  the  small  pieces  as  well.  All 
these  should  have  had  the  cai-e  described  in  the  section  on  Technique,  in  order 
to  preserve  their  vitality.  If  the  bone  is  diseased,  of  course  it  should  not  be 
replaced,  nor  if  it  is  irregular  and  would  produce  irritation  or  pressure.  Pos- 
sibly experience  may  show  that  it  is  best  not  to  replace  it  at  all ;  this  is  yet  an 
open  question. 

In  those  cases  in  which  the  lesion  does  not  lie  over  well-known  centers 
of  motion,  special  senses,  language,  etc.,  but  over  the  latent  zones,  the  scar 
should  still  be  excised  as  above  advised,  but  the  surgeon  should  always  be 
prepared  to  do  a  complete  brain  operation  as  well  as  simple  excision  of  the 
scar,  for  he  can  never  tell  how  far  it  may  be  wise  to  extend  the  operation  until 
after  he  has  lifted  the  scalp  an<l  inspected  the  bone.  If  excision  of  the  scar, 
as  before,  does  not  effect  a  cure,  and  there  is  distinct  evidence,  as  above  stated, 
either  of  fracture  or  of  irregularity  of  the  bone,  or  if  the  scar  is  tender  or  the 
seat  of  an  aura,  or  if  a  fit  follows  pressure  upon  it,  trephining  should  be 
done.  Once  the  bone  has  been  removed,  the  dura  should  be  opened,  and  then 
what  is  to  be  done  either  to  the  dura  or  to  the  brain  must  depend  on  what  is 
found.  Any  dural  scar,  brain  scar,  altered  brain  tissue,  or  cyst  should  be 
treated  by  excision.  Sometimes  in  cases  of  compound  fracture  trejdiining  will 
have  been  done  at  the  time  of  the  accident  and  yet  epilej)sy  will  develop  later. 
In  such  cases,  whether  the  lesion  be  over  the  motor  or  other  well-known  cen- 
ters or  over  the  latent  zones,  as  a  rule  it  will  be  proper  to  lift  a  flap  of  scalp, 
enlarge  the  bony  opening  if  necessary,  and  examine  the  brain.  Trimming  the 
thickened  bone  away  from  the  edges  of  the  opening  left  by  a  compound  frac- 
ture or  a  former  trephining,  or  the  removal  of  any  of  scar  tissue,  will  often  eff"ect 
a  great  improvement,  and  in  some  cases  even  a  cure.  Secondary  operations  of 
this  kind  have  sometimes  proved  very  successful.  In  all  such  operations  as 
this  it  must  be  remembered  that  if  we  undertake  an  operation  at  all  it  must.be 
done  thoroughly.  A  large  trephine  may  be  used,  one  and  a  half  inches  in 
diameter,  or  else  several  small  trephine  openings  should  be  made,  and  enough 
of  the  bone  between  them  be  removed  to  enable  us  to  see  the  brain  tissue  well. 
Timidity  in  this  respect  will  often  result  in  a  fruitless  operation  where  a  bolder 
course  might  have  achieved  success.  In  operations  on  the  brain  it  is  always 
important  to  have  plenty  of  room  for  inspection  of  the  brain,  for  determination 
as  to  what  should  be  done,  and  for  facility  in  dealing  with  hemorrhage. 

In  all  cases  of  epilepsy  it  is  important  that  the  operation  should  be  done  at 
an  early  date,  in  order  to  prevent  secondary  sclerosis  and  the  formation  of  the 
epileptic  habit,  a  point  on  which  Sachs  has  laid  especial  stress. 

II.  NON-TRAUMATIC  EPILEPSY. 

1.  Jacksonian  Epilepsy. — This  term  is  applied  to  tho.?e  cases  of  epilepsy 
in  which  there  is  spasm  of  a  certain  limited  group  of  muscles  u'ithout  loss  of 
co7isciousness.  and  in  which,  therefore,  the  discharging  lesion  seems  clearly  to 
be  limited  to  the  center  corres]K)nding  to  the  muscles  involved.     In  a  number 


DISEASES   A\l>    IXJf'lilES    OF    THE    HEAD.  553 

of  sucli  eases  these  centers  liave  been  exposed,  then  recognized  by  the  battery 
as  already  tiescril)ed,  and  tlic  entire  area  excised.  The  time  has  not  yet  come 
when  a  definite  opinion  can  be  expressed  as  to  tlie  value  of  these  operations. 
The  dan<:er  to  life  is  not  very  great.  A  large  number  of  the  cases  iiave  not 
been  bettered,  but  in  many  great  relief  has  followt-d  both  in  diminished  severity 
and  diminished  frequency  of  the  attacks. 

Some  cases  have  been  reported  in  which  momentary  faradization  of  the 
coi'tical  centers  which  are  evidently  diseased  has  produced  a  fit  entirely  analo- 
gous to  the  typical  ej)ileptic  fits  to  which  the  patient  has  been  a  victim.  Such 
momentary  faradization  of  a  normal  cortex  should  produce  only  a  single  move- 
ment of  the  part  supplied  by  that  portion  of  the  cortex.  Whether  this  will 
be  of  value  in  determining  that  a  cortical  centre  which  appears  to  the  eye  and 
touch  to  be  healthy  is  really  diseased,  is  a  matter  to  be  decided  by.a  larger 
experience. 

The  question  naturally  arises  whether  this  excision  will  not  ])roduce  palsy 
of  the  muscles  supplied  by  this  center.  Complete  j)riniary  paralysis  of  these 
muscles  always  follows  such  removal,  and  not  uncommonl}*  the  pressure  of  the  clot 
or  of  the  exudate  formed  after  the  operation  will  paralyze  neighboring  centeis, 
so  that  there  may  be  complete  hemiplegia  in  many  cases  resulting  from  simple 
excision,  for  instance,  of  the  arm  center.  But  it  is  an  invariable  rule  that  this 
hemij^legia  is  but  temporary.  After  a  few  Aveeks  tlie  patient  will  begin  to  re- 
gain control  over  the  muscles,  and  eventually  he  will  regain  motion  in  its  entire 
ranore,  but  usually  with  some  lessened  muscular  strength  :  that  is,  there  is  a 
certain  paresis  remaining.  Whether  this  regain  of  muscular  control  is  due  to 
the  cortical  center  on  the  opposite  side  of  the  brain  taking  up  the  work  of  the 
lost  center  (as  the  left  hand  may  take  up  the  work  of  the  right  after  amputa- 
tion), or  to  a  regeneration  of  brain  tissue,  is  at  present  in  doubt,  with  perhaps 
a  preponderance  of  testimony  against  regeneration  of  the  cerebral  tissue. 
Experimental  transplantation  of  brain  tissue  itself  from  one  animal  to  another 
has  been  done  with  good  results  from  an  operative  point  of  view.  Whether 
this  can  ever  be  applied  to  man  is  unknown. 

One  precaution  is  very  essential  in  these  cases.  Many  patients  will  describe 
A  fit  of  the  Jacksonian  type  (without  of  course  using  this  term),  which  descrip- 
tion a  closer  observation  will  show  to  be  wholly  erroneous.  In  fact,  so  ab- 
sorbed are  the  relatives  of  an  epileptic  in  seeing  that  he  does  not  injure  him- 
self, and  in  sympathetic  care  for  him,  that  in  most  cases  they  are  the  worst  pos- 
sible witnesses  as  to  the  character  of  the  attacks.  Hence  no  patient  should  be 
operated  on  for  epilepsy  unless  his  attacks  have  been  seen  either  by  the  surgeon 
himself  or  by  a  competent  and  trained  nurse — if  possible,  one  who  has  been 
accustomed  to  observe  such  fits.  Members  of  the  family,  moreover,  are  not 
trained  observers,  and  for  scientific  accuracy  such  training  is  essential.  It  is 
essential  that  the  nurse  should  be  instructed  by  the  surgeon  to  do  absolutely 
nothing  but  observe  and  immediately  record  the  phenomena  observed  in  each 
fit.  Cold,  hard,  scientific  facts  are  what  we  want,  not  sympathetic  statements. 
In  true  Jacksonian  epilepsy  the  patient  himself,  if  a  reasonably  careful  observer, 
can  give  much  help,  because  he  does  not  lose  his  consciousness. 

The  observations  above  referred  to  should  cover,  first,  what  muscles  are  first 
involved,  and,  secondly,  the  march  of  the  fit ;  that  is  to  say,  the  fit  having 
.started  at  such  and  such  a  point,  whether  it  extends  to  other  points  in  any 
definite  order,  and  whether  this  order  is  the  same  in  difi'erent  fits.  Thirdly, 
the  state  of  the  pupils  should  be  very  carefully  observed,  Avhether  dilated  or 
contracted,  whether  equally  so,  whether  responsive  to  light  stimulus,  etc. 
Lastly,  as  soon  after  an  attack  as  the  patient  is  capable  of  using  the  dyna- 


554  A\  A. \/ /:/:/<  A. \   ■iiixr-iKKtK  of  srn(;r:in\ 

monieter  it  should  ])e  iMiiployed  to  (letennino  tlie  comparative  .stron(;tli  of  the 
muscles,  especially  of  those  first  involved,  which  in  such  cases  are  apt  to  be 
paretic  in  conserinoncc  of  oxhaustion  from  the  spasmodic  motion. 

2.  Focal  Epilepsy. —  In  a  certain  number  of  cases  in  which  llicrc  has 
been  no  lesion  of  which  there  was  evidence  by  scar,  depressed  bone,  or  other 
3if];ns,  in  which  there  were  unconsciousness  and  general  epileptic  spasm  instead 
of  monospasm  [e.  //.  of  an  arm  or  a  le;:),  but  the  attacks  always  began  in  a  certain 
set  of  muscles,  as  if  they  always  had  their  orin;in  from  the  cerebral  center 
dominating  these  muscles  as  a  focus,  from  which  they  radiated  to  other  centers, 
an  attempt  has  been  made  to  prevent  their  recurrence  or  extension  by  removing 
the  center  corresponding  to  the  muscles  in  whicli  tlie  fits  start.  In  these  cises, 
even  more  possibly  than  in  those  of  the  Jacksonian  type,  it  is  necessary  to 
have  reliable  and  repeated  observation  of  the  attacks  before  deciding  to  operate. 
Even  with  the  diminished  dangers  of  modern  cerebral  surgery,  exposing  the 
brain,  and  especially  excising  a  cortical  center,  is  not  a  trifling  operation,  but 
a  serious  one,  which  must  not  be  undertaken  without  the  best  evidence  of  its 
necessity.  No  member  of  the  family,  no  friend,  no  one  but  a  trained  observer, 
must  be  trusted  to  determine  these  facts.  The  testimony  of  the  family  may  be 
taken  as  a  corroboration,  but  not  as  a  foundation.  Moreover,  it  has  been  Veil 
pointed  out  by  Putnam  that  the  value  of  spasms  starting  in  the  bands  is  not  sa 
great  as  where  the  spasm  begins  in  a  less  easily  disturbed  part,  as  the  elbow  or 
the  shoulder.  The  finger  motions  are  highly  specialized,  and  therefore  tlieir 
equilibrium  is  much  more  easily  disturbed  than,  so  to  speak,  the  more  phleg- 
matic, coarser,  better-balanced  muscles  of  the  larger  joints  like  the  shoulder. 
If,  therefore,  in  focal  epilepsy  the  muscles  of  the  shoulder  are  those  first 
involved,  the  spasm  extending  from  the  shoulder  finally  over  the  whole  body, 
such  a  case  is  far  better  suited  to  operation  than  one  in  which  the  more  easily 
unbalanced  mtiscles  of  the  hand,  thumb,  etc.  are  the  site  of  the  initial  spasmodic 
movement.  In  other  words,  the  equilibrium  of  the  hand  is  more  easily  disturbed 
than  that  of  the  shoulder,  and  is  therefore  of  less  value  as  a  factor  in  determining 
us  in  favor  of  operation.  Results  seem  thus  far  to  indicate  that  in  a  small  per- 
centage of  cases,  which  can  scarcely  as  yet  be  stated  numerically,  a  cure  may 
possibly  be  effected.  In  a  number  of  cases,  much  larger  than  in  the  last  class, 
considerable  improvement  will  follow ;  in  an  equal  or  still  larger  number  no 
betterment  Avill  follow.  The  operation,  however,  does  not  seem  ever  to  produce 
an  increase  in  the  number  of  attacks.  The  percentage  of  deaths  in  the  reported 
cases  is  not  large,  yet  danger  is  a  factor  in  the  decision  of  the  question  wliether 
an  operation  shall  be  done  or  not,  which  must  on  no  account  be  omitted  in  the 
statement  of  the  case  to  the  patient  and  the  family.  Epilepsy  is  so  direful  a 
disease  that  there  are  few  parents  or  patients  who  would  not  be  willing  to  face 
a  large  risk  to  life  for  the  reasonable  probability  of  betterment,  and  still  more 
if  there  be  a  chance  of  cure,  however  small:  and  tliey  are  all  the  more  willing 
when  there  is  but  slight  cliance  of  death  and  none  of  beinsr  made  worse. 

In  these  cases  it  is  especially  important  always  to  make  a  large  opening  in 
the  bone,  in  order,  if  possible,  to  recognize  the  convolutions.  When  the  brain 
is  exposed,  no  antiseptics  should  touch  it  until  the  battery  has  well  defined  the 
center  which  is  to  be  identified  and  removed.  In  faradizing  the  brain  the  cur- 
rent required  is  about  that  which  is  necessary  to  call  the  muscles  of  the  thumb 
into  action,  and  stronger  currents  should  be  avoided :  although  no  serious 
injury  to  the  brain  has  thus  far  been  reported  as  a  result  of  such  faradization,  yet 
its  possibility  should  lead  us  to  use  as  gentle  a  current  as  will  effect  our  object. 
The  faradization  should  not  be  repeated  any  oftener  than  is  necessary. 

Horsley  has  especially  insisted  here  on  thoroughness  of  excision.      If  any 


j>/s/:as/:s  .im>  /.v./ r /.•//•>•  or  ////■:  jihad.  o5r> 

of  the  ceiitor  be  It'ft,  the  operation  -will  probably  prove  a  failure.  "When  the 
center  sought  for  lias  been  found  and  its  limits  determined,  any  large  veins 
involved  in  its  excision  should  first  be  tied,  and  then  the  center  limited  by 
incisions  made  with  a  sharp  knife  held  vertically  to  the  surface.  This  should 
penetrate  to  the  white  substance.  The  cortex  may  then  be  removed  either  by 
scissors  or  by  knife.  Sometimes  "vvo  can  strip  off"  or  push  away  the  pia  and  its 
vessels  from  the  underlying  convolutions,  and  so  avoid  wounding  any  large 
vessels.  It  will  rarely,  if  ever,  be  necessary  in  cases  of  focal  epilepsy  to 
remove  any  of  the  dura.  After  the  excision,  therefore,  this  should  be  care- 
fully re])laced  and  secured  ])y  sutures,  and  the  operation  terminated  as  hereto- 
fore described. 

Unfortunately,  the  large  majority  of  cases  of  epilepsy  belong  rather  to 
so-called  general  epilepsy  than  to  focal,  Jacksonian,  or  traumatic.  Such 
cases  are  evidently  unsuited  to  any  operation,  and  in  our  new-born  boldness, 
begotten  of  success  in  cerebral  surgery,  Ave  should  not  overstep  the  limits  of 
prudence  and  operate  indiscriminately  and  unwisely.  Each  case  of  epilepsy 
must  be  studied  by  itself  for  days,  and  sometimes  even  for  weeks,  before  we 
reach  a  definite  conclusion  that  it  is  wise  to  operate.  The  surest  way  to  dis- 
credit cerebral  surgery  is  to  practise  unwise  cerebral  surgery.  Hence,  while 
advocating  a  more  radical  treatment  than  that  formerly  thought  to  be  wise,  we 
must  be  careful  not  to  proceed  to  the  opposite  extreme  of  indiscriminate  opera- 
tive interference.  A  progressive  conservatism,  if  the  term  is  allowable,  should 
be  our  rule. 

XIX.— TREPHINING   FOR   INVETERATE   HEADACHE,  INSANITY,  AND  ARRESTED 

DEVELOPMENT. 

I.  Inveterate  Headache. — Occasionally  headache  will  be  fixed  in  its 
locality  and  of  an  excessively  severe  type,  so  that  it  will  interfere  seriously 
Avith  the  patient's  health  and  happiness,  and  may  even  make  any  occupation 
impossible.  The  cause  of  such  a  headache  is  often  traumatism,  resulting  in 
disease  of  the  bones.  The  possible  existence  of  hysteria,  gout,  or  syphilis 
should  always  first  be  considered,  and  the  family  and  personal  history  there- 
fore should  be  investigated  Avith  great  care.  As  a  rule,  especially  in  the  case 
of  a  hysterical  Avoraan,  we  should  refuse  to  undertake  an  operation  until  a 
thorough  trial  of  all  the  remedial  means  at  our  command  for  such  diseases  has 
been  carefully  made  by  a  competent  neurologist.  If  then  no  relief  has  been 
afforded,  in  view  of  the  very  small  risk  to  life  involved  in  simple  trephining  it 
is  proper  that  it  should  be  done.  Trephining  having  been  done,  it  is  better, 
usually,  to  open  the  dura  and  inspect  the  brain,  even  if  nothing  further  be 
attempted.  It  is  not  Avise,  as  a  rule,  to  go  so  far  as  to  trephine  a  patient  and 
then  neglect  the  information  which  may  be  derived  from  the  simple  opening 
of  the  dura.  Properly  done,  this  adds  practically  little  to  the  risk  and  may 
add  immensely  to  our  knoAvledge.  If  nothing  is  found,  the  dura  should  be 
sutured  in  place,  Avithout  replacement  of  the  button  of  bone. 

II.  Insanity  and  other  Mental  Disturbances. — The  most  remarkable 
case  in  Avhich  a  psychical  disturbance  has  given  a  clue  to  the  diagnosis  is 
reported  by  Macew'en.  The  man  had  been  injured,  and  a  year  later  suffered 
from  melancholia  and  a  tendency  to  homicide.  There  Avere  no  motor  phe- 
nomena Avhatever,  but  it  Avas  discovered  that  for  tAvo  Aveeks  after  the  accident 
he  had  suffered  from  the  form  of  apraxia  called  mind-blindness.  Vision  was 
perfect,  but  Avhat  he  saAV  conveyed  no  impression  to  him.  His  NeAv  Testament 
was  recognized  by  touch,  but  on  opening  it  the  printed  words  had  no  mean- 


556  .l.V   AMKHIVAX    TEXT-IK )(>K    OF   Sl'liCERY. 

ing  for  him.  A  lesion  in  tlie  angular  gyrus  was  diagnosticated,  and  on  ope- 
rating it  was  found  that  a  portion  of  the  inner  table  had  been  detached  and 
was  pressing  on  the  suj)rauiarginal  and  angular  convolutions.  1'lie  man  made 
a  good  recovery.  This  case  is  cited  es])eeially  as  an  indication  of  how  a 
minute,  painstaking  investigation  of  the  history  of  an  injury  and  its  sequels 
may  prjve  to  be  of  the  greatest  value  in  locating,  and  therefore  in  relieving, 
the  disorder.  The  number  of  cases  of  insanity  after  injury  is  very  consid- 
erable, and  operation  is  certainly  justifiable  in  such  cases  if  in  any,  provided 
there  be  reasonable  indications  not  only  of  an  injury,  but  also  of  such  connec- 
tion between  the  injury  and  the  insanity  as  would  show  that  the  injury  stood 
in  a  causal  relation  to  the  mental  disturbance.  It  would  be  folly,  for  instance, 
to  trephine  for  an  injury  received  after  the  insanity  began  unless  there  were 
independent  reasons  for  doing  so,  such  as  paralysis,  etc.,  as  a  direct  result  of 
the  injury.  Mr.  Claye  Shaw  has  recently  trephined  also  in  cases  of  general 
paralysis  of  the  insane,  but  the  number  of  cases  is  too  small  and  the  time  since 
the  operations  too  brief  to  give  any  data  for  an  opinion  Avhether  the  operation 
is  wise  and  will  do  any  good. 

III.  Arrested  Development. — If  the  cause  of  the  arrest  of  develop- 
ment be  traumatic,  something  may  be  done  with  a  hope  of  relief,  as  in  a  remark- 
able case  of  Dr.  Felkin  and  Mr.  Hare  in  Avhich  a  girl  of  seventeen  had  sustained 
fracture  of  the  skull  at  the  age  of  ten  months,  followed  by  pai-alysis  and  im- 
perfect development  of  the  right  arm  and  leg.  A  cyst  was  found  two  inches 
in  depth,  Avith  an  osteophyte  half  an  inch  long.  This  existed  outside  the  dura, 
which  was  not  opened.     The  operation  Avas  followed  by  marked  improvement. 

Where,  however,  the  arrest  of  development  is  congenital,  the  cause  has 
undoubtedly  arisen  during  intra-uterine  life,  and  there  is  serious  doubt  whether 
any  good  will  follow  operation  in  such  cases.  As  has  already  been  indicated 
under  the  head  of  Microcephalus,  it  is  possible  that  a  certain  number  of  cases 
of  general  arrest  of  development  of  the  brain  itself  in  size  may  be  benefited  by 
a  linear  craniotomy.  As  a  rule,  however,  in  cases  of  arrested  development  of 
intra-uterine  origin,  with  the  exception  perhaps  of  microcephalus.  it  is  undoubt- 
edly wiser  not  to  operate,  as  operation  simply  exposes  the  patient  to  danger  with- 
out any  reasonable  hope  of  improvement. 


SURGERY   OF    THE  SPINE.  557 


CHAPTER    11. 
SUEGERY  OF  THE  SPINE. 

The  general  anatomical  considerations  in  relation  to  the  spine  whicli 
influence  the  diagnosis  and  treatment  of  its  various  diseases  and  injuries  may 
be  briefly  summarized  as  follows  : 

It  supports  the  weight  of  the  head,  connects  the  bones  of  the  thorax  with 
those  of  the  pelvis,  forms  a  bony  canal  for  the  reception  of  the  spinal  cord, 
gives  a  basis  of  support  and  attachment  for  the  ribs,  and,  owing  partly  to  its 
curves  and  partly  to  the  fact  that  it  is  made  up  of  so  large  a  number  of 
bones  with  the  intervertebral  disks  interposed  between  them,  it  lessens  in  a 
very  remarkable  manner  the  effects  of  shock  transmitted  to  it  from  various 
parts  of  the  body. 

The  normal  curves  of  the  column  are  three  in  number,  and  are  all  antero- 
posterior. In  the  cervical  region  the  normal  curve  is  convex  in  front ;  in  the 
dorsal,  the  convexity  is  posterior ;  in  the  lumbar,  the  convexity  is  again  ante- 
rior. These  curves'^  are  maintained  largely  by  the  varying  thicknesses  of  the 
intervertebral  disks  and  partly  by  the  diff"erences  in  the  vertical  thicknesses  of 
the  bodies  of  the  vertebrse. 

On  each  side  of  the  spine  are  powerful  muscles  which  run  longitudinally, 
the  tendons  of  which  are  inserted  into  the  processes  of  the  vertebrse.  These 
muscles  maintain  the  body  in  an  erect  position,  and  when  in  a  condition  of 
health  preserve  the  vertical  position  of  the  spine  by  preventing  it  from 
inclining  to  one  side  or  the  other.  The  spinal  cord,  which  is  usually  about 
seventeen  or  eighteen  inches  in  length,  does  not  fill  the  spinal  canal,  but  is 
separated  from  the  walls  of  the  latter  first  by  its  investing  membranes,  and 
then  by  some  loose  connective  tissue  containing  a  plexus  of  large  veins.  It 
extends  in  the  adult  from  the  upper  border  of  the  first  cervical  vertebra  to  the 
lower  border  of  the  first  lumbar  vertebra,  where  it  ends  as  a  slender  prolonga- 
tion of  gray  substance  extending  into  the  filum  terminale. 

The  membranes  of  the  cord  consist  of  the  pia  mater,  or  vascular  membrane 
closely  embracing  the  surface  of  the  cord  itself,  the  arachnoid,  separated  from  the 
pia  mater  by  an  interval  known  as  the  subarachnoid  space,  and  the  outermost 
membrane,  the  dura  mater,  separated  from  the  arachnoid  by  an  interval  known 
as  the  subdural  space.  The  arachnoid  and  dura  mater  are  here  and  there  con- 
nected by  areolar  tissue,  but  for  the  most  part  are  simply  in  contact,  the  cerebro- 
spinal fluid  keeping  the  arachnoid  in  close  relation  to  the  under  surface  of  the 
dura.  The  cord  is  steadied  in  the  spinal  canal  largely  by  means  of  the  nerves  which 
find  exit  through  the  intervertebral  foramina  on  each  side  of  the  spinal  column. 
The  anterior  or  motor  roots  are  the  smaller  of  the  two ;  the  posterior  roots, 
which  are  sensory,  are  composed  of  finer  filaments,  and  each  root  bears  a  gan- 
glion which  is  situated  in  the  intervertebral  foramen  just  external  to  the  point 
where  the  nerve  perforates  the  dura.  The  roots  of  the  spinal  nerves  on  leaving 
the  cord  do  not  pass  out  directly  at  the  same  level,  but  run  obliquely  downward, 


55  ^i 


JT  AAf/./>'/(A.\  Ti'.xr-iiooh'  or  sf /,'(;/■: /i'v 


so  that  the  point  at  which  a  particiihir  nerve  emerges  fVom  the  coid  is  r<,u. 
siderahly  higher  than  the  point  :it  whicli  it  emerges  from  the  s|)i:ial  column, 
this  (lifierence  of  level  increasing  from  ahove  downwarfl.  For  exanijde.  the 
eighth  dorsal  nerve  emerges  from  the  spinal  cord  opposite  the  seventh  dorsal 
vertehra,  hut  from  the  spinal  coluuui  hetwcen  the  eighth  and  ninth  dorsal 
vertehr;e.  These  anatomical  and  ])hysiological  facts  will  serve  to  make 
somewhat  clearer  the  descriptions  of  the  various  diseases  and  injuries  of 
the  spine  and  of  spinal  operations. 

r()N(iENITAL    DEFOliMlTIES. 

Spina  Bifida. — The  chief  congenital  deformity  associated  with  the  spine 
is  due  to  an  arrest  of  development,  owing  to  which  the  symmetrical  halves  of 
the  spinal  column  fail  to  unite,  leaving  a  more  or  less  considerahle  space  be- 
tween them.  The  gap  may  extend  completely  through  the  bodies  of  the  ver- 
tebr;v\  or  may  be  limited  to  the  arches  and  the  spinous  processes;   the  latter 

Kio.  232. 


Spina  Hifida  (original). 


is  the  more  common.  The  lum))ar  portion  is  the  part  chieHy  affected,  50  per 
cent,  of  all  cases  occurring  in  this  region.  12  per  cent,  in  the  lum))o-sacral. 
and  27  per  cent,  in  the  sacral.  As  the  result  of  this  deficiency  the  mem- 
branes of  the  cord  are  pressed  through  the  opening,  forming  a  tumor 
known  as  spina  bifida  (Fig.  232),  on  account  of  the  condition  of  the 
spine  which  gives  rise  to  the  deformity,  and  as  hydrorhachis,  on  account 
of  the  fluid  contained  in  this  tumor.      The  latter  varies  in  size  from  that 


srnaKnv  or  Tin:  spixk.  559 

of  a  walnut  or  of  a  closed  fist  to  tliat  of  a  child's  iicad.  It  is  s(jiiiotimes 
covered  with  skin  nonnal  in  color  and  aj)})earance,  but  oftener  the  skin  is  thin 
and  translucent,  or  it  may  he  entirely  absent,  in  which  case  the  tumor  will 
have  a  raw,  florid  a])pearance.  The  true  sac  of  the  tumor  consists  of  the  mem- 
branes of  the  cord  blended  to«^ether  and  enclosing  a  liquid  which  is  ordinarily 
the  cerebro-spinal  fluid.  It  usually  comnmnicates  directly  with  the  brain,  as 
in  the  normal  condition,  through  the  opening  in  the  pia  mater  at  the  lower 
border  of  the  fourth  ventricle.  Pressure  on  a  tumor  of  this  variety  w  ill  there- 
fore sometimes  cause  stupor  by  increasing  the  pressure  upon  the  brain.  The 
cord  is  variously  situated  as  regards  the  sac,  being  sometimes  in  front,  some- 
times behind,  and  sometimes  spread  out  as  a  thin  layer  upon  its  internal 
surface.  When  the  protrusion  consists  only  of  membranes  and  fluid,  it  is 
called  a  spinal  meningocele;  Avhen  it  contains  a  portion  of  the  cord  also, 
it  is  called  a  meningo-myelocele.  When  the  central  canal  of  the  spinal 
cord  is  dilated,  forming  the  cavity  of  the  sac,  the  tumor  is  called  a  syringo- 
myelocele or  syringo-myelia.  The  second  of  these  is  by  far  the  more 
common. 

The  diagnosis  of  this  condition  may  be  made  by  observing  the  follow- 
ing points :  1.  The  tumor  is  congenital.  2,  It  occupies  a  central  position,  a 
peculiarity  which  characterizes  most  tumors  of  intraspinal  origin.  3.  It  may 
probably  be  reduced  by  gentle  pressure,  or  at  least  greatly  diminished  in  size, 
the  diminution  being  attended  with  increased  tension  of  the  fontanelle,  and 
sometimes  with  stupor,  convulsions,  or  other  nervous  symptoms.  4.  The  bony 
margin  of  the  gap  in  the  spine  can  often  be  felt  at  the  base  of  the  tumor.  5. 
The  tumor  becomes  more  tense  when  the  child  cries  or  coughs.  6.  It  is  often 
translucent,  and  when  so  an  opaque  band  or  bands,  consisting  of  the  spinal 
cord  and  nerves,  may  sometimes  be  seen  upon  the  inner  surface  of  its  wall. 
7.  It  is  apt  to  be  associated  with  other  deformities,  such  as  hydrocephalus  or 
talipes,  or  with  paraplegia,  vesical  or  rectal  paralysis,  etc.  8.  The  cutaneous 
covering  of  the  tumor  is  often  absent. 

Occasionally  some  of  these  symptoms  may  exist  and  not  others.  We  may 
have  a  congenital  tumor  situated  over  the  middle  of  the  spine,  fluctuating  and 
with  thin  and  translucent  Avails,  but  not  perceptibly  afiected  by  the  coughing  or 
crying  or  straining  of  the  patient,  and  not  associated  with  hj^drocephalus  or  club- 
foot or  paraplegia.  In  this  case  the  tumor  is  probably  a  meningocele,  in  which 
the  communication  wnth  the  spinal  canal  has  been  shut  off".  The  usual  course 
of  such  cases  is  toward  death,  which  commonly  occurs  within  six  or  eight 
months  ;  spontaneous  cure  occasionally,  but  rarely,  happens,  the  vertebral  arches 
growing  and  developing,  and  the  neck  of  the  sac  correspondingly  contracting, 
and  finally  becoming  shut  off"  from  its  communication  with  the  canal.  Oftener, 
however,  the  integuments  and  membranes  over  the  tumor  ulcerate,  the  con- 
tents of  the  sac  escape,  and  frequently  the  child  dies  in  convulsions  or  will 
perish  soon  afterward  from  a  septic  meningitis  following  infection  through  the 
ulcerated  tract. 

Treatment. — If  the  tumor  is  small,  covered  with  sound  skin,  and  not 
growing  rapidly,  it  should  be  enveloped  in  raw  cotton  and  supported  by  a  very 
loosely-fitting  elastic  bandage ;  or  gutta-percha  may  be  used  as  a  binder ;  or  a 
layer  of  cotton  brushed  over  with  collodion  may  be  applied  to  its  surface.  There 
is  a  chance  by  this  method  that  the  tumor  may  shrink  and  disappear.  The  out- 
look is  seldom  encouraging,  as  even  in  the  most  favorable  cases  the  child  is  small, 
poorly  nourished,  and,  as -has  been  said,  is  apt  to  have  paralytic  compli- 
cations. 

A  number  of  successful  cases  of  excision  have  been  reported,  and  recently 


nnO  AX   AMKIUCAX    TEXT- HOOK    OF   SVUdKliy. 

Bayer  has  rcviowetl  tlio  whole  subject,  and  rejects  the  use  of  the  seton, 
the  injection  of  iodine,  and  the  excision  of  a  part  of  the  sac,  as  being  at  the 
same  time  unsatisfactory  and  dangerous.  lie  urges  tliat  the  condition  is  one 
anah»g()us  to  liernia  and  should  be  treated  in  a  somewhat  similar  manner; 
that  the  danger  of  meningitis  in  the  one  case  is  no  greater  than  tlie  dan- 
ger of  peritonitis  in  tiie  other ;  and  that,  as  compared  with  the  operation 
above  mentioned,  it  is  both  safer  and  more  radical.  In  one  case  he  operated 
in  the  following  manner :  Two  lateral  flaps  were  made  from  the  skin  covering 
the  tumor  and  were  dissected  down  to  its  pedicle,  and  the  sac  of  the  meningo- 
cele was  opened.  The  cauda  equina  was  seen  flattened  out  on  the  posterior 
wall  of  the  sac.  It  was  loosened  after  dilatation  of  the  incision,  and  was 
replaced  in  the  spinal  canal.  The  sac  of  the  meningocele  was  then  removed, 
leaving  oidy  tw'o  lateral  flaps  of  the  dura,  Avliicth  were  sewed  together  after 
thorough  antiseptic  cleansing  of  the  wound.  The  muscles  and  skin  were  after- 
ward brought  together  separately.  The  case  was  successful.  In  some 
instances  the  rudimentary  arches  of  the  defective  vertebr.c  have  been  divided 
at  their  bases  l)y  bone-forceps  or  a  chisel  and  mallet,  and  displaced  toward 
the  middle  line  so  as  to  close  the  bony  defect.  IJobroff  accom])lislied  the 
closure  of  a  defect  in  tlie  sacral  region  by  chiselling  loose  a  ])ortion  of  the 
adjacent  ilium,  and  turning  the  fragment  over  as  upon  a  hinge  to  cover  the 
opening. 

Ilildebraml  has  collected  87  cases  of  excision  with  23  deaths,  a  mortality 
of  26.4  per  cent.  Unquestionably,  operative  measures,  especially  in  men- 
ingocele, are  gaining  ground  in  the  estinjation  of  surgeons. 

Should  the  case  be  unsuitable  for  excision,  the  injection  of  Morton's 
fluid  may  be  tried  as  follows:  the  sac  being  cleaned,  a  syringe  which  will 
hold  about  2  drams  of  an  iodo-glycerin  solution  (iodine,  10  grains;  iodide 
of  potassium,  1  dram;  glycerin,  1  ounce)  is  chosen,  and  a  moderately  fine 
trocar.  The  puncture  in  the  swelling  should  })e  made  well  to  one  side, 
obli(|uely  through  healthy  skin,  and  not  through  the  membranous  sac-wall, 
the  objects  being  to  avoid  wounding  tlie  cord  or  nerves  and  to  diminish 
the  risk  of  leakage  of  the  cerebro-spinal  fluid.  Unless  the  sac  is  very  large,  it 
is  probably  better  not  to  draw  off"  much,  if  any,  of  the  fluid  on  the  first  occasion. 
The  child  should  be  laid  upon  its  side.  About  a  dram  is  the  quantity  recom- 
mended to  be  injected.  Care  must  be  taken  to  prevent  escape  of  the  cerebro- 
spinal fluid,  because  any  leakage  may  lead  to  septic  meningitis  and  death.  When 
the  needle  is  withdrawn  the  tissues  should  be  pressed  around  it  and  the  little  aper- 
ture immediately  painted  with  collodion  and  iodoform  and  covered  by  a  dressing 
of  dry  gauze  secured  with  collodion.  A  little  chloroform  may  be  given,  to  pre- 
vent any  crying  and  straining  at  the  time.  The  child  should  \)Q  kept  as  (juiet  as 
po8sil)le  afterward,  on  its  side,  and  an  assistant  should  make  sure,  for  the  first 
hour  at  least,  that  no  leakao;e  is  ffoinjf  on.  Shrinkin<x  of  the  cvst,  settint;  in 
ra{>idly  and  continuing  steadily,  shows  that  all  is  well.  If  the  injection  fail 
altogether  or  cause  only  partial  obliteration  of  the  sac,  it  should  i)e  rejjcated 
at  intervals  of  a  week  or  ten  days  (Jacobson). 


SPINAL  TUMOES. 
Congenital  tumors  other  than  spina  bifida  are  found  chiefly  in  the  sacral 
region,  and  may  be  of  various  kinds.  Lipomata  sometimes  here  attain  a 
very  large  size,  and  occasionally  spring  from  the  interior  of  the  spinal  canal. 
Dermoid  cysts,  containing  the  usual  contents,  hair,  sebaceous  matter,  etc., 
are  not  infret^uent,  and  may  communicate  with  the  rectum  or  the  bladder.     The 


SmOKRY    OF    THE   SPINE.  561 

so-called  congenital  sacral  tumor  is  a  large  mass  occurring  in  the  region 
of  the  coccyx,  .sonictinies  peilunculated  and  made  up  of  cysts  of  various  sizes, 
often  lined  with  columnar  ej)itlieliuni  and  filled  Avith  a  viscid,  gelatinous  mate- 
rial. Foetal  tumors  of  all  sizes  may  ))c  found  in  the  sanu'  region,  and  may 
contain  iiicrclv  masses  of  the  different  tissues  or  a  considerable  and  Avell-devel- 
oped  portion,  a  limh  or  a  trunk,  of  the  foetus  incorporated  with  the  individual 
who  bears  it. 

All  these  growths  may  be  treated  by  excision,  although,  as  their  extent  is 
often  uncertain  1)efore  operation,  great  caution  should  be  exercised. 

Tumors  of  the  spinal  cord  itself  may  be  either  intra-medullary  or  extra- 
medullary,  and  are  of  great  variety.  The  diagnosis  will  usually  be  made  by  the 
neurologist  rather  than  by  the  surgeon,  but  it  is  proper  to  give  a  brief  outline 
of  the  general  diagnostic  points  which  it  will  be  necessary  to  bear  in  mind 
before  deciding  upon  or  rejecting  operative  interference.  In  the  first  place,  it 
will  be  re([uisite  to  determine  whether  the  symptoms  are  due  to  pressure  on  the 
cord  or  to  inflammatory  or  other  changes  involving  primarily  the  structure  of 
the  cord  itself.  If,  in  a  case  of  paraplegia,  there  is  the  history  of  a  very 
gradual  onset  beginning  with  pain  and  followed  first  by  motor  paralysis  and 
then  by  sensory  paralysis ;  if  the  symptoms  are  irregularly  unilateral ;  if  the 
pain  has  first  seemed  to  be  neuralgic  or  rheumatic  and  burning  and  shoot- 
ing in  character ;  if  the  anesthesia  and  pain  in  the  lower  limbs  ascend  grad- 
ually from  the  soles  of  the  feet  toward  the  trunk  ;  and  if  at  the  same  time 
there  is  a  constant  dull  ache  in  a  distinct  segment  of  the  spinal  column,  accom- 
panied by  a  feeling  of  weakness  at  that  point,  much  heightened  by  fatigue, — 
we  have  a  group  of  symptoms  pointing  strongly  in  the  direction  of  a  neo- 
plasm. In  addition,  it  would  be  found  that  at  first  the  reflexes,^  both  deep  and 
superficial,  were  much  exaggerated,  becoming  gradually  lost  as  destruction  of 
the  cord  with  descending  degeneration  and  wasting  grew  more  marked,  the 
abolition  of  the  reflexes  beginning,  as  in  the  case  of  the  pain  and  anesthesia, 
in  the  plantar  region  and  passing  gradually  upward. 

Later  in  the  disease  we  have  the  development  of  spasms  with  clonus,  which 
are  most  marked  in  the  intradural  cases,  as  is  also  the  symptom  of  rigidity. 
Local  nutrition  is  not  usually  impaired ;  tenderness  of  the  spine  on  percussion 
when  it  occurs  in  the  dorsal  region  appears  to  be  lower  than  the  tumor  pro- 
ducino;  it :  in  the  cervical  region  this  si;eneralization  does  not  seem  to  hold  so 
closely.  The  feeling  of  stiffness  and  weakness  Avill  usually  be  found  to  corre- 
spond to  the  position  of  the  tumor.  Lateral  curvature  of  the  spine  is  a 
secondary  result  of  the  tonic  spasm  of  the  spinal  muscles,  and  therefore  the 
concavity  of  the  bend  is  on  the  same  side  as  the  growth.  The  pupils  are  not 
affected,  except  when  the  cord  is  pressed  upon  above  the  level  of  the  second 
dorsal  nerve. 

The  age  of  the  patient,  judging  from  Mr.  Horsley's  tables,  throws  but  little 
light  upon  the  diagnosis  of  tumor,  as  we  find  lipomata  occurring  at  an  average 
age  of  two  and  a  half  years,  sarcomata  at  eighteen  years,  echinococcus  at  thirty- 
four  years,  tubercle  at  thirty-nine  years,  scirrhus  and  myxoma  at  forty-eight 
and  fifty-three  years.  These  figures  apply  to  extradural  growths.  In  the  case 
of  intradural  groAvths  we  have  tubercle  at  eighteen  and  a  half  years,  myxoma 
at  forty-three  yeai's,  fibroma  at  forty-four  years,  sarcoma  at  forty-one,  psam- 

'  By  a  "  reflex  "  is  meant  an  involuntary  muscular  response  to  certain  irritations  of  the  skin 
(superficial  reflex)  or  of  the  muscles  (deep  reflex),  or,  as  it  is  often  called,  "  tendon-reflex."  The 
commonest  example  of  a  superficial  reflex  is  the  movement  of  the  leg  upon  tickling  the  foot- 
sole  ;  the  best  instance  of  a  deep  reflex  is  the  "  knee  jerk,"  or  sudden  extension  of  the  leg  fol- 
lowing a  tap  on  the  ligamentum  patellae. 
36 


502  AN  AMi:ni(AX    TEXT-nOOK    OF   SVRCEIiV. 

Uioma  at  fifty-one  years.  It  will  be  seen,  therefore,  that  while  a<!;e  may  be  of 
use  in  excluding  certain  forms  of  growth,  as,  for  example,  tubercle  in  intra- 
dural growths  in  persons  beyond  thirty  years,  it  is  of  but  little  value  in  de- 
ciding the  general  (juestion  as  to  the  j)resence  or  absence  of  a  neoplasm. 

Tins  sketch  of  the  ])rincij)al  symj)toms  makes  a  tolerably  distinct  clinical 
picture,  but  one  which  is,  nevertheless.  lial)le  to  great  variation,  and  therefore 
difficult  to  difll'rentiate  from  that  of  certain  conditions  of  the  cord,  some  of 
which  are  due  to  causes  quite  beyond  the  reach  of  operation.  The  chief  of 
these  are — spinal  hemorrhage,  extra-medullary  or  intra-medullary  ;  pachymen- 
ingitis externa,  from  caries ;  chronic  transverse  myelitis ;  jjriniai-y  lateral 
sclerosis  or  spastic  ])araplegia  ;  hypertro{)hic  cervical  meningitis. 

Having  decided  in  any  given  case  that  the  symjjtoms  arc  ])robubly  due  to 
tumor,  the  interesting  question,  whether  it  is  within  or  outside  the  membranes, 
will  still  remain  to  be  settled.  The  best  general  guide  will  be  found  in  the 
fact  that  the  symptoms  of  intra-medullary  growths  are  chiefly  those  of  motor 
and  sensory  impairment,  while  the  extra-medullary  growths  produce  much  more 
markedly  irritative  effects,  as,  for  example,  pain,  spasms,  etc.  In  the  j)resence 
of  a  paralysis  of  gradual  development,  preceded  by  long-continued  signs  of 
nerve-irritation  and  w  ith  a  distinct  unilateral  element,  the  transference  of  paral- 
ysis from  one  to  the  opposite  limb  having  been  effected  slowly  and  after  a 
considerable  interval,  the  diagnosis  of  compression  of  the  cord  by  some  cause 
outside  of  its  own  structure  would  seem  warranted.  Aneurysm  might  be 
excluded  in  the  absence  of  the  characteristic  physical  signs  and  of  evidence 
of  erosion  of  the  spinal  column  ;  gumma  would  be  accompanied  by  a  history 
of  syphilis,  would  often  be  associated  with  other  and  recognizable  specific 
lesions,  and  would  possibly  yield  to  the  use  of  iodide  of  potassium :  a  new  growth 
(cancer  or  tubercle)  in  the  bodies  of  the  vertebrae  themselves  generally  causes 
a  perceptible  deformity.  By  attention  to  the  points  which  have  been  men- 
tioned a  tolerably  correct  opinion  may  be  arrived  at. 

Prognosis. — All  the  evidence  which  we  now  have  points  to  extraordinary 
reparative  power  on  the  part  of  a  cord  which  has  simply  been  suffering  from 
compression,  and  to  an  almost  equally  remarkable  tolerance  to  operative  inter- 
ference. The  material  for  finely  differentiated  prognosis  can  hardly  yet  be 
said  to  exist,  but  in  a  general  way  it  is  safe  to  say  that  the  diagnosis  of 
tumor  (if  it  be  non-malignant)  carries  with  it  a  reasonably  favorable  prog- 
nosis, which  is  strengthened  if,  in  addition,  the  tumor  is  thought  to  be  extra- 
medullary. 

As  a  result  of  these  considerations  it  seems  proper  that  every  case  of  focal 
spinal  lesion  thought  to  depend  on  a  tumor,  and  not  distinctly  a  malignant  and 
generalized  disease,  should  be  regarded  as  amenable  to  operative  interference, 
at  least  of  an  exploratory  character,  no  matter  how  marked  or  how  long  con- 
tinued the  sym])toms  of  pressure  may  have  been.  The  operation  is  ]»racti- 
cally  identical  with  tiiat  of  resection  of  the  laminte.     (See  p.  585.) 

Neuralgia. — In  some  cases  of  intractable  brachial  neuralgia,  and  in  others 
of  spasms  with  violent  neuralgic  pains  in  the  region  supplied  by  the  lumbar  and 
sacral  nerves,  intraspinal  section  of  the  posterior  roots  has  been  performed.  The 
operation  has  been  done  in  five  cases,  in  two  of  them  with  some  improvement, 
in  the  others  without  much  success.  It  should  certainly  for  the  present  l)e 
reserved  for  cases  in  which  it  is  desired  to  verify  a  doubtful  diagnosis,  or  for 
those  in  which  the  pain  is  so  great  and  so  little  aff'ected  by  other  treatment  as 
to  justify  so  serious  an  operation.  It  may  be  performed  by  following  the  direc- 
tions for  resecting  the  arches  and  opening  the  dura  in  the  manner  described  on 
page  585. 


SURGEIiV    OF    THE   SPIXK. 


563 


SPINAL  CURVATURES. 
The  more  common  pathological  curvatures  of  the  spinal  column  are  three 


in    nil 


niber 


Fig.  233. 


Scoliosis,  or  lateral  curvature ;  Kyphosis,  or  Excurvation,  an 
antero-posterior  curve  "svith  the  convexity  backward ;  and 
Lordosis,  or  Incurvation,  an  antero-posterior  curvature  Avith 
the  convexity  forward. 

Lateral  Curvature. — In  scoliosis  the  spine  describes 
two  or  more  lateral  curves  with  their  convexities  on  oppo- 
site sides  of  the  longitudinal  axis  of  the  back  (Fig.  233). 
The  vertebrae  of  the  region  involved  are  also  otherwise 
changed  in  their  relations  to  the  same  axis,  being  rotated 
so  that  their  spinous  processes  point  toward  the  concavities 
of  the  lateral  curves  (PI.  XY,  Figs.  3  and  4). 

Varieties. — The  most  common  curvatures  are  those  in 
the  upper  part  of  the  dorsal  region  with  the  convexity  to 
the  right  side.  The  second  or  compensatory  curve  is  in 
the  lumbar  region  with  its  convexity  toward  the  left  (PI. 
XY,  Figs.  1  and  2).  In  marked  cases  a  third,  also  com- 
pensatory, may  form  in  the  cervical  region,  and  will  also 
have  its  convexity  on  the  opposite  side  from  the  original 
curve.  Occasionally  four  or  five  curves  may  exist,  recip- 
rocally compensating  one  another. 

The  intervertebral  disks  in  the  region  of  the  curve  are 
unequally  compressed,  becoming  wedge-shaped,  with  the 
base  of  the  wedge  toward  the  convexity  of  the  curve. 
The  rotation  of  the  bodies  of  the  vertebrse  (Fig.  234)  is  often  so  extreme 
that  their  anterior  surfaces  point  directly  toward  the  convexity  and  the  spines 


Primary  and  Secondary 
Lateral  Curvatures 
(Agnew). 


Fig.  234. 


>^,r?^ 


Torsion  in  Lateral  Curvature  (Bradford  and  Lovett;. 

toward  the  concavity  of  the  curve.     This  tends  to  bring  the  spines  back  again 
into  the  median  line,  although  sometimes  in  these  cases  the  twist  is  so  great 


564  AN  AMERICAN    TEXT-BOOK    OF  SURGERY. 

that  the  angles  of  the  ribs  and  the  transverse  processes  of  the  vertebrte  occupy 
exactly  the  position  of  the  spinous  processes. 

The  ribs  on  the  convex  side  are  widely  separated,  and  are  more  horizontal 
than  they  normally  should  be ;  their  angles  become  prominent,  and  the  scapula 
is  carried  forward  with  them,  making  a  large  "hump"  in  the  dorsal  region. 
On  the  concave  side  the  obliquity  of  the  ribs  is  exaggerated,  and  in  bad  cases 
thev  may  even  touch  the  crest  of  the  ilium.  The  thorax  is  therefore  generally 
distorted,  and  viewed  anteriorly  will  nresent  an  abnunnal  prominence  of  the  left 
breast  (PI.  X^^  Figs.  8  and  4). 

Causes. — PredisiJOHiny  causes  are  general  weakness,  prolonged  ill  health, 
rickets,  rapid  growth,  struma,  etc.  The  excitiny  causes  are  all  those  conditions 
which  in  such  a  subject  produce  for  long  periods  an  undue  inclination  of  the 
spine  to  one  side  or  the  other.  The  typical  cases  are  accordingly  seen  in  deli- 
cate girls  between  twelve  and  twenty,  whose  muscular  strength  and  develop- 
ment do  not  keep  pace  with  their  growth,  who  sit  for  hours  at  a  desk  with  no 
support  for  their  backs,  and  who  carry  a  heavy  weight  in  the  shape  of  school- 
books  to  and  from  school,  and  usually  on  the  same  side  of  the  body.  Any 
habitual  one-sided  position  of  the  body  will  have  the  same  effect.  Other  causes 
are  obliquity  of  the  pelvis,  produced  by  unequal  length  of  the  lower  limbs  ;  uni- 
lateral muscular  atrophy  due  to  central  changes  when  the  seat  of  the  trouble 
is  in  the  spinal  cord;  unilateral  muscular  hypertrophy,  from  over-use  of  one 
side;  or  spas7n  from  central  disease  will  draw  the  column  toward  the  side  of 
the  enlarged  or  contracting  muscles.  Sacra-iliac  disease,  by  causing  the 
patient  to  lean  away  from  the  aff'ected  side  to  relieve  pressure,  empyema, 
through  the  resulting  contraction  of  the  thorax,  and  morbid  groivths  of  the 
sides  of  the  trunk  or  pelvis,  by  their  weight,  may  produce  the  same  result. 

Symptoms. — The  earliest  development  of  this  trouble  is  often  insidiotis. 
The  first  complaint  of  the  patient,  if  a  boy,  may  be  that  the  suspenders  on  one 
side  slip  off"  his  shoulder,  or  in  the  case  of  a  girl  it  may  be  first  noticed  by  the 
di'essmaker,  who  may  wish  to  pad  out  one  of  her  shoulders.  Examination  will 
show  a  slight  prominence  of  one  scapula,  and  perhaps  of  the  opposite  iliac  crest, 
and  if  the  spinous  processes  are  followed  down  the  back  by  one  finger  with  firm 
pressure,  the  resulting  red  line  on  the  skin  Avill  show  the  curve  unmistakably. 

In  severe  cases  the  "  hump  "  on  one  side,  usually  the  right,  the  elevation  of 
the  right  shoulder,  the  projection  of  the  ilium  on  the  left  side,  the  prominence 
of  the  left  breast,  and  the  ea^sily  recognized  curves  of  the  spine,  constitute  an 
unmistakable  group  of  symptoms,  the  majority  of  which  are  always  present. 

In  hysterical  distortion  of  the  spine  the  curvatures  disappear  on  making 
the  patient  bend  forward  until  the  fingers  touch  the  ground.  In  caries  of  the 
vertebrae  with  lateral  instead  of  antero-posterior  curvation  the  characteristic 
symptoms  of  Pott's  disease  will  be  present.     (See  p.  5(37.) 

Treatment. — Perhaps  the  most  important  advice  to  be  given  to  the  gene- 
ral practitioner  in  relation  to  the  treatment  of  this  condition  is  a  caution  against 
the  use  of  braces,  corsets,  jackets,  and  other  mechanical  appliances  which,  by 
confining  the  movements  of  the  chest  and  supplying  an  artificial  support  in 
place  of  the  muscles  which  it  is  most  desirable  to  develop,  actually  do  great 
harm  to  many  patients  instead  of  good. 

Careful  attention  to  the  general  health,  a  rigid  observance  of  all  hygienic 
rules,  properly  directed  exercise  both  active  and  passive,  and  massage,  consti- 
tute the  essentials  of  the  only  treatment  likely  to  be  of  service. 

The  exercise  should  be  prescribed  by  the  physician.  The  patient  should 
walk  a  certain  time  daily  carrying  a  light  weight  balanced  on  tlie  head  ;  should 
several  times  daily  swing  for  a  few  minutes  by  the  hands  from  a  cross-bar;  and 


SURGERY   OF  THE  SPINE. 


Plate  XV. 


SURGERY    OF    TIT?:   SPINE. 


565 


Fig.  235. 


should  sit  on  a  scat  raised  some  inches  on  the  side  corresponding  to  the  con- 
vexity of  the  himhar  curve,  so  that  the  spine  may  he  strengtliened  during  the 
efi'orts  to  produce  a  curve  compensatory  to  the  ohliquity  of  the  pelvis  produced 
by  the  slanting  seat.  A  high  sole  on  the  shoe  on  the  same  side  has  a  similar 
effect. 

The  patient  should  be  taught  to  hold  the  back  in  the  position  in  which  the 
surgeon  finds  the  curves  to  he  least  perceptible,  as  in  that  position  the  weak 
muscles  must  act  most  vigorously  and  will  gradually  be  strengthened.  A  form 
of  exercise  which  has  been  advocated  by  excellent  authorities  consists  in 
placing  the  patient  face  downward  on  a  table,  bringing 
the  shoulders  and  trunk  over  the  end,  and  then,  while  he  is 
held  on  the  table  by  an  assistant  who  embraces  the  legs  and 
thighs,  causing  him  alternately  to  flex  and  extend  the  body 
at  the  hips  while  the  surgeon  or  masseur  resists  his  efforts. 
Massage  of  the  weak  muscles,  electricity,  "muscle-beating," 
etc.  are  valuable  adjuncts.  In  very  severe  and  long-stand- 
ing cases  with  marked  deformity  and  great  weakness,  the 
use  of  a  spinal  jacket  (Fig.  235),  preferably  of  leather,  but 
it  may  be  of  plaster  or  steel,  may  be  absolutely  necessary. 
Carefully  directed  gymnastics  with  the  use  of  special  appa- 
ratus are  often  beneficial. 

Posterior  Curvature,  or  Kyphosis,  as  a  distinct  dis- 
ease, is  met  with  in  infants  as  a  result  of  rickets,  or  of  hav- 
ing been  nursed  in  a  sitting  posture,  or  encouraged  to  sit  up 
straight  at  a  very  early  age :  at  puberty  it  is  usually  found 
in  the  same  class  of  patients  as  the  subjects  of  scoliosis,  and 
arises  from  the  same  cause;  i.  e.  it  develops  in  weakly  girls 
from  long  continuance  in  a  bad  position,  such  as  they  often 
assume  in  practice  on  the  pianoforte  or  at  a  school-desk  :  in 
adults  it  may  also  be  caused  by  employment  that  necessitates 
constant  stooping  over,  especially  if  this  is  associated  with 
poor  food  and  bad  hygienic  surroundings.  It  is  accordingly 
seen  in  rag-pickers,  miners,  cobblers,  tailors,  etc.  Oftener 
it  is  symptomatic  of  some  other  disease,  as  spondylitis  defor- 
mans, or  is  caused  by  an  unconscious  effort  to  relieve  certain  symptoms,  as 
dyspnea  in  asthma  and  emphysema,  tenderness  in  metritis  and  chronic  peri- 
tonitis, pain  in  muscular   rheumatism  or  in  chronic  rheumatic  arthritis. 

Pathology. — In  the  slighter  forms  of  the  disease  there  is  merely  relaxa- 
tion of  the  vertebral  ligaments,  with  separation  of  the  laminae  and  spinous 
processes.  In  others  there  is  absorption  of  the  anterior  portions  of  the  inter- 
vertebral disks  and  of  the  bodies  of  the  vertebrae. 

Diagnosis. — It  requires  to  be  diagnosticated  only  from  the  deformity  of 
Pott's  disease,  which  may  be  easily  done  by  noting  the  absence  of  muscular 
rigidity,  of  pain  or  tenderness,  of  abscess,  of  complications  of  the  spinal  cord, 
etc.  The  curve  of  kyphosis  is  extensive  and  is  a  true  curve,  not  an  angular 
projection  of  one  portion  of  the  spine.  The  disease  occurs  more  frequently  in 
the  aged  than  in  children. 

The  treatment  consists  in  removing  the  cause  and  in  developing  the  weak 
spinal  muscles  by  appropriate  exercise  and  massage.  In  young  persons  aban- 
donment of  the  vicious  posture,  with  the  use  of  proper  exercise,  will  generally 
effect  a  cure.  In  adults,  and  especially  in  the  aged,  the  condition  is  apt  to  be 
permanent,  and  if  very  pronounced  may  require  the  use  of  some  form  of  spinal 
brace. 


Leather  jacket  and 
jury-mast  (Sayre). 


5<JG  -l.V  AMERJCAX    TEXT-BOOK   OF  SURGERY. 

Anterior  Curvature,  or  Lordosis,  is  often  congenital,  and  may  be  due 
to  rickets  or  to  disease  affecting  the  posterior  ])ortioiis  of  the  vertebral  bodies, 
but  is  commonly  compensatory  and  secondary  t(»  the  deformity  of  Pott's  disease. 
It  may  be  produced  by  ankylosis  of  the  hip-joints  in  partial  tlexion. 

It  is  usually  found  in  the  lumbo-dorsal  region,  and  consists  in  a  marked 
forward  curvation  of  the  lumbar  spine,  throwing  in  the  loins  so  that  a  deep 
concavity  exists  in  the  lumbar  region,  making  the  sacrum  and  the  hips  promi- 
nent, depressing  the  pubes.  and  causing  a  protuberance  of  the  abdomen. 

Treatment. — As  a  rule,  it  requires  no  surgical  interference,  but  occasion- 
ally, wiien  it  depends  upon  caries  of  the  vertebrte,  some  artificial  appliance 
will  be  needed. 

Spondylitis  Deformans  is  a  term  which,  though  etymologically  applicable 
to  an  inflammatory  disease  of  the  vertebrae  producing  deformity,  such  as  Pott's 
disease,  is  employed  clinically  to  denote  chronic  rheumatic  arthritis  of  the 
vertebral  column  (Treves).  It  is  a  disease  of  old  persons,  as  a  rule,  though 
occasionally  it  is  seen  in  middle  life.  It  is  attended  with  the  same  changes  that 
characterize  arthritis  deformans  everywhere  (see  section  on  Diseases  of  Joints), 
and  is  marked  by  absorption  of  the  intervertebral  disks,  by  the  formation  of 
osteophytes  upon  the  bodies  of  the  vertebrae,  and  finally  by  firm  bony  anky- 
losis of  several  vertebra.  The  disease  begins  with  pain  in  the  back,  followed 
by  rigidity  and  the  development  of  kyphosis.  The  curve  increases,  the  ribs 
become  fixed  and  the  thorax  immobile,  so  that  respiration  is  abdominal.  AVhen 
it  comes  on  in  middle-aged  or  elderly  persons,  and  is  moderate  in  extent,  it  does 
not  seem  greatly  to  influence  the  expectation  of  life. 

Treatment  is  of  little  or  no  avail,  but  may  be  conducted  on  the  general 
principles  applicable  to  chronic  rheumatic  arthritis  elsewhere. 

TUBERCULOSIS  OF  THE  SPINE. 

Pott's  Disease,  Spondylitis. — Cause. — Tubercular  inflammation  of 
the  bodies  of  the  vertebrae  is  a  disease  usually  found  in  childhood,  afiecting 
more  frequently  delicate  children  between  the  ages  of  three  and  ten  years,  of 
poor  parents,  and  especially  those  of  tubercular  families.  No  age  or  class  is 
exempt,  however,  and  occasionally  no  family  history  of  struma  or  of  tubercle 
can  be  elicited.  Usually  the  affection  is  ascribed  to  some  slight  traumatism ; 
this  may  be  the  exciting  cause  in  many  instances,  but  the  tubercular  diathesis 
or  soil  is  essential  to  the  production  of  the  typical  disease. 

Pathology. — The  inflammation  begins  in  the  cancellated  structure  of 
the  vertebral  bodies,  which  undergoes  the  changes  characteristic  of  tubercular 
ostitis  elsewhere,  the  extent  and  rapidity  of  the  process  being  proportionate  to 
the  number  and  activity  of  the  bacilli  on  the  one  hand  and  to  the  vitality  of 
the  tissues  and  of  the  individual  on  the  other.  The  results  of  the  rarefying 
ostitis  thus  set  up  may  accordingly  be  threefold  :  1.  Resolution  ;  2.  Caseation  ; 
3.  Liquefaction. 

1.  When  resolution  takes  place,  after  a  certain  stage  has  been  reached,  tha 
normal  cells  get  the  mastery,  the  bacilli  disappear,  the  inflammation  slowly  sub- 
sides, the  exudation  is  reabsorbed,  and  the  parts  return  to  their  original  condi- 
tion.    This  result  is  rare. 

2.  Far  oftener  the  process  of  disintegration  and  caseation  advances,  the  body 
of  the  vertebra  breaks  down,  usually  at  the  anterior  border  first,  and  masses  of 
fungous  granulations  replace  the  osseous  cancelli  and  invade  the  intervertebral 
spaces,  causing  absorption  of  the  disks.  Even  at  this  stage,  however,  repair 
may  begin  ;  ankylosis  may  follow  the  transformation  of  the  granulations  into 


SURGERY   OF    Till-:   SPIXE.  567 

sound  filirous  tissue,  and  a  return  to  health  uitli  little  or  no  deformity  or  func- 
tional disability  may  ensue.  This  is  the  result  aimed  at  by  the  surgeon,  and  as 
a  rule  his  successful  cases  belong  to  this  group. 

3.  In  the  third  class  the  destructive  process  is  of  greater  activity :  the  case- 
ous masses  formed  in  and  between  the  bodies  of  the  vertebrae  licjuefy  and  become 
collections  of  so-called  *•  tubercular  pus ;"  the  anterior  surfaces  and  adjoining 
edges  of  the  affected  vertebrae  disappear,  as  do  the  intervertebral  disks ; 
the  whole  vertebral  body  may  be  absorbed,  or  more  rarely  may  practically 
become  converted  into  a  large  sequestrum  lying  in  a  caseous  abscess  filled 
with  a  serous  exudation  mixed  with  minute  particles  of  bone,  necrotic  frag- 
ments of  connective  tissue,  and  cheesy  ddbris,  which  together  give  its  contents 
a  milky  appearance. 

Still  later,  this  collection  of  fluid  finds  its  way  toward  the  surface  by  one 
of  several  channels  and  becomes  a  so-called  spinal  abscess,  often,  if  it  breaks 
spontaneously  or  is  opened  carelessly,  undergoing  infection  with  pyogenic  germs 
or  Avith  germs  of  putrefaction  or  with  both.  During  this  time  the  disap- 
pearance of  the  bodies  of  the  diseased  vertebrae,  permitting  the  undue  approx- 
imation of  those  above  and  below  them,  has  caused  a  change  in  the  shape  of 
the  spinal  column,  a  falling  forward  of  the  segment  above  the  diseased  area,  a 
backward  projection  of  the  spinous  process  of  the  vertebra  nearest  the  area 
of  disease,  and  the  formation  of  a  distinct  prominence,  which  is  known  by  the 
unscientific  name  of  "angular  curvature"  (PI.  XVI).  This  most  commonly 
occurs  in  the  dorsal  region.  A  compensatory  lordosis  often  follows  in  the 
lumbo-dorsal  region.  This  occurs,  though  very  rarely,  as  a  primary  deformity 
resulting  from  disease  of  the  posterior  portion  of  the  vertebrae.  It  is,  as  has 
been  said,  more  often  congenital  and  hereditary  or  associated  with  rickets. 
Caries  in  the  cervical  or  lumbar  region  first  causes  the  disappearance  of  the 
normal  backward  concavities  of  the  spine  in  these  regions,  so  that  straightness 
of  the  spine  in  the  neck  and  in  the  loins  has  the  same  significance  as  a  mode- 
rate projection  in  the  dorsal  region.  During  this  time  a  slow  thickening  of 
the  connective  tissue  betAveen  the  dura  and  the  walls  of  the  canal  is  going  on, 
a  so-called  external  pachymeningitis,  which  is  the  chief  cause  of  the  paralysis 
occasionally  seen  in  this  disease.  This  inflammatory  growth  is  oftenest  ante- 
rior, and  by  its  pressure  produces  motor  paralysis ;  fi'equently,  however,  it  is 
also  posterior,  and  then  there  is  paralysis  of  both  motion  and  sensation.  Occa- 
sionally, but  rarely,  the  bodies  of  the  displaced  vertebrae  impinge  upon  the 
cord.  Still  more  rarely  there  occurs  a  transverse  myelitis  of  the  cord  itself. 
In  both  these  latter  cases  there  would,  of  course,  be  paralytic  symptoms. 

Symptoms  of  Pott's  Disease. — These  vary  with  the  stage  and  extent 
and  situation  of  the  inflammatory  process,  but  observe  approximately  the  fol- 
lowing order  in  their  development : 

1.  The  child  will  complain  of  pain  in  the  region  supplied  by  the  nerves  aris- 
ing from  the  affected  segment  of  the  cord.  If  the  disease  is  lumbar,  the  pains 
are  abdominal  and  are  apt  to  be  associated  with  vesical  irritability ;  if  dorsal, 
the  pains  are  epigastric  or  intercostal,  and  respiration  is  sometimes  irregu- 
lar and  hurried  from  the  failure  of  the  respiratory  muscles  to  take  their  full 
share  in  the  work ;  if  cervical,  neuralgic  pain  or  numbness  in  the  arms  and 
hands,  a  tickling  cough,  and  difficult  deglutition  are  the  prominent  symptoms. 
It  is  to  be  noted  that  the  pains  are  apt  to  be  symmetrical. 

2.  Increase  of  pain  upon  movemerit,  and  especially  upon  jumping  or  upon 
flexing  or  rotating  the  spine,  is  extremely  significant.  If  the  child  can  jump 
painlessly  from  a  chair  to  the  floor,  it  is  almost  certain  that  no  inflammation 
of  the  body  of  a  vertebra  exists.     If  the  vertebrae  be  crowded  together  by 


568 


jy  AMi:iiicAy  tkxt-hook  of  sriicKiiV. 


pressure  on  the  head  or  shoulders  wliile  the  patient  sits  or  stands  or  while  he 
lies  face  downward  across  the  knees  of  the  surgeon,  the  pain  will  be  nmcli 
increased.  Conversely,  if  while  erect  the  patient  be  gently  lifted  by  the  hands 
under  the  chin  and  occiput,  or  if  in  the  prone  position  on  the  surgeon's  lap  the 
latter's  knees  be  separated  so  that  the  spine  is  elongated,  pain  will  be  relieved. 
Pain  may  be  increased  by  percussion  of  the  spinous  processes,  and  sometimes 
the  skin  over  the  spinal  gutter  and  the  neighboring  muscles  is  tender  to  the 
touch;  but  these  signs  are  of  slight  value  if  present,  and  are  by  no  means 
constant. 

3.  Involuntary  immobilization  of  the  spine,  a  result  of  this  pain  upon 
movement,  is  a  very  characteristic  symptom.  If  the  child  is  asked  to  look  at 
something  behind  him,  he  turns  the  whole  trunk.  If  he  is  requested  to  pick  up 
something  from  the  floor,  he  stoops  by  bending  the  thighs  upon  the  trunk  and 
the  knees  upon  the  thighs,  never  by  flexing  the  spinal  column  in  the  usual 
way  (Fig.  23<j).  In  walking  he  moves  as  though  on  ice,  sliding  or  shufliing 
along  so  as  to  avoid  the  jar  of  successive  steps.  In  standing  he  fixes  the  upper 
portion  of  the  column  by  the  aid  of  the  trapezii  and  the  other  scapular  muscles. 


Fig.  237 


Fig.  236. 


Manner  of  Picking  up  an  Object  in 
Pott's  Disease  (Agnew). 


Standing  Position  in  Pott's 
Disease  (Agnew). 


the  action  of  which  at  the  same  time  raises  the  shoulders  and  throws  the  arms 
out  from  the  side  (Fig.  237). 

4.  In  standing  or  sitting  there  is  also  an  invohintari/  transference  of  the 
weight  of  the  head  and  shoulders  and  parts  above  the  diseased  area  to  the 
pelvis  by  means  of  the  upper  extremities.  The  hands  are  often  placed  upon 
the  hips  and  the  arm  muscles  are  tense.  In  walking  about  a  room  the  little 
patient  will  support  himself  upon  articles  of  furniture,  going  from  one  to  an- 
other with  great  care,  losing  no  opportunity  to  lay  hold  of  a  chair  or  a  couch. 


SURGERY  OF  niK  SPINE. 


Plate  XVI. 


Pott's  disease  of  the  spine  (spondylitis). 


SURGERY    OF    THE   SPIXE. 


569 


5.  The  deformity  Avill  usually  be  charcicteiistic,  and  lias  already  been 
described.  As  a  rule,  the  diagnosis  by  means  of  the  above  symptoms  should 
be  possible  before  any  material  change  in   the  contour  of  the  spine  occurs. 

6.  Spinal  abscess  occurs  later,  and  ^vill  vary  in  its  position  according  to 
the  seat  of  tlic  cjiries.  a.  In  disease  of  the  cervical  vertebra?  the  abscess  is 
apt  to  be  retro-pharyngeal.  A  fluctuating  swelling  appears  in  the  pharynx, 
usually  to  one  side  of  the  median  line.  If  it  shows  externally,  it  does  so 
behind  the  angle  of  the  jaw.  Sometimes  it  follows  the  oesophagus  into  the 
mediastinum,  or  it  may  pass  between  the  longus  colli  and  scalene  muscles  and 
point  on  the  neck  in  front  of  or  behind  the  sterno-mastoid. 

h.  In  dorsal  caries  the  fluid  collects  along  the  front  and  sides  of  the  dorsal 
vertebra;  in  the  posterior  mediastinum.  Thence  it  may  pass  between  the  trans- 
verse processes  to  the  back,  constituting  dorsal 
abscess  ;  or  may  descend  to  the  diaphragm,  pass 
under  the  outer  arcuate  ligament,  and  point  in 
the  ilio-costa!  space  as  a  lumbar  abscess;  or 
go  under  the  inner  arcuate  ligament  to  form  a 
psoas  abscess  (Fig.  238).  The  latter,  being 
prevented  from  spreading  inward  or  backward 
by  the  spine  and  the  last  rib,  and  having  its 
progress  forward  checked  by  the  ligament,  is 
impelled  downward  by  gravity  and  by  its  in- 
crease in  size,  finding  its  way  most  easily  into 
the  space  between  the  two  origins  of  the  psoas, 
gradually  causing  absorption  of  that  muscle, 
and  usually  pointing  in  the  groin  below  Pou- 
part's  ligament  and  to  the  outer  side  of  the 
femoral  vessels.  It  may,  however,  point  above 
Poupart's  ligament,  on  the  inside  of  the  thigh, 
or  even  below  the  knee. 

c.  In  lumbar  caries  the  fluid  remains  out- 
side of  the  sheath  of  the  ilio-psoas  and  occupies 
the  iliac  fossa,  forming  an  iliac  abscess,  which 
is  apt  to  occupy  the  angle  at  the  junction  of 
the  iliac  and  transversalis  fascia  and  to  point  on  the  abdominal  wall  just  above 
the  outer  end  of  Poupart's  ligament ;  or  it  may  gain  access  to  the  true  iliac 
space  W'ithin  the  sheath  of  the  ilio-psoas,  which  will  then  guide  it  below  the 
ligament  to  the  upper  part  of  the  thigh  outside  the  vessels. 

As  variations  from  these  routes,  which  are  the  most  frequent,  we  may  have 
abscesses  passing  between  the  ribs  to  the  side  of  the  chest,  or  opening  into  the 
pleura  or  bronchi,  or  going  through  the  great  sacro-sciatic  notch  to  appear 
under  the  gluteal  muscles,  or  through  the  thyroid  foramen  to  point  on  the 
upper  and  inner  part  of  the  thigh. 

7.  Paralysis,  always  motor  at  first  and  often  not  affecting  sensation  at  all, 
is  the  result  chiefly  of  the  external  pachymeningitis  which  has  been  described. 

Diagnosis. — The  above  symptoms  will  usually  enable  the  disease  to  be 
recognized  and  easily  differentiated  from  thoracic  or  abdominal  aneurysm, 
hysteria,  renal  disease,  rheumatism  and  neuralgia,  empyema  with  subdiaphrag- 
matic abscess,  etc.  The  most  important  symptom  in  the  early  stages  is,  per- 
haps, the  rigidity  of  the  spine ;  later  the  deformity  is  easily  recognizable. 

Treatment. — The  indications  for  treatment  in  Pott's  disease  are,  1.  To 
endeavor  to  secure  resolution  of  the  tuberculous  ostitis ;  2.  To  limit  the  destruc- 
tion of  tissue  and  the  resulting  deformity  as  much  as  possible ;  3.  To  promote 


Psoas  Abscess  (Albert) 


570 


.l.V  AMKRirAX    TEXT- HOOK    OF  SVRGERY. 


Extension  in  the  Recumbent  rositioii  (Reeves). 


ankylosis ;  4.  To  evacuate  pus ;  o.  To  remove  a  sequestrum  or  tlie  focus  of 
carious  bone ;  6.  To  relieve  the  cord  from  pressure  by  pus,  bone,  or,  most  com- 
monly, by  the  products  of  an  external  })achynieningitis. 

The  first  three  may  be  considered  together,  and  are  efjually  mot  by  the 
application  of  the  same  principles. 

Rmt  is  always  the  most  important  consideration.  In  very  young  children, 
in  patients  of  all  ages  "where  there  is  very  active  and  progressive  disease,  and 
in  all  cases  in  which  the  ostitis  or  caries  is  situated  in  the  cervical  or  upper 

dorsal   region,    confinement   to 
l-iG.  239.  bed  in  the  recumbent  ijoaition 

is  almost  imperative.  In  cer- 
vical caries  the  head  and  neck 
should  also  be  fixed  by  sand- 
bags laid  one  on  each  side, 
secured  in  position  by  tapes, 
and  extending  from  the  vertex 
to  the  shoulder.  Extension  in 
bad  cases  with  beginning  pres- 
sure symptoms  may  be  applied 
from  the  chin  and  occiput,  the 
head  of  the  bed  being  suifi- 
ciently  elevated,  or  from  the 
lower  limbs  by  raising  the  foot  of  the  bed  and  applying  adhesive  strips  with 
weight  and  pulley,  as  for  fracture  of  the  femur,  to  both  legs ;  or  the  twa 
methods  may  be  combined.  To  prevent  excoriation  of  the  skin  by  the  adhe- 
sive strips,  the  legs  may  first  be  bandaged  and  the  plasters  applied  over  the 
bandages. 

Whenever  the  patient's  circumstances  make  it  practicable  and  the  general 
health  can  at  the  same  time  be  maintained,  recumbency  with  limitation  of  all 
but  slight  and  necessary  movements  should  be  continued  until  all  symptoms 
have  disappeared,  or,  if  the  disease  has  already  reached  the  stage  of  caseation, 
or  liquefaction,  until  complete  consolidation  has  taken  place. 

This  is  not  always  possible,  nor  will  the  child  always  bear  such  pro- 
longed confinement  to  bed.  It  is,  however,  so  valuable  as  a  method  of 
treatment  that  every  efibrt  should  be  made  to  secure  its  thorough  trial.  The 
bed  should  be  wheeled  into  the  sunlight,  or,  at  the  proper  seasons  of  the  year, 
into  the  open  air.  There  should  be  gentle  massage  and  frictions  of  the  limbs 
and  of  the  abdominal  and  pectoral  muscles.  Alcohol  baths,  and  sometimes  in 
very  young  children  inunctions  with  cod-liver  oil,  are  useful.  The  food  should 
be  nutritious  and  as  abundant  as  digestion  and  assimilation  Avill  permit.  Much 
of  the  success  of  treatment  will  depend  upon  the  care  and  judgment  shown  in 
the  feeding,  and  the  surgeon  cannot  too  closely  scrutinize  the  details  of  diet. 
A  large  variety  of  tonics  have  been  employed  in  these  cases,  but  three  are  te 
be  especially  recommended :  viz.  a  well-made  and  digestible  emulsion  of  cod- 
liver  oil ;  the  phosphates,  which  may  often  be  contained  in  the  same  emulsion  ; 
and  iodide  of  iron  in  doses  to  suit  the  age  and  the  stomach  of  the  patient. 

When  consolidation  has  occurred,  which  will  be  after  a  period  represented 
by  months  rather  than  weeks,  and  is  accompanied  by  a  disappearance  of  symp- 
toms and  an  increase  in  the  general  strength  and  well-being,  the  patient  should 
be  allowed  to  sit  up,  cautiously  at  first,  and  if  the  deformity  has  been  marked 
should  wear  some  light  form  of  spinal  jacket.  The  higher  the  caries  in  the 
vertebral  column,  the  greater  should  be  the  caution  in  permitting  the  erect 
position. 


SURGERY    OF   THE   SPINE. 


571 


Rest  of  the  aifected  region  wlieii  the  disease  is  below  the  mid-dorsal  verte- 
bra3  and  is  not  too  acute  or  extensive,  and  Avliere  the  patient  is  ohl  enough,  may 
be  satisfactorily  obtained  by  the  use  of  some  form  of  spinal  jacket,  by  means 
of  -which  the  weight  of  the  parts  above  the  disease  may  be  transferred  from 
the  spinal  column  to  the  curves  and  bony  prominences  of  the  pelvis  and  hips. 

The  simplest  of  these  jackets  is  that  known  by  the  name  of  Dr.  Sayre,  who 
devised  it.  It  may  be  applied  as  follows  :  The  patient  is  stripped,  and  a  closely- 
fitting  woollen  undershirt,  reaching  below  the  nates  and  provided  with  shoulder- 
straps,  is  put  on.     He  is  then  placed  beneath  a  tripod,  and  a  leather  headgear 


Fig.  240. 


Fig.  241. 


Tripod  for  the  suspension  of  the  patient 

(yayre). 


Patient  in  position  for  the  application 
of  the  plaster  jacket  (Sayre). 


embracing  the  occiput  and  chin  is  adjusted,  and  in  older  children  or  adults 
axillary  bands  are  added  (Figs.  240,  241). 

By  means  of  pulleys  the  patient  is  then  elevated  {a)  so  that  the  toes  just 
touch  the  floor ;  (A)  or  so  that  the  heels  are  about  two  inches  from  the  ground, 
the  "  fore-pads  "  of  the  feet  being  in  contact  with  the  floor ;  (c)  or  so  that  the 
heels  are  merely  raised  from  the  ground.  These  various  degrees  of  extension 
are  to  be  applied  according  to  the  age  and  weight  of  the  patient  and  the  extent 
of  the  disease,  the  first  mentioned  being  suitable  for  the  youngest  and  lightest 
children  and  the  least  extensive  disease,  the  last  applying  to  adults  and  to  more 
severe  forms  of  the  trouble. 

While  the  patient  is  held  in  this  position  the  woollen  shirt  is  kept  drawn 
well  down,  pads  of  cotton  avooI  are  applied  over  the  iliac  spines  and  other  bony 


572 


AN   AMERICAN    TEXT-IKXJk'    O/'  SlJItGERY 


Fig.  242. 


]»r(>iiiinonocs,  tlio  spiice  hetwet-n  tlio  breasts  in  wcmiicii  is  Ullctl  witli  a  tcinpo- 
vary  pad,  and  a  wedge-shaped  pad  is  ])laced  over  the  lower  part  of"  the  ah(h)nien 

under  the  shirt,  with  the  base  of  the  wedge  upward, 
enclosed  in  a  towel  to  admit  of  its  ready  removal. 
This  is  the  so-called  "dinner-pad,"  intended  to  leave 
a  space  after  its  withdrawal  which  will  allow  for  the 
physiological  distention  of  the  abdomen  after  eating. 
Plaster  bandages  are  then  applied,  rollers  2-^  to  3 
inches  in  width  and  6  yards  in  length  being  used.  The 
first  turns  are  made  midway  between  the  trochanter 
and  the  crest  of  the  ilium,  and  they  are  tlien  carried 
regulaily  and  smoothly  up  to  the  axilla,  each  turn 
overlapping  the  preceding  turn  about  one-third  (Fig. 
242).  About  three  layers  are  recjuired.  An  assist- 
ant with  a  basin  of  dry  plaster  and  a  wet  sponge  may 
strengthen  the  dressing  here  and  there  if  rcfiuired, 
and  can  keep  it  smooth.  The  jacket  should  be  left 
on  until  the  plaster  has  set,  usually  about  fifteen  or 
twenty  minutes,  and  the  patient  should  then  be  taken 
under  the  arms  and  carefully  laid  upon  a  hard  mat- 
tress, where  he  should  remain  about  an  hour.  He 
may  then  be  allowed  to  dress  and  go  about.  The 
temporary  pads  should  be  removed. 

If  the  jacket  has  been  well  apjjlied  it  Avill  usually 
give  relief  or  comfort.  It  should  never  be  worn  con- 
tinuously longer  than  ten  or  twelve  weeks.  When 
removed,  the  parts  can  be  inspected  and  abrasions  or 
excoriations  treated  Avhile  the  patient  is  recumbent. 
A  new  jacket  may  then  be  put  on  in  the  same  man- 
ner as  before.  The  advantages  of  the  plaster  jacket 
are  its  cheapness  and  the  readiness  with  which  it 
can  be  applied.  Its  disadvantages  are  its  weight,  its 
liability  to  exert  uneven  pressure,  and  its  conceal- 
ment of  the  parts  beneath  it  for  so  long  a  time. 
Some  of  these  may  be  removed  by  cutting  it  down 
the  front  after  it  has  hardened,  springing  it  off  the 
patient,  and  making  holes  at  a  short  distance  from 
its  two  edges,  after  "binding"  them  with  a  broad 
strip  of  adhesive  plaster,  so  that  it  may  be  laced. 
It  should  not  be  used  in  very  young  children,  in 
early  and  acute  disease,  in  the  presence  of  cardiac  or 
pulmonary  complications,  over  abscess  which  is  pointing,  or  in  extremely  feeble 
and  anemic  patients.  In  all  these  cases  recuml)ency,  with  proj)er  attention  to 
diet  and  hygiene,  is  preferable.  A  jacket  of  half-tanned  leather  (Fig.  235), 
such  as  has  been  recommended  by  Agnew,  can  be  made  by  a  good  surgical 
cutler  from  a  mould  taken  in  plaster  as  just  described,  and  is  much  lighter  and 
more  comfortable.  A  jacket  of  poro-plastic  felt  is  also  recommended,  and  can 
be  readily  applied.  Corsets  of  various  sizes  are  made  of  this  material.  The 
patient  is  suspended,  wet  cloths  are  wrajjped  around  the  body,  and  a  corset  of 
the  proper  dimensions  is  momentarily  dipped  in  scalding  water  and  is  then 
moulded  to  the  figure.  After  it  "sets,"  it  can  be  made  to  lace  doAvn  the  front, 
and  is  easily  removed  and  reapplied. 

In  cases  of  disease  above  the  mid-dorsal  region  the  "jury-mast  "  (Fig.  235) 


Plaster  applied,  and  slit  up  in 
order  to  prepare  plaster  east. 


SURGERY    OF   TIIK   sriXK.  573 

must  be  ;i])|)li(.'(l  ill  addition.  It  consists  of  a  vcr'iical  bar  fitted  to  the  curve 
of  tlie  l)ark  and  neck,  extendin<^  above  the  head,  and  carrying  the  occipito- 
mental leather  a])paratus.  The  jury-mast  removes  injurious  pressure  on  tlie 
softened  vertebral  bodies  by  sup])orting  the  weight  of  the  head  and  of  the  por- 
tion of  the  trunk  above  the  diseased  vertebrte  on  the  chin  and  occiput.  The 
lower  end  of  the  bar  is  hehl  in  the  plaster  by  a  cross-piece  or  is  riveted  to  the 
poro-j)lastic  or  leather  jacket.  In  cases  wliere  the  jury-mast  is  thought  unsafe, 
a  breast-plate  and  collar  for  the  same  cases  have  been  nuide  by  Edumnd  Owen; 
but  such  cases  are  far  better  treated  bv  rccumbenev. 

The  Treatment  of  Spinal  Abscesses  varies  somewhat  with  their  situ- 
ation, but  the  rule  should  be  to  open  them  freely  as  soon  as  they  are  accessible. 
Aspiration  is  usually  a  failure.  Tapping  and  irrigation  with  antiseptic  fluids, 
or  the  injection  of  an  emulsion  of  iodoform,  or  the  swabbing  out  of  the  cavity, 
followed  by  the  use  of  iodoform  and  the  treatment  of  the  cavity  as  a  simple 
wound,  have  all  been  tried  with  more  or  less  success.  The  results  from  any 
of  them  are  vastly  better  than  Avere  obtained  by  any  of  the  older  methods,  but 
their  precise  comparative  value  is  as  yet  uncertain. 

Retro-pharyngeal  abscess  if  pointing  in  the  pharynx  should  be  opened 
promptly,  to  avoid  the  danger  of  suifocation  which  attends  its  spontaneous 
and  unexpected  evacuation.  Of  late,  the  tendency  of  surgeons  is  toward 
reaching  these  abscesses  by  external  incision,  instead  of  through  the  mouth, 
in  order  to  secure  asepsis.  The  incision  is  made  at  either  border  of  the 
sterno-cleido-mastoid  muscle  and  the  abscess  reached  by  a  careful  dissection, 
especially  in  the  neighborhood  of  the  vessels. 

Psoas  abscess  may  be  opened  either  in  the  loin  or  in  the  groin  or  in  both 
localities.  If  only  one  is  selected,  the  former  is  beyond  all  doubt  to  be  pre- 
ferred. A  vertical  incision  at  the  outer  edge  of  the  erector  spinge  should  be 
carried  down  through  the  external  oblique,  internal  oblique,  and  transversalis 
muscles  and  the  lumbar  fascia  until  the  edge  of  the  quadratus  lumborum  is 
seen.  Then  a  transverse  division  of  the  fibers  of  that  muscle  and  of  the  trans- 
versalis fascia  on  the  level  of  the  tip  of  the  second  or  third  lumbar  transverse 
process  avoids  the  lumbar  arteries,  which  are  above  and  below  the  process, 
and  gives  access  to  the  finger,  Avhich  in  lumbar  abscess  will  go  at  once  into 
the  abscess-cavity,  and  in  psoas  abscess  will  easily  pass  through  the  attenuated 
sheath  and  the  few  remaining  fibers  of  the  psoas  into  the  collection  of  pus  (Treves). 

A  second  opening  made  below  Poupart's  ligament  by  cutting  on  the  end  of 
a  long  probe  introduced  through  the  loin  will  permit  of  through-and-through 
irrigation  by  means  of  a  large  drainage-tube,  which  later  may  be  replaced  by 
two  tubes,  to  be  gradually  shortened  so  that  the  abscess-cavity  may  contract  in 
the  middle. 

With  proper  antiseptic  precautions  the  opening  of  a  spinal  abscess  should 
not  be  attended  by  the  development  of  the  hectic  fever,  the  emaciation,  and  the 
rapid  failure  which  so  commonly  followed  this  operation  in  earlier  days.  It 
was  then  thought  to  be  due  to  the  removal  of  the  internal  pressure  of  the  pus 
from  the  vessels  in  the  walls  of  the  "  pyogenic  membrane,"  but  undoubtedly  it 
was  the  result  of  infection  of  a  tubercular  cavity  with  pyogenic  organisms. 

The  lumbar  operation  is  also  to  be  preferred,  as  enabling  us  in  a  certain 
number  of  cases  to  meet  another  indication — namely,  the  removal  of  the  focus 
of  carious  bone.  In  so-called  "posterior  vertebral  disease,"  i.  e.  in  cases  in 
which  the  osseous  lesions  are  localized  in  the  transverse  or  spinous  processes  or 
the  laminte,  operation  is  of  course  both  easy  and  satisfactory,  and  seven  out  of 
eight  recorded  cases  have  given  excellent  results.  Posterior  vertebral  disease  is, 
however,  extremely  rare.     When  the  bodies  of  the  vertebrae  are  diseased,  as  is 


574  AX  AMERICAX    TEXT- HOOK    OF   srUdKin'. 

usually  the  case,  altove  the  twelfth  dorsal  thoy  are  ])raeticallv  inaccessible, 
except  in  very  unusual  cases  associated  with  extensive  caries  of  the  ribs.  At 
and  below  that  point,  however,  an  operation  such  as  the  one  described  above 
may  be  of  great  use.  Fourteen  such  operations  have  been  followed  by 
eight  cures,  five  cases  improved,  and  one  death  Avhich  had  no  relation  to  the 
operation  itself.  They  have  shown  that  the  solidity  of  the  spine  is  not  affected 
by  either  the  curetting  or  the  removal  of  a  sequestrum,  and  have  demonstrated 
that  the  costo-iliac  space  in  proper  cases  {i.  e.  in  those  where  only  one  or  two 
.•ertebn\2  are  affected  and  there  is  l>ut  slight  angular  projection  with  a  curve  of 
large  radius)  is  ample  for  the  work  to  be  done.  For  these  reasons  it  is  safe  to 
say  that  the  search  for  the  focus  of  bone  disease  in  caries  of  the  lumbar  verte- 
bme  is  indicated  with  sufficient  frequency  to  give  the  matter  a  real  surgical 
interest.  The  seat  of  disease  may  be  sought  in  exceptional  cases  even  before 
the  appearance  of  an  abscess,  and  in  the  presence  of  an  abscess  may  often  be 
reached  with  great  ease  and  certainty.  The  bodies  of  the  lumbar  vertebrre  are 
accessible  by  Treves's  operation  even  when  no  abscess  which  is  appreciable  clin- 
ically is  found.  If  an  abscess  exists,  therefore,  even  when  it  points  anteriorly 
it  is  proper  to  open  it  by  the  lumbar  route  and  seek  the  focus  of  disease.  This 
permits  us,  if  the  abscess  depends  on  vertebral  disease,  to  reach  the  twelfth  dor- 
sal vertebra  without  wounding  the  pleura.  The  benefit  to  the  patient  in  suc- 
cessful cases  is  as  definite  and  unmistakable  as  that  following  the  removal  of  a 
focus  of  tubercular  ostitis  and  caries  in  any  other  region. 

The  last  indication  for  operative  interference,  viz.  the  existence  of  paralvsis 
thought  to  be  due  to  pressure  upon  the  cord,  is  to  be  met  in  various  ways. 

It  should  be  clearly  recognized  that  such  cases,  especially  in  children,  fre- 
quently recover  under  careful  hygienic  treatment,  when  the  abscess,  if  any 
exists,  can  be  evacuated  and  the  treatment  by  extension  and  a  spinal  jacket 
employed.  It  has  been  shown  conclusively  by  Weir  Mitchell  that  no  case 
of  Pott's  paralysis  ought  to  be  considered  desperate  without  the  trial  of  sus- 
pension, Avhich  has  succeeded  after  the  failure  of  other  accepted  methods, 
such  as  continued  rest  in  bed,  with  the  administration  of  tonics  and  frequent 
cauterization  with  the  hot  iron ;  that  the  pull  probably  acts  more  or  less  directly 
on  the  cord  itself,  and  the  gain  is  not  explicable  merely  by  the  obvious  effects 
on  the  bony  curve ;  that  the  methods  of  extension  to  be  used  in  these  cases 
may  be  various,  provided  only  that  we  do  get  active  extension  :  and  that  the 
plan  and  the  length  of  time  of  extension  must  be  made  to  conform  to  the  needs, 
endurance,  and  sensation  of  each  individual  case. 

Extension  may  be  employed  by  making  the  bed  an  inclined  plane,  or  more 
forcibly  with  the  patient  in  a  sitting  position.  In  either  case  the  stretching  is 
done  through  traction  from  the  chin  and  occiput  by  means  of  a  collar  resem- 
bling that  used  in  swinging  the  patient  for  the  application  of  a  plaster  jacket 
(Fig.  239).  When  this  form  of  extension  can  be  borne  (and  it  generally  can 
be)  it  is  very  effective.  It  must  be  the  method  used  in  high  dorsal  and  cervical 
caries.  In  other  cases  the  extension  may  be  made  either  from  the  upper  portion 
of  a  spinal  jacket  applied  in  the  usual  way  or  from  both  the  jacket  and  the 
occipito-mental  collar.  This  distributes  the  pull  and  renders  it  a  little  less 
severe,  although  if  suspension  from  the  head  is  done  gently  and  the  amount  of 
the  pull  is  increased  slowly,  very  few  patients  complain  of  it.  If  the  extension 
is  to  be  made  from  a  spinal  jacket,  loops  of  bandage,  like  the  straps  of  a  girl's 
dress,  should  be  carried  up  over  the  shoulders  during  its  application,  their  loose 
ends  being  imbedded  in  the  plas'^er.  In  all  cases  the  extending  force  is  the 
weight  of  the  patient's  body. 

The  apparatus  may  be  improvised  by  having  the  collar  made  of  quilted 


SURGERY   OF    THE  SPINE.  575 

canton  flannel,  the  foot  of  the  Ited  ])eing  raised  if  the  use  of  an  inclined  jdane 
is  indicated,  and  the  cord  attached  to  the  cross-bar,  or,  if  vertical  suspension 
is  desired,  a  gallows  can  be  made  by  a  carpenter  to  straddle  the  bed  and  to 
carry  the  cord  and  pulley.  The  pulley  may  be  fixed  at  the  end  of  an  iron  sup- 
port resembling  that  used  in  the  "jury-mast"  extension  for  Pott's  disease. 
This  may  be  fastened  to  the  back  of  a  reclining  chair,  so  that  it  curves  out 
over  the  head  of  the  ])atient,  ■who  can  then,  if  he  is  old  enough,  regulate  for 
himself  the  amount  of  i)ull  which  he  can  sustain  with  comfort.  Tliis  admits 
of  very  delicate  gi'aduation  of  the  extending  force,  by  suspending  the  patient 
from  a  spring  balance  attached  to  the  jury-mast. 

This  method  of  treatment  should  be  persevered  in  for  weeks  or  months 
if  there  is  the  least  indication  of  improvement,  and  will  sometimes  produce 
remarkable  results  in  apparently  hopeless  cases.  Of  course  the  most  careful 
attention  to  hygiene  must  be  combined  with  this  as  with  any  other  form  of 
treatment  employed.  Electricity  and  massage  to  keep  up  muscular  nutrition, 
good  food,  iron,  and  cod-liver  oil,  pure  air  and  sunlight,  are  as  important  as 
they  always  are  in  tubercular  disease. 

In  cases  in  which  all  this  has  been  tried  unsuccessfully,  or  in  those  in  which 
the  disease  is  slowly  but  steadily  progressing  to  an  unfavorable  termination, 
when  with  more  or  less  complete  loss  of  motion  and  sensation  below  the  level 
of  the  lesion  there  are  incontinence  of  urine  and  feces  and  the  development  of 
bed-sores,  and  especially  when  acute  s^^mptoms  threaten  life,  resection  of  the 
arches  and  laminae  of  the  affected  region  becomes  justifiable. 

When  the  tubercular  process  affects  the  arches  and  there  is  paraplegia,  we 
may  sometimes  operate  in  the  hope,  not  only  of  freeing  the  cord,  but  also  of 
removing  at  the  same  time  the  focus  of  disease.  This  double  indication  may 
also  be  fulfilled  in  those  cases  in  which,  Avithout  bone  disease,  there  is  a  posterior 
pachymeningitis  or  a  tuberculoma  occupying  the  canal.  Here  again,  however, 
time  and  careful  attention  to  hygiene,  including  change  to  sea-  or  mountain-air, 
often  work  wonders.  If  the  lesion  of  the  bodies  of  the  vertebrae  is  in  the  lum- 
bar region  at  a  point  where  these  bodies  are  accessible,  it  may  be  possible  in 
certain  cases  to  expose  the  cord  from  the  back  by  removal  of  the  laminae,  with 
the  object  not  only  of  removing  pressure,  but  also  of  reaching  and  taking  away 
the  diseased  bone  and  tubercular  granulations.  In  tuberculosis  of  the  body  of 
a  vertebra  and  compression  of  the  cord  by  anterior  pachymeningitis  we  can  fulfil 
only  one  indication,  i.  e.  liberate  the  cord  from  pressure.  We  should  operate 
only  in  grave  cases  in  which  acute  compression,  the  appearance  of  respiratory 
complications,  and  the  rapid  development  of  degenerative  processes  force  us  to 
interfere,  or  in  which  the  course  of  a  chronic  case  is  steadily  toward  a  fatal 
termination,  although  no  advanced  visceral  tubercular  lesions  are  present. 

Operation  having  been  decided  upon  for  any  or  all  of  the  above  reasons, 
the  prognosis  will  be  favorable  in  proportion  to  the  youth  and  strength  of  the 
patient,  the  absence  of  generalized  tuberculosis,  and  the  nearness  of  the  lesion 
to  the  base  of  the  spine 

In  1893  Chipault  suggested  the  advisability  of  forcibly  correcting  the 
deforuiity  of  Pott's  curvature  of  the  spine.  The  suggestion  was  not  new 
with  Chipault.  as  Ambroise  Pare  in  1650  advocated  forcible  correction  by  the 
use  of  an  instrument  of  his  invention.  Chipault  accomplished  correction 
while  the  patient  was  anesthetized,  and  subsequently  immobilized  the  spinal 
column  by  wiring  the  spinous  processes  of  the  adjacent  vertebrae  to  each 
other  and  aj3plying  plaster  of  Paris.  Calot  is  a  strong  advocate  of  rapid 
correction.  He  advises  that  the  patient  be  anesthetized,  and  be  placed  prone. 
One  assistant  supports  the  chest  and  upper  abdomen,  another  assistant  the 


570  A^'  AM  ERICA  X    TEXT- BOOK    OF  Sr^ROKin'. 

jH-lvis  and  lower  abdomen.  Wliile  one  assistant  makes  traction  upon  the 
arms  and  another  upon  the  legs,  the  surgeon  makes  downward  pressure  upon 
the  projection.  Plaster  of  Paris  is  applied  so  as  to  include  the  head,  neck, 
chest  and  pelvis,  while  tractitin  an<l  pressure  are  maintained.  In  .<ome  cases, 
before  the  defornuty  can  be  corrected,  it  is  necessary  to  excise  some  of  the 
spines  and  lamin;\>.  Some  surgeons  claim  that  what  is  practically  a  cure 
can  be  obtained  by  this  method.  Others  condemn  it  as  highly  dangerous. 
The  operation  is  not  very  dangerous — in  fact,  it  is  safe  if  violent  force  is  not 
used.  It  is  always  better  to  use  moderate  force  on  several  occasions  than  to 
use  violent  force  at  once.  Forcible  correction  may  cure  paraplegia,  may  for 
a  time  appear  to  cure  deformity  ;  but,  as  Bradford  has  shown,  it  will  not  cure 
the  disease  Avhich  caused  the  deformity,  and  the  correction  may  be  only  tem- 
porary because  bony  repair  may  not  occur.  Calot  and  Ducrotjuet,  on  the 
evidence  of  skiagraphs,  maintain  that  bony  repair  does  occur.  This  method 
of  correction  should  not  be  employed  if  the  tubercular  process  has  not  ceased, 
because  an  inactive  process  may  again  become  active  under  the  influence  of 
injury. 

INJURIES   OF  THE   BACK. 

Sprains. — Sprains  of  the  spine  are  of  all  degrees  of  severity.  The  struc- 
ture of  the  vertebral  column  is  so  complex  and  its  relations  are  so  numerous  and 
varied  that  a  great  variety  of  .symptoms  may  follow  a  sprain  according  to  the 
extent  of  the  damage  which  is  inflicted.  In  the  mildest  degree  of  sprain  the 
muscles  alone  are  involved,  and  we  then  have  merely  a  temporary  stiffness  and 
a  little  local  tenderness  over  a  limited  area.  In  more  serious  accidents,  as 
those  occurring  during  railway  collisions,  the  -ligaments  may  also  be  involved 
and  are  sometimes  actually  torn.  When  this  happens  in  the  case  of  the  liga- 
menta  subflava,  there  may  be  immediate  and  severe  extradural  hemorrhage, 
followed  by  temporary  paraplegia.  The  symptoms  which  are  never  absent  are 
pain  and  stiffness.  Occasionally  there  is  a  little  local  swelling,  but  this  is  not 
constant.  The  pain  is  referred  to  the  extremities  of  the  injured  nerves,  some- 
times shooting  down  the  limbs,  occasionally,  when  the  injury  is  at  the  lumbo- 
dorsal  junction,  being  referred  to  the  pubic  region.  The  skin  over  the  injured 
part  is  apt  to  be  exceedingly  tender.  The  stiffness  produces  a  degree  of  rigid- 
ity of  the  spine  which  resembles  very  much  that  seen  in  Pott's  disease,  the 
patient  involuntarily  immobilizing  the  vertebral  column  and  avoiding  rotation 
and  flexion  as  carefully  as  possible.  When  the  injury  is  unilateral  this  mus- 
cular rigidity  is  very  marked  on  the  injured  side,  and  is  a  valuable  means  of 
distinguishing  real  from  asserted  injury,  especially  in  medico-legal  cases,  as  it 
cannot  be  simulated. 

The  diagnosis  of  severe  sprains  followed  by  great  helplessness  and  by 
some  degree  of  paralysis  will  .sometimes  be  difficult,  as  the  condition  may 
closely  simulate  that  of  fracture.  In  the  latter,  however,  the  paralysis  is  more 
absolute,  the  disability  more  complete,  the  tenderness  over  the  spine  less  dif- 
fuse, and  there  is  often  an  irregularity  in  the  line  of  the  spinous  processes 
which  will  serve  at  once  to  indicate  the  more  serious  character  of  the  injury. 

Treatment. — This  does  not  differ  in  its  general  principles  from  that  of 
sprains  elsewhere.  Rest  of  the  part,  counter-irritation  by  dry  cups  or  by  some 
rubefacient,  gentle  frictions  with  a  liniment  containing  belladonna,  followed 
later  by  massage  of  the  affected  part,  constitute  the  essentials  of  treatment. 
It  should  always  be  borne  in  mind  that  there  may  be  retention  of  urine.  The 
use  of  laxatives  is  freijuently  indicated. 

The  later  symptoms  of  spinal  sprains  are,  after  all,  the  most  serious  and 


l^URGEh'V    OF    Till':   SITNE,  bll 

annoyinor.  At  the  time  of  the  accident  there  may  ho  the  form  of  general 
nervous  depression  which  we  know  as  shock,  wliich  may  even  deepen  into  its 
graver  variety  of  collapse ;  or  in  neurotic  patients  there  may  occur  the  more 
localized  disturbance  of  cerebral  origin  known  as  acute  hysteria,  but  this,  as  a 
rule,  will  disajipear  within  a  short  time.  Later,  however,  two  forms  of  serjuelse 
may  occur  which  take  a  chronic  character,  and  wliich  are  classified  by  Thorburn 
in  his  excellent  book  on  this  subject  as  neurasthenic  and  traumatic  hysteria. 
In  the  former  condition  there  is  a  general  defect  in  the  nutrition  and  nerve- 
power,  which  when  it  follows  a  traumatism  is  manifested  by  weakness,  loss 
of  memory,  mental  confusion  and  irritability,  insomnia,  headache,  eye-strain, 
photophobia,  irregular  and  frequent  pulse,  dyspepsia,  etc.  These  symptoms 
occur  in  patients  who  have  had  mild  shock  at  the  time  of  the  accident,  and 
they  will  generally  pass  away  after  rest  and  tonic  treatment.  They  are  very  com- 
mon, and  are  often  associated  with  those  belonging  to  traumatic  hysteria,  which 
Thorburn  describes  as  a  functional  affection  of  the  nervous  system  resulting 
from  an  injury,  due  probably  to  a  change  localized  in  some  portion  of  the  cere- 
bral cortex,  and  manifested  by  well-defined  and  localized  symptoms.  He  adds 
that  it  has  no  known  organic  basis,  is  not  reflex  in  origin,  and  is  neither  shock 
nor  neurasthenia.  It  is  an  affection  of  middle  life,  three  times  as  common  in 
the  female  as  in  the  male,  occurring  especially  in  persons  of  a  neurotic  temper- 
ament or  in  those  addicted  to  the  excessive  use  of  alcohol.  It  is  favored  by 
great  fright  or  by  horrible  surroundings  at  the  time  of  the  accident  which 
produces  it. 

The  symptoms  may  be  either  psychical,  including  epileptiform  attacks  and 
hysterical  insanity ;  motor,  including  paralysis  and  contractures  of  the  limbs 
and  special  effects  upon  such  organs  as  the  larynx  and  the  bladder ;  sensory, 
in  which  case  there  is  anesthesia,  hyperesthesia,  or  paresthesia  of  the  general 
or  special  sensory  nerves ;  or  lastly,  there  may  be  vaso-motor,  secretory,  or 
trophic  trouble.^ 

As  to  its  essential  cause,  the  theory  of  Charcot,  that  traumatic  hysteria  is 
frequently  identical  with  the  conditions  produced  by  suggestion  during  hypnotic 
sleep,  is  the  most  plausible  which  has  yet  been  advanced.  In  lightly  hypno- 
tized persons  a  slight  blow  on  an  extremity  is  often  followed  by  motor  and 
sensory  paralyses  if  these  are  forcibly  suggested  by  the  operator :  the  same 
symptoms  may  follow  even  without  suggestion.  The  trifling  traumatism 
evokes  from  the  cerebral  cortex  in  its  unaltered  state  the  idea  of  severe 
injury,  and  this  is  promptly  followed  by  the  loss  of  power  and  sensation  which 
might  really  follow  a  genuine  injury.  In  traumatic  hysteria  the  nervous  shock 
replaces  the  hypnotism,  and  the  abnormal  sensation  caused  by  the  injury  gives 
rise,  as  in  the  above  instance,  to  the  "auto-suggestion  "  which  replaces  sugges- 
tion by  the  operator. 

The  treatment  should  consist  in  isolation,  and  in  endeavoring  to  obtain 
control  over  and  influence  upon  the  patient,  and  should  conform  to  the  prin- 
ciples which  govern  the  treatment  of  neurasthenics  fey  the  rest  cure. 

Concussion  as  applied  to  injuries  of  the  spinal  cord  is  a  term  which  may  be 
retained  for  convenience,  but  which  has  no  accurate  pathological  signification. 
When  it  is  remembered  that  the  cord  does  not  entirely  fill  the  spinal  canal, 
that  it  is  connected  Avith  it  only  at  those  places  where  the  nerves  pass  through 
the  intervertebral  foramina  and  by  the  ligamentum  denticulatum,  that  it  is 
closely  embraced  by  its  pia  mater,  that  it  is  surrounded  by  fluid,  and  that  the 
canal  and  its  contents  are  protected  in  the  most  thorough  manner  imaginable 

^  For  a  detailed  description  of  thif5  condition,  with  illustrative  cases,  the  monograph  of 
Thorburn  on  the  Surgery  of  the  Spinal  Cord  sliould  be  consulted. 

37 


578  ^l.V   AMKl^Kwy    TKXT-HOOK    OF   sriidKin. 

from  tlio  effects  of  violeiiee  tiaiisniitted  tluoii^li  surrouiidiii;!  stnictines.  it  is 
evident  tliat  a  trauniatisni  Avliicli  Avitliout  eausiii;i  some  jiross  lesion  uoiild  ))ro- 
duee  a  condition  of  the  cord  justifying  the  use  of  the  term  "concussion  ""  must 
be  of  rare  occurrence.  As  a  matter  of  fact,  it  is  probable  that  some  actual 
lesion  in  the  substance  of  the  cord  occurs,  possibly  a  rupture  of  delicate  nerve- 
fibers,  possibly  a  capillary  hemorrhage,  or,  it  may  be,  merely  a  vaso-motor 
disturbance  with  slight  serous  exudation.  In  any  event,  the  sym|»toms  are 
those  which  attend  a  moderate  degree  of  shock  ;  that  is,  a  tendency  to  syncope, 
pallor  of  the  face,  nausea  and  vomiting,  cold  perspiration,  etc.,  superadded  to 
■which  are  the  special  symptoms  which  arise  from  the  cord,  such  as  numbness  or 
tingling  or  loss  of  power  in  the  lower  extremities  ;  or  hiccough,  wry-neck,  tem- 
porary paralysis  of  the  arms,  a  sense  of  constriction  of  the  thorax,  or  similar 
symptoms  if  the  upper  portion  of  the  cord  suffers.  The  treatment  appropriate 
to  sprains  of  the  spine  applies  to  injuries  of  this  character. 

Contusion  of  the  sjjinal  cord  may  result  from  severe  sprain,  but  usually 
occurs  as  a  consequence  of  forced  flexion  of  the  vertebral  column.  It  is 
accompanied  by  hemorrhage  into  the  substance  of  the  cord — hematomyelia — 
which  usually  occupies  the  gray  substance,  and  may  extend  to  a  considerable 
distance.  It  is  accomj^anied  by  motor  and  sensory  paralysis  and  a  diminution 
of  the  reflexes.  It  may  be  followed  by  acute  myelitis  and  all  the  phenomena 
attendant  upon  degeneration  or  destruction  of  the  substance  of  the  cord.  It 
is  obviously  difficult  to  diagnosticate  from  a  fracture  in  which  no  deformity 
exists.  The  prognosis  is,  however,  more  favorable,  and  in  cases  of  contusion 
of  the  cord  of  moderate  severity  the  improvement  which  occurs  at  the  end  of 
the  first  or  second  week  will  serve  to  show  the  character  of  the  lesion. 

Wounds  of  the  spinal  cord  are  comparatively  rare.  From  in  front  the  cord 
is  obviously  inaccessible,  except  to  injuries  otherwise  fatal;  from  behind,  the 
oblique  downward  direction  of  the  spinous  processes  serves  as  a  protection. 
The  most  exposed  region  is  between  the  occiput  and  atlas  and  the  atlas  and 
axis.  Of  course  if  the  vulnerating  body  takes  an  upward  direction  it  may 
reach  the  cord  in  the  dorsal  region,  and  in  cases  of  gunshot  wound  the  cord 
may  be  wounded  by  the  ball  or  by  fragments  of  bone,  just  as  in  other  fractures. 
As  a  rule,  wounds  of  the  cord  are  fatal,  especially  those  which  are  inflicted  in 
the  upper  segments,  and  if  the  wound  be  in  the  cervical  region  above  the  ori- 
gin of  the  phrenics,  death  will  follow  almost  immediately. 

Compression  of  the  Spinal  Cord. — {a)  From  blood.  Spinal  hemor- 
rhage may  occur  as  a  conseijuence  of  injury,  and  may  proceed  from  the  vessels 
contained  in  the  substance  of  the  medulla  or  from  those  between  the  latter  and 
its  membranes,  or  from  the  large  plexus  of  veins  found  in  the  space  between 
the  dura  mater  and  the  walls  of  the  spinal  canal.  The  symptoms  of  extra- 
Tnedullary  hemorrhage  as  given  by  Gowers,  Mills,  and  others  are  as  follows : 
1,  sudden  and  violent  pain  in  the  back,  more  or  less  diffused ;  2,  pain  along 
the  course  of  the  nerves  passing  through  the  membrane  near  the  extravasation  ; 
3,  abnormal  sensations,  tingling,  etc.,  and  hyperesthesia,  referred  to  the  same 
parts ;  4,  spasm  involving  vertebral  and  other  muscles  supplied  by  affected 
nerves,  and  also  sometimes  the  muscles  su{)plied  by  the  cord  below  the  seat  of 
the  hemorrhage ;  5,  general  convulsive  movements ;  6,  spasmodic  retention  of 
urine ;  7,  consecutive  paralytic  symptoms,  but  not  usually  complete  paralysis. 

Some  points  of  differential  diagnosis  between  meningeal  hemorrhage  and 
extravasation  into  the  substance  of  the  cord  should  be  borne  in  mind.  Symp- 
toms of  irritation,  such  as  pain,  hyperesthesia,  and  spasm,  in  meningeal  hemor- 
rhage usually  arise  immediately  or  very  early,  and  may  precede  ])aralysis, 
"vvhich  is  commonly  not  complete.     In  hemorrhage  into  the  substance  of  the 


scnai:!!)'  of  77//;  srixi:.  579 

cord  j)iiralysi.s  may  be  complete  at  first  or  may  rapidly  become  so,  and  symp- 
toms of  irritation  may  be  very  largely  wanting.  Hemorrhage  may,  and  not 
infre(|uently  does,  involve  not  only  the  membranes,  but  also  the  substance  of 
the  cord,  giving  rise  to  complex  symptoms. 

The  symptoms  of  hitra-nwdullarii  hemorrhage  are  as  follows :  The  onset  is 
sudden  :  there  is  a  history  of  traumatism  or  of  disease  associated  with  profound 
blood-changes ;  the  symptoms  are  bilateral :  there  is  pain  in  the  back,  with 
disappearance  of  the  reflexes  connected  with  the  affected  segment ;  spasms, 
rigidity,  and  paralysis  come  on  rapidly,  as  does  also  the  girdle  symptom. 
Bed-sores,  incontinence  of  feces,  and  retention  of  urine  develop  very  early  in 
the  case,  which  runs  a  rapid  course  and  is  often  fatal. 

The  treatment  of  spinal  hemorrhage  will  dejiend  upon  the  severity  and 
the  persistence  of  the  symptoms.  The  presence  of  rapidly-extending  paralysis, 
thought  to  be  due  to  extra-medullary  hemorrhage  and  threatenino;  life  through 
involvement  of  important  centers,  might  justify  an  immediate  resort  to  opera- 
tion. Persistent  paraplegia  with  the  development  of  bed-sores  and  the  occur- 
rence of  cystitis,  these  symptoms  extending  over  some  weeks  in  a  case  in  which 
the  lesion  is  believed  to  have  been  one  of  hemorrhage,  might  also  warrant  a  con- 
sideration of  the  propriety  of  operation.  The  prognosis  will  be  the  more  favor- 
able, either  with  or  without  operation,  the  lower  the  seat  of  the  compression  of 
the  cord.  The  most  favorable  cases  will  be  those  in  which  a  clot  occupies  the 
lowest  portion  of  the  canal,  pressing  upon  the  lumbar  cord  or  the  cauda  equina. 

{h)  Compression  from  lymph. — Meningitis  may  result  from  any  one  of  the 
forms  of  injury  which  have  been  considered,  and  may  be  accompanied  by  an 
exudation  of  inflammatory  lymph,  which  in  many  cases  is  sufficient  to  cause 
grave  compression  symptoms.  The  most  common  form  of  this  is  the  external 
pachymeningitis  of  Pott's  disease,  already  described.  More  rarely  a  meningi- 
tis becomes  transformed  into  a  myelitis  which  involves  a  certain  portion  of  the 
cord  transversely,  and  is  accompanied  by  progressive  paralysis,  pain  in  the  back, 
the  girdle  symptom,  increased  reflexes,  ankle  clonus,  etc. 

As  to  the  diagnosis  of  these  various  forms  of  injury,  the  time  which 
elapses  between  the  accident  and  the  development  of  the  symptoms  is  one  of 
the  most  important  factors.  (1)  If  the  symptoms  occur  instantaneously  after 
a  grave  injury,  the  cord  has  probably  been  compressed  by  a  displaced  vertebra, 
and  the  case  has  been  one  of  fracture  or  luxation  or  of  the  common  lesion 
which  combines  them  both,  the  so-called  fracture-dislocation.  (2)  If  the  symp- 
toms have  not  made  their  appearance  for  some  time,  possibly  hours,  after  the 
injury,  the  cause  is  probably  hemorrhage,  paralysis  not  having  been  produced 
until  a  sufficient  amount  of  blood  had  accumulated  to  cause  the  necessary  pres- 
sure. If  the  hemorrhage  is  intra-medullary,  less  time  will  elapse  than  if  it 
occurs  between  the  membranes  and  the  walls  of  the  canal.  (3)  If  the  symp- 
toms of  paralysis  do  not  appear  until  a  period  varying  from  a  week  to  one  or 
two  months,  they  are  probably  due  to  pressure  by  inflammatory  lymph  the 
result  of  an  external  pachymeningitis. 

FEACTUEES  OF  THE  SPINE. 

As  compared  with  other  fractures,  those  of  the  vertebrae  are  rare,  constitut- 
ing only  3.3  per  cent,  of  nearly  52,000  fractures  treated  in  the  London  Hospital 
during  thirty-five  years.  Gurlt's  table  shows  that  fractures  of  the  cervical  and 
dorsal  vertebras  are  almost  equally  frequent,  those  of  the  lumbar  vertebrae 
much  less  common;  that  the  vertebriB  most  frequently  broken  are  the  fifth 
and  sixth  cervical,  the  last  dorsal,  and  the  first  lumbar  ;  that  is,  those  which  are 


580 


AX  AMERICAX    TEXT-IKX tK    OF   sriidKin'. 


situated  at  tlio  junction  of  the  more  niovay>le  ^vitll  the  more  fixed  portions  of 
the  spinal  column.  More  than  one  vertehra  is  usually  l)roken  when  the  injury 
involves  the  upper  portion  of  the  column.  The  cervical  fractures  are  by  far 
the  most  fatal.  The  great  majority  of  spinal  fractures  occur  during  middle 
life.  They  are  found  more  frequently  in  males  than  in  females,  probably 
owing  to  the  greater  exposure  of  the  former  to  injury.  The  body  of  the 
vertebra  is  the  portion  fractured  in  the  majority  of  cases,  constituting,  accord- 
ing to  Gurlt.  about  two-thirds  of  all  fractures  in  the  cervical  region  and  seven- 
eighths  of  all  in  the  dorsal  region.  Fracture  of  the  arches  is  found  in  about 
one-half  of  the  cases  of  cervical  fracture,  one-seventh  of  those  in  the  dorsal 
region,  and  one-eighth  of  those  affecting  the  lumbar  vertebrae.  There  is  rea- 
son to  believe  that  the  frequency  of  fracture  of  the  arches  has  been  somewhat 
under-estimated.  Stimson  remarks  that  it  does  not  seem  improbable  that  some 
of  the  severe  sprains  of  the  lower  portion  of  the  back  which  leave  a  more  or 
less  permanent  weakness  or  sensitiveness  of  the  part  may  be  fractures  of  the 
arch  without  displacement  and  possibly  without  union.  Certainly  when  the 
fracture  occurs  from  direct  violence,  which  is  comparatively  rare,  the  arches 
are  especially  likely  to  be  broken.  In  81  cases  of  resection  of  the  spine  for 
fracture  and  luxation  White  found  a  record  of  fracture  of  the  laminae  or  arches 
in  no  less  than  45  per  cent.  Of  course,  as  he  remarks,  this  does  not  represent 
the  actual  frequency  of  this  form  of  fracture,  as  doubtless  in  many  of  these 
cases  it  was  recognized  previous  to  the  operation  and  constituted  one  of  the 
principal  indications  therefor.  The  most  common  cause  of  fracture  of  the  spine 
is  forced  flexion,  the  head  and  neck  being  bent  fonvard  upon  the  chest,  or  the 
thorax  upon  the  pelvis.     This  occurs  commonly  in  accidents  in  which  embank- 

Fio.  ?43. 


Fracture  of  Spine,  with  I-aceration  sf  the  Cord  (Shaw). 


ments  cave  in  or  scaffoldings  fall,  and  probably  enters  into  those  forms  of 
fracture  in  which  the  patient  falls  upon  the  feet  or  the  sacrum  or  the  head 
from  a  considerable  height.  In  all  these  cases  we  have  associated  with  the 
fracture,  as  a  rule,  tearing  of  muscles,  laceration  of  ligaments,  crushing  of 
the  cancellated  tissue  of  the  body  of  the  vertebra,  hemorrhage  into  the  spinal 
canal,  and  commonly  some  displacement.  The  portion  of  the  sjdne  above 
the  fracture  slips  forward  and  pinches  the  spinal  cord  between  the  arch  of 


FRACTURES  OF  THE  SPINE.  Plate  XVII. 


Fracture  of  the  spine. 


SURGERY    OF    THE  SPINE.  T>?>\ 

the  vcrtt'hra  iinmodiately  above  ami  the  e(l<^e  of"  the  body  of  the  broken 
vertebra  (IM.  X\'II.  and  Fig.  243).  Oecasionally  a  piece  of  bone  is  driven 
into  the  sj»in:il  cniial  and  compresses  the  cord. 

'JMie  symptoms  common  to  all  fractures  of  the  vertebrte  are  pain,  in- 
creased on  motion,  tenderness  on  pressure,  ecchymosis,  and  more  or  less 
extensive  paralysis  of  motion  or  of  sensation  or  of  both. 

Subsidiary  symptoms  found  in  the  majority  of  cases  are  deviation  of 
the  spinous  processes  and  occasionally  angular  deformity  of  the  spine,  phos- 
pliatic  urine,  and  disorders  of  the  sexual  organs,  shown  in  the  male  by 
priapism. 

The  prognosis  in  all  cases  is  unfavorable,  both  as  to  recovery  of  func- 
tion and  as  to  great  prolongation  of  life,  becoming  more  serious  in  direct 
proportion  to  the  higher  situation  of  the  fracture,  the  severity  of  the  injury 
which  causes  it,  and  the  amount  of  crushing  or  of  dislocation. 

Fractures  of  the  Lower  Three  Lumbar  VERTEBRiE. — These  are  not 
very  common,  and  are  frequently  unattended  by  serious  symptoms.  Owing  to 
the  fact  that  the  cord  terminates  at  the  level  of  the  second  lumbar  vertebra 
and  that  the  long  roots  of  the  cauda  equina  surrounded  by  a  firm  fibrous  mem- 
brane slip  smooths  one  upon  the  other,  and  thus  slide  out  of  the  way  of  fragments 
of  broken  bone,  they  often  escape  injury  altogether.  On  account  of  the  less- 
ened rotation  in  the  lumbar  portion  of  the  spine  and  of  the  large  muscular 
masses  that  surround  the  vertebrae  there  is  apt  to  be  no  crepitus,  deformity, 
or  preternatural  mobility,  and  in  the  absence  of  paralysis  the  only  symptoms 
are  local  pain  and  tenderness  and  a  feeling  of  weakness  and  instability  Avhen 
the  patient  attempts  to  stand.  As  this,  however,  would  obviously  accompany 
a  severe  contusion  of  this  region,  it  is  evident  that  a  positive  diagnosis  is 
scarcely  possible.  In  exceptional  cases  paralysis  and  other  symptoms  of  frac- 
ture are  present.  As  a  rule,  the  prognosis  is  favorable  as  to  life,  and,  in  fact, 
complete  restoration  to  strength  and  to  functional  ability  often  follows. 

Fractures  between  the  Second  Lumbar  and  Tenth  Dorsal  Ver- 
tebra.— These  fractures  are  followed  by  paralysis  of  the  portions  of  the 
body  which  receive  their  nervous  supply  from  the  lumbar  and  sacral  plexus. 
Paralysis  of  the  lower  limbs  and  of  the  bladder  and  rectum  is  exceedingly 
common.  Sensation  is  sometimes  not  so  completely  abolished  as  motion,  but, 
as  a  rule,  the  paralysis  of  both  motion  and  sensation  is  absolute.  There  is  at 
first  retention  of  urine,  which  as  the  bladder  becomes  distended  is  imperfectly 
relieved  by  a  slight  overflow  or  dribbling,  the  so-called  "incontinence  of  reten- 
tion." This,  in  cases  which  are  neglected  or  in  those  in  which  septic  instru- 
ments are  used  for  catheterism,  or,  in  many  cases,  in  spite  of  the  greatest  care, 
is  folloAved  by  a  violent  cystitis,  with  phosphatic  and  ammoniacal  urine.  The 
retention  of  feces  which  at  first  occurs  is  due  to  a  paralysis  of  the  muscular 
walls  of  the  intestine ;  as  these  gradually  recover  their  pow'er  to  some  slight 
extent,  the  contents  of  the  bowels  are  passed  on  toward  the  lower  intestine, 
and,  owing  to  the  paralysis  of  the  sphincter,  escape  involuntarily.  When  the 
motions  are  solid,  this  takes  place  at  long  intervals  ;  when  they  are  liquid,  they 
flow  away  continuously,  the  patient  having  neither  control  nor  knowledge  of 
their  escape.  The  nutrition  of  the  paralyzed  parts  is  feeble;  the  skin  becomes 
coarse  and  branny  and  covered  with  desiccated  epidermic  scales.  The  muscles 
waste,  points  exposed  to  pressure  become  red  or  purplish,  and  unless  the 
greatest  care  is  exercised  gangrene  follows,  producing  bed-sores  which  tend 
to  extend,  rapidly  involving  in  such  cases  the  entire  thickness  of  the  soft 
tissues  down  to  the  bone  and  spreading  in  every  direction. 

The  prognosis  in  these  cases  is  distinctly  unfavorable,  although  some 


582  .l.V   AMKRlCAy    TEXT-liOOK    OF   smcEliY. 

undoubted  instances  of  recovery  have  been  recorded.  Life  is  usuallv  pro- 
longed for  from  six  months  to  two  years.  The  patients  die  finally  from  exhaus- 
tion or  from  the  septic  eft'ects  of  the  bed-sores  or  the  cystitis. 

Fractures  of  the  Dorsal  A'ertebr.e. — In  frattures  between  tiie  tenth 
and  second  dorsal  vertebra^  tliere  are  all  the  above-mentioned  symptoms,  with 
the  addition  of  marked  paralysis  of  the  abdominal  muscles,  distention  of  the 
intestines  with  gas.  giving  rise  to  tympany,  and  difficulty  in  respiration,  which 
will  be  greater  the  higher  the  position  of  the  fracture,  owing  to  the  involvement 
of  a  progressively  larger  number  of  the  intercostal  muscles.  In  addition  to 
the  causes  of  death  already  mentioned,  such  patients  may  die  from  hypostatic 
congestion,  or  from  pneumonia  which  gradually  follows  the  plugging  up  of  the 
air-vesicles  and  the  bronchi  with  mucus,  which  the  patient  is  unable  to  dislodge 
by  coughing  or  expectoration.  The  expectation  of  life  is  distinctly  less  than 
in  the  dorso-lumbar  fractures. 

Fractures  in  the  Ceryico-dorsal  and  Cervical  Reoions. — There  is 
in  these  fractures,  of  course,  paralysis  of  sensation  at  a  much  higher  level  than 
in  those  already  considered.  A  want  of  symmetiy  in  the  sensory  paralysis 
is  often  observed  at  first,  but  disappears  as  degenerative  changes  occur  in  the 
cord.  Occasionally  there  is  a  hyperesthetic  area  immediately  above  the  upper 
limit  of  anesthesia,  due  probably  to  the  congestion  and  irritation  of  the  region 
just  above  the  seat  of  injury.  If  the  fracture  involves  only  the  first  or  the 
second  dorsal,  but  one  cord  of  the  brachial  plexus  will  be  involved  and  the 
paralysis  of  the  upper  extremities  will  be  incomplete.  If,  however,  it  runs 
through  the  lower  cervical  vertebra,  there  is  likely  to  be  absolute  motor  and 
sensory  paralysis  of  both  arms.  It  is  important  to  remember  that  the  seat  of 
the  compression  of  the  cord  will  in  the  great  majority  of  cases  be  higher  than 
that  of  the  anesthesia  or  paralysis  by  the  length  of  the  course  of  the  nerves 
involved  within  the  spinal  canal,  and  that  it  will  usually  be  caused  by  the  for- 
ward luxation  of  the  vertebra  above  the  seat  of  fracture.  For  example,  the 
nerve  which  supplies  the  interosseous  muscles  and  the  intrinsic  muscles  of  the 
hand  is  the  first  dorsal.  Its  root  in  the  spinal  cord  is,  however,  on  a  level 
with  the  seventh  cervical  vertebra.  Therefore  if,  in  a  case  of  fracture,  we 
had  marked  prominence  of  the  spinous  process  of  the  first  dorsal  vertebra,  we 
would  understand  that  the  cord  was  probably  injured  by  the  dislocation  for- 
ward of  the  vertebra  immediately  above  it.  and  that  the  highest  level  of  the 
paralysis  which  would  follow  would  be  indicated  by  the  distribution  of  the 
first  dorsal  nerve. 

Thorburn's  tables,  which  are  probably  approximately  correct,  but  require 
confirmation,  give  the  distribution  of  the  most  important  nerves  as  follows : 

Fourth  cervical  nerve  supplies  the  supra-  and  infraspinatus. 

Fifth  "  "  "         "     biceps,  brachialis  anticus,  deltoid,  and  supina- 

tors. 

Sixth  "  "  "  "     subscapularis  (this  appears  to  be  the  highest), 

pronators,  teres  major,  latissimus  dorsi,  tri- 
ceps, pectoralis  major. 

Seventh      "  "  "  "     extensors  of  the  wrist. 

Eighth       "  "  "  "     flexors  of  the  wrist. 

First  dorsal  "  "  "     interossei  and  intrinsic  muscles  of  the  hand. 

This  is  very  well  illustrated  by  one  of  Thorburn's  cases,  in  which  there  was 
a  fracture-dislocation  of  the  seventh  cervical  and  first  dorsal  vertebnie,  the  first 
dorsal  having  been  fractured  while  the  seventh  cervical  was  displaced  forward, 
carrying  with  it  the  fragment  of  the  first  dorsal.  The  cord  was  compressed  at 
that  level,  and  was  softened  for  a  short  distance  above  and  below  the  site  of 


suRciKny  OF  Tin-:  spfne. 


583 


Fig.  244. 


Fracture-dislocation  of  the  Seventh 
Cervical  and  First  Dorsal  Vertebrae 
(Thorburn). 


compre.s.'^ioiK  its  centre Lein;:;  occupied  by  an  effusion  of  l)loo(l  reaching;  as  liijrh 
as  the  fifth  cervical  nerve-roots  in  the  form  of  a  narrow  cone  (  Fig.  244).  In  this 
case  the  injury  was  at  the  extreme  lower  part 
of  the  cervical  region,  and  must  at  first  have 
involved  the  region  of  the  first  dorsal  nerve, 
and  probably  to  some  extent  that  of  the  eighth 
cervical.  At  first  there  was  paralysis  only  of 
the  intrinsic  muscles  of  the  hand  and  the  inter- 
ossei,  but  thereafter  from  day  to  day  it  was 
possible  to  watch  the  extension  upward  of  the 
myelitis,  the  motor  power  failing  in  the  fol- 
lowing muscles  in  the  order  named :  (1)  flexors 
of  the  wrist ;  (2)  extensors  of  the  wrist ;  (3)  tri- 
ceps and  pectoralis  major;  (4)  latissimus  dorsi ; 
(5)  teres  major  and  subscapularis  ;  (6)  deltoids, 
flexors  of  the  elbow,  supra-  and  infraspinati. 

In  the  majority  of  cases  of  fracture  of  the 
spine  in  which  life  is  prolonged  for  any  time  a 
similar  series  of  phenomena  will  be  observed. 

Fracture  of  the  Atlas  and  Axis. — In 
fractures  above  the  fourth  cervical  vertebra 
when  the  cord  sustains  damage  the  injury  is 
either  immediately  fatal,  or  more  often  the 
patients  survive  for  a  period  o£  time  varying 
from  a  few  hours  to  two  weeks.  In  one  case 
(Hilton)  the  patient  lived  fourteen  ^^ears,  and 
in  another  (Shaw)  for  fifteen  months.  Frac- 
tures of  the  upper  two  cervical  vertebrse,  however,  are  especially  dangerous, 
on  account  of  the  close  relations  between  these  vertebrae  and  the  medulla 
oblongata,  and  also  from  their  position  above  the  roots  of  the  phrenic  nerves 
and  of  the  nerves  supplying  the  external  muscles  of  respiration. 

The  symptoms  of  fracture  are  complete  paralysis  of  all  the  parts  below^  the 
seat  of  the  fracture,  rigidity  of  the  neck,  pain  in  the  neck  or  occiput,  and 
sometimes  distinct  crepitus.  These  symptoms,  however,  result  also  from 
dislocation,  and  a  differential  diagnosis  is  frequently  impossible.  The  axis  is 
more  frequently  broken  than  the  atlas,  and  the  odontoid  process  is  sometimes 
broken  alone.  The  structure  of  the  body  of  the  axis  is  more  spongy  than  that 
of  the  atlas,  and  its  weakest  point  is  about  one  centimeter  below  the  neck  of 
the  process,  which  explains  the  seat  of  one  of  the  most  common  fractures.  In 
cases  of  fracture  of  the  odontoid  process  with  accompanying  dislocation,  the 
head  is  rigidly  maintained  in  a  fixed  position,  and  in  cases  of  unilateral  dis- 
placement is  turned  to  the  opposite  side.  There  is  often  an  unusual  prominence 
of  the  larynx,  and  the  posterior  wall  of  the  pharynx  may  be  pushed  forward 
by  the  body  of  the  dislocated  vertebra. 

The  treatment  for  such  an  accident  should  consist  in  gently  straightening 
the  spine  and  placing  the  patient  in  a  supine  position,  w^ith  fixation  of  the  head 
if  the  fracture  involves  a  cervical  vertebra,  by  applying  sand-bags  to  each 
side.  The  character  of  the  bed  upon  which  the  patient  is  placed  is  of  great 
importance.  The  water-bed  is  preferable  to  any  other,  but  in  cases  Avhere  this 
cannot  be  procured  an  ordinary  mattress  covered  with  mackintosh  may  be  em- 
ployed, and  air-cushions  and  rubber  rings  may  be  used  to  protect  the  most 
salient  points.  The  bladder  should  be  emptied  every  six  hours  by  means  of  a 
N^laton  or  Mercier  catheter,  Avhich  should  be  kept  scrupulously  aseptic.     If 


hSi  AX   AMEJi'/(A.\    TKXT-JiOOK    OF  SURGERY. 

cyi'titis  occurs  in  spite  of  tliis,  it  is  sonictiincs  useful  fo  wasli  out  tlie  bladder 
with  solutions  of  boric  acid,  jieroxidc  of  hydro<^en,  etc.  If  tlie  constipation 
which  ininu'diately  follows  the  accident  is  ])ersistent,  it  is  well  t»)  <rive  a  cathar- 
tic. The  <xreatest  care  must  be  exercise<l  in  cleansiiif^  the  j)arts  after  any 
dribbling  of  urine  has  occurred  or  after  there  has  been  an  action  of  the  bowels. 
The  patient  should  be  washed  daily  and  turned  gently  from  side  to  side,  so  that 
the  laps,  the  sacrum,  and  all  ))ortions  of  the  back  may  be  rubbed  with  alcohol 
or  soap  liniment,  and  afterward  anointed  with  zinc  ointment  containing  enough 
carbolic  or  salicylic  acid  to  ])revent  decomj)osition  of  the  secreti«»ns.  The  bed 
must  be  ke])t  smooth  and  the  drawsheets  and  other  bed-clothing  al»solutely 
without  wrinkles.  If  bed-sores  form  in  spite  of  these  precautions,  the  affected 
regions  must  be  immediately  relieved  from  all  pressure  by  the  use  of  rubber 
rings,  and  the  sores  themselves  cleansed  and  dressed  antiseptically.  In  this 
way  the  greatest  amount  of  comfort  may  be  obtained  while  carrying  out  a 
purely  palliative  and  expectant  treatment.  It  is  obvious,  however,  that  the 
case  is  being  left  during  this  time  to  the  unaided  efforts  of  nature,  the  results 
of  which  in  the  great  majority  of  cases  are,  as  has  been  seen,  most  unsatisfac- 
tory. The  tendency  of  modern  surgery  is  toward  rather  more  active  interfer- 
ence with  these  cases,  and  it  is  probably  safe  to  say  now  that  in  the  nuijority 
of  spinal  fractures  in  which  there  is  recognizable  deformity  immediate  rectifica- 
tion of  the  abnormal  position  is  thought  to  be  indicated,  just  as  in  any  other 
fracture.  This  in  many  cases  can  be  done  by  the  usual  methods  of  extension 
and  counter-extension  with  manipulation.  The  lower  limbs  may  be  gently 
drawn  upon  by  one  assistant,  while  the  head  is,firmly  held  in  position  by  another 
with  his  hands  upon  the  chin  and  occiput.  The  surgeon  can  often  under  the.se 
circumstances  press  the  displaced  bones  into  position  while  the  patient  lies  either 
upon  his  face  or  upon  his  back.  If  the  fracture  is  high  and  the  abdominal 
muscles  and  external  res])iratorv  muscles  are  paralyzed,  great  care  must  of 
course  be  observed  in  turning  the  patient  on  his  f^tee  not  to  interfere  with  the 
action  of  the  diaphragm  by  pressing  upward  the  abdominal  contents,  as  this  has 
been  known  to  cause  fatal  asphyxia. 

If  the  deformity  cannot  be  relieved  in  this  way,  extension  on  an  inclined 
plane  may  effect  the  same  pur|)ose.  and  a  fixed  dressing  can  be  applied  at  the 
same  time  by  slipping  beneath  the  u})per  portion  of  the  trunk  of  the  patient,  as 
he  lies  supine  upon  a  mattress,  a  many-tailed  bajulage  made  of  stout  flannel  and 
then  three  to  six  layers  of  crinoline  plaster  bandages.  The  ordinary  suspension 
collar  used  in  Potts  disease  should  then  be  applied  to  the  chin  and  occiput,  and 
the  head  of  the  mattress  or  of  the  bed  gradually  raised  so  as  to  use  the  weight 
of  the  patient's  body  as  an  extending  force,  the  collar  being  fastened  to  the 
head-piece  of  the  bed  or  being  hehl  very  firmly  by  an  assistant.  The  layers 
of  bandage  may  then  be  moistened  and  brought  into  position,  a  strip  of  ordi- 
nary bandage  being  interposed  between  their  anterior  extremities,  so  that  the 
jacket  may  be  easily  opened  and  removed  if  it  seems  desirable.  Extension 
from  the  shoulders  in  cases  of  dorso-lumbar  fracture,  or  from  the  chin  and  occi- 
put in  cases  of  fracture  at  a  higher  level,  may  then  be  c^uitiously  applied  daily, 
or  in  some  ca.ses  may  even  be  made  permanent  during  the  process  of  consoli- 
dation. 

The  results  in  a  number  of  cases  in  which  this  method  or  some  modification 
of  it  has  been  adopted  are  suflBciently  encouraging  to  warrant  its  trial  in  a 
much  larger  proportion  of  fractures  of  the  spine  than  heretofore,  ten  cases 
out  of  sixteen  reported  by  Burrell  having  been  greatly  benefited.  In  many 
cases,  however,  no  results  follow,  and  of  course  the  method  is  open  to  the  objec- 
tions that  there  are  some  risks  of  increasing  pressure  on  the  cord  in  rectifying 


SURGERY   OF    THE  SPINE.  585 

tlic  (Icfonnitv.  and.  furtlu-r,  that  it  is  dinicult  to  avoid  unpleasant  pressure  effects 
in  spinal  (."isos  in  ^vliicli  a  fixed  dressini;  of"  this  sort  is  used.  Kenienibcring, 
however,  the  e.xtreuiely  unfavorable  outlook  in  cases  of  fractuix's  of  the  spine 
treated  expectantly,  it  seems  worth  while  to  run  these  or  even  greater  risks 
if  in  a  fair  proportion  of  cases  the  ])atients  can  be  benefited.  Of  late  years 
resection  of  portions  of  the  spine  has  been  em])loyed  with  increasing  fre- 
quency in  those  cases  in  which  the  expectant  treatment  or  tlie  treatment  by 
extension  had  obviously  failed,  and  in  some  cases  has  been  resorted  to  imme- 
diately after  the  fracture.  The  observations  are  now  sufficiently  numerous  to 
show  that  even  extensive  resections  of  the  laminae  do  not  greatly  or  perma- 
nently weaken  the  spine,  that  under  antiseptic  methods  the  risk  of  consecutive 
infiannnation  of  the  cord  or  membranes  is  practically  very  slight,  and  that 
danger  from  hemorrhage  or  from  loss  of  cercbro-spinal  fluid  is  not  to  be  feared. 
They  also  show  that  it  happens  not  infVe([uently  that  the  cord  is  directly  com- 
pressed by  fragments  of  the  lamina;  themselves.  The  operation  is  therefore 
one  which  should  no  longer  be  rejected  on  the  sole  remaining  ground  that  we 
cannot  be  certain  in  any  given  case  as  to  the  exact  amount  of  damage  which 
has  been  done  to  the  tissues  of  the  cord.  On  the  contrary,  in  the  light  of 
experience  this  would  seem  rather  to  favor  operation  than  to  contraindicate  it. 
Whites  statistics  show  that  thirty-seven  operations  for  fracture  performed  during 
the  antiseptic  era  have  resulted  in  6  complete  recoveries  from  the  operation  and 
injury,  6  recoveries  with  benefit,  11  recoveries  unimproved,  and  14  deaths,  a  mor- 
tality of  38  per  cent.  Those  cases  in  which  the  lesion  occupied  the  lumbar  region, 
and  especially  those  in  which  only  the  cauda  equina  were  involved,  were,  as  might 
be  expected,  especially  favorable.  So,  too,  those  cases  in  which  fractures  of  the 
arches  or  lamiucTe  existed  gave  on  the  whole  good  results,  while  the  prognosis, 
just  as  in  the  expectant  treatment,  became  unfavorable  in  direct  proportion  to 
the  severity  of  the  injury  and  the  height  of  the  fracture.  It  is  safe  to  say, 
however,  that  the  results  of  recent  operative  interference  in  properly  selected 
cases  of  fractures  of  the  spine  are  encouraging,  and  are  likely  to  lead  to  the 
more  frequent  employment  of  resection  of  the  posterior  arches  or  laminne  (a)  in 
all  cases  in  which  depression  of  those  portions,  either  from  fracture  or  from  dis- 
location, is  obvious;  (h)  in  some  cases  in  which  after  fracture  rapidly  progressive 
degenerative  changes  manifest  themselves ;  (c)  in  all  cases  in  which  there  is 
compression  of  the  cauda  equina  from  any  cause,  whether  from  anterior  or  poste- 
rior fracture  or  from  cicatricial  tissue ;  (tZ)  in  the  presence  of  characteristic 
symptoms  of  spinal  hemorrhage,  intra-  or  extra-medullary. 

Operation  is  contraindicated  by  a  history  of  such  severe  crushing  force  as 
would  be  likely  to  cause  disorganization  of  the  cord.  What  will  remain  in 
doubt  previous  to  operation  will  usually  be  the  extent  of  damage  done  to  the 
cord  and  the  possibility  of  its  reparative  action.  As  to  this,  the  safest  rule  is 
that  which  has  been  formulated  by  Lauenstein — namely,  that  if  after  the  lapse 
of  six  or  ten  weeks  there  is  incontinence  of  urine  with  cystitis  or  incontinence 
of  feces,  and  especially  if  there  are  also  the  development  and  spreading  of 
bed-sores,  but  little  is  to  be  hoped  for  from  the  unaided  efforts  of  nature.  If, 
however,  these  symptoms  be  absent,  and  if  there  be  the  least  improvement  in 
either  sensation  or  motion,  it  will  be  proper  for  the  surgeon  to  delay  operative 
interference  still  lono-er. 

The  operation  itself — laminectomy — may  be  done  in  the  following  man- 
ner: The  patient  is  placed  in  a  prone  position,  a  gentle  curve  having  been  given 
the  spine  by  means  of  a  firm  small  pillow  placed  under  the  lower  ribs.  A  long 
incision  should  be  made  directly  doAvn  to  the  tips  of  the  spinous  processes,  the 
middle  of  the  incision  being  opposite  the  seat  of  the  fracture.     The  muscles 


■;-!(]  AX  AMi.nrcAX  Ti: XT- HOOK  or  smoERY. 

slidulil  lie  frcclv  scpMvatcd  IVdiii  the  sides  of  the  spinous  processes  iind  the 
])()steri()r  suvtacos  of  the  hiiniiKO.  The  periosteum  may  Ix-  reflected  by  mak- 
iii<i;  an  incision  tlirough  it  ah)n,i:;  the  angle  between  the  sjtinous  processes  and 
the  himinnc,  turning  up  its  edge  at  this  point  Avith  the  help  of  dissecting 
forceps,  and  then  scraping  the  surfaces  of  the  vertebral  arches  Avith  a  curved 
periosteal  elevator.  This  should  be  done  neatly,  so  as  to  leave  as  little  ragged 
muscular  tissue  as  possible,  since  this  may  become  necrotic  and  produce  later 
troul)le.  Then  the  periosteum  is  similarly  reflected  on  the  opposite  side. 
Retractors  of  moderate  size,  not  large  or  clumsy  enough  to  be  in  the  -way, 
are  all  that  is  needed  to  keep  the  muscular  masses  from  interfering  Avith  the 
sul»sequent  procedures.  This  being  completed,  the  hemorrhage  should  be  ar- 
rested by  hemostatic  forceps,  by  packing  hot  sponges  between  the  spinous  pro- 
cesses and  the  detached  muscular  mass,  and  by  ligatures.  The  next  step  con- 
sists in  the  division  of  the  spinous  processes  close  to  their  bases  by  means  of 
laro-e,  strong  bone  forceps  set  at  an  obtuse  angle.  This  adds  nothing  to  the 
severity  of  the  operation,  while  it  aff'ords  much  freer  exposure  of  the  laminae, 
Avhich  are  the  next  parts  to  be  attacked.  They  can  be  expeditiously  and  safely 
divided  by  the  rongeur  forceps  or  by  a  pair  of  strong  bone  forceps,  either 
straight  or  having  a  large  obtuse  angle  as  may  be  preferred  by  the  operator. 
The  vertebra  at  the  center  of  the  incision  or  the  displaced  vertebra  should  be 
selected,  and  the  vertebral  spaces  above  and  below  its  laminre  should  be  recog- 
nized with  the  tip  of  the  finger.  The  lamina?  should  then  be  cut  through  by 
successive  short  nips  of  the  bone  forceps,  the  line  of  section  being  as  close  to 
the  transverse  processes  as  possible.  This  gives  the  greatest  exposure  of  the 
cord  and  of  the  membranes. 

The  color  of  the  dura  should  be  noted,  particularly  with  the  vicAV  of  deter- 
mining in  cases  of  traumatism  Avhether  it  is  or  is  not  necessary  to  open  it.  If 
it  be  dark  or  purplish  from  the  presence  of  exuded  blood  beneath  it,  or  yelloAv- 
ish  from  the  presence  of  pus,  it  Avill,  of  course,  be  proper  to  incise  it  in  order 
to  empty  and  to  explore  the  subdural  space.  If  it  is  determined  to  open  it,  it 
mav  be  picked  up  in  the  median  line  and  at  the  middle  of  the  incision  with  a 
pair  of  delicate  toothed  forceps,  nicked  Avith  a  knife  or  the  scissors,  and  then 
divided  either  upon  a  director  or  Avith  a  pair  of  blunt-pointed  scissors  to  any 
required  extent  upAvard  and  doAvnAvard.  It  can  be  easily  and  gently  retracted 
to  either  side,  so  as  to  expose  the  Avhole  posterior  surface  of  the  cord  to  both 
inspection  and  palpation,  permitting  the  gentle  insertion  of  the  tip  of  the  finger 
betAveen  its  inner  surface  and  the  lateral  aspect  of  the  cord,  and  permitting 
also,  if  need  be,  the  investigation  of  the  anterior  and  antero-lateral  subdural 
spaces  by  means  of  a  blunt  curved  instrument,  such  as  a  pedicle  needle  or  an 
aneurysm  needle.  The  inspection  having  been  comjjleted,  or  it  having  been  de- 
termined after  removal  of  the  cause  of  compression  that  no  iuditation  for  further 
operation  exists,  the  incision  in  the  dura  should  be  stitched  up  Avith  fine  inter- 
rupted catgut  sutures.  These  may  be  introduced  very  readily  and  speedily  by 
means  of  a  pair  of  staphylorrhaphy  or  Hagedorn  needles,  the  one  not  in  use 
being  threaded  by  an  assistant  Avhile  each  stitch  is  being  put  in  place ;  the 
stitches  should  be  inserted  at  intervals  of  about  one-eighth  to  one-sixth  of  an 
inch,  and  Avhen  all  are  in  place  can  be  easily  tied,  the  ends  being  cut  oft'  short. 
A  small  rubber  drainage-tube  and  a  dozen  strands  of  chromicized  catgut  should 
then  be  laid  throughout  the  entire  length  of  the  wound,  the  umscles  being 
united  above  them  by  means  of  buried  chromicized  catgut  sutures,  after 
Avhich  the  skin  and  aponeurosis  are  brought  together  by  silk  or  silver  Avire  as 
may  be  preferred.  It  is  hardly  necessary  to  say  that  the  most  rigid  antiseptic 
precautions  should  be  observed  from  first  to  last. 


SURGEL'V   OF    Tin-:  srfNE. 


687 


Autero-lateral  View  of  a  Cervical  Dislocation,  slMiwiii_'  the 
prominence  of  the  upper  vertebra,  and  at  x  a  displaced  artic- 
ulating process  (KoeniK). 

Fig.  24tj. 


DISLOCATIONS   OF  THE   VERTEBRiE. 

These,  as  lias  been   said,  are   eominonly  associated   with  fracture,  but  a 
number  of  cases  have  been  reported  and  verified  by  post-mortem  examination 
in   which   uncomplicated   dis- 
location has  occurred.     They  Fifi.  24o. 
Avere  nearly  all  of  the  cervical 
region.      A   few  dorsal  dislo- 
cations have  been  noted,  the 
majority  of  them  aft'ecting  the 
twelfth  dorsal  vertebra.    Only 
three  or  four  cases  of  dislo- 
cation  of  the  lumbar   verte- 
bi'ie  Avithout  serious  fracture 
have  been  recorded  and  con- 
firmed by  autopsy. 

Vertebral  dislocation  may 
be  caused  by  forced  flexion 
or  extreme  extension.  AVhen 
j)roduced  by  such  forces  they 
will  uniformly  be  bilateral  and 
either  forward  or  backward 
(Figs.  240  and  246).  They  may 
also  be  produced  by  extreme 
lateral  motions  of  the  spine 
or  by  excessive  rotation.  In 
either  of  these  cases  they  may 
be  unilateral,  either  forward  or 
backAvard,  and  may  be  incom- 
plete, that  is,  the  articular  sur- 
faces may  remain  in  contact 
at  their  edges ;  or  complete,  in 
which  case  the  inferior  process 
of  the  upper  vertebra  passes 
farther  forward  and  sinks  into 
the  notch  between  the  body 
and  the  superior  articular  process  of  the  loAver  vertebra  (see  Fig.  247). 
It  is  usual  in  treating  of  dislocations  of  the  vertebr.Te  to  speak  of  the  upper 
one  as  the  vertebra  that  has  been  dislocated.     Of  course,  there  are  the  usual 

associated  lesions,   including 
^^^-  rupture    of  ligaments,   mus- 

cles, and  blood-vessels,  in- 
juries to  nerves,  and  often 
laceration  of  the  interverte- 
bral disks.  In  the  absence 
of  deformity  the  symptoms 
will  be  the  same  as  those 
of  fracture  of  the  vertebree. 
Crepitus  and  preternatural 
mobility  are  not  ahvays  ob- 
tainable in  fracture,  and  in- 
deed  cannot  wdth   propriety 

Complete  Unilateral  Dislocation  by  Rotation  or  Abduction  of  a     \^q  sOU^ht  for  in  the  maioi'itV 
cervical  vertebra  (Koenig).  <•         P  t        i    '  • 

01  such  cases.     In  the  cervi- 
cal region  it  may  be  possible  to  recognize  the  change  in  the  relations  of  the 


Anterior  View  of  Figure  2-15  (.Koenig). 


588 


AX   AMK/.'JCAy    Ti:XT-li(}OK    OF  ,S  I '/,'(,' /■:/,')■ 


transverse  processes,  the  Ixxly  of  the  disldciitcil  vcrtclmi  may  ])e  felt  rlmniirli 
the  ]»h:innx,  and  the  absence  of  the  e()n('sj)()ii(lin<r  spinoiis  jirooess  niav  he 
noted  on  the  hack  of  tlie  neck.  The  rigidity  and  the  attitude  in  which"  the 
neck  is  held  will  often  be  very  suggestive  (Fig.  248),  but  may  be  closely 
simulated  by  the  muscular  contraction  and  pain  due  to  contusion  of  muscles 
or  to  inflammation  of  the  intervertebral  joints.  The  paralysis  will  dej)end 
upon  the  extent  of  the  displacement  and  the  corres))onding  damage  to  the  cord, 

and  may  vary  from  a  very  slight  pare- 
sis to  extensive  para])legia.  Usually 
motor  paralysis  is  more  marked  and 
extensive  than  sensory  paralysis,  and 
both  kinds  are  apt  to  be  less  abso- 
lute in  dislocation  than  in  fracture.  In 
some  cases  of  dislocation  paralysis  has 
been  entirely  absent. 

Although  many  surgical  authorities 
have  objected  to  any  effort  lacing  made 
to  reduce  luxation,  on  the  ground  that 
the  attempt  may  cause  the  immediate 
death  of  the  patient,  especially  if  the 
luxation  is  in  the  upper  cervical  region, 
it  yet  seems  proper  in  the  majority  of 
cases  in  which  dislocation  is  diagnosti- 
cated to  attempt  to  replace  the  part  by 
means  of  traction  aided  by  flexion  or 
rotation.  It  is  right  that  the  patient 
and  his  friends  should  ])e  informed  of 
the  risk  of  immediate  death  during  this 
procedure,  but  the  surgeon  may  con- 
scientiously and  urgently  advise  that 
this  risk  be  accepted.  The  manocuvers  will  depend  upon  the  seat  of  the  dis- 
location, but,  as  a  rule,  no  special  method  can  be  indicated.  If  in  a  cervical 
luxation  an  unnatural  prominence  in  the  pharynx  can  be  felt,  reduction  may 
be  facilitated  by  making  backward  pressure  with  the  finger  through  the  mouth 
•while  at  the  same  time  traction  is  kept  up  from  the  chin  and  occiput.  When 
the  displacement  is  unilateral,  rotation  should  be  used  in  addition  to  exten- 
sion and  counter-extension.  The  head,  which  is  apt  to  be  inclined  to  one  side, 
should  be  carried  still  farther  in  that  direction,  so  as  to  disengage  the  processes 
of  the  luxated  vertebra,  after  which  it  should  be  gently  rotated  and  bent  toward 
the  opposite  side,  extension  and  counter-extension  being  kept  up  during  the 
whole  of  this  procedure.  In  the  lower  segments  of  the  spine  the  methods 
already  described  for  rectifying  the  deformity  in  fractures  apply  equally  to 
luxations.  In  the  majority  of  cases  the  operator  will  be  in  doubt  as  to 
whether  or  not  a  fracture  coexists. 

The  prognosis  is,  of  course,  more  favoral)le  in  uncomplicated  luxations 
which  have  been  reduced  than  in  fracture,  but  the  injury  in  all  cases  must 
be  regarded  as  a  very  serious  one.  Even  after  reduction  paralysis  often  per- 
sists, and  death  ensues  on  account  of  the  injury  to  the  cord. 


Luxation  of  the  Fifth  Cervical  Vertebra  (Blasius). 


suRGKin'  or  Tin:  RrsriitATonv  organs.  589 


CHAPTER   III. 

SURGERY    OF    THE    RESPIRATORY    ORGANS. 

section  i.— the  nose  and  nasal  cavities. 

Congenital  and  other  Deformities  of  the  Nose. 

The  nose  varies  naturally  within  wide  limits  in  shape  and  size,  and  has 
been  studied  alike  by  the  artist  and  the  surgeon,  but  outside  of  the  natural 
limits  of  variation  we  occasionally  see  more  or  less  conspicuous  deformity.  This 
may  be  either  a  failure  to  develop  properly  or  an  unusual  width  of  space 
between  the  nasal  processes  of  the  upper  jaws.  A  few  instances  are  on  record 
where  the  nose  was  totally  lacking  at  birth.  On  the  other  hand,  a  supple- 
mentary nose  of  such  size  as  to  cause  the  individual  to  be  regarded  as  having  a 
double  nose  is  not  unknown.  The  fissure  between  the  lower  lateral  cartilages 
has  been  known  to  remain  so  conspicuous  as  to  cause  the  individual  to  display 
a  bifid  nose.  Monks  has  recently  remedied  this  by  a  vertical  incision  and 
suture  of  the  separated  cartilages.  Failure  to  develop  in  length  along  the 
dorsal  aspect  may  give  rise  in  a  prominent  degree  to  that  condition  com- 
monly known  as  snub-nose.  That  peculiarities  in  conformation  of  the  nose 
arc  particularly  likely  to  be  transmitted  by  heredity  is  well  illustrated 
in  the  Jewish  race.  The  subjects  of  inherited  syphilis  fre(juently  present 
noses  which  have  little  or  no  bridge,  or  which  are  so  flattened  between  the 
orbits  as  to  be  unpleasant  to  regard.  Fractures  often  result  in  such  a  depres- 
sion as  to  cause  the  deformity  known  as  "saddle-shaped"  nose.  This  too 
has  recently  been  successfully  remedied  by  the  insertion  of  a  silver  gilt  or 
celluloid  plate  through  a  small  incision  at  the  side  or  under  the  tip  of  the 
nose.  Strict  asepsis  is  needful  for  success.  The  plate  remains  indefinitely 
in  situ. 

But  the  most  common  deformities  of  the  nose  or  nasal  cavities  are  not  those 
which  appear  externally  or  which  leave  more  than  a  slight  external  sign,  but 
those  which  produce  variations  of  contour  within  the  nasal  foss?e.  Perhaps  the 
most  common  of  these  is  deviation  of  the  nasal  septum,  which,  though  often 
acquired,  is  most  often  of  congenital  origin.  This  may  be  slight  in  extent  or 
may  be  so  marked  as  to  lead  to  the  virtual  occlusion  of  the  nasal  passage  on  one 
side.  Furthermore  it  frequently  happens  that  the  pressure  of  such  a  bulging 
septum  against  the  turbinated  bone  produces  various  reflex  irritations  which 
are  at  times  quite  severe.  AVhen  the  degree  of  deviation  is  slight  there  is  but 
little  evidence  of  it,  but  when  it  is  extensive  there  is  usually  irregularity  of 
external  configuration. 

The  nostrils  are  occasionally  contracted  from  birth,  and  rarely  are  com- 
pletely occluded  by  more  or  less  tough  membrane.  When  this  membranous 
occlusion  is  met  with  later  in  childhood,  in  the  majority  of  instances  it  will  be 


r.iio  .i.v  AMi.h'icAX   Ti:xT-i:()()k'  or  ,sri:(; i:in\ 

found  to  result  from  cicatricial  tissue  followinp;  ulceration  about  the  anterior 
narcs.  Such  nostrils  may  be  enlarged  by  a  slow  process  of  dilatation  ;  or  a 
combination  of  incision  and  stretching,  which  latter  must  extend  over  a  long 
period  of  time,  may  be  practised.  When  the  nostrils  are  completely  occluded 
or  obliterated  a  combination  of  incision  and  dilatation  is  absolutely  necessary. 

A  form  of  elepliantiasis  occurs  rarely  in  middle  or  later  life.  It  has  been 
known  to  attain  enormous  ])roportions.  It  can  be  treated  only  in  one  way, 
if  at  all ;  that  is,  by  excision  of  the  affected  tissue  and  proj)er  closure  of  the 
wound, — if  necessary,  by  some  plastic  method. 

A  diseased  condition  much  ros(>m1)]ing  the  above,  but  due  to  a  very  differ- 
ent cause,  is  that  known  as  rhinoscleroma.  This  is  described  by  Ilebra  as 
an  affection  of  the  nose,  the  nostrils,  and  even  the  upper  lips  and  the  adjoining 
parts.  It  is  characterized  by  the  a])pearance  of  hard  swellings  or  tumors, — in 
other  words,  of  cutaneous  nodosities, — sometimes  almost  polypoid  in  shape,  iso- 
lated or  confluent,  sometimes  of  a  darker  color  than  the  adjoining  parts. 
These  nodosities  are  more  or  less  separated  by  fissures  from  which  exudes  a 
yellowish  fluid.  The  growths  themselves  may  present  cartilaginous  hardness. 
They  distort  the  nostrils  and  make  hideous  the  nose,  and  invade  even  the  parts 
about  the  mouth.  Rhinoscleroma  is  due  to  the  presence  of  n  bacillus  in  the 
tissues.  Stepanow  has  been  able  to  reproduce  the  disease  in  animals  by  inocu- 
lation. It  is  amenable  to  but  one  form  of  treatment — that  is,  free  excision 
during  its  early  stages. 

Rhinophyma  is  a  hypertrophic  form  of  acne  rosacea  confined  to  the 
nasal  region,  and  is  characterized  by  much   vascular  new  growth. 

Fissures  of  the  Nose. — These  are  almost  always  connected  with  defects 
of  development  and  failures  to  close  at  or  near  the  middle  line,  and  are  nearly 
always  confined  to  cases  of  cleft  palate  and  hare-lip  in  Avhich  the  fissure  extends 
up  into  the  nasal  fossaj.  Their  proper  consideration  and  treatment  are  connected 
with  the  surgery  of  the  mouth  and  face.  It  has  happened  once  to  the  writer 
to  see  a  fissure  of  the  septum,  the  effect  of  which  was  that  there  appeared  to 
be  three  nostrils.  Under  chloroform  the  thickest  portion  of  this  divided  septum 
was  cut  away  and  the  third  nostril  abolished. 

Asymmetry. — Asymmetry  of  the  nasal  portion  of  the  face  has  been  studied 
especially  by  Zuckerkandl  and  Allen.  While  it  may  be  of  congenital  origin, 
in  the  majority  of  cases  it  is  due  to  pre-existing  stenosis  of  one  nasal  fossa, 
which  is  thereby  deprived  of  its  proper  nutrition  and  does  not  develop  sym- 
metrically with  its  fellow.  This  view  is  corroborated  by  the  result  of  ex- 
cluding the  entrance  of  air  into  one  nostril  of  vounsr  animals.  A  variety  of 
experiments  and  clinical  experiences  makes  it  certain  that  obstruction  of  the 
respiratory  canals  by  enlargement  of  tonsils,  hypertrophy  of  mucous  membrane, 
and  adenoid  vegetations  in  the  pharynx  occurring  early  in  life  is  the  principal 
exciting  cause  of  developmental  defects  in  the  nose. 

Synechia,  or  adhesion  or  fusion  of  parts  within  the  nasal  fossje,  is  not 
care,  although  those  cases  in  which  it  is  properly  of  congenital  and  develop- 
mental origin  are  rare,  since  it  is  usually  the  result  of  some  previously  exist- 
ing ulceration. 

Diseases  and  Displacements  of  the  Septum. 

Abscess. — Abscesses  in  the  septum  may  be  acute  or  chronic.  Acute  abscess 
comprises  those  forms  which  follow  local  traumatism,  /.  r.  the  purulent  trans- 
formation of  a  clot  beneath  the  mucous  membrane,  as  well  as  those  abscesses 
consecutive  to  furuncle,  in  the  vicinity  of  a  foreign  body,  or  to  adjoining  ulcera- 


SURGERY  OF  THE  RESPIRATORY  ORGANS.  5i>l 

tion.  Corainonly  the  s\\t'lliiig  of  the  septiini  can  l)e  noticed  by  inspection 
through  the  nostrils.  It  feels  warm  and  is  extremely  ])ainful  to  the  touch.  Not 
unfreiiuently  perforation  of  the  septum  or  loosening  of  its  bony  or  cartilaginous 
margins  results.  AVhen  due  to  spread  of  septic  influences  from  the  neighbor- 
hood this  affection  may  be  unilateral.  ^JMie  local  treatment  consists  of  early 
and  sulliciently  free  incision. 

Chronic  abscess  is  a  more  progressive  and  slowly  destructive  condition,  with 
minor  or  no  inflammatory  signs  and  few  if  any  acute  symptoms.  It  has  been 
mistaken  for  polyp  and  for  a  malignant  disease.  It  is  usually  either  of  syphilitic 
or  of  tubercular  origin.  When  cither  of  these  forms  of  intranasal  disease  is 
primary,  it  may  be  followed  by  erysipelas  of  the  face,  by  more  or  less  local 
destruction  of  tissue,  or  even  by  deep  ])hlebitis  and  meningitis.  1'hey  are 
quite  likely  to  be  followed  by  loss  of  the  septum  and  consequent  deformity  of 
the  nose. 

Acute  Coryza. — This  is  an  acute  inflammation  of  the  Schneiderian  mem- 
brane, affecting,  at  least  at  first,  that  portion  of  it  which  covers  the  septum 
and  the  lower  turbinated  bone,  an<l  is  that  condition  known  to  the  laity  as 
severe  "cold  in  the  head."  A  similar  condition  met  with  in  the  new-born  or 
in  very  young  infants  is  a  not  uncommon  sign  of  inherited  syphilis.  Except 
for  the  distress  which  it  sometimes  causes  or  its  reflex  efi'ects,  it  is  scarcely 
of  surgical  interest,  unless  it  occurs  in  those  who  have  already  some  patho- 
logical changes  in  these  parts.  The  influence  of  cold  and  wet  is  predomi- 
nant in  its  causation,  since  a  slight  chilling  of  the  body  is  often  enough  to 
produce  it.  It  may  also  be  caused  by  irritating  vapors,  e.  g.  of  bromine,  by 
certain  animal  or  vegetable  products,  such  as  pollen,  by  the  odors  of  certain 
flowers  in  susceptible  individuals,  by  various  foreign  bodies,  including  polyps, 
by  traumatism,  or  by  eczema  or  other  eruptions  within  the  nose.  It  may  also 
be  attendant  upon  periostitis,  upon  furuncle  or  carbuncle,  upon  severe  con- 
junctivitis, or  it  may  appear  in  the  course  of  certain  general  diseases,  like 
measles,  diphtheria,  the  grippe,  etc.  In  certain  individuals  it  appears  so  con- 
stantly with  attacks  of  asthma  as  to  indicate  something  more  than  mere  coin- 
cidence. The  young  and  those  of  a  tubercular  diathesis  seem  to  be  more  fre- 
quently affected. 

Its  local  signs  are  those  of  profuse  discharge  of  nasal  mucus,  with  extreme 
susceptibility  and  irritability  of  the  Schneiderian  membrane,  and  so  much 
obstructive  swelling  as  to  impair  or  make  impossible  nasal  respiration.  A 
peculiarly  uncomfortable  and  tickling  sensation  within  the  nose  and  a  tend- 
ency to  sneeze  on  little  or  no  provocation  are  its  most  marked  symptoms. 
So  tumefied  does  the  mucous  membrane  become  as  not  merely  to  prevent  that 
passage  of  air  through  the  nose  which  distinct  speech  requires,  but  even  the 
quality  of  the  voice  is  changed.  When  the  disease  is  severe  the  frontal  and 
maxillary  sinuses  are  affected  by  extension,  and  the  pain  and  discomfort  are 
thereby  considerably  increased.  Often  pharyngitis  will  further  complicate  the 
disease,  in  which  case  there  will  probably  be  more  or  less  implication  of  the 
Eustachian  tube,  with  its  attendant  complaints.  In  proportion  to  its  severity 
the  sense  of  smell  is  impaired  or  temporarily  lost. 

An  uncomplicated  case  of  this  character  will  ordinarily  last  five  or  six  days. 
If  anterior  and  posterior  rhinoscopy  be  practised  an  excellent  demonstration 
of  the  cardinal  signs  of  inflammation  will  be  afforded. 

Treatment. — Acute  coryza  is  virtually  a  self-limited  disease,  but  its  course 
may  be  shortened  by  local  and  general  treatment.  The  administration  of  a 
brisk  cathartic,  followed  by  foot-baths  at  night,  a  sedative  and  antipyretic 
mixture  internally  (phenacetin  and  quinine  with  small  doses  of  morphia),  the 


592  ^l^Y  AMERICAN  TEXT-BOOK  OF  SURGERY. 

inhalation  of  steam  from  boiling  water  into  wliicli  a  little  ])(t\v(lciiMl  camphor 
has  been  tlirown,  and  the  use  of  antisejitie  alkaline  spray  to  wliit-h  \  to  1  jicr 
cent,  of  coeaine  and  •}  to  o  per  cent,  of  antipyrine  are  added,  will  be  found  to 
give  very  great  relief.  A  snuff"  eontaining  menthol  is  often  of  great  value. 
When  the  watery  discharge  is  ])rofuse  the  aildition  of  one-tenth  of  1  ))er  cent, 
of  atropine  to  the  spray  will  materially  diminish  its  excess.  If  local  distress 
be  very  great,  a  triturate  may  l)e  ordered  of  1  part  of  morj)hia  with  25  parts 
of  bismuth  subcarbonate  or  subnitrate,  and  the  insufflation  of  a  few  grains  of 
this  will  have  a  ha]»))y  effect.  Avoidance  of  exposure  to  draught  and  cold  is 
of  course  an  important  adjunct  in  the  treatment. 

Ozena. — This  is  a  term  applied  to  a  condition  of  fetid  ulceration  commonly 
due  to  syphilis  or  other  disease  of  the  Schneiderian  membrane,  or  else  to  an 
atrophic  form  of  inllaiuniation  of  the  same  commonly  knoAvn  as  atrophic  rJii- 
nitin.  The  ulcerative  form  gives  rise  to  discharges  of  a  mixed  muco-sanguino- 
purulent  character,  with  expulsion  of  crusts  and  scabs,  and  imparts  a  most 
unpleasant  and  fetid  odor  to  the  breath.  In  the  atrophic  form  of  the  disease 
there  is  little  or  no  ulceration,  but  so  much  lack  of  moisture  as  to  lead  to  the 
partial  evaporation,  decomposition,  and  drying  of  what  discharge  there  may 
be,  with  more  or  less  disposition  to  the  same  characteristic  odor  of  the  breath. 
Some  writers  include  under  this  term  disease  of  the  adjoining  sinuses  and  cel- 
lular cavities,  which  undoubtedly  frequently  occurs,  though  not  necessarily. 
Practically,  the  term  is  applied  to  those  cases  of  intranasal  disease  which  give 
rise  to  fetor  of  breath  rather  than  any  one  distinctive  pathological  condition. 

In  every  such  case  careful  rhinoscopy  should  be  practised,  the  treat- 
ment depending  upon  the  condition  found.  In  most  cases  before  such  exami- 
nation can  be  satisfactory  nasal  douches  must  be  repeatedly  given,  and  crusts 
and  liardened  masses  washed  away  by  means  of  a  spray  with  a  compressed- 
air  force  of  from  ten  to  fifteen  pounds.  Not  until  the  nasal  cavity  has  thus 
been  thoroughly  cleansed  and  the  immediate  congestion  caused  by  this  inter- 
ference subdued,  either  by  waiting  a  little  or  by  the  application  of  a  very  weak 
solution  of  cocaine,  can  an  exact  estimation  of  the  condition  be  made.  In 
ulcerative  forms  small,  ragged,  more  or  less  unhealthy  ulcers  may  be  found 
in  almost  any  part  of  the  cavities,  though  these  occur  more  commonly  in  parts 
most  easy  of  examination.  More  than  this,  it  often  happens  that  small  or 
relatively  large  areas  of  spongy  bone  will  be  found  neerosed  and  loose  or  easy 
of  detachment,  or  that  a  necrosed  area  of  cartilaginous  or  bony  septum  will  be 
discovered.  Patients  will  sometimes  present  small  portions  of  bone  which  have 
been  expelled  spontaneously,  which  will  be  very  suggestive. 

Ulcerations  in  the  nose  which  produce  this  condition  may  be  of  the  follow- 
ing varieties:  1,  simple,  which  may  have  been  originally  of  traumatic  origin, 
due  to  the  finger-nail  of  the  individual,  to  the  presence  of  some  foreign  body, 
or  to  the  eff'ect  of  some  caustic  previously  applied  ;  2,  tubercular,  in  which  case 
the  general  condition  of  the  patient  will  be  extremely  significant :  3,  syphilitic, 
where  there  are  almost  sure  to  be  other  evidences  of  secondary  or  tertiary  dis- 
ease, the  examiner  having  probably  to  look  no  farther  than  the  mo.uth  of  the 
patient  in  order  to  corroborate  his  diagnosis. 

In  all  these  forms  of  ulceration  diseased  or  dead  bone  may  occur,  but  this  is 
relatively  infrequent  in  the  first.  The  entire  turbinated  body,  or  one  or  more 
of  the  turbinated  bones,  along  with  the  septum,  may  be  thus  destroyed,  and 
even  exfoliated  extrrnally,  and  many  a  sunken  bridge  of  the  nose  is  evidence 
of  the  destruction  which  has  gone  on  beneath,  due  for  the  most  part  to  the  rav- 
ages of  tertiary  syphilis. 

The  treatment  of  this  variety  of  ozena  consists  in  the  main  of  removal 


SURGERY  OF  THE  RESPIRATORY  ORGANS. 


593 


of  diseased  bone,  cauterizalion  of  the  ulcer  proper  and  its  conversion  into 
healthy  granulating  tissue,  and  such  measures  as  may  be  appropriately  di- 
rected toward  cleanliness  and  antisepsis.  If  necessary,  operation  may  be 
undertaken,  with  cocaine  or  general  anesthesia,  for  removal  of  set^uestra.  Dur- 
ing the  treatment  the  general  condition  of  the  patient  should  not  be  neglected, 
and  in  syphilitic  cases  a  vigorous  antispecific  and  tonic  treatment  will  effect 
almost  as  much  benefit  as  do  the  measures  instituted  locally. 

In  that  form  of  ozena  due  to  atrophic  rhinitis  there  is  frequently  necessity 
for  general  and  constitutional  treatment,  while  the  local  treatment  is  directed 
first  toward  cleanliness  and  freedom  from  the  presence  of  decomposing  crusts, 
and  secondly  toward  gentle  stimulation  of  the  nmcous  membrane  in  order  to 
favor  healthy  secretion.  The  jiowders  or  sprays  that  are  used  for  this  pur- 
pose contain  substances  which  are  mildly  stimulating,  such  as  preparations  of 
benzoin,  to  Avhicli  menthol  may  be  added. 

Perforating  Ulcer  of*  the  Septum. — Under  this  name  there  has 
recently  been  described  an  ulcerative  process  occurring  usually  along  the 
border  of  the  cartilaginous  septum,  which'  determines  later  its  perforation,  and 
presents  characteristics  which  apparently  entitle  it  to  separate  description,  inas- 
much as  it  is  independent  of  syphilis,  tuberculosis,  or  lupus.  The  ulcer  is  round 
or  oval,  and  when  oval  has  its  long  diameter  placed  antero-posteriorly.  The 
mucous  membrane  appears  to  be  first  affected.  Local  destruction  advances 
more  and  more  deeply;  finally  the  ulceration  thus  formed  usually  tends  to 
general  cicatrization  about  its  borders.  It  appears  to  attack  old  men  oftener 
than  others.  Histologically,  the  lesion  seems  to  consist  of  an  infiltration  with 
epithelial  cells,  as  well  as  their  subsequent  multiplication. 

Concerning  its  intimate  cause  we  are  yet  ignorant.  In  some  respects  it 
seems  to  correspond  to  perforating  ulcer  of  the  foot.  It  calls  for  little  save 
antiseptic  treatment. 

Deviation  of  the   Septum. — Deviations  of  the  nasal  septum  are  very 
common  (Fig.  249),  and   constitute  the  most  important  abnormalities  of  the 
nose.     Mackenzie,  for  in- 
stance, in  examining  2152  Fig.  249. 
individuals,    found   devia- 
tion in  77  per  cent.,  and 
of  a  total  of   34-46  cases 
examined  by  several   ob- 
servers there  was  deviation 
in  about  60  per  cent. 

Deviation  toward  the 
left  appears  to  be  more  common  than  toward  the  right.  It  varies  in  amount  and 
character  from  a  simple  warping  of  the  septal  plate  to  complete  displacement. 
The  causes  of  the  deviation  are  by  no  means  clear.  In  the  infant  the  nasal 
fossae  are  small  and  simple  in  conformation.  The  sinuses  are  not  yet  formed, 
and  the  plates  of  the  ethmoid  are  still  cartilaginous.  The  cribriform  plate  is 
even  membranous  and  continuous  with  the  falx  cerebri  and  the  dura  mater,  and 
is  thus  flexible  at  a  time  when  the  vomer  is  already  ossified.  At  the  age  of 
two  the  frontal  and  ethmoidal  sinuses,  as  well  as  the  antrum,  have  begun  to 
form.  The  development  of  the  turbinated  bone  is  also  tardy,  and  relative 
activity  of  growth  of  these  parts  is  a  somewhat  late  manifestation.  The 
posterior  or  free  boundary  of  the  vomer  is  seldom  misshapen,  since  it  is 
thick  and  strong,  but  its  anterior  portion  is  very  liable  to  displacement,  of 
which  traumatism  is  a  frequent  cause.  Thus  it  appears  that  the  vomer,  occu- 
pying the  middle  of  a  cavity  with  walls  more  rigid  than  itself,  frequently 
as 


Varieties  of  Deflection  of  the  Nasal  Septum  (Roberts). 


594  ^-V  AMERICAN  TEXT-BOOK  OF  SURGERY. 

bends  in  the  direction  of  least  resistance,  owing  to  injury  or  to  unequal  develop- 
ment of  surrounding  parts.  Deflections  of  the  cartilaginous  sections  are  most 
common,  next  those  of  the  bony  parts,  and  finally  those  of  the  entire  septum. 
The  cartilage  may  be  bent  upon  itself  vertically  or  horizontally,  presenting 
along  the  line  of  deflection  a  bulging  sufiiciently  prominent  to  occlude  the 
nares.  Horizontal  bending  is  much  more  common.  The  deep  concavity  of 
the  opposite  nostril  often  corresponds  with  the  convexity  of  the  bend.  It  may 
cause  serious  obstruction  to  the  respiration.  AVhen  the  warping  is  but  slight 
it  ordinarily  gives  rise  to  no  symptoms  and  calls  for  no  interference.  It  not 
unfreciuently  happens  that  we  have  to  deal  with  an  enlargement  of  the  middle 
turbinated  bone  corresponding  with  the  deflection  of  the  septum,  and  second- 
arily with  a  greater  obstruction. 

Another  form  of  deformity  of  the  septum  is  caused  by  development,  near 
the  sutural  line  of  the  vomer  and  the  palatal  process,  of  a  bony  or  cartilag- 
inous ridge  which  constitutes  a  spur,  as  it  is  usually  called,  and  which  is  in  fact 
an  exostosis  or  ecchondrosis,  and  may  extend  horizontally  for  some  distance. 
It  may  be  met  with  on  one  or  both  sides  ;  it  helps  to  obstruct  the  inferior  mea- 
tus, always  leads  to  thickening  of  the  overlying  mucous  membrane,  and  should 
alwavs  be  removed  when  met  with.  When  the  septum  exhibits  a  double  curve, 
being  warped  first  to  one  side  and  then  to  the  other,  it  is  described  as  repre- 
sentinor  a  sigmoid  flexion.  This  mav  meet  and  touch  the  inferior  turbinated  on 
one  side  and  the  middle  turbinated  on  the  other. 

As  might  naturally  be  supposed,  when  the  septum  is  markedly  deflected  we 
frequently  find  the  hard  palate  to  be  very  high-arched  or  Gothic  in  contour. 
Its  transverse  diameter  is  short,  and  the  alveolar  arch  may  be  much  more 
oval  or  relatively  smaller,  by  which  the  front  teeth  are  thrown  forward  and  a 
characteristic  expression  given  to  the  face.  Delavan  calls  attention  to  the  fact 
that  this  condition  is  frequently  associated  with  the  habit  of  mouth-breathing, 
and  that  it  is  often  a  family  peculiarity. 

Treatment  of  Deviated  Septum. — For  the  rectification  of  this  deform- 
ity a  large  variety  of  operative  methods  have  been  suggested,  depending  in  their 
conception  and  for  their  successful  performance  upon  the  degree  of  deflection. 
It  is  of  some  interest  to  know  that  this  particular  branch  of  surgery  is  one  of 
quite  recent  origin  and  development,  and  that  almost  all  the  operations  prac- 
tised for  this  purpose  have  originated  within  comparatively  few  years,  although 
the  proceeding  itself,  after  a  rude  fashion,  is  of  great  antiquity.  By  a  few  sur- 
geons, Adams  for  instance,  it  was  suggested  to  seize  the  crooked  sei>tum  between 
the  two  blades  of  strong  forceps  and  fracture  it  sufficiently  to  allow  of  resto- 
ration to  its  normal  outline.  To  keep  it  in  the  desired  position  head-bands 
with  pads  and  screws,  or  masks  with  adjustable  pads,  or  intranasal  apparatus 
of  more  or  less  elaborate  form.  Avere  called  into  requisition.  Then  it  was 
suggested  to  cut  out  of  the  septum,  with  a  punch  (Fig.  250)  fashioned  after 
a  conductor's  punch,  smaller  or  larger  pieces  of  .shape  according  to  the  fancy 

of  the  operator,  by  which  the 
septum  would  be  so  weak- 
ened as  to  be  easy  of  replace- 
ment. This  method  is  open 
to  the  objection  of  leaving  an 
opening  where  nature  did  not 
intend  one  to  exist,  and  fur- 

,   „      ^  thermore  leaves  the  septum  so 

Jams  s  Puuch.  ,  ,  •  i      j 

weakened  as  sometimes  to  lead 
to  subsequent  falling  in  of  the  bridge  of  the  nose.     A  much  more  successful 


SURGERY  OF   THE  RESPIRATORY  ORGAIiS. 


595 


application  of  tins  tbrm  of  instrument  is  that  by  whi  h  a  s^Ha^  mc^^ 
n  ade  in  the  septum,  yet  without  removal  of  any  of  it.  ih.s  ^^^^^'^'^^ens  ^ 
that  it  can  he  sprung'  back  into  position,  and  yet  leaves  no  perforation  ,  but  this, 
le  all  otlier  procedures  where  nothing  is  removed  requires  the  «ubsequen  u  e 
for  a  considerible  k.^th  of  time  of  plugs  by  which  the  partition  shall  be  held 
S  p^=^until  Its  tendency  to  warp  is  overcome.  The  saine  oUl-;^on  o^  le^g 
a  perforation  often  obtains  against  the  use  of  the  nasal  saw  (tig.  2.)1),  which 


Fig.  2.-)1. 


Park's  Nasal  Saw. 

Otherwise  is  a  very  useful  instrument.  Its  especial  range  of  usefulness  is  in  the 
?emoTao  outgrowths  from  the  turbinated  bones  or  of  spurs  or  bridges  from  the 
se  rm  It  will  be  spoken  of  again  later.  A  very  simple  method  for  uncom- 
pl  cated  cases  is  that  of  incision  through  the  protuberance  along  its  long  axis 
Kwhich  the  septum  is  forcibly  replaced  by  means  of  the  finger  in  the  nos- 
t  1  Its  elasticit}  being  thus  temporarily  overcome,  it  is  held  in  place  by 
packin..  the  previously  obstructed  nostril  with  plugs  of  antiseptic  gauze  oi  of 
mbber^or  other  suitable  material.  These  are  removed  daily,  and  the  parts 
carefully  cleansed,  after  which  the  plugs  are  replaced.  If  necessary,  any  re- 
dundant  portion  can  be  pared  with  a  knife  or  removed  with  a  saw. 

ingals  has  modified  Ibis  plan  by  incisions  through  the  mucous  membrane 
its  detachment  from  the  underlying  cartilage,  and  the  removal  of  a  triangular 
portion  of  the  latter,  the  base  of  the  triangle  being  at  Jhe^floor  of  the  nose     Of 
CO  u^e  the  membrane  on  each  side  of  this  piece  should  be  detached      Robe  ts 
ha   dev^^ed  an  ingenious  and  very  eifective  way  of  overcoming  septal  deformity. 
If  there  L  angular  deflection,  he  makes  an  incision  from  front  to  back  ;  if  the 
deflection  is  alrooved  one,  he  splits  the  cartilage  along  the  most  prominent  por- 
tn  aid  cuts  iSto  the  rest  of  the  septum  repeatedly  until  it  has  lost  ^ts  resiliency^ 
An;  small  portions  that  protrude  at  the  lower  margin  are  removed  ^^^^h  knife  or 
saw      If  onlv  small  fragments  of  the  entire  thickness  are  cut  a.^^y  the  1  ttle 
perforations  thus  caused^ubsequently  heal.     The  septum  is  now  held  m  place 
by  steel  pins  made  for  the  purpose,  which  may  be  in- 
serted through  the  nostril  or  from  the  outside  (tig. 
25-'^)      The  point  is  thrust  through  the  inferior  por- 
tion of  the  septum,  which  is  then  placed  in  the  desired 
position,   after  which   the    pin   is   thrust   still   farther 
onward  and  its  point  buried  deeply  in  the  firm  and 
untouched  tissues  at  the  back  part  of  the  nasal  cham- 
ber     Two  or  more  pins  may  be  used  for  this  purpose  ; 
they  should  be   left   a   few  days  in   sM.      By   this 
method  the  use  of  plugs  is  avoided,  and   antiseptic 
douches,  powders,  or  sprays  can  be  used  as  frequently 
as  desired.      When  ridges  or  projections  of  mucous 


Fig.  252. 


Pins  inserted  for  Deviation  of 
Septum  in  Roberts's  method 
of  operation. 


596  ^l^V  AMERICAN  TEXT-BOOK  OF  SURGERY. 

membrane  are  the  cause  of  the  obstruction,  or  even  Avhen  this  is  composed 
of  soft  cartihige.  Jarvis  recommends  to  transfix  them  with  a  needle  and  then 
remove  them  with  his  steel  wire  snare. 

Besides  the  methods  thus  briefly  described  (for  more  information  concerning 
which  the  reader  is  referred  to  special  text-books),  it  has  been  proposed  to 
remove  the  offending  cartilage  or  bone  by  rapidly  revolving  burrs  or  trephines 
operated  by  the  dental  engine,  by  hand  power,  or  by  small  electric  motors,  or 
to  attack  them  with  fine  chisels  and  gouges,  the  force  being  applied  either  with 
the  hand  or  with  a  small  inallot.  When  properly  performed,  any  or  all  of  these 
methods  are  admissible,  and  all  are  capable  of  afibrding  relief  In  almost  every 
instance,  however,  there  is  necessity  for  long-continued  care  to  preserve  the 
septum  in  its  proper  place  and  prevent  it  from  again  warping  while  still 
weak. 

Almost  all  these  cases  are  complicated,  however,  by  more  or  less  hyper- 
trophy of  the  mucous  membrane  of  opposing  surfaces,  and  it  is  relatively 
seldom  that  attention  to  the  septum  alone  will  suffice.  This  brinf^s  us  to  the 
consideration  of  the  causes  which  produce  this  other  condition. 

Hypertrophic  and  Atrophic  Nasal  Catarrh. — The  complicated  struc- 
ture and  character  of  the  Schneiderian  membrane,  as  well  as  the  fact  that, 
especially  in  its  lower  portions,  it  is  studded  with  large  numbers  of  minute 
glands  Avhose  function  it  is  to  secrete  the  nasal  mucus,  must  not  be  overlooked 
in  accounting  for  this  condition.  These,  being  true  glands,  partake  of  the 
usual  adenoid-tissue  arrangement.  Evidently,  then,  irritations  which  affect 
the  membrane  will  also  involve  the  glands,  and  the  hypertrophy  of  one 
without  a  corresponding  aff'ection  of  the  other  is  out  of  the  question.  This 
membrane  is  more  exposed  to  external  influences  than  any  other.  Thus 
it  happens  that  repeated  attacks  of  acute  inflammation  or  the  continuous 
action  of  relatively  trifling  irritations  lead  to,  first,  a  chronic  congestion,  and 
second,  tissue  new-formation.  This  process,  once  begun,  rapidly  increases 
in  extent  and  severity.  The  new  growth  is  very  likely  to  occur  along 
that  inferior  turbinated  bone  which  comes  most  closely  in  contact  with  a 
deviated  and  protruding  septum,  and.  as  a  rule,  the  structures  over  the  lower 
turbinated  bone  are  much  more  commonly  and  extensively  involved  than  those 
over  the  other  bones.  This  diseased  tissue  is  usually  more  or  less  spongy  or 
erectile  in  character,  and  is  composed  of  such  a  mixture  of  glandular  and  paren- 
chymatous elements  as  to  be  commonly  termed  adenoid,  the  one  form  or  the 
other  predominating  according  to  the  type  of  the  structure  first  attacked.  Hy- 
pertrophy of  the  mucous  membrane  over  the  posterior  portions  of  these  turbi- 
nated bones  is  more  frequent  tlian  of  that  over  the  anterior  portions.  The  ste- 
nosis caused  by  these  conditions  may  be  partial  or  complete  and  temporary  or  per- 
manent. Many  individuals  have  just  so  much  thickening  as  to  suffer  from  alter- 
nate stoppage  and  patency  of  the  nostrils  according  to  the  condition  of  the  weather 
and  their  freedom  from  congestions  due  to  colds.  Anything  which  favors  flow  of 
blood  to  the  parts  will  occasion  stoppage.  Hence  some  persons  complain  of  ina- 
bility to  breathe  in  bed  through  that  side  of  the  nose  which  is  lowermost.  Others 
enjoy  freedom  of  respiration  in  dry  weather,  while  because  of  the  hygrometric 
condition  of  the  atmosphere  they  suffer  inconvenience  during  damp  weather,  and 
some  operators  even  take  advantage  of  this  latter  circumstance  ia  order  to  seize 
these  growths  when  their  increased  size  makes  them  easier  to  attack. 

But  interference  with  respiration  is  by  no  means  the  only  trouble  j)roduced 
by  this  kind  of  hypertrophy.  AVhen  the  stenosis  is  posterior,  and  especially 
when  the  adenoid  tissue  of  the  naso-pharynx  is  involved,  pressure  is  made  upon 
the  orifice  of  the  Eustachian  tube,  with  the  result  of  more  or  less  impairment 


SURGERY  OF  THE  RESPIRATORY  ORGANS. 


597 


of  heavin-.  It  is  very  important  to  boar  this  in  niina,  since  not  a  few  cases  of 
deafness  iil  one  ear,  or  in  both  ears,  depend  primarily  not  upon  disturbance  m 
the  middle  ear,  but  upon  this  conditi<.n  of  the  naso-pharynx.  iherefore  in 
treating  patients  for  diafness  an  examination  of  the  throat  and  nose  is  as  essen- 
tial  as  an  examination  of  the  meml)rana  tympani. 

After  having  made  a  careful  examination  and  having  recognized   so  far  as 
possible,  the  condition  above  described,  there  is  considerable  range  of  choice  as 
\o  methods  for  obviating  the  difficulty,  the  choice  being  mainly  between    he  rad- 
c-il  method  of  extirpation  of  the  obstructing  mass  and  that  of  its  partia  destiuc- 
on    y  caustics  or  the  actual  cautery,  trusting  to  the  resulting  cicatricial  contrac- 
io      0  produce  the  desired  diminution  in  size.     The  choice  must  be  governed 
to  a  certain  extent  by  the  occupation  and  the  personal  and  constitutional  habits 
of  die  patient,  and  the  means  at  hand.     In  either  case  local  anesthesia  can  be 
u.uallv  accomplished  with  solutions  of  cocaine  varying  in  strength  from  2  to 
8  ner  cent    usin-  the  stronger  only  when  the  weaker  fail.     Ihese  may  be 
appHed  fii!;;  by  the  spray,  tlfen  by  contact  of  small  plugs  o    cotton  saturated 
ki      e  solution,  or  rarely,  when  necessary,  by  its  injection  mto  the  tissues  with 
tL  fine  neelof  the  ordinary  hypodermatic  syringe     The  operator  must  ahvays 
expect  the  deeply  colored  and  turgid  appearance  ot  these  growths  to  be  modified 
bv  the  constriniig  effect  of  the  cocaine.     Small  crushing  forceps  and  scissors 
have  been  devised  with  which  those  parts  of  the  nasal  cavity  most  subject  to 
thTs  condition  can  be  reached,  and  the  hypertrophy  when  distinct  or  peduncu- 
lated can  sometimes  be  most  easily  removed  by  their  aid 

But  some  form  of  wire  snare  or  ^craseur  is  perhaps  the  favorite  instru- 
ment for  this  purpose,  and  of  the  vanous  forms  of  this  ^^f  "^^.^;;^.^7p^:f  ^^3^.* 
in  this  country,  is  more  popular  than  that  suggested  by  Jarvis  (Fig.  253). 


Fig.  253. 


Jarvis's  Snare. 


Its  wire  loop  is  passed  within  the  nose,  and  by  the  aid  of  artificial  illumination 
is  lod-ed  around  the  base  of  the  mass  which  it  is  proposed  to  remove  after 
which"  the  loop  is  slowly  tightened,  and  the  fine  wire  cuts  its  way  through 
the  tissue  so  slowly  that,  vessels  being  crushed  across,  the  operation  is  almost 
bloodless.  In  the  attack  upon  posterior  hypertrophies  the  manipulation  is 
sometimes  quite  difficult  and  requires  the  skill  of  an  expert.  It  is  made  more 
difficult  by  the  sensibility  of  the  part  and  by  the  reflex  motions  of  the  palate 
and  pharynx,  which  are  usually  beyond  the  possibility  of  voluntary  control. 
These  are  in  some  measure  obviated  by  the  use  of  palate  retractors,  or  by  the 
introduction  of  tapes  through  the  nostrils  into  the  pharynx  and  bringing  them 
out  through  the  mouth  and  tying  them  in  front  of  the  upper  lip.  By  their 
aid  not  onlv  is  the  palate  retracted  and  its  movements  controlled,  but  illu- 
mination of"^tlie  parts  is  also  possible.  These  masses  are  sometimes  removed 
with  a  peculiar  burr  attached  to  some  revolving  mechanism,  by  which  removal 
is  made  as  effective,  though  much  more  bloody. 

The  other  method  of  treatment,  by  the  use  of  caustics,  avoids  some  ot  the 
unpleasantness  of  an  operation,  but  usually  produces  much  more  pain  and  dis- 
comfort, while  snaring  off  a  mass  of  adenoid  tissue  with  the  wire  loop  causes 
frequently  very  little  pain. 


598 


.l.V  AMERICAN  TEXT- BO  OK  OF  SURGERY. 


An  even  more  effective  and  commonly  less  painful  method,  certainly  one 
which  leaves  fewer  unpleassant  immediate  consequences,  is  the  use  of  the  gal- 
vano-cautery :  the  parts  being  prepared  as  above,  the  galvano-caustic  knife  or 
point  is  applied  as  was  the  caustic,  and  is  made  to  burn  more  or  less  deeply 
and  widely  according  to  the  effect  desired.  The  resulting  sloughs  separate  in 
about  the*  same  length  of  time,  antl  the  after-treatment  in  each  instance  con- 
sists mainlv  in  local  cleanliness  and  antisepsis.  The  final  benefit  may  not  be 
obtained  until  after  the  lapse  of  a  number  of  weeks.  This  latter  procedure  of 
course  implies  the  possession  of  a  suitable  cautery  or  storage  battery  and  the 
necessary  electrodes  or  cautery  points,  all  of  which  are  expensive.  But  when 
it  is  applied  with  skill  the  result  is  usually  very  satisfactory. 

A  collection  of  adenoid  tissue  seldom  exceeding  7  or  S  mm.  in  diameter 
has  been  described  by  Luschka  as  the  pharyngeal  tonsil.  This  is  found  at  the 
vault  of  the  pharynx,  and  may  become  enlarged  under  the  same  conditions  as 
those  which  give  rise  to  hypertrophy  or  as  those  which  produce  adenoid  tissue 
in  the  nose. 

The  pharyngeal  tonsil  is  itself  of  interest,  since  along  with  another  col- 
lection of  similar  tissue  spread  out  at  the  base  of  the  tongue  it  constitutes 
what  has  been  called  the  ring  of  adenoid  tissue  around  the  pharynx,  the 
principal  portions  of  this  ring  being  of  course  formed  by  the  faucial  ton- 
sils. When  this  tissue  in  the  pharynx  is  involved  in  hypertrophic  changes, 
it  must  be  removed,  either  with  spoons  fashioned  for  the  purpose  or  with  cut- 
ting forceps  with  somewhat  dulled  edges  (Fig.  254).     When  diseased  it  may 

Fig.  254. 


Raynor's  Naso-pharyngeal  Scissors. 


produce  various  reflex  disturbances  of  about  the  same  character  as  those  men- 
tioned under  Neuroses  of  the  Nose. 

The  Lingual  Tonsil. — Completing  the  circle  of  glandular  tissue  around 
the  oro-pharynx  there  is  more  or  less  of  lymphoid  and  adenoid  structure 
across  the  base  of  the  tongue,  which,  described  together,  has  l»cen  known  as 
"the  lingual  tonsil."  The  principal  difference  between  it  and  the  faucial  is 
that  the  adenoid  tissue  here  is  disseminated  in  small  groups  over  a  consider- 
able surface.  There  are  here  no  glands,  properly  speaking,  nor  excretory 
ducts  nor  outlets,  but  small  enclosures,  three  or  four  lines  in  diameter,  of 
adenoid  material  covered  by  mucous  membrane.  These  follicles  much  resem- 
ble Peyer's  patches  in  the  intestines.     They  exist  in  the  normal  condition, 


SURGERY   OF    THE  RESPIRATORY   ORGANS.  599 

but  they  become  nmcb  hyi^crtrophied,  and  of  about  the  size  attained  by 
lesions  of  adenoid  tissue  in  the  otlier  parts  of  the  ])barynx.  They  are 
located  between  the  circunivallate  paj)ill£e  and  the  epiglottis,  and  are  incon- 
spicuous except  when  enlarged. 

Normally,  there  is  a  free  interval  between  the  base  of  the  tongue  and  the 
epiglottis,  but  this  is  more  or  less  encroached  upon  when  this  tissue  is  hyper- 
trophied,  and  sometimes  tlie  tip  of  the  epiglottis  may  seem  almost  buried  in 
a  mass  of  tonsillar  structure.  This  hypertrophy  may  even  extend  laterally 
to  a  considerable  extent.  When  carefully  viewed  these  masses  will  be  seen  to 
form  an  aggregation  whose  component  parts  may  be  distinctly  distinguished. 
When  these  tissues  are  hypertrophied,  there  is  sometimes  complaint  of  pain 
shooting  up  toward  the  ears,  or  there  may  be  reflex  discomfort  in  the  larynx 
or  along  the  course  of  the  pneumogastrics ;  and  when  inflammation  compli- 
cates the  hypertrophy  there  may  be  actual  sharp  pain.  The  voice  is  more  or 
less  altered,  and  fatigue  in  speaking  and  singing  is  a  common  symptom.  In 
certain  cases  the  voice  is  made  uncertain  and  unreliable.  Most  patients  suffer 
from  more  or  less  reflex  cough,  either  violent,  spasmodic,  or  incessant,  or  else 
of  a  hacking  character.  Part  of  this  cough  is  due  to  friction  between  the 
tongue  and  the  glottis.  It  is  ([uite  likely  that  the  so-called  "globus  hyster- 
icus "  is  in  many  instances  a  sign  of  value,  and  due  to  the  presence  of 
enlargements  of  this  lymphoid  tissue.  Dyspnea  and  even  asthma  may  occur 
in  patients  with  enlarged  lingual  tonsils.  The  only  radical  treatment  con- 
sists in  the  removal  of  the  hypertrophies  by  caustics  or  mechanical  measures. 
The  latter  will  consist  either  of  the  wire  snare  or  of  the  sharp  spoon  in  some 
of  its  modifications.  The  galvano-cautery  is  often  resorted  to,  and  is  prob- 
ably the  most  satisfactory  method  of  treatment.  These  operations  can  usually 
be  made  by  aid  of  cocaine  without  pain. 

Atrophic  Catarrh. — This  is  to  a  large  degree  a  result  of  the  previous 
form,  which  when  untreated  has  gone  on  to  such  complete  formation  of  new 
connective-tissue  elements  that  the  glandular  portion  has  disappeared.  The 
result  is  now  not  so  much  the  impediment  to  respiration  as  the  dryness  of  the 
parts,  by  which  the  patient's  comfort  in  breathing  is  very  materially  dimin- 
ished, and  he  has  probably  by  this  time,  if  not  before,  become  changed  from 
a  nose-breather  into  a  mouth-breather.  Still,  with  all  this,  there  may  be 
such  relics  of  previous  hypertrophic  obstruction  as  to  call  for  purely  surgical 
relief  by  one  or  another  of  the  methods  above  described.  This  form  of  disease 
is  likely  to  be  more  offensive  than  the  previous,  since  the  dried  and  thickened 
mucous  membrane  is  covered  with  crusts  of  desiccated  secretion,  which  may  be 
more  or  less  advanced  in  decomposition  or  which  may  cover  over  actual 
ulceration  in  the  tissues  beneath.  In  this  way  we  may  have  to  deal  with  a 
combination  of  atrophic  catarrh  and  ozena.  On  account  of  the  length  of  time 
required  to  bring  about  this  condition  these  cases  pursue  a  very  stubborn 
and  chronic  course.  Their  treatment  is,  first,  local  cleanliness ;  second,  the 
removal  of  any  actual  obstruction ;  third,  applications  to  whatever  ulceration 
may  exist ;  and  finally,  the  endeavor  to  stimulate  the  long-disused  remain- 
ing glands  into  greater  activity  ;  in  other  words,  the  restoration  of  the  natural 
secretion.  This  is  to  be  accomplished  mainly  by  stimulating  and  antiseptic 
sprays  or  other  applications,  fluid  or  dry.  It  will  require  daily  attention  at 
least  by  the  patient  himself,  and  often  by  the  surgeon,  and  is  a  process  so 
slow  as  often  to  lead  to  discouragement  and  disappointment.  Nevertheless,  if 
carefully  persisted  in,  it  may  be  productive  of  great  good,  if  not  of  complete 
restoration  of  the  normal  condition. 


ooo  ^i.v  AMi:iiu\{y  Ti:xT-Ji<)()K  oi   srn(;i:iiy. 


NASAL    CATAKIMl. 

Besides  the  acute  and  clin»nic  tonus  of  inllainination  of  tlie  Rchneiderian 
membrane  already  referred  to  under  the  headings  of  (joryza  and  Adenoid 
Thickenin«^,  there  is  another  form  of  chronic  intiammation  which  is  as  com- 
mon perhaps  as  anv,  and  which  deserves  consideration  by  itself  under  the 
term  of  chronic  catarrhal  inflammation.  This  may  bejLiin  almost  as  a  chronic 
condition,  or  may  be  secondary  to  acute  inllammations.  As  a  rule,  the 
more  chronic  the'  condition  the  more  it  involves  the  posterior  nasal  surfaces 
alon<T  with  those  of  the  pharynx,  and  we  have  practically  to  deal  with  a  retro- 
nasal or  naso-pharyngeal  catarrh.  Narrowness  of  conformation  may  exert 
some  predisposing  influence.  Nevertheless,  the  condition  prevails  in  all  coun- 
tries an<l  climates ;  l)ut  it  appears  to  be  most  frequent  where  atmospheric 
chan'^es  are  most  sudden.  For  the  treatment  of  this  condition,  which  is  in  the 
main  medical,  the  reader  is  referred  to  special  text-books. 

ULCERS. 

Ulcers  and  ulcerations  within  the  nasal  cavities  may  be  of  the  following 
types:  1.  Catarrhal ;  2.  Tubercular  (and  Lupous) ;  3.  Syphilitic  ;  4.  Leprous  ;  5. 
Malignant.  It  seems  hardly  necessary  here  to  go  into  a  description  of  each  of 
theseforms.  Their  nasal  characteristics  in  no  wise  differ  from  those  which  the 
same  forms  of  lesion  display  elsewhere.  Among  the  first  must  be  reckoned 
the  kind  of  ulceration  which  one  may  see  where  two  surfaces  which  were  not 
intended  to  touch  each  other  have  come  into  contact,  or  which  the  surface  of 
a  nasal  polypus,  for  instance,  may  exhibit.  Tubercular  ulceration  of  any- 
thing like  long  duration  will  probably  be  accompanied  by  caries  or  necrosis 
of  the  underlying  bone.  The  same  is  true  of  the  syphilitic  form.  Leprous 
ulceration  cannot  be  considered  apart  from  general  leprous  disease,  nor  can  it 
so  occur.  Malignant  ulcers  are  simply  expressions  of  degeneration  of  malig- 
nant neojdasms.  and,  while  they  may  be  regarded  as  among  their  disagreeable 
phases,  the  ulcer  itself  is  of  little  consequence  as  compared  with  the  primary 
disease,  unless  it  produce  frequent  hemorrhages. 

In  the  above  statement  no  note  is  made  of  two  or  three  other  specific  vari- 
eties of  ulcerations  which  may  occur  in  the  nose,  such  as  those  accompanying 
glanders,  actinomycosis,  rliinoscleroma,  etc.  These  are  so  rare  in  this  country 
as  to  deserve  only  mention. 

The  treatment  of  each  of  these  forms  must  be  obvious.  The  catarrhal 
ulcer  needs  only  cleanliness,  freedom  from  irritation,  and  proper  restoration  to 
a  condition  of  healthy  granulation,  in  order  rapidly  to  heal.  The  tubercular 
form  mav  rec^uire  removal  of  diseased  bone,  and  certainly  should  be  thoroughly 
cauterized  or  scraped,  after  which  it  can  be  coaxed  to  heal  by  simple  measures, 
unless  the  systemic  infection  be  too  pronounced.  The  treatment  of  the  syphi- 
litic form  is  inseparable  from  that  of  constitutional  syphilis,  and  calls  for  anti- 
specific  medication.  When  one  has  to  deal  with  a  malignant  ulcer  in  these 
parts,  the  question  is  in  the  main  whether  the  primary  disease  can  be  removed 
by  operation,  no  matter  how  severe,  or  not.  If  it  appear  that  it  can  be,  no 
time  should  be  lost  in  practising  it.  If,  on  the  other  hand,  the  case  appear 
inoperable,  much  nuiy  be  done  by  repeated  curetting,  or  destruction  of  neo- 
plastic tissue  with  the  actual  cautery,  or  its  removal,  or  at  least  the  removal 
of  so  much  of  it  as  is  accessible,  with  the  scissors,  knife,  or  snare.  In  this 
way,  without  thought  of  radical  cure,  life  may  frequently  be  prolonged  or 
made  less  offensive  both  to  the  patient  and  to  those  around  him. 


SURGERY   OF   THE  RESPIRATORY   ORGANS.  601 


EPISTAXIS. 

The  term  epistaxis  originally  denoted  bleeding  from  any  point  aljout  the 
nose,  but  is  now  generally  limited  so  as  to  mean  hemorrhages  frcjm  the  nasal 
and  connecting  cavities.  It  may  occur  either  as  the  result  of  trifling  or  severe 
injury  or  spontaneously,  and  it  may  be  active  or  passive.  No  mucous  mem- 
brane in  the  body  is  so  naturally  disposed  to  bleed  both  by  liability  to  insult 
and  by  character  of  construction  as  tliat  which  lines  the  nose.  Hyperemia  is 
very  easily  ])roduced,  and  the  l)lood- vessels  of  tlie  part  have  little  or  no  natural 
support  outside  of  their  own  walls.  The  traumatic  form  folhjws  various  inju- 
ries, not  necessarily  applied  directly  to  the  nose.  Falls  of  all  kinds  will  fre- 
quently produce  it,  and  especially  falls  or  blows  upon  the  head.  It  is  known 
to  occur  frequently  in  connection  with  fractures  of  the  skull,  especially  of  the 
base.  It  may  occur  from  picking  the  nose  or  from  rude  introduction  of  some- 
tliing  into  the  nostrils,  and  occasionally  follows  explosions  of  some  violence ; 
thus  men  handling  heavy  pieces  of  artillery,  especially  within  small  compart- 
ments, are  frequently  annoyed  with  it.  When  slight  causes  give  rise  to  it, 
there  is  nearly  always  some  local  or  constitutional  predisposition,  usually  in 
the  so-called  full  habit  of  body,  or,  in  the  aged,  extreme  fragility  of  vessels,  or 
a  more  or  less  varicose  condition  of  the  parts,  in  those  who  have  this  condition 
elsewhere.  The  so-called  spontaneous  form  may  arise  from  inhalation  of  irri- 
tating vapors  ;  from  over-filling  of  the  capillaries,  due  to  violent  over-action  of 
the  heart  or  to  too  severe  exercise  ;  from  some  act  like  coughing  or  sneezing ; 
from  previous  ulceration ;  from  the  presence  of  foreign  bodies  or  parasites ; 
or  from  the  presence  of  tumors ;  in  fact,  from  anything  which  tends  to  produce 
a  filling  of  arteries  and  obstruction  to  venous  return.  It  is  common  in  pleth- 
oric children  and  adults.  It  is  frequently  the  precursor  of  apoplectic  lesions 
in  the  brain  and  eye.  It  occurs  often  in  passage  from  dense  to  rarefied  air  or 
the  reverse,  as  in  balloonists  or  those  working  in  caissons.  In  such  cases,  in 
fact,  it  is  to  be  regarded  as  an  apoplexy  of  the  Schneiderian  membrane.  It 
is  a  symptom  of  several  acute  diseases,  for  instance  of  typhoid,  and  accompa- 
nies scurvy,  purpura,  chlorosis,  etc. 

It  may  be  of  a  vicarious  character,  and  may  then  occur  from  suppression 
of  menses,  urine,  or  perspiration,  or  even  of  hemorrhages  from  varicose  veins 
or  malignant  tumors.  Children  approaching  the  age  of  puberty  seem  to  be 
liable  to  it,  and  some  pregnant  women  frequently  suffer  from  it.  Extremes  of 
heat  and  cold  upon  the  surface  seem  often  to  favor  it,  and  psychical  impres- 
sions ai-e  occasionally  sufficient  to  excite  it.  In  degree  and  extent  it  may 
vary  from  the  escape  of  a  few  drops  of  blood  to  a  hemorrhage  so  violent  as 
to  endanger  life  or  even  terminate  it.  It  usually  comes  from  one  nostril, 
sometimes  from  both,  and  may  escape  through  the  naso-phai-ynx  into  the 
mouth,  whence  it  may  be  expectorated  or  swallowed.  The  presence  of  blood 
which  has  thus  entered  the  stomach  may  excite  the  act  of  vomiting,  by  which 
still  further  hemorrhage  may  be  favored.  As  a  rule,  it  escapes  from  some  point 
in  the  anterior  nares,  perhaps  more  often  upon  the  septum  than  elsewhere. 

The  diagnosis  seldom  offers  the  slightest  difficulty ;  only  in  some  cases  of 
grave  constitutional  disease  where  blood  runs  down  the  trachea  or  oesophagus 
without  the  knowledge  of  the  patient  can  uncertainty  arise.  While  in  general 
epistaxis  is  to  be  checked  at  once,  there  are  circumstances  which  may  make  this 
inadvisable.  If,  for  instance,  it  appear  to  be  a  relief  of  supercharged  intra- 
cranial vessels,  it  should  be  regai'ded  rather  as  an  advantage  than  otherwise, 
and  checked  only  in  case  it  become  excessive.  Many  congestions  of  the  brain 
and  important  parts  within  the  skull  have  been  relieved  by  this  spontaneous 


(;()2  .(.V  AMERK'AX    TEXT-BOOK   OF  SURGERY. 

venesection.      J>ut,  as  a  rule,  it  is  sonictliin<f  Avhicli  should  Ite  clicfkcd  as  soon 
as  practica1tk\  especially  if  collapse  threaten. 

Treatment. — To  I)ogin  with,  if  possible,  the  cause  should  be  ascertained 
and  removed.  Removal,  however,  is  seldom  ])racticable,  and  treatment  must 
depend  upon  the  exigencies  of  the  case.  First  of  all,  position  and  rest  should 
be  attended  to.  Naturally  the  higher  the  head  the  better,  and  patients  should 
not  be  allowed  to  lie  down  unless  they  be  very  weak.  All  pressure  of  clothing 
about  the  neck  and  thorax  should  be  removed,  and  patients  should  ])c  cautioned 
against  cougliing  and  sneezing,  as  also  particularly  against  constant  efforts  to 
blow  the  nose  and  thus  expel  the  blood,  since  by  this  act  the  formation  of  a  clot 
is  prevented.  It  has  been  found  that  extension  and  elevation  of  the  arms  above 
the  head  produce,  by  reflex  vaso-motor  mechanism,  contraction  of  the  nasal  ves- 
sels, as  does  also  sometimes  pressure  at  the  root  of  the  nose  or  about  the  nasal 
region  of  the  face,  and  these  measures  are  to  be  recommended  as  worthy  of  trial. 
Pressure  against  the  bone  upon  either  side  of  the  ala  nasi  Avill  often  check  epis- 
taxis  occurring  from  the  anterior  portion  of  the  nose,  as  the  lateral  nasal  ves- 
sels supply  the  mucous  membrane  of  this  portion  of  the  nasal  cavities.  Pres- 
sure upon  the  carotid  would  also  be  indicated  were  it  not  that  the  jugular 
vein  is  obstructed  at  the  same  time.  The  application  of  cold  to  the  back  of 
the  neck,  ice-water  enemata,  and  similar  measures  may  also  produce  reflex  vas- 
cular spasm  within  the  nose.  If  these  measures  be  found  inefficient,  astrin- 
gents may  be  employed  by  the  nasal  douche,  such  as  ice-water  or  water  as  hot  as 
can  be  borne,  or  solutions  of  alum,  tannin,  etc.  The  stronger  the  astringent, 
however,  the  more  disagreeable  the  general  effect,  and  if  the  bleeding  point  can 
be  localized  it  will  be  much  better  to  apply  some  dry  astringent  directly  to  the 
part.  It  has  been  a  common  practice  to  employ  tents  within  the  nostrils  or 
to  pack  the  anterior  naris  with  some  material  like  cobweb,  which  not  only 
acts  as  a  styptic,  but  also  serves  to  entangle  tlie  blood  and  favor  coagulation. 
For  cases  of  moderate  severity  or  for  hemorrhage  following  ordinary  intranasal 
operations  the  writer  has  found  a  solution  of  antipyrine,  of  5  to  10  per  cent, 
strength,  the  most  serviceable  and  the  least  disagreeable.  Its  effect  upon  the 
blood-vessels  is  like  that  of  cocaine,  only  more  lasting,  and  it  makes  a  very 
serviceable  styptic  for  general  surgical  purposes,  since  to  its  astringent  proper- 
ties is  added  that  of  being  antiseptic. 

AVhen  hemorrhage  is  alarming,  however,  it  is  better  not  to  waste  time  with 
measures  of  the  above  character,  but  to  proceed  at  once  to  plugging  the  nasal 
passages.  If  the  hemorrhage  be  anterior,  the  introduction  of  tampons  through 
the  nostril  may  be  quite  sufficient.  A  series  of  these  should  be  tied  to  a  single 
piece  of  stout  silk,  by  means  of  which  all  are  under  control.  If,  however,  this 
be  not  enough,  the  posterior  naris  may  be  occluded  by  a  very  simjile  procedure 
which  gives  rise  to  no  particular  pain.  The  most  serviceable  instrument  for 
this  purpose  is  the  little  canula  devised  by  Belloc(i  (Fig.  "l^y^i) ;  but  in  the 

absence  of  this  an  ordinary 
Fig.  25.'i.  silk  catheter  may  be  armed 

with  a  piece  of  stout  silk  or 
twine  by  threading  one  end 
of  a  piece,  15  inciics  long, 
through  its  eye.  This  cathe- 
ter is  now  passed  in  along  the 
floor  of  the  nose  until  it  is 
Benocq's  canula.  deflected    downward    by    the 

posterior  wall  of  the  pharynx. 
So  soon  as  its  point  is  seen  behind  the  uvula  the  silk  thread  may  be  caught  with 


SUMGERY    OF    THE    R  ESP  Hi  A  TORY    ORGANS.  003 

a  toniU'uluin  or  iurcops  and  thawii  out  tliroii;;li  tlie  inuutli,  while  the  catheter  is 
withdrawn  from  the  nose.  One  end  of  the  thread  is  now  hanging  from  the  nos- 
tril, the  other  from  the  mouth.  The  middle  of  the  latter  is  firmly  tied  around 
a  |)l(Ml(Tet  of  cotton  or  of  sponge,  which  is  then  drawn  backward  and  upward 
by  pulling  on  that  portion  which  hangs  from  the  nose,  guiding  the  tampon 
with  the  index  finger  of  the  other  hand  over  tlie  tongue  into  the  pharynx  and 
then  up  and  behind  the  soft  ))alate.  It  is  an  advantage  if  the  portion  which 
still  hangs  out  from  tlie  mouth  have  been  left  so  long  that,  a  day  or  two 
later,  when  it  is  desired  to  remove  the  tampon,  this  may  be  done  by  pulling 
downward  again  hy  means  of  this  portion  rather  than  having  to  dislodge  the 
plug  Avith  curved  forceps  in  the  pharynx  or  to  push  it  backward  by  something 
introduced  again  within  the  nose.  If  this  end  be  left  long  enough  for  this 
pitrpose,  it  may  be  brought  out  of  the  mouth  and  knotted  to  the  other  end,  so 
that  by  means  of  this  continuous  loop  perfect  control  of  the  tampon  is  afforded. 
After  plugging  the  nostril  posteriorly,  anterior  plugs  may  be  inserted  in  case 
the  other  be  found  insufficient.  This  method  is  usually  very  effective,  and 
if  the  plugs  be  not  left  so  long  in  place  that  decomposition  takes  place, 
it  is  quite  safe.  Posterior  plugging  without  means  of  control  by  attached 
threads  is  by  no  means  free  from  danger,  since  death  by  suffocation  during 
sleep  has  been  known  to  occur  from  its  spontaneous  dislodgment.  Such  a  plug 
should  never  be  left  in  place  for  more  than  two  days.  If  there  be  necessity 
for  longer  protection  it  should  be  renewed.  Plugs  inserted  through  the  nostril 
should  be  tied  successively  to  a  single  piece  of  stout  silk,  so  that  later  they  may 
be  easily  dislodged  and  withdrawn  by  pulling  gently  upon  its  anterior  end. 

FOREIGX   BODIES. 

The  ears  and  nose  alike  are  exposed  to  the  introduction  of  foreign  bodies 
either  by  accident  or  by  design.  This  occurs  naturally  most  frequently  in 
children  who  have  not  yet  reached  the  age  of  reason.  A  list  of  possible 
foreign  substances  would  include  almost  everything  of  size  not  too  large  to 
enter  the  nostril,  and  no  attempt  need  be  made  to  catalogue  them.  Introduced 
nearly  always  from  without,  it  may  be  possible  for  them  to  enter  from  the 
naso-pharynx,  as  Avhen  a  substance  is  taken  into  the  mouth  and  almost  swal- 
lowed, being  finally  expelled,  not  into  the  mouth  again,  but  upward  into  the 
posterior  nares.  These  substances  are  by  no  means  necessarily  always  inert, 
since  insects  not  infrequently  effect  an  entrance  into  the  nostrils.  A  small 
particle  is  usually  expelled  by  a  reflex  act  as  soon  as  introduced,  but  if  it 
remain  long  it  may  gather  about  it  sufficient  tenacious  mucus  to  retain  it  in 
place  or  even  enable  it  to  resist  expulsion.  On  the  other  hand,  a  mass  which 
is  large  enough  to  be  introduced  with  some  difficulty  or  one  which  by  imbibi- 
tion of  moisture  may  expand  may  give  rise  to  a  great  deal  of  trouble  in  its 
removal. 

The  signs  and  symptoms  of  foreign  bodies  in  the  nose  are  usually 
unmistakable.  Little  children  will  sometimes  not  give  evidence  of  their  pres- 
ence until  decomposition  or  bleeding  or  profuse  discharge  attracts  attention. 

Treatment. — When  the  foreign  mass  is  visible  with  ordinar}^  artificial 
illumination,  it  can  usually  be  grasped  with  forceps  and  removed  or  be  dragged 
out  after  the  insertion  of  a  small  hook  or  tenaculum  point,  and  ordinarily  there 
is  nothing  difficult  about  this  manoeuver;  but  young  children  are  frequently 
so  uncontrollable  that  the  assistance  of  an  anesthetic  is  necessary,  and  the 
surgeon  can  accomplish  in  a  few  seconds  by  the  aid  of  chloroform  that 
which  would  require  a  long  struggle  without  it.     At  times  when  the  mass  is 


()04  AN  AMERICAN    TEXr-JiOOK   OF  SURGERY. 

located  too  i'ar  back  within  tlic  iiilV-rior  meatus  for  easy  witli(lr;i\val  it  will  be 
foiintl  much  easier  to  pass  in  some  sim])le  instrument  and  ])usb  it  backward  so 
that  it  shall  drop  into  the  naso-jiliarynx,  whence  it  should  be  removed  by  the 
surgeon  himself  in  order  to  avoid  further  complications.  Sometimes  sudden 
forcible  blowing  into  the  other  nostril  by  means  of  a  tube  over  the  end  of 
which  the  nostril  is  closed  will  expel  the  foreign  body.  Only  when  some  sim- 
ple procedure  of  this  kind  fails — and  tliis  will  ])e  very  rarely — will  anything 
in  the  nature  of  an  operation  be  rcijuired.  If  it  be  a  piece  of  metal  or  some- 
thing rigid  which  has  been  already  lodged  in  a  position  not  permitting  with- 
drawal, then  it  may  be  necessary  to  cut  away  some  portion  of  the  turbinated 
bone  or  make  some  atypical  operation  according  to  the  exigencies  of  the  case. 

EIIIXOLITIIS. 

These  are  calculi  or  calculous  concretions  varying  in  size  from  1  mm.  to  2 
or  3  cm.,  which  are  formed,  much  as  are  those  in  the  bladder,  by  the  deposition 
of  alkaline  salts,  mainly  phosphates,  around  a  foreign  particle  within  the  nasal 
passages.  This  foreign  particle  may  be  a  small  mass  of  desiccated  mucus.  They 
are  usually  unilateral,  and  commonly  lie  against  the  septum  or  Avithin  the  infe- 
rior or  the  middle  meatus.  The  general  congestion  or  inflammatory  changes 
around  them  may  give  rise  to  symptoms  alrendy  doscri])ed. 

AVhen  the  rhinolith,  as  such,  produces  symptoms,  they  are  much  like  those 
produced  by  any  other  foreign  body.  Nasal  discharge  and  obstruction  to  res- 
piration, with  accompanying  alteration  in  tone  and  voice,  and  perhaps  anosmia 
(loss  of  smell),  will  be  the  most  common  results.  If  any  portion  of  such  a  con- 
cretion presents  to  the  view,  it  will  probably  be  discolored  and  perhaps  almost 
black,  appearing  much  as  necrosed  ])one  in  the  same  location  often  does,  and 
may  be  mistaken  for  it.  Furthermore,  its  gritty  surface  may  increase  the  liabil- 
ity to  error ;  but  it  is  very  seldom  that  diseased  bone  alone  will  give  rise  to  so 
much  fetor  as  accompanies  an  aggravated  form  of  rhinolith.  Careful  examina- 
tion of  the  nasal  cavities  after  approved  methods  will  enable  a  diagnosis  to  be 
made,  after  which  it  Avill  probably  be  an  easy  task  with  suitable  dressing  for- 
ceps or  a  small  spoon  to  dislodge  and  remove  the  concretion.  If  necessary,  and 
if  no  tissue  around  it  calls  for  removal,  the  rhinolith  may  be  broken  into  pieces, 
being  usually  very  friable,  and  removed  piecemeal. 

PARASITES. 

The  parasites  which  infect  the  nasal  passages  are  mainly  insects  and 
worms.  In  this  country  they  are  very  rare.  In  the  tropics  such  cases  are 
frequent,  and  sometimes  of  serious  character.  Danger  comes  not  so  much  from 
the  adult  insect  as  from  the  larvae  which  it  may  deposit,  and  Avhich  may  be  aspi- 
rated into  the  deeper  cavities  with  inspiratory  movements.  Almost  the  only 
parasite  found  in  this  country  in  the  nose  is  the  maggot.  In  certain  catarrhal 
and  ozenous  affections  there  is  sometimes  such  fetor  of  discharge  as  to  attract 
flies,  which  penetrate  the  nasal  cavity  during  sleep,  deposit  eggs  there,  and 
leave  them  to  be  hatched  as  maggots,  their  incubation  being  favored  by  sur- 
rounding warmth  and  moisture.  Bv  anv  of  these  larv{\i  the  mucous  membrane 
may  be  destroyed,  and  the  cartilage  and  the  bones  become  necrosed. 

The  principal  symptom  is  an  itching  in  the  nose  which  sometimes  becomes 
intense,  with  various  ill-defined  but  well-located  disagreeable  sensations,  which 
in  nervous  and  susceptible  children  may  precipitate  convulsive  attacks.  Almost 
always  there  will  be  reflex  headache,  especially  in  the  frontal  region.     Hemor- 


SURGERY   OF    THE   RESPIRATORY   ORGANS.  605 

rhai^es  may  otx-ur  tlu-rt'  purely  as  tlie  result  of  ulceration  or  of  violent  expulsive 
eftorts.  Sonietinics  a  cellulitis  of  the  nasal  region  of  the  face  may  be  set  up, 
and  swelling  may  be  so  severe  as  nearly  to  close  the  eyelids.  In  the  tropics  the 
condition  may  be  fatal  within  a  few  hours,  from  local  and  general  disturbance. 
Antiseptic  douches  and  inhalations  of  chloroform  vaj)or  or  of  a  solution  of  iodine 
in  chloroform  will  be  efiective  in  destroying  the  ])arasite8. 

rOLYl'I   AND  TUMORS. 

The  principal  neoplasms  of  the  nasal  cavities  are  myxomata  and  myxo- 
fibromata,  which  usually  occur  in  polypoid  form,  vascular  tumors,  adenomata, 
exostoses  and  osteomata,  enchondromata,  and  the  malignant  tumors,  including 
various  forms  of  sarcomata  and  carcinomata.  Of  these  the  polypi,  which  are 
usually  adenomata  or  forms  of  myxomata,  are  the  most  frecjuent.  They  are 
composedof  very  soft  tissue  of  gelatinoid  consistence,  varying  a  little  in  firmness 
according  to  the  amount  of  fibrous  tissue  which  they  contain.  They  are  usually 
P3'riform  in  shape  and  pedunculated,  of  a  pale  flesh  tint,  almost  translucent,  vary- 
ing in  size  from  that  of  a  pea  to  that  of  an  almond,  and  annoy  mainly  from  the 
discomfort  which  they  cause  and  their  obstruction  to  respiration.  The  causes 
of  nasal  polypi  are  very  obscure.  Certainly  it  cannot  be  chronic  inflammation 
alone,  otherwise  they  would  be  met  with  in  a  large  majority  of  individuals. 
Men  are  more  liable  to  them  than  women,  and  children  usually  escape.  They 
are  met  with  sometimes  singly  ;  at  other  times  they  occur  by  dozens  and  form  a 
cluster,  several  of  which  may  perhaps  be  removed  at  one  time.  Some  of  these 
are  throughout  of  the  same  consistence,  others  have  a  cystic  interior ;  they  are 
covered  with  epithelium,  and  have  very  few  vessels,  if  any,  and  no  nerves  at  all. 
The  ordinary  mucous  polypi  do  not  adhere  to  the  bone.  Those  which  spring 
from  parts  beneath  the  mucosa  must  be  largely  fibrous  in  their  structure.  If 
they  grow  rapidly  they  cause  more  disturbance  than  Avhen  of  slow  growth. 

So  far  as  their  location  is  concerned,  they  grow  most  frequently  from  the 
middle  turbinated  body,  next  from  the  superior  turbinated  bone  and  meatus. 
They  rarely  spring  from  the  lower  turbina1;ed  bone  and  meatus  ;  in  other  words, 
they  will  usually  be  found  in  the  upper  and  more  anterior  portions  of  the  nose. 
They  almost  never  spring  from  the  septum.  While  they  may  extend  backward 
into  the  naso-pharynx  or  occasionally  into  the  sphenoidal  sinus,  they  never 
fully  escape  spontaneously  from  the  nostrils.  When  of  considerable  size  they 
may  adhere  at  different  points,  so  that  the  determination  of  their  pedicle  is 
difficult.  It  is  stated  that  the  pear-shape  forms  arise  from  sharp  prominences, 
while  those  wnth  broad  bases  arise  from  flat  surfaces. 

Symptoms. — These  are  at  first  insignificant  and  vague.  The  patient 
usually  complains  of  copious  secretion  from  the  nostrils  and  of  difficulty  in 
breathing  through  one  or  both  of  the  nares.  Later  comes  complaint  of  some 
discomfort,  and  the  patient  will  frequently  snuflf  in  the  endeavor  to  free  the 
nostrils  from  some  obstruction.  After  a  while  the  secretion  becomes  muco- 
purulent, with  perhaps  unpleasant  odor,  and  the  voice  acquires  a  peculiar  twang 
which  is  always  indicative  of  nasal  obstruction.  Perhaps  the  occurrence  of 
epistaxis  may  be  the  means  of  directing  especial  attention  toward  the  nose. 
The  symptoms  are  augmented  by  humidity  of  atmosphere,  since  mucous  polypi 
are  very  hygrometric.  Respiration  may  become  audible,  accompanied  by  a 
Avhistling  sound.  These  signs  and  symptoms  will  vary,  of  course,  with  the 
extent  of  the  disease.  Aside  from  these  purely  local  features,  there  occur 
more  or  less  frequent  reflex  disturbances,  among  which  should  be  mentioned 
asthma,  cough — often  distressing — hemicrania,  facial  and  cranial  neuralgia, 


<;(ii; 


Ay    AMiJncAX    TEXT- HOOK    OF   srilOKHY 


A,  Mucous  Polypi  in  the  Nose  ;  B,  anterior  view  of 
same,  normal  size  (Sajous). 


vertigo,  an<l  even  epilepsy.      ^\  hen  the  nasal  eavity  is  fille<l  with  polypi,  the 
nose  often  becomes  more  prominent  and  distended  (Fig.  25Gj. 

It  is  of  course  taken  for  granted  that  any  complaint  of  nasal  obstruction 
will  lead  to  a  careful  examination  of  the  nose.     Nasal  polypi  can  scarcely  be 

taken  for  anything  else  save  possibly 
adenoid  and  catarrhal  hypertrophy 
of  the  mucous  membrane.  When 
cocaine  solutions  are  applied  to  the 
former,  they  are  not  at  all  affected, 
while  the  latter  at  once  shrink  and 
retract  under  their  influence.  It 
will  be  found  also  that  a  probe 
carefully  manipulated  may  be 
passed  under  or  around  the  ordi- 
nary polypus,  so  that  it  can  per- 
haps be  moved,  or  as  it  were 
swung,  from  its  stem,  while  it  may 
often  be  seen  to  sway  or  move 
in  a  current  of  expired  air.  Aside  from  the  local  reflex  annoyance  which 
it  causes,  tbe  condition  can  scarcely  be  considered  dangerous.  There  is  a 
great  liability  to  recurrence  after  removal,  which  is  due  undoubtedly  to  failure 
to  make  extirpation  complete  and  to  cauterize  and  destroy  the  surface  or  base 
from  which  each  polyp  has  sprung.  Moreover,  when  the  condition  is  multiple, 
minute  or  incipient  polypi  may  elude  observation,  develop  later,  and  take  the 
place  of  those  which  were  removed.  Furthermore,  the  very  causes  which 
operate  in  the  first  place  to  produce  them  may  continue  so  to  act. 

While  polypi  may  be  spontaneously  expelled,  their  proper  treatment  is 
always  surgical.  Formerly  the  endeavor  was  made  to  inject  into  them  some 
escharotic,  such  as  acetic,  chromic,  or  carbolic  acid,  or  some  powerful 
astringent ;  but  safer  and  more  dexterous  manipulations  have  taken  the  place 
of  these  rude  attempts,  and  measures  for  their  removal  now  include  avulsion, 
excision,  and  the  galvano-cautery.  By  avulsion  is  meant  the  use  of  forceps  of 
suitable  device  by  which  the  polypus  is  seized  as  firmly  as  may  be,  and  with  as 
little  force  as  is  necessary  twisted  off  from  its  base.  If  the  operator  know 
thorou^hlv  his  anatoniv  and  can  make  out  the  exact  location  of  the  jrrowth, 
he  will  work  much  less  in  the  dark  than  according  to  the  old-fashioned  way  of 
practically  tearing  away  with  the  forceps  whatever  they  may  seize.  This  latter 
method  is  painful  and  bungling,  and  likely  to  produce  copious  bleeding,  where- 
as the  former  is  satisfactory  so  far  as  it  goes.  The  naris  should  be  illuminated, 
and  when  the  polyp  can  be  neatly  grasped  it  is  better  to  twist  it  off  by  revolv- 
ing the  instrument  until  it  is  dislodged  than  rudely  to  tear  it  away.  In  this 
as  in  the  other  operations  cocaine  solutions  give  the  greatest  aid.  not  only  by 
obtunding  sensibility,  but  also  by  causing  retraction  of  surrounding  tissue  and 
better  exposure  of  the  growths. 

For  excision  or  abscission  a  most  serviceable  instrument  is  that  form  of 
^craseur  devised  by  Jarvis,  by  which  pedunculated  growths  can  be  blood- 
l^ssly  and  almost  painlessly  removed  (Fig.  253).  Some  dexterity  and  prac- 
tice are  necessary  for  its  skilful  manipulation,  yet  these  may  be  easily 
acquired.  The  base  of  the  growth  is  caught  by  the  wire  loop,  and  its  size 
rapidly  or  slowly  diminished  according  to  the  amount  of  discomfort  cau.sed. 
After  removal  of  the  polyp  its  base  should  be  cauterized  with  some  chemical 
caustic  or  the  galvano-cautery.  Of  course  both  indications  are  carried  out 
when  the  galvano-caustic  loop  is  employed.     The  principal  objection  to  this 


SURGERY    OF    rilE    RESPIRATORY    ORGANS.  607 

method  is  tlie  number  of"  re))etition.s  usually  necessarv  to  secure  entire  removal 
of  myxomatous  tissue.  Almost  ahvays  alter  thus  operating  some  local  treat- 
ment Avill  be  found  necessary  in  order  to  overcome  the  condition  of  chronic 
hyperemia  or  inilaiiimation  consequent  upon  it. 

Naso-pharyngeal  Polyp. — A  denser  and  more  fibrous  form  of  polypoid 
growtli,  composed  of  mixed  mucous  and  fibroid  tissue,  occurs  farther  back  in 
the  nose,  and  occasionally  ])olypoid  tumors  of  nearly  pure  fibromatous  character 
S])rin*i:ing  from  the  jieriosteum  or  the  bone  at  the  base  of  the  skull  or  the 
adjoining  facial  bones  Avill  be  found  projecting  into  the  pharynx.  These  be- 
come of  more  serious  nature  in  proportion  to  the  amount  of  fibrous  tissue  they 
contain,  since  the  latter  will  prove  a  pretty  accurate  index  of  their  vascularity. 

When  these  spring  from  the  septum  or  turbinated  bones,  they  can  usually 
be  removed  by  the  ex])ert  with  the  snare  or  the  galvano-caustic  loop,  but  a 
genuine  fibroid  growing  from  the  base  of  the  skull  and  projecting  downward 
into  the  naso-pharyngeal  cavity  is  an  afi'air  of  a  most  serious  nature.  For 
the  removal  of  such  growths  operations  of  the  greatest  magnitude  have  been 
undertaken,  with  varying  success.  The  upper  jaw  of  one  side  has  been  re- 
sected, or  the  roof  of  the  mouth  cut  away,  or  both  upper  jaw^s  so  far  loosened 
from  their  connections  as  to  be  temporarily  depressed,  an  incision  being  made 
clear  across  the  face,  by  means  of  which  extensive  operative  procedure  access  has 
been  gained  to  the  naso-pharynx.  Even  after  this  has  been  done  the  removal 
of  the  growth  is  by  no  means  an  easy  matter,  and  the  writer  has  seen  in  one 
case  a  patient  perish  on  the  table  from  hemorrhage  from  one  of  these  growths 
during  such  an  operation,  which  even  the  skill  of  a  celebrated  surgeon  could 
not  check.  Langenbeck's  osteo-plastic  resection  of  the  upper  jaw  consists  in 
an  incision  from  the  inner  angle  of  the  orbit  to  the  malar  bone,  and  a  second 
from  the  nostril  to  the  malar  bone,  joining  the  first.  The  soft  parts  are  left 
adherent  to  the  bone.  The  bone  is  then  sawn  through  both  incisions  to  the 
retro-maxillary  fossa,  which  is  exposed,  when  the  bony  flap  thus  made  hinging 
on  the  central  line  of  the  nose  is  thrown  over  on  the  opposite  cheek.  This 
lays  open  the  whole  naso-pharyngeal  cavity  and  retro-maxillary  space.  The 
parts  are  then  returned  to  their  normal  position  after  removal  of  the  tumor. 

VASCULAR  AND  OTHER  TUMORS. 

Angeiomata  in  the  nose  are  rare.  They  are  to  be  sharply  distinguished 
from  a  simple  varicose  condition  of  a  limited  area  of  mucous  membrane,  which 
is  quite  common.  They  occur  mostly  in  males  during  adolescence.  Of  the 
symptoms,  epistaxis  is  the  most  frequent  and  most  prominent,  the  bleeding 
being  most  profuse  and  persistent. 

Adenomata. — Enough  has  already  been  said  to  show  that  a  multiple 
adenomatous  affection  of  the  mucous  glands  is  very  common,  and  such  enlarge- 
ments constitute  the  principal  type  of  adenomata  occurring  in  the  nose.  As  a 
rule,  they  are  inseparable  from  hyperplasia  of  the  surrounding  tissue.  Trans- 
formation from  adenoma  into  carcinoma,  though  infrequent,  is  well  known  to 
occur.  When  met  with,  the  tumor  must  be  removed  after  the  approved  fashion 
with  the  cold  or  hot  wire  loop. 

Exostoses  and  Osteomata. — Outgrowths  of  bone  which  after  a  fashion 
simulate  physiological  or  normal  protrusions  are  to  be  considered  as  exostoses, 
while  those  which  bear  no  such  resemblance  are  termed  osteomata.  These  are 
sometimes  of  cancellous  bone,  but  more  often  of  compact  bony  tissue.  They 
are  not  common,  are  most  often  met  with  in  the  young,  and  at  times  may  attain 
large  size.     The  symptoms  which  usually  attract  attention  are  increased  dis- 


COS  AN  AMERICAN    TEXT-BOOK    OF   SURGERY. 

charge  ul'  mucus,  lu'inorrhai^e,  a  feeling  of  obstruction  and  of  disconifoi-t  or 
itcliing,  sometimes  severe  neuralgic  pain,  and  perhaps  loss  of  smell.  Proper 
examination  will  reveal  the  obstruction,  and  the  probe  or  other  instrument 
must  be  used  in  order  to  determine  by  its  hardness  and  rigidity  whether  it  be 
composed  of  soft  tissue,  cartilage,  or  bone.  If  of  long  duration  there  may 
be  ulceration  and  even  necrosis.  If  the  latter  have  taken  place  tliere  will 
be  a  fetid  discharge  which  Avill  certainly  attract  attention.  In  size  and  shape 
they  vary  very  much.  Fortunately,  it  is  usually  easy  to  separate  them  fron) 
the  bone  from  which  they  spring.  This  removal  may  be  effected  with  the  wire 
loop,  with  stout  scissors  adapted  to  the  purpose,  or  with  one  of  the  forms  of 
intranasal  saw.  In  a  few  instances  when  the  growth  was  large  and  firm  it 
has  been  found  necessary  to  lay  open  the  nose  so  as  to  expose  well  the  nasal 
cavity  of  one  side ;  but  such  operations  are  done  much  more  often  in  Europe, 
since  American  ingenuity  has  devised  the  dental  engine  or  its  substitutes,  by 
means  of  which  a  rapidly-revolving  trephine  or  burr  may  be  made  to  cut  away 
even  firm  osseous  tissue  with  little  shock  and  with  no  necessity  for  external 
incisioTis. 

Enchondromata. — These  are  much  more  rare  than  bony  tumors,  al- 
though an  ecchondrosis  corresponding  exactly  to  the  idea  conveyed  by  the 
term  exostosis  is  a  very  frequent  occurrence  in  the  nose,  forming  a  cartilag- 
inous spur  or  projection  often  seen  on  the  septum.  Their  detection  and 
removal  in  no  wise  differ  from  those  of  bony  growths,  and  need  no  further 
description  here. 

Malignant  Tumors. — Although  the  nose  is  fre([uently  involved  in  can- 
cerous growths,  they  are  rarely  of  primary  origin  in  this  locality.  Even  with 
all  the  irritations  to  which  the  Schneiderian  membrane  is  exposed,  primary 
epithelioma  is  very  uncommon.  Sarcomata  arise  more  frequently  from  the 
septum,  while  epitheliomata  are  perhaps  equally  common  upon  the  septum  and 
upon  the  turbinated  bones.  While  thorough  extirpation  here  as  elsewhere  is  the 
only  serviceable  method  of  treatment,  this  may  be  done  perhaps  better  by  the 
actual  cautery  operated  through  the  natural  passages  than  with  more  formidable 
cutting  operations.  If  complete  destruction  can  be  accomplished  safely  by  some 
chemical  means,  such  as  lactic  acid,  there  is  no  reason  why  it  should  not  be  as 
effective  as  removal  by  operation.  In  proportion  as  these  growths  affect  the 
parts  nearer  the  pharynx  they  become  less  accessible,  more  likely  to  infiltrate 
and  affect  the  surrounding  lymphatics,  and  both  more  difficult  and  more  danger- 
ous to  attack  by  operation.  Still,  whatever  good  is  to  be  accomplished  in  such 
cases  must  be  achieved  either  by  use  of  instruments  or  by  the  galvano-cautery. 

AFFECTIONS  OF  THE  SINUSES. 

Frontal  Sinuses. — Injuries. — These  occur,  as  a  rule,  from  direct  vio- 
lence upon  the  forehead,  Avhich  may  cause  either  sim])le,  compound,  or  commi- 
nuted fracture  of  its  walls.  Simple  fracture,  Avitli  absence  of  cerebral  symp- 
toms, is  common.  It  may  be  complicated  by  emphysema  of  the  surrounding 
soft  parts,  which  may  occur  through  the  escai)e  of  air  from  the  nose.  If 
there  be  depression  of  the  outer  table,  it  should  be  elevated  to  prevent 
deformity.  Compound  and  comminuted  fractures  may  be  complicated  by  the 
lodgment  of  a  foreign  body.  They  are  made  more  serious  when  the  posterior 
wall  is  also  broken  and  the  dura  exposed.  Operative  interference  is  always 
indicated  in  such  a  case.  They  are  known  to  have  been  followed  sometimes  by 
fistulous  openings  through  which  air  may  pass,  and  plastic  operations  have  beea 
made  for  their  closure. 


SURGERY    OF    THE    RESPIRATORY    ORGANS.  609 

Foreign  Bodies  an;  either  introduced  from  above  or  make  their  way 
upward  from  the  nose.  The  hitter  are  usually  insects  which  creep  up  and  may 
either  die  there  or  deposit  larvio  which  hatch  and  live.  It  is  said  that  centi- 
pedes have  been  found  witliin  the  frontal  sinus.  These  parasites,  if  they  cause 
any  trouble  at  all,  will  usunlly  set  up  an  acute  inflammation  which  will  termi- 
nate ])y  abscess. 

Inflammation. — This  may  be  acute  or  chronic.  When  the  latter,  it  is  usu- 
ally due  to  tuberculosis  or  syphilis.  Inflammation  may  be  the  result  of  exten- 
sion from  the  mucosa  of  the  nose  or  from  the  surrounding  bone.  According 
to  its  intensity  will  be  the  severity  of  its  symptoms,  which  consist  in  the  main 
of  pain  and  headache  and  a  sense  of  weight  and  fulness  in  the  forehead,  with 
usually  the  symptoms  of  acute  coryza.  The  local  signs  are  swelling  and  ten- 
derness, more  or  less  fever,  rigors,  and  even  delirium  in  the  most  acute  cases. 
When  pus  has  formed  and  has  escaped  from  the  sinus  proper  into  the  cranial 
cavity,  it  may  produce  various  pressure-signs.  An  erysipelatous  blush  of  the 
overlying  skin  sometimes  occurs.  AVhen  the  disease  is  of  syphilitic  origin 
there  wnll  be  other  signs  of  the  constitutional  condition.  When  of  tubercular 
origin  it  will  probably  be  accompanied  by  caries  or  necrosis  of  the  enclosing 
bone,  with  other  local  manifestations. 

A  collection  of  pus  in  the  frontal  sinus  is  often  spoken  of  as  empyema 
of  the  same,  which,  if  old,  will  have  produced  marked  change  in  the  external 
contour  of  this  part  of  the  face.  The  roof  of  the  orbit  is  sometimes  depressed, 
and  even  the  globe  of  the  eye  altered  in  position.  When  long  existent  the 
bony  wall  may  have  so  far  disappeared  by  absorption  as  to  yield  a  kind  of 
parchment  crepitation  upon  pressure,  with  fluctuation  underneath.  This  puru- 
lent collection  tends  to  evacuate  itself  spontaneously  in  the  direction  of  least 
resistance,  which  may  be  either  externally  into  the  nose  or  orbit  or  internally 
into  the  ethmoid  cells  or  the  cranial  cavity. 

When  signs  of  inflammation  first  present  themselves  here,  leeching  will 
often  aiford  relief.  This  may  be  combined  with  whatever  other  treatment  is 
suggested  by  the  condition  within  the  nose  ;  but  just  so  soon  as 'signs  of  pus 
are  present  or  of  cerebral  disturbance  or  any  other  serious  condition,  no  time 
should  be  lost  in  perforating  the  external  surface  with  a  small  trephine  or  other 
instrument  and  cleansing  and  draining  the  cavity.  In  spite  of  the  resulting 
scar,  it  is  wiser  to  do  this  by  external  incision  rather  than  by  operating 
through  the  nose,  as  many  have  done  in  time  past. 

Cystic  Dilatation  or  Dropsy  of  the  Frontal  Sinus  has  been  described 
by  various  writers,  as  well  as  hematomata  and  hydatid  cysts.  It  is  enough 
here  to  mention  the  possibility  of  their  occurrence,  referring  the  student  to 
the  larger  treatises  for  their  further  description. 

Tumors  also  occur  within  this  sinus,  both  benign,  like  myxoma  and 
fibroma,  and  malignant,  such  as  sarcoma  and  scirrhus.  If  considered  suitable  to 
attack,  they  must  be  removed  by  external  incision.  The  entire  thickness  of 
the  frontal  bone  has  been  more  than  once  removed  in  order  to  extirpate  growths 
of  this  kind,  and,  providing  the  condition  of  the  patient  be  at  all  favorable,  no 
operation  can  expose  to  so  much  damage  and  danger  as  does  such  a  tumor. 

Ethmoidal  Cells. — The  ethmoidal  cells  are  liable  to  affection  by  direct 
extension  from  the  Schneiderian  membrane,  by  which  they  are  occasionally 
involved  in  catarrhal  thickening,  polypoid  growths,  and  even  caries  with  per- 
foration of  the  bones  of  the  skull,  accoi'ding  to  Virchow.  Diphtheritic  disease 
has  also  extended  as  far  as  these  cells,  and  it  is  stated  that  a  frequent  cause 
of  ozena  is  to  be  found  here. 

Sphenoidal  Sinus. — W^hat  has  just  been  stated  with  reference  to  the 

.39 


fJlO  Ay   AMKIUCAX    TF.XT-liOOK    OF   SURGERY. 

ethmoidal  cells  holds  good  also  with  relerence  to  this  sinus,  hut  witii  this 
difterence,  that  disease  here  is  more  favorahly  located  for  surgical  relief. 
Escape  of  cerebro-spinal  fluid  has  been  observed  after  injuries  of  this  sinus. 
Furthermore,  by  virtue  of  its  intimate  relation  with  the  internal  carotid  and  the 
cavernous  sinus,  injuries  to  these  vessels  have  followed  wounds  to  this  bony  cav- 
ity, and  pulsating  exophthalmos  has  been  known  thus  to  result.  Caries  and  ne- 
crosis of  the  body  of  the  sphenoid  may  produce  lesions  of  the  nerves  above  men- 
tioned, separation  of  fragments  of  l)one,  hemorrhage  which  nuiy  be  fatal,  retro- 
pharvngeal  abscess,  thrombosis  of  the  cavernous  sinus,  and  perforation  of  the 
baseof  the  skull.  We  may  also  have  an  empyema  of  this  cavity  from  causes 
similar  to  those  mentioned  before,  the  signs  and  symptoms  of  which  would 
include  headache  and  spasmodic  and  sympathetic  affections  of  the  nerves  in 
intimate  relation  with  it ;  for  example,  photophobia  and  blepharospasm.  The 
sinus  has  been  operated  upon  in  recent  years  by  three  different  paths:  through 
the  naso-pharynx  ;  through  the  orbit  after  enucleation  of  the  eye;  and  by  the 
nose,  which  seems  to  be  the  preferable  route. 

Tumors  of  the  same  character  as  those  which  involve  the  frontal  sinus  may 
also  be  met  with  here,  although  much  less  amenable  to  operative  relief. 

The  Antrum  of  IIigiimore,  or  the  Maxillary  Sinus. — The  outer 
wall  of  this  cavity  is  t|uite  exposed,  and  is  liable  to  simple  fracture  by  a  blow,  or 
to  compound  injury  with  perforation  by  a  weapon  or  other  foreign  substance. 
The  entire  cavity  is  sometimes  perforated  by  a  foreign  body,  such  as  a  bullet. 
When  the  outer  wall  is  depressed  by  injury  or  comminuted,  it  may  perhaps  be 
elevated  bv  instruments  introduced  directly  or  from  within  the  mouth  or  nose. 
Swelling  of  the  overlying  soft  parts,  which  may  occur  very  frequently  and 
very  <iuickly,  will  sometimes  mask  a  depression  of  the  bone.  Mistake  can  be 
best  avoided  by  exploration  with  the  finger  in  the  mouth. 

The  antrum  is  sometimes  filled  with  blood,  either  as  the  result  of  injury 
from  without  or  as  the  result  of  epistaxis.  Almost  always  after  plugging  the 
nose  blood  will  force  its  way  into  the  cavity.  Ordinarily  it  Avill  be  easily  and 
quickly  resorbed,  but  decomposition  may  result  and  abscess  ensue.  Insects 
and  foreign  bodies  may  also  exceptionally  be  found  in  it. 

The  most  common  affection  of  the  antrum  is  inflammation  with  subse- 
quent abscess.  This  may  be  the  result  of  a  propagation  of  the  inflam- 
matory lesion  from  the  nose,  or  not  infrequently  of  disease  following  up  the 
roots  of  the  teeth,  which  sometimes  project  a  little  distance  into  this  cavity. 
As  to  the  former,  it  may  be  said  that  the  average  size  of  the  opening  of  the 
antrum  into  the  middle  meatus  of  the  nose  is  4  by  8  mm.  A  second  opening 
rarely  exists,  and  has  l)een  ascribed  by  Giraldes  to  a  rarefying  atrophy.  When 
we  remember  the  ease  of  communication  from  one  cavity  to  the  other,  the 
■wonder  is  that  abscess  does  not  occur  much  more  frequently  than  is  the  case. 
Not  a  few  cases  have  followed  attacks  of  the  grippe  in  which  the  nasal  symp- 
toms were  especially  severe.  The  presence  of  polypi  appears  to  be  some- 
times the  exciting  cause.  The  second  form  appears  to  be  an  extension  by  an 
alveolar  periostitis  which  is  the  result  of  dental  caries;  and  a  third  form  may 
arise  from  purely  traumatic  causes. 

Whatever  the  cause,  the  symptoms  are  about  the  same,  consisting  of  local 
pain  radiating  in  various  directions,  especially  toward  the  nose,  swelling  of  the 
overlying  soft  parts,  and  thinning  of  the  bone  so  that  sometimes  it  gives  rise 
to  a  parchment-like  crepitation.  If  the  nasal  outlet  be  still  patulous  and  pus 
be  present  in  the  antrum,  it  will  be  found  that  in  certain  positions  of  the  head 
it  Avill  floAV  into  the  nose,  passing  either  anteriorly  or  posteriorly.  When 
this  pathognomonic  symptom  is  present  the  pus  is   very  frequently  offensive. 


siR(;i:iiy  of  tiik  UKsriRATijuy  org  Ays.  Gil 

With  the  nasal  specuhim  it  may  jierhaps  be  seen  trieklin^f  into  the  nose. 
AVhen  the  symptoms  are  very  severe  there  may  occur  an  expansion  of  the 
•whole  jaAv  with  elevation  of  the  malar  bone,  displacement  of  the  eyeball, 
extreme  alveolar  tenderness,  and  extension  of  trouble  along  various  nerve- 
sheaths,  with  spontaneous  perforation  in  some  direction  if  timely  relief  be  not 
afforded.  Percussion  over  the  two  antra  will  reveal  a  dull  sound  on  the  side 
of  the  abscess.  Attention  has  been  called  to  the  possiliility  of  derivin<r  infor- 
mation from  the  use  of  an  electric  light  in  the  mouth,  l;ut  Zeim  does  not  think 
the  diagnosis  of  suppuration  in  the  antrum  can  be  luade  with  any  certainty  by 
this  means.  Between  long-existing  abscess,  cystic  degeneration,  and  tumor 
within  the  antrum  there  may  be  some  difficulty  of  diagnosis,  but  the  presence 
or  absence  of  early  signs  of  inflammation  Avill  aid  as  between  the  first  two,  while 
as  between  cystic  degeneration  and  tumor  the  existence  of  cachexia  or  of  local 
signs  of  inflammation  will  be  most  significant. 

The  treatment  of  inflammation  previous  to  the  formation  of  an  abscess 
may  consist  in  leecliing  and  hot  applications,  with  appropriate  general  measures. 
When  pus  has  already  accumulated,  a  free  opening  for  its  evacuation  is  essential. 
If  the  disease  has  extended  upward  from  a  tooth,  the  old  method  of  removal 
of  the  tooth  and  the  perforation  of  the  antrum  at  its  base  will  l>e  proper.  But 
when  the  teeth  are  sound,  it  is  a  pity  to  sacrifice  one  of  them  for  this  purpose, 
and  it  is  preferable  to  perforate  the  antrum  at  the  point  of  election,  which  is 
above  the  point  of  the  root  of  the  second  bicuspid,  about  an  inch  above  the 
border  of  the  gum.  The  mucous  membrane  of  the  buccal  fold  may  be  incised 
at  this  point  and  the  thin  wall  of  bone  perforated  Avith  a  trocar  or  a  delicate 
gouge  Avith  the  exertion  of  very  little  force.  By  this  means  a  free  opening 
can  be  made  with  drainage  into  the  mouth.  More  perfect  drainage,  however, 
may  be  obtained  by  making  a  counter-opening  into  the  inferior  meatus  of 
the  nose,  ^'.  e.  on  a  level  Avith  the  floor  of  the  antrum;  and  if  this  be  done  a 
drainage-tube  may  be  drawn  through  from  the  mouth  into  the  nose  and  left 
protruding  at  the  nostril  for  a  fcAV  days.  This  permits  such  thorough  irriga- 
tion as  to  ensure  reasonably  rapid  recovery  from  the  empyemic  condition  without 
making  the  operation  in  any  sense  more  severe  or  more  serious.  Daily  irriga- 
tion should  be  practised,  and  one  or  both  openings  should  be  kept  patulous  Avith 
a  proper  packing  or  suitable  device  so  long  as  any  pus  is  discharged. 

Tumors. — Morbid  groAvths  Avithin  the  antrum  are  by  no  means  uncommon, 
originating  less  frequently  from  the  alveolar  border  than  from  the  muco-perios- 
teum.  Of  307  cases  tabulated  by  Weber,  133  Avere  carcinomata,  84  sarcomata, 
32  osteomata,  20  cysts,  17  fibromata,  and  the  remainder  miscellaneous  ;  in  other 
words,  on  the  average  tAvo-thirds  of  the  tumors  of  the  antrum  are  malio;nant. 
Their  general  character  as  to  benignity  or  malignity  must  be  judged  by  their 
rapidity  of  groAvth  and  by  the  general  condition  of  the  patient.  Their  earlier 
stages  are  marked  by  fcAV  if  any  symptoms,  Avhile  their  later  symptoms  are 
almost  identical.  If  aftection  of  the  neighboring  lymphatic  glands  can  be 
detected,  the  probability  is  that  they  are  malignant,  although  it  must  be  said 
of  cancer  of  the  antrum  that,  as  a  rule,  the  external  lymphatics  are  slow  to 
become  involved.  If  a  tumor  be  recognized  in  this  location,  a  decision  as  to 
Avhether  to  operate  must  be  formed  partly  upon  the  age  and  general  state  of 
the  patient,  and  partly  upon  the  absence  or  presence  of  signs  of  involvement 
of  the  adjoining  and  especially  the  surgicalh'  inaccessible  parts.  To  this  end 
careful  examination  of  the  nose  and  naso-pharynx  should  be  made,  vision  should 
be  tested,  and  all  the  nerves  of  special  sense,  as  well  as  the  motor  and  sensory 
nerves  of  this  region,  should  be  studied  in  order  to  recognize  signs  of  involve- 
ment of  any  of  them.     It  having  been  decided  to  operate,  the  operation  is 


612  ^.V  AMERICAN"    TKXT-r.OOK    OF  SURGKJiV. 

practically  that  of  removal  of  the  ujjjter  jaw,  which  is  described  in  aiKjther 
place.  If  the  trouble  be  malignant,  the  surgeon  cannot  be  too  thorough  in 
removing  tissues  M'hich  are  even  suspicious.  If  the  neoplasm  be  benign,  it 
may  be  enough  to  lay  open  the  cheek  by  the  usual  incision  for  the  more  for- 
midable procedure,  and  then  to  expose  the  interior  of  the  antrum  by  cutting 
away  its  anterior  wall.  This  will  permit  the  easy  extirpation  of  polypi,  fibro- 
mata, cysts,  etc. 

INJURIES  OF  THE  NOSE, 

Fractures  and  Dislocations  of  the  nasal  bones  are  considered  elsewhere. 

Wounds  of  the  nose  may  be  contused,  incised,  or  lacerated.  They  de- 
mand care  in  treatment  mainly  for  the  prevention  of  deformity.  Accurate 
coaptation  of  edges,  readjustment  of  parts  in  proper  position,  and  reduc- 
tion by  suitable  means  call  for  a  high  degree  of  surgical  skill.  Some  in- 
ternal support,  as  from  a  rubber  or  glass  tube  or  an  antiseptic  plug,  may 
be  advisable,  and  externally  the  collodion  dressing  reinforced  by  a  few  cot- 
ton fibers  will  be  found  atlmirable.  When  a  portion  of  the  nose  has  been 
actually  carried  away,  some  plastic  operation  for  its  repair  becomes  neces- 
sary. Experience  has  also  shown  that  when  the  nose  has  been  partially  or 
even  completely  detached  it  is  possible  for  complete  union  to  occur  if  it  be 
immediately  restored  to  its  proper  position  and  suitably  held  in  place.  Foreign 
bodies,  of  course,  should  be  immediately  removed.  Burns  and  scalds  of  the 
nose  are  of  particular  importance,  because  of  possible  cicatricial  contraction 
and  consequent  deformity.  This  is  bad  enough  at  any  part  of  its  surface,  but 
is  worst  of  all  when  occurrinj^  around  the  nostrils.  It  is  to  be  fruarded  against 
by  the  utmost  care  during  the  healing  process.  an<l  perhaps  by  some  artificial 
intranasal  support,  which  must  be  worn  steadily  for  some  time  and  after  a 
while  may  be  Avorn  only  during  the  night.     (See  also  Deformities.) 

Surgical  Emphysema  of  the  Nose. — This  occurs  quite  commonly  after 
any  injury  by  which  a  lesion  of  the  mucous  membrane  is  produced,  especially 
after  fracture  and  dislocation.  The  term  implies  a  distention  or  blowing  up  of 
the  cellular  tissue  by  air,  especially  during  the  expiratory  act,  and  is  particularly 
likely  to  take  place  when  clots  of  blood  fill  up  the  nasal  cavity  and  by  their 
presence  excite  the  patient  to  frequent  involuntary  efforts  to  expel  them.  The 
condition  varies  from  the  slightest  recognizable  puffiness  of  the  skin  about  the 
bridge  of  the  nose  to  a  most  marked  swelling  of  the  soft  parts  about  the  face, 
eyes,  and  forehead,  b}'  which  the  patient's  features  may  be  made  almost  unrec- 
ognizable. When  the  palpating  fingers  are  placed  upon  the  distended  tissues 
a  very  fine  bubbling  crepitation  is  at  once  detected.  This  condition,  though 
terrifying  to  the  laity,  is  one  by  itself  of  no  serious  importance.  Only  in  case 
germs  of  decomposition  enter  and  set  up  a  septic  cellulitis  will  any  trouble 
follow.  Should  this  result,  the  phlegmonous  cellulitis  might  be  serious  or 
even  fatal.     It  would  call  for  constitutional  treatment  and  free  incisions. 

EHINOPLASTY. 

The  tenn  rhinoplasty  includes  all  operations  having  for  their  object  the 
restoration  or  repair  of  the  nose.  They  are  called  for:  1st,  for  correction 
of  congenital  deformity;  2d,  to  repair  effects  of  injury;  and  3d,  for  restora- 
tion from  the  ravages  of  disease,  the  latter  being  malignant  or  ulcerative, 
with  or  without  caries  or  necrosis  of  the  bone.  No  operation  of  the  kind 
should  be  performed  until  the  destructive  process  lias  been  positively  checked 
or  all  actually  diseased  tissue  removed  by  excision  or  ablation.     These  ope- 


SURCTEMY   OF    THE   RESPIRATORY   ORGANS.  613 

rations  date  back  to  the  earliest  days  of  surgery,  and  seem  to  have  been  suc- 
cessfully practised  at  a  time  when  o])erative  surgery  in  general  was  very 
crude.  Kliiiioplasty  is  divided  into  total  and  partial.  For  the  relief  of  par- 
tial deficiencies,  such  as  defect  of  one  of  the  ahe,  a  flap  may  be  taken  from 
the  upper  side  of  the  nose  or  from  the  tissues  of  the  cheek ;  usually  only 
when  it  requires  to  be  very  large  will  it  be  necessary  to  take  it  from  the  fore- 
head. These  flaps  are  almost  invariably  made  by  the  process  of  transplantation, 
leaving  a  pedicle  for  vascular  supply,  which  should  not  be  twisted  too  tightly, 
lest  this  su])))ly  be  cut  off".  After  the  flap  is  fii-ndy  im])lanted  in  its  new  posi- 
tion, say  in  from  ten  to  fourteen  days,  the  pedicle  may  be  divided,  or,  if  neces- 
sary, a  redundant  portion  exsected.  An  extreme  condition  of  pug-nose  has 
been  remedied  by  cutting  transversely  across  the  nose,  drawing  the  tip  down 
to  the  desired  position,  and  then  transplanting  flaps  from  the  cheeks  to  fill  the 
wedge-shaped  defect.  A  new  columna  nasi  is  sometimes  formed  from  the  upper 
lip  by  exsecting  a  small  part  at  the  middle  line  and  then  turning  the  strip 
upward,  the  inside  of  the  tip  of  the  nose  l)eing  freshened  for  its  reception. 
The  wound  in  the  lip  is  then  closed,  as  in  the  case  of  hare-lip,  with  pins  or 
sutures.  For  the  relief  of  fistulous  openings  on  one  or  both  sides  it  is  neces- 
sary cleanly  to  excise  the  ulcerated  or  cicatrized  margin,  and  then  to  slide  or 
transplant  a  flap  fi'om  the  adjoining  cheek. 

For  restoration  of  the  entire  nose  two  quite  diff'erent  methods  have  been 
suggested,  both  of  which  are  old.  The  procedure  is  as  follows :  First  of  all, 
it  is  necessary  to  have  an  idea  of  the  amount  of  skin  to  be  transplanted. 
In  order  to  do  this,  a  pattern  is  made  with  a  piece  of  oiled  silk  by  fash- 
ioning it  over  the  normal  nose  of  some  other  individual,  or  by  building  up 
on  the  face  of  the  patient  with  wax,  clay,  or  dough  a  model  of  a  nose  which 
shall  suit  the  other  features.  The  pattern  thus  made  will  be  rudely  pyriform, 
and  it  will  be  seen  that  a  peculiar  projection  is  to  be  arranged  for  at  the  dis- 
tal border,  from  which  the  columna  or  septum  is  to  be  formed.  This  pattern  is 
to  be  used  on  either  the  forehead  or  the  arm  of  the  patient,  according  to 
the  selection  of  the  operator. 

The  Tagliacotian  method  (Fig.  257),  named  from  Tagliacozzi,  a  famous 
Italian  surgeon  of  the  sixteenth  century,  comprehends  the  use  of  a  flap  of  skin 
raised  usually  from  the  left  arm  of  the  patient.  This  flap  is  marked  out  upon 
the  arm  by  means  of  the  pattern  already  referred  to, 
allowing  one-third  on  every  side  for  shrinkage,  since  Fig. 

the  human  skin  may  be  always  expected  to  shrink  to 
about  this  extent  after  the  division  or  raising  of  a  flap. 
The  original  procedure  includes  the  detaching  of  this 
flap  except  its  pedicle,  and  leaving  it  for  about  two 
weeks  in  order  that  it  may  become  more  vascular  and 
thickened  and  its  lower  surface  covered  with  granula- 
tion. After  two  weeks  the  stump  or  remains  of  the  orig- 
inal nose  are  pared,  and  all  surfaces  to  which  it  is  in- 
tended that  the  new  flap  shall  unite  are  freshened  with 
scissors  or  knife,  and  then  the  arm  is  brought  up  to 
the  head,  the  flap  trimmed  to  the  exact  necessary  shape, 
and  fastened  in  its  new  position  by  numerous  sutures, 
after  which  the  hand  is  placed  upon  the  top  of  the  head, 
and  hand  and  forearm  suitably  bandaged  thereto  by  a  ■svarreu's  Apparatus  for  re- 
somewhat  complicated  combination  of  slings  and  band-  MetL'wi.  ^^  Tagiiacozzi's 
ages :  a  substitute  for  the  original  apparatus  may  be 
made  of  plaster  of  Paris.     As  soon  as  the  flap  is  supposed  to  be  firmly  ad- 


G14 


AN  AMERICAN    TEXT- HOOK    OF  SURGERY. 


Indian  Method  of  Rhinoplasty  (Prince). 


berent,  say  in  ten  or  twelve  days,  its  pedicle  is  divided  and  trimmed  as  may  be 
necessary.  Tbe  columna  is  su1)se(iucntly  made  from  tlic  upper  lip.  Tlie  orig- 
inal operation  contemplated  tbat  tbe  flap  sbould  he  made  from  tlie  arm.  Mod- 
ern operators  liave  modified  it  by  takin<r  it  from  tlie  forearm,  but  tbe  necessary 
confinement  of  bead  and  arm  is  so  irksome  tbat  tbe  operation  is  at  present 
scarcely  ever  done,  altbougli  in  certain  cases  it  oflfers  good  prospect  of  success, 
provided  tbe  subject  be  patient  and  acquiescent. 

Tbe  otber  operation,  now  generally  practised,  is  tbat  commonly  known  as 
tbe  Indian  metbod,  and  was  brought  to  Europe  from  Ilindoostan.  Tbe  model 
and  tbe  pattern  are  made  as  before,  l)ut  tbe  flap  is  now  taken  from  tbe  fore- 
head, still  alloAving  one-tbird  for  siirinkage,  tbe  pattern  l^eing  applied  either 
perpendicularly  or  obliquely,  depending  much  upon  its  contour  (Fig.  258)  and 

the  distance  between   ttie  eyebrows 
FifJ-  '-•"'^-  and  tbe  hair.     Tbe  incision  is  car- 

ried down  to  tbe  periosteum,  begin- 
ninii  at  the  ri^bt  marjiin  of  tbe 
defect  and  terminating  at  tbe  upper 
end  of  tbe  left  superciliary  ridge,  tbe 
pedicle  of  tbe  flap  being  about  two 
centimeters  wide.  It  is  necessary 
not  to  interfere  with  tbe  angular 
artery,  since  upon  it  depends  tbe 
nourishment  of  tbe  flap,  but  the  flap 
thus  outlined  is  dissected  off  and  is 
made  to  include  tbe  frontal  aponeu- 
rosis. Sometimes  tbe  periosteum  is 
raised,  at  least  over  the  lower  part  of 
the  flap.  Koenig  has  suggested  to  raise  along  with  the  periosteum  tbe  outer 
table  of  tbe  skull  or  at  least  its  superficial  portion,  especially  along  the  cen- 
tral and  lower  portion,  in  order  that  a  firm  bony  bridge  of  the  nose  may  be 
produced.  If  this  be  done — and  tbe  writer  has  practised  this  with  success 
and  urges  its  performance — the  integument  sbould  in  no  wise  be  raised  from 
that  portion  of  the  periosteum  and  bone  which  it  is  intended  to  utilize.  Ex- 
cept in  the  very  young  it  will  be  impossible  to  detach  this  bone  with  the  chisel 
or  any  otber  instrument  in  anything  like  a  continuous  layer:  the  bone-flap  will, 
in  fact,  be  more  like  a  series  of  thin  flat  chips  which  cling  to  tbe  periosteum. 
By  virtue  of  the  osteoblasts  which  abound  on  the  outer  surface  of  the  bone 
and  in  the  deeper  layer  of  the  periosteum,  perfect  osteogenetic  power  is  pre- 
served, and  tbe  result  will  be  the  same.  As  soon  as  hemorrhage  has  subsided 
tbe  flap  is  rotated  into  its  proper  position,  and  tbe  process  of  attachment  with 
fine  and  rather  numerous  sutures  begun.  Tbe  abie  and  nostrils  are  formed  by 
an  inward  duplication  of  tbe  lateral  parts,  and  the  septum  is  formed  from  tbe 
appropriate  portion  and  stitched  down  to  tbe  outer  portion  of  tbe  upper  lip,  in 
which  a  groove  sbould  be  made  for  it.  The  more  perfect  the  apportionment 
of  amount  tbe  more  ornamental  tbe  result.  Tbe  defect  in  tbe  forehead  will  at 
first  be  larger  than  the  size  of  tbe  flap,  since  the  edges  will  retract.  It  will 
be  worth  while  to  dissect  the  tissues  loose  from  the  frontal  bone  for  an  inch  or 
two  all  round  this  defect,  in  order  that  by  sliding  and  by  the  tension  of  silk 
sutures  the  size  of  the  defect  may  be  reduced  at  least  by  one-half.  Some- 
times it  will  be  worth  while  to  extend  tbe  incisions  upon  tbe  scalp,  so  that 
by  rearrangement  of  tbe  flaps  the  defect  may  be  still  further  covered.  Tbe 
portions  which  cannot  thus  be  protected  must  be  allowed  to  heal  by  granula- 
tion, or  it  may  be  possible  to  accomplish  a  good  deal  by  skin-grafting  after 


SURGERY   OF    TJIE   RESPIRATORY   ORGANS.  61-5 

Tbier.ch-s  methu.l.  The  .omul  upon  the  fV.rehe.Hl  is  best  .Ivessed  ^vith  i.Kh> 
form  ana  careen  silk  protective  underneath  the  or.l.nary  asepf  c  .  ressmc,..  i  e 
nAv  nose  ulv  need  oine  artificial  support,  ^vhich  can  be  lurnished  ;;xtorna  ly 
i  ha  Ires  in.  of  cotton  or  collo,li,.n,.vhile  internally  t.e  nostnls  ai^  kept  patu- 
ou  an  I  1  e  tl^p  supported  by  the  introduction  of  rubber  tubes  It  is  be  t  to 
m^ke  c  hp  apparintlv  too  larj^e,  since  the  new  organ,  which  seems  dispro- 
n,n-donlZ TaiJ  a  first,  will  in  the  course  of  months  shnnk  and  perhaps 
CT^^V^ont  because  not  large  enough.  Noses,  thus  ^-^^^  i.p  are 
often  very  sitisfactory,  and  leave  but  little  evidence  of  the  somewhat  extensive 
disturbance  by  which  they  were  first  produced.  is  referred 

For  more  exact  descriptions  and  variations  in  methods  the  leadei  is  reterrea 
to  the  special  works  on  plastic  surgery.  When  from  one  cause  or  another  it 
m.y  iXi  mp  acticable  to  repro^duce  this  organ  by  plastic  surgery,  much 
"  '  -  be^h  eln^plastic  art  in  another  direction,  and  artificial  noses  are  now 
^:^pared  f^m  ce  luloid  or  similar  materials,  which  are  kept  firmly  m  p  ace  by 
Ce  tacl  -  ms,  as  if  the  patient  were  wearing  glasses.  These  can  be  made  with 
sSi  accuracy  and  worn  with  such  exactness  and  comfort  as  almost  to  defy 
detection  except  on  close  inspection. 

SECTION   II.-DISEASES  AND  INJURIES  OF  THE  LARYNX   AND  TRACHEA. 

Congenital  Deformities  and  Defects. 
Congenital  absence  of  one  or  more  of  the  laryngeal  cartikges  ha^  been 

The.o.teon™oneongennala™^^^^^ 

and  fistul?e.      ihese  aie  to  oe  aiuiuu  fourth  branchial 

"'  ra'-'VJfe'fexHen::  "  in  *   'fo  rci  t  Opening  ^o.U  be  unilat- 

the  middle  line.  Fissure  of  the  epiglottis  ''f^  »^''',.^f  °„7'JJ/^e  so  minute 
fistuh.  are  the  lea«t  uncommon  of  -^^^l'^^^^'^^^^  dSw  discharge  of 
as  to  elude  ordinary  exammat.on  /!'«  f  ,3*7'  f 'le  oriS''''"  i"  ""^  °^  *" 
two  or  three  drops  of  muco-purulent  fluid  from  %™'"''t«  ""°f  '  .    ^        i. 

LARYNGITIS. 
Larvngitis  may  be  either  acute  or  chronic,  and  may  be  catai-rh-l-  croup- 

^rat^hl^gmors',  sav':  .^"r  circu^crihed,  .hen  we  have  an  abscess  of 

"""  i'P'.t^  r.tarrhal  Laryngitis  mav  be  primary  or  the  result  of  extension 

Acute  Catarrhal  ^ary ngii  j        f         - ,       j  jjopathic  it  is  usually 

from  the  pharynx  above  o.  fiom  '^^\f^^^^^^.^^^^^  i„,uced  by  over-use  of  the 

the  result  of  exposure,    it  may  a  so  oe  mecu  .  i,.j.i,.;tion  of  noxious 

^d^:^^^TZZI^l^:Z^^  of^s;r.on  and  to 


01(j  AN   AMERICAN    TEXT-BOOK   OF  SURGERY. 

fre(iuent  violent  and  cvrii  suflociitin^  attacks  of  eou;^liiii;^,  with  ]taitial  or  com- 
plete loss  of  voice.  U]>on  laryu^oscopit:  insjieotion  tlic  imicoiis  iiiciiibranc  will 
be  found  conj^ested  and  swollen,  the  swelling  being  usually  symmetrical.  Accu- 
mulations of  mucus  at  various  points  may  simulate  ulceration,  and  will  be  found 
especially  on  the  vocal  cords.  Should  the  symptoms  be  very  severe,  oedema 
of  the  larynx  may  ensue. 

Tiio  treatment  consists  in  the  removal  of  the  cause  when  recognized  ;  fur- 
thermore, in  iiihalaiions  of  steam  impregnated  with  sedative  and  astringent 
substances,  as  well  as  in  the  administration  of  aperients  and  sedatives  and  the 
continuous  application  of  cold  wet  compresses  or  else  the  employment  of  leeches 
over  the  larynx.  Weak  solutions  of  cocaine  will  give  the  same  relief  here 
that  they  do  in  similar  affections  in  the  nose,  but  are  usually  to  be  avoided  for 
the  reasons  already  given.  There  is  danger  in  the  application  of  strong  astrin- 
gents, such  as  nitrate  of  silver,  etc.,  that  they  may  produce  sudden  and  serious 
oedema.  The  medicinal  treatment  of  croup  and  of  diphtheria  is  not  considered 
here. 

Chronic  Laryngitis. — This,  too,  may  be  idiopathic  or  secondary.  The 
former  may  be  the  result  of  repeated  attacks  of  acute  inflammation  or  of 
extension  of  similar  trouble  from  above.  The  latter  is  almost  always  an 
extension  of  similar  trouble  elsewhere,  and  may  occur  in  arthritis  (gout), 
tuberculosis,  syphilis,  lupus,  and  cancer.  The  chronic  variety  is  attended  with 
thickening  of  mucous  membrane,  more  or  less  constant  irritation,  and  usually 
with  hypersecretion.  Erosions  are  unusual.  A  peculiar  vai'iety  of  chronic  lar- 
yngitis called  laryngitis  sicca  occurs  principally  in  females ;  it  involves  espe- 
cially the  mucous  glands,  the  viscid  products  of  which  adhere  to  the  mucous 
membrane,  wliere  they  dry  into  crusts  which  are  sometimes  fetid.  These  are 
detached  by  violent  coughing-spells,  and  leave  behind  them  excoriations  which 
may  bleed.  The  result  of  this  is  an  atrophic  and  dry  condition  of  the  mucous 
membrane.  These  affections  are  to  be  treated  after  about  the  same  manner 
as  the  similar  condition  in  the  naso-pharynx,  namely,  careful  dislodgment  by 
the  alkaline  antiseptic  spray  of  mucus  and  crusts,  and  then  the  application  of 
stimulating  and  antiseptic  solutions. 

(EDEMA   OF  THE   LARYNX. 

The  most  violent  and  serious  sequel  of  inflammation  of  the  larynx  is  the 
condition  known  as  oedema,  which  is  sometimes  incorrectly  spoken  of  as  oedema 
of  the  glottis.  This  is  an  infiltration  of  fluid  into  the  submucous  connective 
tissue  of  the  larynx  or  that  of  the  epiglottis  or  the  mucous  membrane  immedi- 
ately adjacent.  This  is  less  often  a  mere  passive  accumulation  of  serum  than 
an  active  inflammatory  fluid  exudate,  the  fluid  being  sometimes  sero-sanguino- 
lent  or  sero-purulent.  In  certain  cases  this  occurs  with  great  rapidity,  espe- 
cially when  serous,  and  may  destroy  life  by  suffocation  Avithin  a  very  short 
time,  an  amount  of  infiltration  which  elsewhere  would  be  trifling  serving  at  this 
point  to  obstruct  the  passage  of  air  thi'ough  the  narrowest  portion  of  the  air- 
channel.  So  serious  is  it  as  to  call  usually  for  the  promj)test  surgical  interfer- 
ence. In  time  past  this  condition  was  confused  with  that  of  croup.  The  deaths 
of  General  Washington  and  the  empress  Josephine  were  due  to  oedema,  and  not, 
as  has  been  ordinarily  stated,  to  croup.  Of  course  the  oedema  is  owing  to  impedi- 
ment to  free  circulation,  whether  from  purely  inflammatory  process,  mechanical 
obstruction  by  tumor,  or  perhaps  vaso-motor  ])aralysis.  It  has  often  followed 
wounds,  sometimes  even  of  the  neck  when  the  larynx  has  not  been  imj)licated. 
It  has  been  noted  also  in  aneurysm,  erysipelas,  typhoid,  glanders,  whooping 


SUliGERY   OF   THE   RESPIRATORY   ORGANS.  G17 

cougli,  j)nounioiii;i,  septicemiii,  etc.  A  death  from  this  cause  occurred  on  the 
baseball  fieUl  a  few  years  ago,  due  to  fracture  of  the  larynx. 

Tlie  symptoms  are  sonietiiiies  so  sudden  that  even  with  aid  close  at  hand 
the  jiaiient  dies  before  it  can  reach  him.  The  princijial  symptoms  are  local 
discomlbrt,  increasing  perhaps  to  agony,  stridor  in  breathing,  especially  in 
insj)iration,  cough,  impulsive  and  violent,  loss  of  voice,  dysphagia  and  dyspnea 
in  fatal  cases,  rapidly  increasing  to  apnea  and  death  by  suffocation.  Along 
"Nvith  these  of  course  go  intense  agitation,  flushing  of  the  face,  then  lividity, 
and  then  cyanosis,  protrusion  of  the  e^'cballs,  gasping  respiration,  and  flicker- 
ing pulse.  The  ])icture  above  presented  is  that  of  a  fatal  case.  In  a  mild 
degree  it  may  be  imitated  during  the  recurring  attacks  of  oedema  which  accom- 
pany acute  or  chronic  laryngitis. 

The  prognosis  must  depend  on  the  predisposition  and  exciting  cause. 
The  principal  danger  is  that  of  suffocation  ;  if  this  is  avoided,  much,  if  not 
everything,   may  be  accomplished  by  treatment. 

Treatment. — AVhen  the  case  is  not  too  acute,  the  best  treatment  consists 
in  nniltiple  punctures  into  the  tumid  mass  of  swollen  mucous  membrane,  which 
may  be  made  with  a  sharp  curved  bistoury,  the  blade  of  which  is  protected 
nearly  to  the  point  with  adhesive  plaster.  If  possible,  this  should  be  done  with 
the  aid  of  the  laryngoscopic  mirror.  These  punctures  should  not  be  made  in  the 
interior  of  the  larynx,  but  upon  the  swelling  exposed  to  vieAv  by  means  of  the 
mirror,  since,  although  we  desire  free  hemorrhage,  we  Avish  to  avoid  entrance  of 
blood  into  the  air-passages.  AYhen  hemorrhage  is  insuflicient  it  may  be  encour- 
aged by  gargling  with  warm  water  or  by  inhalations  of  steam.  The  punctures 
may  have  to  be  repeated  at  intervals  of  a  foAV  hours  or  days.  Should  the  case 
be  too  violent  to  permit  the  time  necessary  for  this  kind  of  relief,  intubation 
or  tracheotom}'  will  be  indicated.  The  very  condition  which  makes  suffocation 
threaten  will  make  intubation  at  least  difficult,  while  appiopriate  tubes  are  not 
usually  at  hand.  Tracheotomy  can  always  be  done  with  the  simplest  instru- 
ments, and  a  patient  should  not  be  allowed  to  die  of  suffocation  from  this  cause 
if  a  reasonably  sharp  penknife  be  at  hand.  Indeed,  as  a  precautionary  meas- 
ure, if  the  patient  threaten  to  require  tracheotomy  at  any  moment,  it  will  be 
far  better  and  safer  to  perform  it  deliberately  than  wait  to  be  called  to  do  it 
hastily  with  the  chance  of  arriving  too  late.  The  serous  infiltration  usually 
rapidly  subsides  after  the  performance  of  this  operation. 

ABSCESS   OF  THE   LAEYNX. 

This  may  be  intra-,  peri-,  or  retro-laryngeal.  It  is  almost  invariably  a 
secondary  affection,  most  frequently  resulting  from  disease  of  the  cartilages. 
Still,  phlegmonous  and  traumatic  laryngitis,  tuberculosis,  syphilis,  glanders, 
smallpox,  pyemia,  and  the  exanthemata  have  been  mentioned  as  determining 
causes.  The  inferior  surface  of  the  epiglottis,  the  internal  aspect  of  the  aryte- 
noid cartilage,  and  the  false  vocal  cord  are  the  most  frequent  seats  of  circum- 
scribed abscess  not  resulting  from  injur3^  The  local  symptoms  are  pain,  dys- 
phonia,  dyspnea,  dysphagia,  and  cough.  The  patient  may  even  be  threatened 
with  suffocation. 

The  diagnosis  must  be  made  by  means  of  the  laryngoscope,  though  it 
may  be  impossible  on  account  of  swelling  above ;  but  ordinarily  the  lesion  can  be 
recognized  as  a  swelling  the  base  of  which  is  red  and  the  apex  yellowish.  The 
principal  danger  is  from  suffocation  either  by  the  condition  spoken  of  or  by 
oedema.  Spontaneous  evacuation  usually  occurs  if  surgical  relief  be  not  pre- 
viously afforded.     The  treatment,  of  course,  is  incision  with  a  properly  curved 


G1.S  J.V    AMHlilCAX    TEXT-BOOK    OF  SURGERY. 

and  <5iianl(Ml  kiiifi'-])(>iiit.  >i;iii<U'(l  l»y  ilie  l:iryiigoscoj)C.  Should  this  not  bf  feasi- 
ble or  should  sufibeation  threaten,  a  preliniinarv  tracheotomy  sh(»uld  always  be 
made.  Extra-larynixeal  abscess  is  recognizable  by  the  common  signs  of  this 
complaint,  and  should  be  treated  in  accordance  with  the  ordinary  rules. 

PERICHONDKITIS   AND  CllONDIMTIS. 

The  latter  is  always  preceded  by  the  former,  which  itself  may  be  traumatic 
or  secondary  to  previous  disease.  Idiopathic  perichondritis  is  nearly  if  not 
quite  unknown.  The  most  common  causes  of  disease  of  the  cartilages  are 
syphilis,  tuberculosis,  cancer,  ty])hoid  fever,  and  the  exanthemata;  more  rarely 
chronic  laryngitis.  Pathologically  distinct,  clinically  the  two  conditions  are 
indistinguishable.  The  cricoid  and  arytenoid  cartilages  are  those  commonly 
involved.  When  there  is  suppuration  beneath  the  perichondrium,  necrosis  of 
the  cartilage  proper  occurs,  and  tlien  an  abscess  forms  which  often  discharges 
spontaneously,  following  which  there  is  usually  cicatricial  contraction,  while 
stenosis  is  the  final  result.  Sometimes  the  arytenoid  cartilages  are  thus  dis- 
charged entire.  The  route  of  pus  from  such  a  source  to  the  surface  is  some- 
times very  indirect,  while  fistula  often  results  and  extensive  emphysema  may 
take  place. 

The  symptoms  are  those  of  more  or  less  severe  laryngitis,  with  pain  on 
motion  or  ])ressure  and  sometimes  during  deglutition  or  phonation.  Later  ap- 
pear hoarseness,  cough,  and  dyspnea  with  paroxysms  of  stridor:  with  an  attack 
of  unusual  severity  there  nuiy  be  spontaneous  evacuation  followed  by  marked 
relief.  By  suitable  external  and  internal  examination  a  pretty  accurate  diag- 
nosis of  the  location  of  the  disease  may  be  made,  especially  if  an  abscess  has 
already  formed  and  broken. 

Treatment. — In  the  earlier  stages  antiphlogistic  measures  are  indicated, 
with  the  ordinary  local  treatment  and  such  constitutional  medication  as  the 
condition  of  the  patient  may  call  for.  Should  swallowing  become  impossible, 
nourishment  by  stomach-tube  or  the  rectum  will  be  necessary,  while  when 
local  symptoms  are  severe,  tracheotomy  or  laryngotomy,  with  cleaning  out  of 
the  abscess-cavities,  is  the  only  rational  course. 

ULCERS  OF   THE   LARYNX. 

These  may  be  catarrhal,  tubercular,  syphilitic,  or  malignant.  Only  the 
catarrhal  will  l)e  referred  to  here,  the  other  forms  being  described  under  their 
respective  headings.  Of  this  we  may  have  all  degrees,  from  the  most  smiple 
erosion  to  an  ulcer  of  large  extent.  They  are,  as  a  rule,  the  result  of  chronic 
processes,  but  possibly  of  injury,  especially  by  lodgment  of  foreign  bodies.  The 
mucous  membrane  around  the  periphery  is  usually  slightly  altered  and  some- 
times infiltrated.  They  may  be  found  at  almost  any  point,  but  most  commonly 
are  in  the  neighborhood  of  the  vocal  cords  or  upon  them  ;  at  times  they  are 
even  excavated.  They  may  vary  in  size  from  that  of  a  pin-point  up.  Some- 
times in  laryngoscopic  examination  we  find  cicatrices  showing  where  old  ulcers 
have  been  healed. 

The  symptoms  of  ulceration  are  scarcely  distinctive,  and  are  included 
under  those  of  infiammation.  When  the  vocal  cords  are  involved  their  func- 
tion is  correspoiulingly  impaired,  and  there  is  partial  or  complete  loss  of  voice, 
usually  with  irritating  cough  and  severe  laryngeal  irritation.  When  the  larynx 
is  in  this  condition  there  is  always  danger  of  oedema. 

Treatment. — This  consists  in  the  ordinary  methods  of  combating  inflam- 
mation  and   in   the  local   application   of  some  stimulating  substance,  which  is 


SURGKIiY    OF    THE   JiKSrUiATORV   ORGANS.  619 

usually  praetisi'tl  by  means  of  a  laryngeal  ])i'obe  upon  whose  tip  a  little  nitrate 
of  silver  is  fused.  Perfect  rest  sliouhl  l»e  insisted  upon,  and  constitutional 
treatment,  such  as  the  exliiltitioii  of  tonics,   etc.,   is  coninionly  recjuired. 

STEICTUEE  OF  THE   LARYNX   AND  TRACHEA. 

This  is  usually  sj)oken  of  as  stenosis,  and  may  arise  from  causes  within  or 
without  these  parts.  One  or  both  may  be  implicated,  and  sometimes  there  is 
more  than  one  stricture.  AVhen  produced  from  without  it  is  called  compres- 
sion stenosis,  and  may  l)e  the  result  of  abscesses,  of  tumors  of  the  thyroid  or 
thymus  or  lym])li-glands  or  elsewhere  about  the  neck,  of  cicatrices,  or  of  aneu- 
rysm. Sometimes  the  stricture  is  produced  simply  by  the  deflection  of  the  re- 
spiratory tube,  sometimes  by  pressure  and  occlusion.  Stricture  from  within,  or 
occlusion  stenosis,  may  be  due  to  congenital  causes,  to  foreign  bodies,  to  tumors, 
to  cicatricial  contraction  following  ulceration,  and  to  paralytic  or  spasmodic 
affection  of  the  intrinsic  muscles ;  also  to  oedema,  to  submucous  hemorrhage,  to 
the  presence  of  false  membrane,  to  inflammatory  adhesions,  and  to  the  result 
of  suicidal  attempts.  The  constriction  may  occur  at  any  point,  the  amount 
varying  within  the  extremest  possible  limits.  Even  complete  obliteration  is 
known.  Its  most  common  situation  is  naturally  at  a  point  where  the  channel 
is  narrowest,  namely,  at- the  glottis;  and  here,  of  course,  it  assumes  an  import- 
ance begotten  of  anatomical  location. 

It  will  be  seen,  then,  that  constriction  may  be  temporary  or  permanent, 
slight  or  most  serious,  and  implies  various  degrees  of  organic  and  tissue 
changes.  In  proportion  to  the  amount  of  stenosis  there  will  be  dyspnea,  espe- 
cially on  inspiration  and  exertion,  by  which  the  voluntary  muscles  of  inspi- 
ration are  called  upon  to  an  unwonted  degree.  Loud  breathing  merges  into 
stridor,  and  this  later  into  an  agonizino;  suffocative  and  stridulous  choking 
respiration.  In  extreme  cases  the  face  is  anxious  and  cyanotic,  the  pulse  be- 
comes small  and  frequent,  and  the  muscular  effort  to  breathe  is  most  painful  to 
witness.  The  symptoms  are  about  the  same  no  matter  Avhat  may  be  the  cause. 
There  is  always  danger  that  in  a  severe  case  of  cicatricial  stenosis  there  may' 
be  added,  at  the  last,  an  oedema  of  the  parts  which  will  hasten  the  termination. 

When  time  and  opportunity  afford,  a  careful  study  of  the  case  should  be 
made  in  order  to  locate  the  stricture  and  determine  its  character,  suitable  meas- 
ures then  being  decided  upon.  On  the  other  hand,  when  the  case  is  extreme 
the  trachea  should  be  opened  as  low  as  convenient,  profiting  by  the  fact  that 
most  of  these  lesions  are  located  above  the  lowest  accessible  portion  of  the 
windpipe.  It  may  be  that  a  large  tumor  or  abscess  so  occupies  the  inferior 
and  middle  portions  of  the  neck  that  even  tracheotomy  will  be  impossible. 
When  there  is  time  for  careful  study  and  deliberation,  the  relief  must  depend 
upon  the  cause.  At  one  time  it  may  be  dilatation  of  a  cicatricial  contraction, 
at  another  the  removal  of  a  polyp  or  other  tumor  either  by  intra-  or  extra- 
laryngeal  methods,  at  another  the  performance  of  a  tracheotomy,  or  possibly 
a  still  more  radical  operation,  such  as  removal  of  the  larynx.  At  all  events, 
tracheotomy  is  often  the  temporary  and  almost  always  the  final  expedient. 
Sometimes  an  artificial  larynx  is  re(|uired,   perhaps  permanently. 

SYPHILIS  OF  THE   LARYNX. 

Syphilis  of  the  larynx  may  be  acute  or  chronic.  There  is  an  acute  form 
which  corresponds  to  the  congestion  and  inflammation  of  the  pharynx  met  with 
in  the  early  portion  of  the  secondary  stage,  which  may  give  rise  to  temporary 
hoarseness  and  even  to  other  signs  of  laryngeal  irritation.     When  seen  with  a 


ii'2(>  AX  AMERICAN    TEXT-BOOK    OF  SURGERY. 

laryngoscope  the  interior  of  the  larynx  will  present  the  .same  livid  and  tume- 
fied aj>))earance  that  -sve  recognize  in  the  pharynx.  The  treatment  for  this 
form  .should  be  vigorous  and  constitutional,  with  such  local  measures  as  may 
be  necc.s.sary  to  subdue  irritation. 

A  chronic  form  of  syphilitic  laryngitis  is  cominf>n,  and  is  marked  by  infil- 
tration and  inflexibility  of  mucous  membrane,  which,  with  time,  go  on  to  the 
formation  of  mucous  patches  or  extensive  granulomatous  tissue-formation,  or  to 
extensive  ulceration  Avith  destruction  even  of  underlying  cartilage,  and  in  any 
event  to  more  or  less  reduction  of  caliber,  or  sometimes  to  the  formation  of 
serious  stenosis  or  even  to  complete  occlusion. 

Aside  from  mucous  patches,  extensive  ulceration  and  even  gummatous  infil- 
tration, or  possibly  formation  of  distinct  gummata,  may  take  place.  About 
these  ulcerations  there  is  usually  a  symmetry  of  location  which  is  one  of  the 
points  of  differential  diagnosis  between  them  and  tubercular  ulcerations. 
Ulceration  of  the  epiglottis  especially  is  a  common  manifestation  of  the  ter- 
tiary stage.  Such  ravages  as  these  seldom  go  on  within  the  larynx  without  such 
external  or  other  manifestations  of  syphilis  as  to  leave  scarcely  a  doubt  con- 
cerning the  nature  of  the  lesion. 

While  local  treatment  is  not  to  be  excluded,  the  constitutional  is  the  more 
important  of  the  two,  save  when  immediate  consequences  threaten. 

TUBEECULOSIS  OF  THE  LARYNX. 

Primary  tuberculosis  of  the  larynx  is  rare.  Although  these  cases  are 
seen  mostly  by  specialists,  there  is  no  reason  why  the  general  practitioner 
should  not  be  able  to  recognize  their  characteristics.  In  the  first  place, 
there  ai'e  the  ordinai'y  evidences  of  chronic  laryngitis  with  thickening  of 
the  mucous  membrane,  Avhich  goes  on  to  the  formation  of  multiple  ulcer- 
ations, ordinarily  at  first  minute,  coalescing  later,  accompanied  by  more  or 
less  hacking  cough  or  alteration  of  the  voice.  There  is  no  part  of  the  larynx 
which  is  exempt  from  attack,  but  the  most  marked  manifestations  occur 
about  the  arytenoid  cartilages,  the  vocal  cords,  and  the  epiglottis.  The  nat- 
ural outlines  of  the  larynx  as  seen  in  the  mirror  become  blurred,  and  there 
is  commonly  an  intumescence  of  the  glotto-epiglottic  folds  and  bands ;  later 
there  occurs  not  only  ulceration  as  such,  but  also  the  development  of  gran- 
ulations, which,  as  a  rule,  are  elevated  above  the  surface,  and  which,  when 
on  the  posterior  wall  and  in  the  middle  line,  are  by  many  authorities 
regarded  as  pathognomonic  of  the  condition.  This  condition  is  usually  sec- 
ondary to  pulmonary  tuberculosis,  but  may  be,  as  above  mentioned,  purely 
primary. 

AVhen  the  disease  is  of  the  primary  type  it  requires  usually  to  be  differen- 
tiated from  .syphilis  on  the  one  hand  and  malignant  disease  on  the  other. 
Asymmetry  of  ulceration,  Avith  the  peculiarity  of  granulation  spoken  of  above, 
is  always  at  least  suggestive,  Avhile  the  absence  on  the  one  hand  of  evidences 
of  .syphilis  elsewhere,  and  the  existence  on  the  other  of  a  family  history  of 
consumption,  or  of  a  history  of  progressive  emaciation,  or  of  elevation  of  tem- 
perature, especially  in  the  evening,  will  greatly  aid  in  diagnosis.  Tiie  crucial 
test,  Avhen  it  can  be  established,  is  the  presence  of  tubercle  bacilli,  either  in 
the  infected  tissue  or  in  the  sputum. 

Between  tubercular  and  malignant  disease  of  the  larynx  it  is  at  times  in 
the  early  stages  excessively  difficult  to  determine,  and  it  is  necessary  to  watch 
for  a  time  before  making  an  ab.solute  diagnosis.  A  study  of  family  history,  of 
temperature  range,  of  constitutional  conditions,  will  be  of  great  aid.  Malig- 
nant disease  is  more  likely  to  have  a  more  definite  origin  and  limit,  around 


SUBGEllY   OF    THE  RESPIRATORY  ORGANS.  621 

■which  healthy  or  nearly  healthy  tissue  will  be  met  with.  Tubercular  disease, 
on  the  other  hand,  is  likely  to  leave  its  marks  in  almost  every  portion  of  the 
larynx,  as  well  as  to  cause  more  local  irritation,  while  there  will  be  little  if  any 
such  infdtration  as  to  cause  fixation  of  the  larynx  upon  the  outside  or  involve- 
ment of  the  lymphatic  glands  in  the  vicinity.  More  will  be  said  on  this  topic 
when  speaking  of  Cancer  of  the  Larynx. 

In  time  past  primary  laryngeal  tuberculosis  was  supposed  to  be  irre- 
trievably fatal,  but,  while  it  is  still  to  be  regarded  as  of  extreme  giavity, 
nuich  can  be  effected  by  treatment.  This  consists  in  both  constitutional 
and  local  measures,  the  latter  being  those  indicated  in  tubercular  disease, 
and  consisting  of  frequent  applications  of  lactic  acid  to  the  ulcerated  pas- 
sage, and  insufflation  of  iodoform  or  aristol  or  of  some  other  dry  anti- 
septic material  by  which  tissue-changes  are  influenced,  as  well  as  of  some 
anodyne  poAvder,  such  as  one  containing  very  small  portions  of  cocaine  and 
morphia,  com})ined  perhaps  with  menthol,  bismuth  subnitrate,  and  sugar  of 
milk.  In  aggravated  cases  absolute  rest  of  the  larynx  as  enforced  by  a 
tracheotomy  is  sometimes  of  great  benefit.  If  we  could  be  assured  that  the 
disease  was  purely  local,  it  might  be  justifiable  to  extirpate  the  organ;  but 
patients  thus  far  have  proved  unwilling  to  submit  to  this  extreme  measure  at 
a  time  when  it  promised  them  any  abiding  benefit. 

TUMORS  OF  THE   LARYNX. 

Most  laryngeal  tumors  involve  the  interior  surface,  although  they  may 
rarely  develop  on  the  exterior,  whence  they  may  perforate. 

Benign  Tumors. — The  majority  of  laryngeal  tumors  are  non-malignant,  and 
of  these  two-thirds  are  probably  papillomata.  Their  origin  is  always  obscure, 
though  they  are  usually  referred  to  local  irritation.  They  are  rarely  multiple, 
and  the  anterior  portions  of  the  larynx  are  most  often  involved.  Males  are 
much  more  liable,  and  children  frequently  present  this  condition,  even  young 
infants.  Nearly  all,  if  not  all,  of  the  so-called  benign  tumors  have  been  met 
with  within  the  larynx.  They  vary  in  size  from  that  of  a  small  seed  to 
masses  sufficient  to  protrude  beyond  normal  laryngeal  limits.  They  occur  prob- 
ably with  greatest  frequency  in  the  vocal  cords.  It  must  never  be  forgotten 
that  the  transformation  of  benign  into  malignant  tumors  occurs  more  typically 
here  than  perhaps  anywhere  else  in  the  body.  This  would  include  the  change 
of  papilloma  into  epithelioma,  of  fibroma  into  fibro-sarcoma,  and  of  adenoma 
into  carcinoma,  this  transformation  taking  place  usually  in  elderly  adults  at 
that  period  when  age  predisposes  to  such  changes  in  various  parts  of  the  body. 

Symptoms. — The  symptoms  of  laryngeal  tumor  are  uniform,  no  matter 
what  its  histology.  They  vary  only  according  to  its  size  and  location.  Hoarse- 
ness or  dyspnea  occurs  when  the  action  of  the  vocal  cords  is  interfered  with, 
but  seldom  at  other  times.  Preceding  this  condition,  however,  is  one  of  un- 
certainty of  voice,  with  alteration  of  timbre  and  of  tone  limits.  What  is  known 
as  double  voice,  or  diphthonia,  has  followed  symmetrical  growths  dividing  the 
glottis  into  two  portions.  Finally,  complete  aphonia  may  result.  Dyspnea 
occurs  in  proportion  to  the  amount  of  obstruction  of  the  respiratory  channel. 
When  the  growth  is  slow  there  appears  to  be  a  compensatory  arrangement  of 
the  parts  by  which  even  a  large  growth  will  cause  but  little  obstruction.  Dys- 
phagia is  rare  unless  the  growth  occupy  some  portions  of  the  pharyngeal  aspect 
of  the  larynx.      Cough  and  pain  are  late  symptoms. 

The  final  diagnosis  is  made  with  the  laryngoscope:  Avhen  this  is  imprac- 
ticable, as  in  children,  the  finger-tip  inserted  as  far  as  may  be  carefully  done 


<;22 


.l.V  AMERICAN   TEXT- BOOK    OF  SURGERY. 


v,'\\\  sometimes  aid.  After  making  out  the  presence  of  the  tumor  in  the  larynx, 
a  fine  curved  laryngeal  probe  should  be  introduced  in  order  to  determine  its 
exact  location  and  fixation.  Papilloma  and  fibroma  are  usually  pedunculated 
(Figs.   2r)!>,  '2(>()),  the  latter  more  often  so  than  the  former,  and^are  commonly 


Fk;.  260. 


Fi(i.  2ri9. 


Polyp  of  Laryii 


PapiUoma  of  larynx  (Stoerck). 


easily  seen.  Angeiomata  are  usually  dark  in  color  and  seated  upon  the  vocal 
cords.  Cysts  occupy,  as  a  rule,  the  ventricles  or  the  epiglottis.  Enchondro- 
mata  occupy  merely  the  posterior  portion  of  the  larynx,  especially  the  arytenoid 
cartilages.  With  the  presence  of  these  tumors  there  may  or  may  not  be  signs 
of  irritation  or  inflammation  of  the  surrounding  parts.  The  principal  dangers 
which  tliey  cause  are  those  of  suffocation,  and  not  a  few  deaths  have  been  thus 
induced. 

Treatment. — "When  removal  is  possible  it  should  be  accomplished  with 
the  smallest  necessary  disturbance.  They  may  be  removed  by  the  natural 
channel  or  after  external  incision.  The  intra-laryngeal  method  includes  cauter- 
ization, incision,  excision,  crushing,  snaring,  and  avulsion.  Very  small  and 
accessible  papillomata  may  be  attacked  with  chromic  or  nitric  acid  or  with 
the  galvano-cautery.  These  are  all  to  be  used  with  extreme  caution,  for  fear  of 
resulting  oedema.  The  instrument-makers  supply  cautery  points  by  means  of 
which,  guided  by  the  laryngoscopic  mirror  and  a  steady  hand,  the  action  of  the 
cautery  may  be  limited  to  the  desirea  point.  Incision  is  resorted  to  only  in 
cases  of  cysts.  Excision  is  performed  Avith  curved  scissors  or  guillotine  knives. 
When  crushing  is  resorted  to,  it  is  with  a  hope  of  destroying  vitality  and  caus- 
ing a  slough.  The  ^craseur  has  also  been  employed  for  intra-laryngeal  snaring 
of  tumors,  but  is  difficult  to  operate.  Avulsion,  or  rudely  tearing  away  the 
growth  by  forceps,  is  perhaps  the  most  common  procedure.  Pedunculated  masses 
are  thus  readily  removed,  and  sessile  growths  can  be  torn  away  en  masse.  All 
these  instruments  can  be  guided  by  the  mirror.  They  require  special  dexterity 
and  considerable  practice,  and  such  operations  are  mainly  relegated  to  special- 
ists. Great  facility  has  been  acquired  in  this  direction  by  a  few,  and  the 
intra-laryngeal  method  in  the  hands  of  an  expert  offers  better  possibility  of 
success  than  does  a  clumsy  incision  at  the  hands  of  a  general  practitioner. 

A\  hen,  however,  it  appears  necessary  to  open  the  larynx,  the  operation  is 
known  as  thyrotomy  or  thyroid  laryngotomy,  an<l  consists  in  incision  in 
the  middle  line,  with  sijlitting  of  the  thvroid  cartilage  beneath  the  line  where 
the  two  aire  join,  and  the  exposure  of  the  interior  of  the  larynx  to  sight  and 
to  more  radical  operative  attack.  The  thyroid  being  so  intimately  connected 
with  the  cricoid  below  and  the  hyoid  above,  it  will  be  usually  necessary  to  divide 
the  former  as  well  as  the  membrane  both  above  and  below.     After  whatever 


SURGEllV    OF    nil-:    HKSrillATORY    ORGANS. 


G2;i 


Fig.  2(51. 


growth  is  present  has  thus  heeu  removed,  the  cartihiginous  rin<2;.s  may  be  united 
by  suture  of  the  periehonch-ium,  or  even  thi'oufjli  tlie  cartihijiie  itself.  It  Avill  be 
■wise  to  extend  the  incision  downAvard  thr()u<ih  the  lirst  and  second  tracheal 
rings  and  to  insert  a  tracheal  tube,  since  the  laryngeal  wound  will  heal  much 
more  kindly  if  thus  placed  absolutely  at  rest. 

Malignant  Tumors. — These  arc  composed  of  various  forms  of  sarcoma 
and  carcinoma  (Fig.  261).  The  epiglottis  is  perhaps  the  most  common  seat 
of  sarcoma,  Avhich  may  be  met  with  in  rela- 
tively young  patients.  The  large  ])roportion 
of  true  carcinomata  will  be  found  to  have 
resulted  from  generations  of  previously  benign 
tumors. 

Symptoms. — So  fiir  as  symptoms  are 
concerned,  they  are  those  of  benign  tumors 
already  considered,  plus  sensations  as  of 
foreign  bodies,  greater  dysphagia,  pain, 
often  shooting  upward  toward  the  ears,  and 
emaciation  and  lymphatic  involvement.  Sar- 
coma is  much  less  likely  to  be  ulcerated.  That 
it  is  not  always  possible  even  for  experts  to 
settle  these  questions  of  difference  of  diag- 
nosis is  evidenced  by  the  case  of  the  late  Em- 
peror Frederick  of  Germany.  The  prog- 
nosis is  always  bad  unless  the  disease  can  be 
arrested  by  radical  operation.  An  encourag- 
ing percentage  of  cure  has  resulted  from  operations  involving  complete  or 
partial  removal  of  the  larynx.  One  case  lived  nearly  six  years  after  the  extir- 
pation, and  then  died  of  an  acute  disease. 

Treatment. — The  treatment  of  cancer  of  the  larynx  is  addressed,  accord- 
ing to  circumstances,  either  to  alleviation  or  to  radical  cure.  The  former  consists 
in  local  astringent  and  anodyne  applications,  with  perhaps  the  occasional  removal 
of  projecting  masses  or  the  application  of  the  actual  cautery,  by  which  the 
growth  may  certainly  be  temporarily  checked  in  many  instances.  When  in 
time  the  laryngeal  symptoms  become  so  severe  as  to  harass  the  patient,  trache- 
otomy Avill  give  a  respite  of  several  Aveeks  or  months.  On  the  other  hand, 
when  the  disease  is  apparently  local  and  no  trace  of  it  can  be  found  outside  of 
proper  laryngeal  confines,  and  when  the  general  condition  and  fortitude  of  the 
patient  warrant  so  severe  an  operation,  partial  or  complete  extirpation  of  the 
organ  may  be  proposed,  and,  with  the  consent  of  the  patient,  carried  out. 
Laryngotomy  and  laryngectomy  will  be  described  with  other  operations. 


Carcinoma  of  the  Larynx  (Stoerck). 


TUMORS  OF  THE  TRACHEA. 

Every  variety  of  tumor  has  been  found  within  the  windpipe,  although  tumors 
arise  more  frequently  from  the  membranous  than  from  the  cartilaginous  portion, 
and  are  more  common  nearer  its  upper  portion.  These  tumors  are  often,  but  by 
no  means  necessarily,  associated  with  others  elsewhere.  Male  adults  are  the  most 
often  affected.  The  causes  are  absolutely  obscure.  A  considerable  number  of 
these  cases  are  now  on  record,  and  the  condition  is  one  which  can  ordinarily  be 
recognized  with  the  laryngoscope.  The  benign  tumors  are  usually  peduncu- 
lated, the  malignant  seldom  so.  The  symptoms  are  SDmewhat  indistinct,  and 
do  not  vary  much  from  those  of  laryngeal  tumor,  save  that  respiration  is  more 
permanently  aff"ected  and  phonation  much  less  so,  if  at  all.     The  main  sign  is 


624  J.Y  AMERICAN    TEXT-BOOK    OE  SURGERY. 

dyspnea,  which  should  always  lead  to  laryngoscopic  inspection.  In  almost  every 
instance  a  tracheotomy  will  be  called  for,  and  according  to  circumstances  it  may 
or  may  not  he  possible  to  remove  the  tumor  through  the  same  incision,  which 
may  be  prolonged  to  the  necessary  extent.  The  operation  of  resection  of  the 
windpipe  has  been  suggested,  but  not  yet  made  feasible. 

TRACHELOCELE. 

This  term  is  applied  to  a  hernia  of  the  mucous  membrane  of  the  trachea 
between  two  of  its  rings  or  through  a  congenital  defect.  The  tumor  thus 
formed  on  its  exterior  consists  of  a  cyst  of  mucous  membrane,  the  contents  of 
which,  instead  of  being  fluid,  consist  of  air.  It  may  be  anterior  or  lateral, 
and  may  vary  in  size  from  that  of  a  pea  up  to  that  of  a  hen's  egg.  Usu- 
ally unilateral,  it  is  sometimes  bilateral.  It  is  most  common  in  the  adult 
male.  The  symptoms  are  dyspnea,  altered  voice,  sometimes  even  aphonia. 
Externally  there  will  be  found  a  compressible  gaseous  tumor,  which  mav  be 
distended  when  the  patient  makes  forced  expiration  with  closed  mouth  and  nose. 
It  may  come  on  slowly  or  suddenlv. 

The  treatment  should  consist  at  first  in  pressure,  although  radical  opera- 
tion may  be  necessary  for  its  cure. 

WOUNDS  AXD  INJURIES  OF  THE  LARYNX. 

These  may  be  of  external  or  internal  origin.  Those  from  within  are  caused 
usually  by  foreign  bodies,  those  from  without  in  various  ways.  The  most  com- 
mon of  the  latter  are  contusions,  and  incised  wounds  made  in  suicidal  or 
homicidal  attempts.  The  average  would-be  suicide  is  too  ignorant  to  make  his 
incised  wound  on  the  side  of  the  neck,  where  the  great  vessels  would  be  more 
easily  divided,  but  makes  usually  an  extensive  gash  in  front,  at  a  point  where 
he  most  commonly  divides  the  thyro-hyoid  or  sometimes  the  crico-thyroid 
membrane,  and  the  violence  exerted  is  expended  before  the  region  of  the 
great  vessels  is  reached.  This  constitutes  the  ordinary  form  of  cut-throat, 
many  instances  of  which  occur  every  year.  Sometimes  the  epiglottis  is  par- 
tially, perhaps  completely,  separated,  and  the  incision  may  even  involve  the 
posterior  wall  of  the  pharynx.  While  the  wound  thus  inflicted  opens  widely 
by  a  retraction  of  tissue,  and  presents  sometimes  a  horrible  aspect,  it  is  not 
nearly  so  dangerous  as  it  would  appear  to  be,  the  majority  of  these  cases  recov- 
ering if  early  and  properly  treated. 

Treatment. — If  seen  early,  the  treatment  should  consist  in  approxima- 
tion of  all  the  divided  tissues,  the  deeper  parts  being  united  with  catgut,  while 
for  the  integument  catgut  or  silk  may  be  used  according  to  fancy.  In  certain 
cases  local  rest  should  be  ensured  by  performance  of  a  low  tracheotomy,  and 
where  feeding  is  difficult  or  impossible  the  stomach  or  rectal  tube  may  be 
employed  so  long  as  necessary.  Aside  from  such  injuries,  punctured  wounds 
and  gunshot  wounds  of  the  larynx  or  trachea  may  occur,  and  call  for  much  or 
little  treatment  according  to  circumstances. 

Wounds  of  internal  origin  are  produced  mainly  by  foreign  bodies,  such  as 
fish-hooks,  needles,  fish-bones,  pieces  of  glass,  etc.  These  may  tear  or  punc- 
ture according  to  their  size  and  location,  and  may  excite  mild  or  intense  symp- 
toms of  laryngeal  irritation  with  inflammation  and  oedema  or  abscess.  Similar 
substances  frequently  excite  spasm  of  the  glottis,  which  may  necessitate  trache- 
otomy or  may  even  kill  before  such  aid  can  be  rendered.  In  all  such  cases  the 
condition  should  be  investigated  with  the  laryngoscope  if  possible.  If  urgent 
gymptoms  arise,  tracheotomy  must  be  performed  ;  if  seen  at  once,  the  foreign 


SURGERY   OF    THE   RESPIRATORY   ORGANS.  G25 

body  can  often  be  located  and  removed  with  suitable  forceps.  If  not  seen  for 
some  hours  or  days,  it  may  be  so  hidden  by  tumefaction  or  by  exudate  and 
membrane  as  to  be  invisible.  In  such  a  case  considerable  local  treatment 
which  shall  be  astringent,  antiseptic,  and  ano<lync  may  be  necessary  before 
it  can  be  discovered.  Sometimes  after  such  injuries  hemorrhage  occurs  by 
which  alarming  or  fatal  results  may  be  brought  about.  In  such  cases,  when 
the  patient  survives,  there  is  always  a  possibility  of  secondary  hemorrhage. 
Should  bleeding  be  alarming,  it  can  be  best  checked  by  a  tracheotomy,  with 
plugging  of  the  windpipe  by  a  tampon  above  the  tracheal  tube.  To  wait  for 
its  arrest  by  syncope  is  to  take  very  much  more  risk  than  is  involved  in  mak- 
ing an  early  incision. 

Fractures  of  the  larynx  are  known,  although  fjuite  infrequent.  The 
fracture  is  usually  limited  to  the  thyroid  and  cricoid  cartilages.  Such  injuries 
are  produced  usually  by  blows  from  without.  In  elderly  individuals  in  whom 
senile  calcification  has  occurred  such  lesions  may  be  produced  with  much  less 
violence  than  in  the  young.  The  most  common  cases  are  blows  with  the  fist 
or  some  blunt  weapon,  or  received  from  balls  in  athletic  games,  attempts  at 
choking — accidental  or  premeditated — and  falls  upon  hard  objects  with  crush- 
ing violence. 

The  symptoms  must  vary  somewhat  with  the  cause  of  the  injury  and  its 
extent.  A  blow  on  the  larynx  Avhich  does  not  fracture  it  will  often  produce 
unconsciousness,  as  has  been  seen  upon  the  cricket  field.  In  1889  a  death 
occurred  upon  the  baseball  field,  where  the  player  was  struck  in  the  throat  by 
a  swiftly-thrown  ball  which  fractured  the  larynx.  He  fell  unconscious,  and 
died  in  a  few  moments  of  oedema,  timely  tracheotomy  not  having  been  per- 
formed. Pain,  dyspnea,  cough,  ejection  of  frothy  blood  and  mucus,  dysphonia 
or  aphonia,  and  dysphagia,  are  the  common  symptoms  in  cases  not  quickly 
fatal.  They  may  be  followed  in  a  short  time  by  emphysema  spreading  more 
or  less  widely,  and  by  oedema  of  the  larynx,  always  serious,  sometimes  fatal, 
as  above.  The  prognosis  is  most  serious  Avhen  the  cricoid  has  been  broken, 
only  two  cases  of  recovery  from  this  injury  being  on  record. 

Treatment. — The  most  timely  and  life-saving  measure  that  can  be  prac- 
tised is  a  tracheotomy,  by  which  at  least  security  from  suffocation  will  be 
afforded.  This  still  leaves  an  injury  unattended  to.  It  has  been  found 
inadvisable  to  try  to  suture  broken  cartilages  in  these  cases,  even  though  the 
fracture  be  compound.  Perfect  rest,  such  coaptation  as  external  support  may 
afford,  and  intralaryngeal  medication  to  some  extent,  will  bring  about  the  best 
results. 

Dislocation  of  the  laryngeal  cartilages  is  known,  but  is  very  rare.  The 
most  common  form  is  luxation  of  an  arytenoid  cartilage  from  the  cricoid  upon 
which  it  rests.  This  may  be  associated  with  fracture.  A  pathological  form 
of  dislocation  is  known  resulting  from  cicatricial  contraction  from  within  or 
without.  Complete  separation  of  the  trachea  from  the  hirynx,  the  result  of 
an  accidental  hanging,  has  been  seen. 

The  treatment  must  depend  on  the  urgency  and  permanency  of  the  symp- 
toms. Intubation  or  tracheotomy  will  probably  be  called  for  if  anything  be 
required,  while  in  the  pathological  form  measures  for  dilatation  of  the  stricture 
will  be  indicated. 

FOREIGN   BODIES   IN   THE  AIR-PASSAGES. 

The  entrance  of  a  foreign  body  into  the  air-passages  is  one  of  the  common- 
est of  accidents.  Ordinarily  the  substance  is  at  once  expelled  in  a  violent  and 
reflex   fit  of  coughing.     Natural  expulsion   may  be   aided   by  inverting  the 

40 


626  A.\  AMERICAN    TEXT-BOOK   OF  SURGERY. 

patient,  often  a  child,  and  slapping  somewhat  freely  upon  the  back.  These 
foreign  bodies  are  most  commonly  introduced  in  a  sudden  inspiration,  volun- 
tary or  involuntary,  while  the  substance  is  in  or  close  to  the  mouth.  The 
greatest  variety  of  substances  are  thus  introduced,  among  the  more  common 
being  artificial  teeth,  material  rejected  from  the  stomach  during  the  act  of 
vomiting,  including  curdled  milk  and  particles  from  the  alimentary  canal  or 
the  respiratory  passages  above,  fragments  of  teeth  dislodged  during  attempts 
at  extraction,  particles  of  cork  or  sponge,  broken  instruments,  necrosed  bone, 
toys,  etc.  On  the  other  hand,  foreign  bodies  enter  from  the  outside  by  direct 
puncture,  as  gunshot  missiles,  or  through  previous  wounds,  like  that  described 
when  speaking  of  cut-throat.  Fluids  of  all  kinds,  blood,  pus,  etc.,  also  have 
easv  access  to  the  larvnx  and  trachea  in  manv  instances.  When  inorganic 
these  materials  are  not  likely  to  undergo  change,  but  when  animal  or  vegetable 
they  may  absorb  moisture  and  increase  in  size  or  macerate.  When  retained 
for  long  periods  they  may  become  covered  with  mucus  or  even  calcareous  mat- 
ter. They  are  most  likely  either  to  be  entangled  at  a  point  between  the  epi- 
glottis and  the  level  of  the  glottis,  or  to  pass  down  and  become  impacted  in  a 
bronchus.  It  frequently  happens  that  a  very  small  particle  will  cause  a  pro- 
digious amount  of  irritation. 

The  usual  symptoms  are  spasmodic  cough,  spasm  of  the  larynx,  and  a 
feeling  of  suftocation.  At  times  the  symptoms  are  violent,  and  the  patient  may 
become  unconscious  from  deficient  oxidation  of  the  blood.  Foreign  bodies 
ai"e  also  the  cause  of  some  cases  of  prolonged  and  chronic  laryngeal  symptoms, 
ulceration,  or  abscess,  in  Avhich  the  actual  cause  is  either  unsuspected  or  can- 
not be  detected.  Inspection  is  always  necessary,  and  the  laryngeal  probe  will 
be  of  great  assistance.  Endeavors  to  locate  and  appreciate  accurately  the  body 
are  always  necessary,  save  where  urgency  does  not  warrant  any  delay.  In  not 
a  few  instances,  however,  suffocation  occurs  within  the  moment  during  which 
there  is  no  one  at  hand  with  sufficient  knowledge  to  render  any  assistance. 
Thus  the  writer  has  known  of  two  young  men  who  were  (juickly  suffocated  by 
pieces  of  meat  within  the  entrance  to  the  larynx,  and  more  than  one  death  which 
has  been  ascribed  to  anesthetics  has  been  caused  by  plugging  of  the  parts  with 
masses  of  undigested  food  rejected  from  the  stomach  during  the  reflex  act  of 
vomiting.  This  affords  a  most  cogent  reason  for  insisting  upon  an  empty  stom- 
ach before  beginning  anesthesia,  as  well  as  turning  the  patient  upon  one  side 
or  upon  the  face  whenever  vomiting  occurs  during  this  condition  of  loss  of 
voluntary  control. 

The  prognosis  should  be  always  guarded,  as  a  foreign  body,  which  to-day 
causes  no  distress  and  scarcely  any  symptoms,  months  or  years  later  may  kill 
by  a  slow  process  of  ulceration,  necrosis,  or  something  equally  disastrous. 

Treatment. — Excej)t  in  the  severest  emergencies  the  first  endeavor  should 
be  to  dislodge  the  substance  by  the  simplest  possible  manoeuvers,  which  con- 
sist, perhaps,  in  inverting  the  body  and  slaj>]iing  the  ])atient  on  the  back  or 
chest.  Many  substances,  like  those  of  a  mineral  nature,  may  l)e  thus  easily  dis- 
lodged and  expelled.  If  it  ])e  a  body  of  some  size,  the  presumption  is  that  it 
has  lodged  within  reach  of  the  finger,  in  which  case  the  mouth  should  be  widely 
opened,  if  necessary  held  so,  and  the  index  finger  pushed  deeply  into  the 
pharynx  and  swept  beneath  the  epiglottis  and  down  toward  the  glottis.  If 
there  be  any  substance  there  which  the  finger  alone  cannot  dislodge,  it  may  be 
aided  with  anything  at  hand  wliicli  will  serve  the  ])urpose.  It  is  often  well 
in  these  cases  to  seize  the  larynx  from  the  outside  with  the  other  hand,  and 
raise  it  well  up  toward  the  lower  jaw,  by  which  it  is  l)rought  within  better  reach 
of  the  inside  finger.     Effort  of  this  kind  failing,  artificial  light  and  the  laryn- 


SURGERY    OF    THE    RESPIRATORY   ORGANS.  627 

goscopic  mirror  must  be  brout^ht  into  play,  aud,  accordin<^  to  the  substance  at 
fault  and  the  ingenuity  and  dexterity  of  the  surgeon,  the  foreign  body  when 
seen  may  be  grasped  and  removed  uith  more  or  less  readiness.  Various  kinds 
of  forceps  and  otlier  means  for  removing  foreign  bodies  have  been  devised, 
and  may  be  used  as  recjuired.  Finally,  in  cases  where  there  is  every  reason  to 
think  that  some  foreign  body  is  present,  although  it  cannot  be  seen,  the  better 
way  will  be  to  wait,  making  repeated  examinations,  accustoming  the  patient  to 
laryngoscopic  methods,  and  cultivating  the  throat  to  tolerate  the  mirror.  It 
may  be  possible,  after  a  process  of  schooling  of  this  kind,  to  see  and  withdraw 
the  intruding  substance.  While  the  medical  attendant  should  be  ever  ready 
to  operate  by  intubation  or  by  tracheotomy,  these  procedures  should  be  held 
in  reserve  so  long  as  there  is  no  urgent  necessity  for  them. 

One  point  which  the  student  should  always  bear  in  mind  is  that  symptoms 
of  laryngeal  irritation  sometimes  exist  long  after  the  expulsion  of  the  substance 
which  caused  them,  and  that  patients  will  sometimes  insist  that  they  have  not 
yet  been  relieved  Avhen  it  is  certain  that  the  foreign  body  has  been  expelled. 
Moreover,  the  irritation  of  foreign  bodies  is  often  successfully  imitated  in  hys- 
terical individuals. 

BURNS  AND  SCALDS  OF  THE  LAEYNX   AND  TRACHEA. 

These  are  practically  never  dissociated  from  similar  injuries  to  the  parts 
above,  and  perhaps  to  the  oesophagus.  Burns  are  produced  by  the  inhalation 
of  hot  steam  and  superheated  air.  Scalds  are  commonly  produced  by  hot  and 
caustic  fluids.  Caustic  fluids  taken  internally  are  not  always  swallowed,  but 
often  "go  the  wrong  way."  The  consequence  of  these  injuries  is  a  very  acute 
laryngitis,  which  supervenes  at  once,  with  excessive  intumescence  and  oedema. 
In  proportion  to  the  extent  and  severity  of  the  lesion  will  be  the  amount  and 
depth  of  the  tissue-destruction.  Following  the  first  violence  of  the  lesion  a 
membranous  exudate  is  formed  which  separates  by  sloughing,  and,  if  the 
patient  survive,  may  undergo  extensive  cicatricial  contraction.  These  cases 
are  often  complicated  with  bronchitis  of  a  most  serious  and  even  a  fatal 
<;haracter. 

The  symptoms  produced  by  burns  are  immediate  and  violent;  those  pro- 
duced bv  caustics  may  come  on  much  more  slowly. 

So  far  as  treatment  is  concerned,  immediate  death  by  suffocation  can 
easily  be  averted  by  tracheotomy,  though  it  may  not  avail  to  save  the  patient 
from  secondary  lesions.  Scalds  produced  by  caustic  acids  or  alkalies  are 
usually  seen  too  late  to  admit  of  any  antidote  or  to  avert  their  destructive 
effects.  The  symptoms  must  be  treated  as  they  arise,  and  while  the  introduc- 
tion of  a  trachea-tube  will  make  respiration  easier,  the  probability  is  that  the 
attendant  will  have  to  treat  a  comjilicated  case  of  lesion  of  the  mouth  and 
larynx,  if  not  of  the  oesophagus,  which  will  finally  baflle  his  most  persist- 
ent and  well-directed  efforts.  Iced  and  mucilaginous  drinks,  antiseptic 
mouth-washes  and  gargles,  and  anodynes  under  the  skin  or  by  the  rectum, 
with  rectal  nourishment,  sum  up  the  principal  indications  in  the  way  of 
treatment. 

TRACHEOTOMY. 

Under  the  general  term  tracheotomy  are  included  all  those  operations  by 
which  the  respiratory  channel  is  opened  from  without  at  any  point  between  the 
thyroid  cartilage  and  the  sternum.  To  be  more  exact,  we  speak  of  laryngotomy 
when  the  incision  is  through  the  crico-thyroid  membrane  or  thyroid  cartilage ; 


628 


AN   AMERICAN    TEXT- BOOK    OF  SURGERY. 


of  laryngo-tracheoUnny  when  tlie  cricoid  and  upper  rin^rs  of  the  trachea  are 
divided ;  and  of  trneheotomif  proper,  or,  a-s  it  is  sometimes  improperly  called, 
bronchotomy,  when  the  trachea  itself  is  opened.  One  or  another  of  these  opera- 
tions i.s  done,  partly  according  to  the  choice  of  the  operator  and  partly  according 
to  the  necessities  of  the  case.  They  are  undertaken  for,  first,  croup  and  diph- 
theria ;  second,  for  oedema  or  acute  inflammatory  affections:  thir<l,  in  sy[)hili8 
and  tuberculosis  of  the  larynx  in  order  to  give  it  rest ;  fourth,  for  malignant 
disease  in  order  to  relieve  obstructions  to  respiration  ;  fifth,  in  certain  rare  spas- 
modic affections  or  strictures ;  and  sixth,  for  the  removal  of  foreign  bodies. 
Many  of  the  indications  for  tracheotomy  have  already  been  discussed.  We  do 
not  deem  it  wise  here  to  go  into  the  question  of  indications  in  cases  of  croup 
and  <liphtheria,  beyond  this  remark,  that  a  large  projiortion  of  fjital  cases  are 


KiG.  202. 


Carutis  inter na  et  txterna 

Vnin  fiicialin  ruiiimiinis 

R.  ,le.v,l.  S.  XII. 

Vpiiii  jiiiinlnrix  interna 

Vena  thyreoid,  unper 

S.  fthren 

ficnieiiiis  iiiif 


o-(ieitlo-  inaxtoideHM 
fa  rill  I  is  rmiimnnix 
eo-lii/oiil  mnsile 
hi/oiil  mnxrie 

rnii-hyiiid 


liiiio  rri-oidea 


npezius 


Hiiperfirintis 
.[rttrin  trnnKrersiilix  i-olli 
Arteria  tmiixrerxnliM  xrnpitlir      J ^ 
I'eiin  jiit/ntiirix  externa 

Vena  thyreoid,  inferior. 


Omo-hyoid 
Arteria  xnhrlaria 
Steruo-rleido-inaxtoideiis 
Clarirnla 
Isthmns  fjland.  thyroid. 


The  Structures  of  the  Nefk  iiiflcr  Ilciikei. 

the  apparent  result  of  operations  postponed  too  long,  and  that  it  is  very  unfair 
to  the  operative  procedure  to  speak  of  it  as  having  terminated  fatally.  It 
should  rather  be  said  of  it  that  it  failed  to  save  life  because  too  long  delave<l. 
The  interests  of  surgery  and  of  humanity  alike  dictate  that  operation  should 
be  done  at  the  earliest  moment  after  the  indication  has  arisen.  Euthanasia 
may  be  a  desirable  achievement  after  a  late  operation,  but  the  rescue  of  a 
human  life  usually  depends  upon  early  operative  interference. 

Operation  being  decided  upon,  the  operator  is  next  to  elect  at  Avhat  point 
he  will  open  the  windpipe.  This  will  depend  in  some  measure  upon  the  time 
which  he  feels  can  be  devoted  to  it,  or,  in  other  words,  upon  the  urgency  of 
the  case.  When  patients  are  in  the  last  gasp  of  dyspnea,  everything  else  mtist 
give  way  to  the  nece.ssity  for  opening  the  trachea  at  once,  and  even  if  the 
isthmus  of  the  thvroid  be  <livided  or  some  larire  vein  be  cut.  one  may  be  sure 


sunaERV  OF  Till-:  liEsrinAronv  <>n<iAXs.  <)2i> 

that  hemorrhage  ean  be  ehecked  within  a  few  seconds,  and  that  even  if  bh)od 
goes  into  the  traehea,  air  will  go  in  with  it. 

In  these  circumstances  the  trachea  will  be  opened  wherever  it  can  be 
first  reached.  On  the  other  hand,  when  the  operator  is  afforded  plenty  of 
time  he  may  select  his  point  of  attack,  according  to  the  age  of  the  patient, 
the  relative 'thickness  and  length  of  the  neck,  and  the  purpose  for  which  he  is 
operating.  The  two  points  most  commonly  chosen  are  the  cricoid  cartilage 
and  the  first  ring  of  the  traehea,  by  which  we  gain  access  above  the  thyroidal 
isthmus,  or  the  tracheal  rings  immediately  below  it.  This  istlimus  of  the 
thyroid  is  rather  a  bugbear  to  young  operators  than  an  actual  detriment,  since 
when  met  with  it  is  but  the  work  of  a  moment  to  slip  a  double  ligature  under- 
neath it,  tie  in  two  places,  and  divide  it  between  them,  or  even  to  catch  and 
divide  it  between  two  pressure  forceps.  In  young  children  with  very  short, 
plump  necks  one  works  with  greater  ease  if  he  keeps  near  the  larynx.  On  the 
other  hand, -when  the  trachea  lies  near  the  surface  and  the  neck  is  long,  and 
when  also  the  light  is  good,  the  opening  can  be  made  lower  down. 

Tracheotomy  is  simple  upon  the  cadaver,  and  perhaps  the  easiest  import- 
ant operation  which  can  be  there  made.     In  a  living  patient,  under  certain 
circumstances,  it  may  l)e  equally  easy,  but  when  in  the  presence  of  a  desperate 
emergency,  Avith  poor  light  and'untrained  assistants  and  a  windpipe  moving  up 
and  down  because  of  the  violent  efforts  at  respiration,  it  may  be  one  of  the  most 
trying  ordeals  which  even  a  skilled  operator  has  to  face.     Two  anatomical  con- 
ditions especially  serve  to  embarrass  the  operator  or  even  endanger  the  patient's 
life.     The  first  is  the  plexus  of  veins  which  sometimes,  but  not  always,  is 
spread  over  the  anterior  surfiice  of  the  trachea.     In  the  ideal  normal  condition 
these  are  arranged  in  such  a  way  as  not  to  involve  the  middle  line,  but,  as  is 
often  the  case,  they  may  cross  it  irregularly  and  often,  and  sometimes  a  vein  of 
good  size  will  present  at  just  that  portion  of  the  tube  which  we  have  exposed 
for  incision.    When  this  condition  is  met  with,  these  veins  may  be  pushed  aside 
or  may  be  deliberately  ligated  or  caught  with  forceps,  or,  if  exigency  require, 
they  must  be  divided  without  these  precautions.     They  are,  under  these  cir- 
cumstances, usually  engorged  in  connection  with  the  very  congested  condition 
of  all  parts  of  the  head  and  neck.     As  soon  as  a  few  inspirations  have  been 
taken  and  oxygen  has  had  access  to  the  blood,  a  restoration  of  equilibrium 
takes  place  and  this  congestion   quickly  subsides.      Consequently,   the  vein 
which  bleeds  viciously  for  the  instant  may  almost  entirely  collapse  a  few  moments 
or  seconds  later.     It' will  comfort  young  operators  if  they  remember  this  fact. 
The    other    principal  anatomical  danger  is  an    adventitious   or    abnormal 
artery  which  arises  occasionally  from  the  arch  of  the  aorta,  or  sometimes  from 
one  of  the  large  arteries  at  the  base  of  the  neck,  and  takes  its  course  upward 
along  the  trachea,  in  rare  instances  to  its  full  length.     It  is  known  as  the  thy- 
roidea  ima,  and  may  lie  directly  in  the  track  of  the  incision.     When  met  with 
it  is  to  be  dealt  with  as  any  other  artery  would  be.     It  must  also  be  borne  in 
mind  that  the  innominate'  artery  sometimes  courses  as  high  as  the  seventh 
tracheal  ring.     Lower  in   the  neck   the  trachea  is  deeper  and  smaller,  and  is 
consequently  less  accessible.     In  young  children  the  thymus  gland  may  also  be 
an  obstacle"^;  consequently  with   them  it  is  always  desirable  to  work  on  the 
upper  portion  of  the  respiratory  tube. 

Whether  in  child  or  in  adult,  the  head  and  neck  should  be  stretched  over  a 
pillow  or  sand-bag,  and  an  anesthetic  should  always  be  given,  unless  the  patient 
be  already  unconscious  or  cocaine  be  used.  The  middle  line  is  always  the  line 
of  safety.'  and  in  this  line  the  incision  is  made,  ordinarily  from  the  cricoid  for 
five  to  seven  centimeters  downward.     After  cutting  through  the  skin  and  pla- 


G30  ^^V   A  mi:  Jiff 'AN    TPJXT-BOOK    OF  SURdFJtV. 

tysraa  the  endeavor  sliould  l»e  made  to  separate  or  cut  between  the  pairs  of 
pre-tracheal  nniseles.  The  traehea  is  steadied  with  the  left  hand  of  the  operator, 
and  the  incision  iind  dissection  are  continued,  stoppin<j  only  for  arrest  of  the 
heniorriia)^e,  until  the  cartilages  are  felt.  Fortunately,  these  are  unmistakable, 
and  so  long  as  the  operator  can  feel  them  or  can  find  them  he  need  have  no 
fear  of  going  wrong.  After  they  have  been  exposed  and  the  bleeding  has  been 
checked,  a  tenaculum  is  used  to  hook  up  the  trachea,  in  order  to  bring  it  well 
to  the  front  before  incision,  and  to  steady  it.  When  this  is  once  secured  it 
should  not  be  let  go  until  opened.  The  opening  is  made  with  a  pointed  knife 
and  two  or  three  rings  are  divided,  or  the  cricoid  cartilage  and  one  ring,  accord- 
ing to  circumstances.  At  once  there  is  a  rush  of  air  accompanied  with  violent 
and  irregular  respiratory  motions.  During  inspiration  blood,  if  present,  will  be 
sucked  into  the  trachea,  and  during  expiration  blood  and  mucus,  and  perhaps 
false  membrane,  will  be  expelled,  probably  into  the  face  of  the  operator,  a 
danger  to  be  carefully  guarded  against,  especially  in  diphtheria.  ^  If  there  be 
only  a  hissing  of  air,  without  free  play,  it  may  be  known  either  that  the  open- 
ing is  not  large  enough  or  that  it  is  plugged  with  some  shred  of  tissue  or  with 
false  membrane  or  some  foreign  body.  In  the  former  case  it  must  be  carefully 
enlarged ;  in  the  latter  case  it  should  be  dilated,  while  Avith  forceps  or  probes 
the  membrane  or  foreign  body  is  removed. 

It  will  sometimes  happen  that  just  at  the  most  critical  moment  the  patient, 
usually  a  child,  will  entirely  cease  to  breathe.  This  may  occur  just  before  or  just 
after  making  the  opening.  In  this  emergency  the  tracheal  wound,  if  made, 
must  be  quickly  searched,  to  learn  if  it  be  plugged ;  if,  on  the  other  hand,  it 
appear  to  be  open,  the  most  promising  procedure  will  be  to  suspend  the  patient 
by  the  heels  and  to  slap  vigorously  on  the  back,  or  while  in  this  position  to 
make  artificial  respiration  by  compressing  the  thorax  by  the  arms  and  then 
raising  them  in  order  to  expand  it. 

It  is  advisable  to  insert  into  the  trachea,  on  each  side  of  the  incision, 
a  silk  suture,  which  is  ordinarily  passed  through  the  skin  as  well.  This 
should  be  tied  and  the  ends  left  hanging  long.  In  this  way  a  permanent 
and  most  serviceable  retractor  is  provided,  by  means  of  which  the  surgeon 
and  the  nurse  have  absolute  control  of  the  trachea.  Indeed,  so  simple  and  so 
effective  is  this  manoeuver  that  one  need  never  hesitate  to  practise  tracheotomy 
even  though  he  have  no  trachea-tube  at  hand,  since  by  means  of  an  elastic  tied 
around  the  neck  or  extemporized  hooks  fastened  into  the  suture  and  then  con- 
nected with  an  elastic  tape  back  of  the  neck,  every  purpose  of  the  operator  can 
be  complied  with.  This  is  the  so-called  operation  without  tubes,  which  every 
practitioner  should  understand  and  be  able  to  make  in  an  emergency. 

Trachea-tubes  (Figs.  26-5,  264,  and  2(>r>)  are  made  of  hard  rubber,  as 
well  as  of  silver  and  aluminum.  The  rubber  tubes  are  heavy  and  thick, 
and  those  of  aluminum  are  always  preferable.  They  are  made  double,  in 
order  that  the  inner  tube  may  be  taken  out  and  cleansed  or  freed  from 
dry  mucus  as  often  as  is  necessary.  When  cleansing  them  it  is  much  better 
to  use  an  alkaline  solution,  by  which  the  mucus  is  more  readily  removed. 
The  outer  tube  has  a  little  shield  which  is  held  in  place  by  a  tape  passed 
around  the  neck.  The  largest  tube  which  will  comfortably  enter  the  trachea 
should  be  used.  In  cases  of  obstruction  from  false  membrane  it  is  advisable 
sometimes  to  remove  both  tubes,  and  with  a  small  probang  firmly  fastened  to 
a  handle  or  with  a  little  cotton  tightly  wrapped  around  a  wire  (juickly  and 
dexterously  to  pass  this  down  through  the  opening,  and  as  quickly  withdraw 
it,  by  which  means  membrane  is  dislodged  and  expelled  by  coughing.  Even 
this  procedure,  however,  is  itself  dangerous,  and  should  not  be  practised 


SURGERY    OF    THE   RESPIRATORY   ORGANS. 


631 


oftener  than  inav  seem  to  l.e  re.iuired  by  the  trachea  filling  up  Avith  that 

wliich  cannot  be  expelled. 
^'"*-  '-''•'  The    after-treatment    of    cases 

-where  traciieotoniy  has  been  per- 
formed recpiires  to  be  almost  as  judi- 
ciously carried  out  as  the  operation 
itself.  Inasmuch  as  air  enters  directly 
into  the  lungs,  it  should  be  properly 

Fig.  2G5. 


I'ark's  Divided  Trachea-Tube. 
Fig.  264. 


Keen's  Trachea-Tube. 


Johnson's  Modified  Durham's  Trachea-Tube. 


warmed  and  moistened  :  the  room  should  be  kept  at  a  temperature  of  80  F.  if 
possible,  and  the  air  kept  moist  with  steam.  Most  of  the  conditions  which  neces- 
sitate tracheotomy  are  those  which  produce  profound  depression,  and  tonics  ana 
stimulants  are  essential.  Of  these  strychnia  and  alcohol  are  the  most  desir- 
able. The  nutrition  and  the  excretions  should  be  carefully  looked  after,  along 
with  such  internal  medication  as  the  surgeon  may  select.  No  rule  can  be 
given  as  to  how  long  the  tube  should  remain ;  this  must  depend  upon  the  sub- 
sidence of  the  indication  for  which  it  was  performed.  If  for  a  foreign  body,  usu- 
ally one  or  two  days  ;  if  for  croup  or  diphtheria,  five  to  ten  days  or  longer ;  it  tor 
rel'ief  of  ulceration  or  stenosis,  perhaps  for  a  month  or  months  and  even  years ; 
and  if  for  temporary  relief  in  case  of  cancer,  until  death  terminates  the  case. 
Sometimes  a  mass  of  granulations  develops  around  the  tracheal  wound  alter  a 
few  days,  and  causes  considerable  trouble  either  in  reintroduction  of  the  tube 
or  in  producing  obstruction  to  respiration  after  its  removal.  Rarely  they  lead 
to  cicatricial  contraction  later,  and  to  what  is  known  as  granulation  stenosis 
of  the  trachea.  When  present,  if  possible,  these  should  be  removed  with  caus- 
tics, with  scissors,  or  with  galvano-cautery.  Other  dangers  connected  with  the 
operation  are  secondary  hemorrhage,  sloughing  around  the  wound,  emphysema, 
and  ulceration  and  abscess.  When  the  latter  results,  pus  may  burrow  down- 
ward into  the  mediastinum  and  cause  death.  Cellulitis  is  probably  the  least 
common  untoward  sequel  of  the  operation.  It  must  be  treated  upon  general 
principles. 


():}2 


A.y  AMERICAN    TEXT- HOOK    OF  SURGERY. 


INTUBATION  OF  THE  LARYNX. 

This  is  a  distinctively  American  improvement  upon  the  ohl  operation  of 
tracheotomy  which  we  owe  to  tlic  ingenuity  and  patience  of  O'Dwyer :  not  that 
previous  efforts  in  this  direction  had  not  hcen  made,  but  that  he  first  made  it 
practicaljle.  Enough  time  has  elapsed  since  its  intnxluction  to  make  it  very 
plain  that  it  constitutes  a  large  addition  to  our  means  of  affording  instru- 
mental relief,  and  to  give  it  a  dignity  and  importance  which  perhaps  no  other 
operation  of  equal  simplicity  possesses.  The  indications  for  the  operation  are, 
in  the  main,  the  same  as  those  for  tracheotomy.  It  is  performed  mainly  in  cases 
of  diphtheria  and  croup,  and  occasionally  for  relief  from  symptoms  produced  by 
burns  and  scalds,  by  foreign  bodies,  and  by  pressure  of  tumors,  especially  those 
located  outside  the  larynx ;  also  fjr  certain  cases  of  ulceration  and  stenosis,  the 
tube  in  this  instance  acting  as  a  permanent  dilator. 

In  the  ordinary  cases  of  obstruction  it  is  obvious  that  the  sooner  it  is 
performed  the  better,  since  by  delay  the  patient  is  more  exhausted  and  his 
blood  more  loaded  with  deleterious  products.  The  originator  of  the  operation 
considers  that  the  most  pressing  indication  for  intubation  is  recession  at  those 
parts  of  the  chest  which  yield  to  external  air-pressure,  with  continued  restless- 
ness due  to  insufficient  oxygenation,  as  well  as  feebleness  of  respiration.  The 
two  great  advantages  which  intubation  possesses  over  tracheotomy  are  the  speed 
with  which  it  can  be  performed  and  the  bloodlessness  and  lack  of  shock  follow- 
ing it.  The  principal  disadvantage  is  that  the  necessary  instruments  must  be 
at  hand,  while  tracheotomy  can  be  performed  with  almost  any  instruments. 

As  ordinarily  sold,  the  set  of  intubation  instruments  comprises  five  tubes  (Fig. 
266,  a),  of  sizes  suitable  for  children  from  the  earliest  weeks  of  infancy  up  to  the 
age  of  twelve.  A  metal  gauge  or  scale  (B)  has  marked  upon  it  the  lengths  of  the 
tubes  and  the  ages  for  which  each  is  suitable.  Selecting  the  proper  tube,  a  fine 
silk  thread  is  passed  through  a  small  hole  near  the  anterior  angle  of  its  upper 
opening.    This  is  for  the  purpose  of  retracting  it  if  it  should  be  lodged  in  a  wrong 


Fig.  266. 


O'Dwyer's  Intubation  Instruments. 


8-12 
5-7 

.'3-4 

2 
1 


.*,;, 


position.     Each  tube  is  supplied  with  a  separate  obturator,  which  is  screwed 
into  the  handle  by  which  it  is  introduced.     The  patient  is  held  upright  upon 


SURGERY    or    Till-:    JIESPIRATORV    ORGAXS.  633 

the  lap  of  au  assistant,  the  head  ujioii  the  assistant's  left  shoulder.  The  arms 
should  be  secured,  either  by  wrapping  a  towel  or  sheet  around  the  patient's 
body  or  by  being  grasped  below  the  elbows  and  held  firmly  against  the  body 
until  the  tube  is  inserted  and  the  thread  removed.  Unless  the  hands  are  thus 
secured  the  patient  nuiy  seize  it  and  jerk  the  tube  out  of  place.  The  mouth-gag 
(C)  which  accompanies  the  set  is  then  inserted  at  the  left  angle  of  the  mouth  well 
back  between  the  teeth,  opened  and  clamped  in  such  position  that  the  mouth  is 
open  to  its  natural  limit.  Another  assistant  stands  behind  the  patient  with  his 
hands  firmly  grasping  the  head,  steadies  it,  and  at  the  same  time  with  his  left 
hand  keeps  the  gag  in  place.  The  patient  should  be  so  held  that  body,  neck, 
and  head  are  ke})t  naturally  in  a  straight  line.  The  operator  then,  keeping  the 
thread  looped  around  his  right  little  finger,  holds  the  introducer  (D)  in  the  right 
hand  while,  inserting  the  index  finger  of  the  left,  he  seeks  with  the  tip  of  it  for 
the  epiglottis,  which  he  raises  with  it,  thereby  uncovering  the  glottis.  By  the 
time  this  is  done  the  lower  extremity  of  the  tube  has  been  passed  down  by  a 
manoeuver  much  resembling  that  by  which  the  laryngoscopic  mirror  is  put  in 
place ;  the  index  finger  is  now  the  guide  by  which  it  is  passed  downward  into 
the  larynx.  This  manoeuver  is  the  most  difficult  of  those  by  which  intubation 
is  performed.  The  tip  of  the  tube  must  be  kept  in  the  middle  line  and  close 
under  and  in  contact  with  the  epiglottis,  which  has  been  raised  into  a  vertical 
position.  At  the  same  time  the  index  finger  must  be  shifted  to  the  patient's 
right,  in  order  not  to  take  up  that  space  in  the  pharynx  in  the  middle  line  which 
the  tube  must  now  occupy  as  it  is  passed  downward.  As  the  tube  is  lowered  by 
raising  the  other  end  of  the  handle,  the  introduced  finger  must  also  ascertain 
that  it  is  not  being  passed  into  the  oesophagus ;  on  the  contrary,  that  the  pos- 
terior wall  of  the  larynx  can  be  felt  behind  the' tube.  When  it  is  ascertained 
in  this  way  positively  that  the  tube  is  in  the  larynx,  no  time  should  be  lost 
in  sending  it  home  to  its  proper  position,  and  at  the  same  instant  dislodging 
it  from  the  obturator  by  pushing  the  slide  upon  the  handle  with  the  thumb 
of  the  right  hand.  If  the  upper  end  of  the  tube  is  not  by  this  means  sent  low 
enough  down,  it  can  be  pressed  home  by  the  finger  which  is  still  in  the  pharynx. 
It  is  recommended  also,  while  the  finger  is  still  in  the  throat,  to  make  sure  by 
palpation  that  the  tube  is  in  place,  which  can  be  done  by  inserting  its  tip  into 
the  oesophagus  and  from  that  point  feeling  it  in  the  larynx.  With  practice 
such  dexterity  is  obtained  that  the  entire  little  operation  requires  but  a  very 
few  seconds  from  the  time  the  finger  is  first  introduced.  The  writer  advises 
that,  the  arms  of  the  child  being  still  firmly  held,  the  gag  be  for  a  few  moments 
removed  in  order  to  make  sure  that  there  is  no  necessity  for  removing  the  tube 
at  once,  as  well  as  that  it  is  in  place  and  affording  the  desired  relief;  theii  that 
the  gag  should  be  introduced  for  an  instant  while  the  finger  is  once  more  well 
introduced,  and  pressed  down  upon  the  upper  end  of  the  tube  to  hold  it  in  place 
during  the  fraction  of  the  second  required  to  catch  hold  of  one  end  of  the 
thread  and  pull  it  out  from  the  hole  in  the  tube.  Then  the  gag  and  the 
restraint  are  removed  and  the  patient  allowed  perfect  freedom.  The  instan- 
taneous relief  afforded  by  this  operation  is  among  the  most  cheering  spectacles 
which  the  surgeon  ever  meets.  There  is  usually  some  coughing,  often  with 
expulsion  of  membrane,  and  rarely  expulsion  of  the  tube  as  the  result  of  vio- 
lent cough.  It  is  ordinarily  best  to  reinsert  the  tube  should  it  be  thus  expelled, 
using  perhaps  the  next  larger  size. 

The  dangers  of  intubation  are  few.  One  danger  is  suffocation  from  too 
large  a  finger  or  one  held  too  long  in  the  larynx  ;  consequently  several  rapid 
attempts  are  better  than  one  prolonged  effort.  Another  danger  is  that  of 
pushing  down  membrane  ahead  of  the  tube  in  quantity  sufficient  to  produce 


634  AN  AMERICAN   TEXT- HOOK    OF  SURGERY. 

obstructioTi  ;  but  tliis  liappens  very  rarely.  Should  it  occur,  tlie  tul)c  must 
bo  (juickly  removed  by  the  string,  and  then  reintroduced  as  soon  as  the  mem- 
l)rane  has  been  expelled.  Small  pieces  of  membrane  are  usually  coughed  up 
and  driven  through  the  tube.  Tubes  when  expelled  from  the  larynx  are  rarely 
Bwallowed,  but  are  ejected  through  the  mouth.  The  only  danger  of  losing 
the  tube  into  the  stomach  is  from  not  placing  it  properly  in  the  larynx,  or 
else  from  leaving  the  thread  to  be  subseijuently  swallowed  and  draw  the  tube 
after  it.  Even  if  swallowed  the  tube  will  usually  pass  without  trouble.  These 
tubes  are  to  be  retained  on  an  average  for  six  days.  Sometimes  they  may  be 
removed  sooner,  or  if  coughed  up  may  not  need  to  be  reintroduced.  It  must 
be  remembered  that  they  rest  upon  the  false  vocal  cords,  and  not  upon  the 
true,  and  consequently  the  loss  of  voice  which  is  apparent  after  their  removal 
is  not  likely  to  be  more  than  very  temporary.  Of  course  while  the  tube  is 
in  place  the  child  can  only  whisper. 

One  positive  disadvantage  which  these  tubes  entail  is  difficulty  of  degluti- 
tion, especially  during  the  time  they  are  worn.  This  is  to  be  overcome  in  two 
or  three  different  ways :  First,  by  feeding  the  child  only  so  small  an  amount 
of  fluid  that  even  if  a  part  of  it  enter  the  trachea  through  the  tube  it  can 
cause  no  serious  irritation.  Secondly,  by  putting  the  child  in  such  position 
that  the  force  of  gravity  will  prevent  this  accident.  This  is  done  either  by 
turning  the  child  well  over  on  its  side,  or,  better  still,  by  putting  it  in  a  position 
where  the  head  is  lower  than  the  body  while  drinking  or  feeding.  This  can 
be  easily  done  in  spite  of  theoretical  objections.  Thirdly,  by  giving  it  food 
which  is  of  semifluid  consistency,  and  for  this  purpose  ice-cream  is  often  found 
to  be  soothing,  palatable,  and  nutritious.  During  the  time  that  the  tube  is 
worn  the  air  in  the  room  should  be  kept  warm  and  moist,  while  such  medical 
and  local  applications  are  continued  as  to  the  surgeon  may  seem  fit. 

Finally,  after  a  few  days  comes  the  question  of  removal  of  the  tube.  This 
is  sometimes  solved  by  its  expulsion  by  the  patient ;  at  other  times  it  has  to 
be  removed  by  a  manceuver  quite  similar  to  that  by  which  it  was  introduced, 
the  patient  being  held  in  the  same  way,  and  the  left  index  finger  being  again 
the  guide  by  which  the  point  of  the  extractor  (E)  is  carefully  guided  into  the 
opening  in  the  metal.  The  point  being  engaged  in  the  caliber  of  the  tube, 
the  blades  are  sprung  apart  by  the  thumb  of  the  right  hand  acting  on  the 
shank  of  the  instrument,  and  the  tube  is,  as  it  were,  hooked  out  and  withdrawn. 
This  procedure  is  usually  more  difficult  than  the  introduction  of  the  tube,  but 
practice,  especially  upon  the  cadaver,  Avill  quickly  make  perfect.  These  tubes 
are  of  metal  plated  with  gold,  with  an  expansion  at  their  middle,  and  are 
purposely  made  heavy  in  order  to  prevent  their  spontaneous  expulsion. 
After  use  in  one  case  they  must  be  carefully  cleaned,  sterilized  over  the  flame 
or  by  boiling,  and  thus  may  be  used  over  and  over  again.  They  may  also  be 
replated  from  time  to  time. 

Intubation  is  also  a  measure  which  may  be  resorted  to  for  the  treatment 
of  syphilitic  or  cicatricial  stenoses  of  the  larynx,  and  this  simple  method  can 
be  made  to  take  the  place  of  the  more  painful  and  less  serviceable  dilatations 
of  the  larynx  recommended  by  various,  especially  foreign,  surgeons.  In  a 
case  of  this  kind  it  answers  every  purpose  to  let  the  patient  wear  an  intuba- 
tion-tube for  a  few  hours,  or  a  day  or  two,  at  a  time,  (|uieting  reflex  excita- 
bility, if  necessary,  by  local  applications  of  cocaine  or  by  morphine  or  other 
opiates  internally.  The  advantage  of  the  continuous  dilatation  lasting  for 
several  hours  over  a  momentary  dilatation  by  an  instrument  like  Schroetter's 
will  be  apparent  at  once. 

The  systematic  practice  of  intubation  has  been  a  distinct  advance  in  the 


SURGERY   OF    THE   RESPIRATORY   ORGANS.  635 

surgery  of  the  windpipe  and  larynx,  and  a  larjjer  proportion  of  lives  can  be 
saved  by  this  measure  tlian  by  anything  else  that  we  know  of  When  the 
question  of  operative  relief  is  raised,  it  slionld  therefore  be  decided,  if  prac- 
ticable, in  favor  of  intubation  early  performed. 

One  practical  hint  in  the  after-treatment  of  cases  either  of  tracheotomy  or 
intubation  seems  of  great  importance,  and  that  is  not  to  lose  sight  of  the  fact 
that  many  of  these  little  patients,  especially  those  suffering  from  diphtheria, 
are  in  a  state  of  profound  systemic  poisoning,  with  the  heart  muscle  very  much 
weakened,  and  that  part  of  the  secret  of  after-success  lies  in  recumbency,  in 
proper  nourishment,  and  in  appropriate  tonic  and  stimulant  treatment  addressed 
to  the  heart,  for  Avhich  purpose  alcohol  and  strychnia  seem  especially  indicated. 

LARYNGECTOMY. 

Resection  or  extirpation  of  the  larynx  is  one  of  the  modern  operation.^ 
conceived  of  on  theoretical  grounds  and  proved  feasible  by  experiment  upon 
animals.  It  is  performed  especially  in  cases  of  malignant  tumor  located  with- 
in the  larynx,  with  little  or  preferably  no  involvement  of  adjoining  tissue. 
The  operation  has  also  been  performed  for  stenosis,  for  lupus,  for  necrosis, 
and  once  or  twice  for  tuberculosis.  A  few  operators  have  not  hesitated  to 
extend  the  field  of  operation  beyond  the  larynx  proper,  and  in  one  case  Lang- 
enbeck  extirpated  the  larynx  along  with  the  hyoid  bone,  the  base  of  the  tongue, 
the  submaxillary  glands,  and  a  part  of  the  pharynx  and  oesophagus ;  during  the 
operation  he  was  compelled  to  tie  both  the  external  carotids.  The  operation 
is  alwavs  one  of  grear  gravity,  the  amount  of  which  neverthless  depends  in  an 
appreciable  degree  upon  the  condition  of  the  patient.  Nevertheless,  its  results 
have  been  so  conspicuously  successful  in  cases  otherwise  absolutely  hopeless 
that  one  need  never  hesitate  to  advise  it  when  the  general  condition  outside 
of  the  larynx  is  favorable. 

When  the  patient's  general  condition  is  bad  from  the  long-continued  dys- 
pnea it  is  a  great  advantage  to  make  a  preliminary  tracheotomy  one  or  two 
weeks  before  the  operation,  as  it  accustoms  the  patient  to  breathing  through 
the  tube  and  improves  the  aeration  of  his  blood.  In  fact,  most  operators  per- 
form tracheotomy  either  as  the  first  step  of  the  laryngectomy,  or  a  week  or 
two  beforehand.  Keen  has  recently  described  a  method  of  operating  which 
seems  to  simplify  the  operation  very  much  and  to  lessen  its  dangers.  He  avoids 
tracheotomy  entirely.  His  method  of  operating  is  as  follows  :  first,  the  pre- 
liminary preparation  extends  over  at  least  two  or  three  days.  The  teeth  are 
first  thoroughly  cleaned  by  a  tooth-brush ;  every  two  hours,  when  the  patient 
is  awake,  each  nostril  and  the  mouth  are  sprayed  Avith  boric  acid  and  listerine 
or  other  similar  disinfectant.  Chloroform  is  administered  in  the  horizontal 
position.  All  of  the  usual  antiseptic  precautions  being  taken,  an  incision  is 
made  in  the  middle  line  from  a  little  above  the  hyoid  bone  nearly  to  the 
sternum,  and  is  deepened  until  the  thyro-hyoid  membrane,  the  larynx,  and 
two  or  more  rings  of  the  trachea  are  exposed.  The  isthmus  of  the  thyroid 
gland  is  divided,  and  if  necessary  is  ligated.  If  there  is  any  doubt  as  to 
whether  unilateral  or  total  laryngectomy  should  be  performed,  the  thyroid 
cartilage  is  split  precisely  in  the  middle  line  so  as  not  to  injure  the  cords. 
The  two  halves  of  the  larynx  are  drawn  well  apart  by  retractors  and  the 
interior  is  carefully  examined.  The  amount  of  blood  lost  up  to  this  time  is 
exceedingly  slight.  If  total  laryngectomy  is  decided  upon,  the  soft  parts 
attached  to  the  larynx  are  dissected  away  by  the  knife,  scissors,  raspatory, 
or  Allis's  blunt  dissector.  Care  must  be  taken  to  adhere  very  closely  to  the 
larynx.     If  the  disease  is  found  to  have  extended  beyond  the  larynx,  the 


G'Mi  AX    .l.l//.7.'/r.LV    yAA'/W/OOA'    or   srii(ii:iiV. 

operation  should  be  abandoned.  This  docs  not  apply,  liowever,  to  cases  in 
which  the  only  extension  is  by  glandular  infection.  All  such  glands  are  to 
be  removed  before  the  operation  is  terminated.  The  soft  parts  are  separated 
from  the  larynx  on  each  side  until  the  (esophagus  is  reached.  All  vessels 
are  immediately  clamj»ed  and  tie<l  witli  catgut.  I5v  this  dissection  the  larynx 
is  entirely  freetl,  excepting  jtosteriorly  and  at  the  upjier  and  lower  ends. 

The  patient  is  now  placeil  in  the  Trendelenburg  ])osition,  and  the  trachea 
is  divided  horizontally  at  such  a  point  as  will  extirpate  the  entire  disease.  It 
is  also  important  that  this  division  should  be  below  the  level  of  the  beard  in 
men.  lest  the  hairs  grow  into  the  trachea.  The  u)»|)er  end  of  the  trachea  is 
(piiekly  secured  to  the  skin  by  three  sutures.  Into  the  open  end  is  inserted  an 
ordinary  tracheotomy  caiiula.  the  outer  tube  of  which  has  a  caliber  of  12  mm. 
This  is  secured  around  tiie  neck  by  disinfected  tapes;  into  it  is  passed  a 
metal  tube  which  connects  by  rubber  tubing  with  a  funnel  covered  with  flan- 
nel, through  which  the  chloroform  is  subse(juently  administered.  Of  course, 
the  tracheotomy  tube  and  the  rubber  tubing  will  have  been  carefully  disin- 
fected. The  upper  end  of  the  trachea  is  now  pulled  forward  and  the  larynx 
is  carefully  separated  from  the  oesojihagus  by  the  finger,  aided  by  Allis's 
dissector,  and  occasionally  the  knife  or  scissors.  If  the  oesophagus  is  acci- 
dentally buttonholed,  the  opening  should  be  closed  immediately  by  ordinary 
Lembert  sutures.  When  the  upper  border  of  the  larynx  is  reached  the  soft 
])arts  are  divided  transversely  in  front  and  behind,  and  at  the  sides.  The  epi- 
glottis is  now  drawn  down  through  the  wound  and  removed;  the  anterior  wall 
of  the  resoj^hagus  is  next  attached  to  the  tissues  just  below  the  hyoid  bone  by 
silk  sutures  placed  close  together.  The  advantage  of  this  step  is. that  it  pre- 
vents food  and  anv  secretions  of  the  mouth  gaining  access  to  the  wound  left 
by  the  removal  of  the  larynx  and  infecting  it.  The  tracheotomy  tube  is  now- 
removed  from  the  upper  end  of  the  trachea,  and  what  little  chloroform  is 
needed  is  administered  on  a  pledget  of  cotton  covered  with  gauze  held  by  a 
pair  of  forceps  over  the  opening  in  the  trachea.  The  external  Avound  is 
entirely  closed  by  silkworm  sutures,  the  space  formerly  occupied  by  the  larynx 
being  suitably  drained  for  twenty-four  hours.  The  parts  are  dressed  with 
aseptic  gauze  above  and  below  the  tracheal  opening,  which  is  protected  by 
any  framework,  such  as  a  pill-box  with  the  top  and  bottom  removed,  covered 
with  gauze  to  prevent  dust  from  entering.  The  patient  is  |)laced  in  bed 
without  bolster  or  pillows  and  the  foot  of  the  bed  elevated  on  a  chair.  This 
Trendelenburg  position  is  maintained  for  one  or  two  days.  By  the  third  day 
the  patient  is  encouraged  to  sit  up  in  bed,  or  even  out  of  bed.  For  one  or 
two  days  food  is  administered  entirely  by  enemata.  By  the  third  day  the 
patient  can  swallow  eitlier  liijuid  or  sometimes  solid  food.  Entire  healing 
per  primam  may  be  expecte<l.  Any  tendency  to  contraction  of  the  tracheal 
opening  is  met  by  intermittent  use  of  a  tube. 

The  Trendelenburg  position,  not  only  during  the  operation,  hut  after- 
ward, is  intended  to  prevent  the  access  of  infection  to  the  lungs.  The  imme- 
diate closure  of  the  entire  wound,  and  the  separation  of  the  laryngeal  wound 
from  the  cavity  of  the  mouth  and  from  the  end  of  the  trachea,  and  the  absence 
of  any  tracheotomy  wound,  reduce  the  amount  of  infected  fluids  which  can 
obtain  access  to  the  lungs  to  those  from  the  cut  end  of  the  trachea.  Another 
advantage  of  this  method  is  that  it  dispenses  with  the  use  of  any  tampon 
canula,  which  has  many  dangers.  If  the  surgeon  however  decides  to  use  one 
ot  these,  that  of  Gerster  is  to  be  preferred.  The  disadvantage  of  attaching 
the  cut  end  of  the  trachea  to  the  skin  and  of  uniting  the  oesophageal  wall  to 
the  hyoid  is  that  it  prevents  the  use  of  an  artificial  larynx  ;  but  this  at  the 


SURGERY  or  Till-:  REsrihwronv  organs.  g:57 

best  is  a  poor  substitute,  and  in  the  frreat  inajority  of  cases  is  not  used  at  all. 
In  (V)lien"s  woll-known  case.  tlH)u<:li  no  coninninifation  existed  between  the 
trachc;!  Mild  the  nioutli,  tlit'  |iaticiit  had  audil)le  voice. 

Unilateral  laryngectomy  is  a  modification  of  tlie  foregoin;^  wliich 
includes  the  removal  of  a  lateral  half  of  the  larynx,  luiturally  for  disease  lim- 
ited to  one  side.  It  is  performed  upon  the  same  general  principles  as  the  com- 
plete extirpation,  but  while  less  formidable  in  theory  and  in  description,  it  is 
perhaps  a  more  difficult  operation,  inasmuch  as  the  mechanical  details  have  to 
be  carried  out  in  a  restricted  space.  The  ))artial  operation  has  been  successful 
in  about  one-half  of  the  total  number  of  instances,  and  the  complete  operation 
in  something  like  "25  or  30  per  cent. 

SECTION   III.— INJURIES  AND  DISEASES  OF  THE  CHEST,  PLEURA,  AND  LUNGS. 

Pleuritic  Effusions. — Serous  effusions  into  one  or  both  pleural  cavities 
may  be  the  result  of  acute  or  chronic  inflanmiation  of  the  pleura  or  lungs,  or 
both,  also  of  the  presence  of  tumors  or  foreign  bodies.  The  tumors  need  not 
involve  the  pleura,  but  may  cause  passive  effusions  by  obstructing  the  return 
circulation.  The  large  majority,  however,  of  cases  of  hydrothorax  Avith  which 
we  have  to  deal  are  the  result  of  so-called  pleui'isy  with  effusion.  These  cases 
become  of  special  surgical  interest,  naturally,  when  the  collection  of  the  fluid 
assumes  such  magnitude  or  such  permanency  as  to  call  for  mechanical  measures 
for  its  removal. 

The  signs  of  the  presence  of  fluid  in  a  pleural  cavity  are  virtually  the 
same  whether  this  fluid  be  serum,  blood,  or  pus.  In  brief,  they  are  these : 
The  patient  is  apt  to  lie  on  the  affected  side,  by  which  the  sound  lung  is  afforded 
better  play.  On  inspection  there  will  be  found  limitation  of  motion  of  this 
side,  and  the  intercostal  spaces  may  bulge  or  at  least  be  level  with  the  surfaces 
of  the  ribs.  The  apex  of  the  heart,  too,  will  be  dislocated  to  one  side  or  to 
the  other  in  proportion  to  the  quantity  of  fluid  present.  Its  displacement  to 
the  left  is  never  so  great  as  that  to  the  right.  The  liver  may  be  displaced 
downward.  On  palpation  there  is  no  friction  ;  fremitus  and  vocal  fiemitus  are 
diminished  or  lost  over  the  fluid.  When  the  chest  wall  is  oedematous  the  con- 
tained fluid  is  purulent.  By  measurement  the  affected  side  will  be  found  larger 
than  the  Avell  side.  Upon  percussion  there  will  be  dulness  over  the  lower  and 
posterior  surface  of  the  chest,  giving  place  to  flatness,  and,  as  fluid  is  increased 
in  amount,  accompanied  by  a  sensation  of  increased  resistance  under  the  percuss- 
ing finger.  This  dulness  will  have  a  certain  level,  which  in  all  probability 
will  alter  with  the  position  of  the  y»atient,  while  there  will  be  pulmonary  reso- 
nance just  above  this  line.  When  the  amount  of  fluid  is  very  great,  flatness 
may  extend  upward  to  the  clavicle.  Over  the  sound  lung  there  is  exaggerated 
vesicular  resonance  upon  auscultation ;  the  respiratory  murmur  is  w^ak  or 
absent  over  those  portions  (jccupied  by  fluid,  while,  as  the  lung  is  compressed, 
the  breathing  takes  on  a  bronchial  character.  In  mild  cases  friction  sounds 
are  sometimes  heard. 

When  these  signs  are  found,  one  may  be  quite  sure  of  the  presence  of 
fluid.  In  order  positively  to  prove  the  diagnosis,  if  such  conviction  be  required, 
the  needle  of  a  hypodermatic  syringe  or  of  an  aspirator  may  be  introduced ; 
through  this  thin  serum  will  always  flow.  It  may  be  possible,  however,  for  a 
small  needle  to  become  clogged  by  a  fragment  of  blood-clot  or  of  fibrin  or  of 
caseous  pus,  so  that  while  the  discovery  of  fluid  with  a  fine  needle  is  always 
positive  evidence,  failure  with  the  same  needle  to  get  fluid  is  not  necessarily 
the  reverse,  and  only  with  the  large-sized  needle  can  this  question  be  settled. 


638  .l.V   AMERK'AX    TKXr-HOOK    OF  SURGERY. 

EMPYEMA. 

This  term  is  applied  to  a  collection  of  pus  in  any  cavity,  but  by  common 
consent,  unless  some  other  cavity  is  specified,  it  is  understood  to  refer  to  that  of 
the  pleura.  Pus  may  be  found  here  as  the  result  of  the  same  causes  that  bring 
about  serous  effusion,  plus  the  contamination  ))y  organisms  from  the  lungs  or 
more  remotely  through  the  systemic  circulation.  In  cases  of  penetrating 
injury  of  the  pleura,  when  air  has  entered  this  cavity  it  is  not  unlikely 
that  collections  of  blood  or  serum  will  become  thus  directly  contaminated, 
and  empyema  be  the  result  almost  from  the  outset.  As  a  rule,  however,  it  is 
the  result,  perhaps  the  termination,  of  a  chronic  process.  In  recent  cases  the 
pleura  does  not  have  time  to  become  very  much  thickened;  but  in  long-stand- 
ing cases,  especially  those  in  which  spontaneous  perforation  has  occurred,  the 
pleura  becomes  infiltrated  and  altered,  so  as  to  lose  all  resemblance  to  its 
original  structure,  and  to  be  found  sometimes  a  centimeter  thick.  Under  these 
conditions  it  is  more  like  leather  than  like  a  living  tissue.  A  collection  of  pus 
having  occurred  within  the  pleural  cavity  from  any  cause,  several  possibilities 
exist  for  it :  its  fluid  portion  may  be  gradually  absorbed  and  its  soli<l  material 
remain  to  cement  the  pleural  surfaces  together  and  to  caseate,  and  finally  to 
disappear ;  or  it  may  excite  further  production  of  fluid  of  the  same  character, 
which  will  produce  such  urgent  symptoms  as  to  necessitate  relief;  or  it  may 
evacuate  itself  either  by  rupture  into  a  bronchus  or  bronchiole  and  escape  by 
the  mouth  or  by  perforation  elsewhere  in  any  one  of  various  directions.  Thus 
it  has  been  known  to  burrow  down  around  the  external  intercostal  muscles  which 
terminate  under  the  intercostal  cartilages  and  to  appear  at  various  points  about 
the  thorax,  or  to  perforate  or  burrow  around  the  fibers  of  the  diaphragm  and 
cause  perhaps  a  subdiaphragmatic  abscess,  or  to  take  some  other  unusual 
course.  It  has,  for  instance,  been  known  to  perforate  behind  the  mammary 
gland,  and,  pushing  itself  forward,  to  assume  enormous  size  as  a  retro- 
mammary abscess ;  or  to  separate  the  diaphragm,  and  then  the  peritoneum, 
and  to  make  such  a  dissection  of  it  from  the  abdominal  wall  as  to  appear  in 
the  pelvis  and  in  the  abdominal  wall  as  an  enormous  extra-peritoneal  abscess. 
But  these  are  unusual  cases,  and  it  ordinarily  gives  rise  to  the  same  character 
of  disturbance  as  a  collection  of  serous  fluid,  with  the  addition  of  the  consti- 
tutional signs  of  the  presence  of  pus,  such  as  chills,  irregular  high  temper- 
ature, emaciation,  hectic,  etc. 

I.  The  idiopathic  forms  of  empyema  may  be  thus  classified  : 

a.  Staphylococcus  and  streptococcus  form  of  infection  of  pleuritic  ex- 
udate. 

h.  Diploeoccus  form,  from  Frankel's  diplococcus  pneumonia?,  probably 
originally  the  result  of  a  pleuro-pneumonia,  the  pneumonic  lesion 
having  cleared  up. 

c.  Tubercular  form,  the  result  of  tubercular  pleurisy,  which  may  be  con- 

taminated with  pyogenic  cocci.  * 

d.  Secondary  and  embolic  form,  due  to  a  suppurative  focus  elsewhere 

(e.  g.  retro-pharyngeal  abscess,  perforating  peritonitis,  pyemia,  etc.). 

e.  Putrid  form,  from  contamination  by  saprophytic  bacteria. 

II.  The  traiunatic  form  must  be  regarded  as  comj)rising  cases  of — 
Simjde  and  mixed  infections  from  burns,  wounds,  foreign  bodies,  etc. 
The  surgical  treatment  of  empyema — and  it  scarcely  permits  any  other — 

is  by  paracentesis,  i.  e.  aspiration,  or  free  incision  and  drainage.  In  simple 
cases  the  former  may  be  first  tried,  as  described  above.  Serious  or  long- 
standing cases  should  not  have  time  thus  wasted  upon  them,  but  should  be 
subjected  at  once  to  some  form  of  thoracotomy  (p.  G40). 


SURGERY    OF    THE    11  EXPIRATORY   ORGANS.  639 

HEMOTHORAX. 

By  this  term  is  meant  a  collection  of  blood  in  tlie  pleural  cavity.  It  is 
almost  always  of  traumatic  ori«;in,  altlioun^li  the  possiljility  of  spontaneous  hem- 
orrhage cannot  be  excluded.  We  meet  with  it  most  often  in  cases  of  fractured 
ribs,  where  a  sharp  fragment  of  bone  has  scraped  the  surface  of  the  lung  dur- 
ing respiration  until  the  lung  is  removed  from  harm's  w^ay  by  the  presence  of 
serum  or  blood  pressing  it  away.  Furthermore,  it  is  seen  in  cases  of  gunshot 
or  stab  wound  where  an  intercostal  artery  or  some  vessel  in  the  lung  has  been 
divided,  and  where  blood,  even  to  fatal  amount,  has  collected.  The  general 
physical  signs  already  given  in  some  detail  will  point  to  the  presence  of  fluid, 
and  the  history  of  the  case  or  of  the  injury,  with  aspiration,  if  necessary,  will 
enable  the  surgeon  to  decide  which  condition  he  has  to  deal  with. 

OPERATIVE  TREATMENT  OF  FLUID  COLLECTIONS  IN  THE  PLEURAL  CAVITIES. 

Paracentesis. — The  indications  for  removal  of  fluid  from  the  pleural 
cavities,  without  reference  to  the  stage  of  the  disease,  in  moderate  eff'usions  are 
dyspnea  and  distress,  and  the  recognition  of  the  presence  of  large  amounts  of 
fluid,  whether  other  symptoms  and  signs  are  violent  or  not ;  furthermore, 
the  failure  of  nature  or  art  to  cause  resorption  within  reasonable  time,  on  the 
average  thi-ee  weeks ;  .spontaneous  perforation  into  the  lung  ;  the  presence  of 
fever,  perhaps  with  chills,  and  bulging  of  intercostal  spaces,  with  oedema  of 
the  overlying  skin,  which  are  supposed  to  indicate  the  presence  of  pus  ;  or  the 
certainty  from  the  history  and  physical  signs  that  blood  has  been  poured  out 
and  has  not  been  resorbed.  There  are  other  reasons  than  the  mere  necessity 
to  obtain  immediate  relief  why  evacuation  should  be  secured.  By  the  pres- 
ence of  fluid  the  lung  is  naturally  compressed  and  its  integrity  impaired,  with 
a  pro.spect  of  permanent  injury  to  its  function  if  it  be  not  permitted  to  resume 
its  former  shape  and  size  within  a  reasonable  time.  We  may  also  be  sure  that 
the  longer  it  has  been  compressed  the  less  elastic  it  is  and  the  more  difficult 
will  be  its  expansion. 

Paracentesis  Thoracis. — The  term  paracentesis  is  applied  to  evacuation 
of  fluid  from  any  cavity,  the  particular  cavity  being  specified  in  the  name  of 
the  operation.  To  Bowditch  of  Boston  is  due  the  credit  of  having  first  applied 
suction  for  the  evacuation  of  fluid  effusions,  a  method  which  has  now  become 
so  general  as  scarcely  to  call  for  comment.  For  this  purpose  there  are  needed 
a  hollow  needle  or  fine  ti'ocar,  some  flexible  tubing,  and  some  mechanical 
device  for  suction.  In  the  absence  of  all  other  mean.s,  siphonage  may  be 
practised  through  a  yard  or  more  of  rubber  tubing  first  filled  with  aseptic 
solution  and  its  lower  end  kept  constantly  under  water;  or  a  Davidson  syringe 
may  be  used,  or  one  of  the  more  elegant  forms  of  aspirator,  or  the  Allen  sur- 
gical pump,  although  if  the  emergency  be  very  dire  an  ordinary  trocar,  or  even 
the  puncture  of  a  tenotome  blade,  may  be  resorted  to.  The  two  main  indica- 
tions are  to  withdraw  the  fluid  and  to  prevent  the  admission  of  air.  If  air  can 
be  kept  out,  the  lung  must  necessarily  tend  to  expand  in  order  to  take  the  place 
of  the  fluid  which  is  removed.  Inasmuch  as  this  should  be  anything  but  a  rapid 
process,  the  needle  should  be  only  large  enough  to  permit  fluid  to  run  ea.^ily 
through  it  and  carry  perhaps  Avith  it  fine  flocculi  of  fibrin,  otherwise  pulmonary 
hemorrhage,  or  at  least  violent  intrathoracic  distress,  might  ensue.  Before 
using  it  the  needle  should  be  cleaned  and  polished  and  then  sterilized  by  pass- 
ing it  through  the  alcohol  flame.  Unless  patients  are  too  w-eak  to  sit  up,  they 
are  placed  in  a  sitting  posture.  It  is  well  to  give  a  little  stimulant  before  and 
perhaps  during  the  operation.     The  needle  is  inserted  in  an  intercostal  space 


640  AX  AMKincAX  ri: XT- BOOK  OF  smoKity. 

eitlier  just  below  the  lower  angle  of  the  scajiula  at  the  back,  or  at  the  side  just 
in  front  of  the  latissinuis  dorsi  muscle.  Before  introducing  the  needle  the  skin 
should  be  scoured  and  made  aseptic  ;  and  it  should  be  inserted  quickly.  It  is 
perhaps  well  to  guard  the  needle  with  the  finger,  lest  by  too  forcible  a  plunf^e 
it  be  inserted  too  far.  There  is  always  a  possibility  with  a  too  fine  needle  that 
some  particle  of  fibrin  or  clot  or  caseated  pus  may  obstruct  it  so  that  nothincr 
will  flow  out.  Most  of  the  aspirat(»r  needles  are  provided  with  wires  which 
may  be  inserted  into  them  after  being  cleansed,  and  with  which  they  may  be 
cleared  out.  Should  fluid  still  refuse  to  come,  especially  if  the  anterior  end  of 
the  needle  appear  to  work  freely  as  if  in  a  cavity,  it  is  better  to  withdraw  it  to 
see  that  it  is  clear,  and  then  to  introduce  a  larger  one.  The  withdrawal  of 
a  needle  should  be  done  as  quickly  as  its  introduction  ;  after  which  the  punc- 
ture is  sealed  with  plaster  or  collodion. 

Sometimes  patients  becon)e  so  weak  or  faint  that  it  is  necessary  to  put 
them  in  the  recumbent  position  or  even  to  stop  the  aspiration  for  the  time. 
The  sudden  expansion  of  the  previously  compressed  lung  certainly  does  often 
cause  a  most  disagreeable  sensation,  while  the  withdrawal  of  the  fluid  perhaps 
allows  the  heart  ((uickly  to  return  to  its  normal  position,  by  which  its  action 
may  be  temporarily  disturbed.  I*erfect  rest  should  be  enforced  for  a  number 
of  hours  after  the  operation. 

Should  the  lung  persistently  refuse  to  re-expand  after  repeated  tappings,  it 
is  scarcely  worth  while  to  make  many  efforts.  Constitutional  treatment  with 
tonics  will  probably  do  more  for  these  cases  than  surgery.  However,  should 
it  be  necessary  after  prolonged  effort  to  do  something,  it  would  have  to  be 
in  the  line,  probably,  of  excision  of  ribs  as  described  below.  It  has  been 
recently  found  tliat  empyema,  following  pneumonia,  is  occasionally  cured  by 
tapping.  When,  therefore,  the  pneumococcus  is  found  tapping  should  first 
be  done. 

When  the  effused  fluid  is  purulent  the  prognosis  after  simple  aspiration 
is  not  nearly  so  good.  In  rare  instances,  esjit-cially  in  children,  and  in 
pneumonic  empyemas,  one  or  two  tappings  may  suffice,  but  a  condition  of 
empyema  or  pyothorax  differs  but  little  from  any  other  large  abscess,  save 
that  it  has  a  bony  and  unyielding  wall,  and  it  calls  for  incision  and  drainage 
after  the  same  fashion. 

THORACOTOMY. 

Thoracotomy,  or  0})ening  the  wall  of  the  thorax  for  evacuation  of  collec- 
tions of  fluid,  consists  sim|)ly  in  an  incision,  jierhaps  two  inches  long,  throuL'h 
the  skin  over  an  intercostal  space,  the  opening  througli  the  pleura  Ix'ing  an 
inch  or  half  an  inch  in  length.  When  peiforming  this  operation  the  skin 
should  be  cleansed,  as  well  as  the  operator's  hands;  the  skin  may  then  be 
slid  upwanl  for  an  inch  or  more  above  the  point  at  which  the  opening  is  to 
be  made,  in  order  that  when  it  returns  to  its  place  it  shall  exercise  .somewhat 
of  a  valve-like  action.  This  will  be  of  little  use  so  lonj;  sis  the  draina'^e- 
tube  IS  in  use,  but  may  be  of  service  later.  To  avoid  a  mistake  it  is  well 
before  finally  dividing  the  jdeura  to  insert  a  needle  or  fine  trocar  to  see  if 
pus  be  underneath.  If  found,  no  hesitation  need  be  felt  in  perfi»rating  the 
pleura,  being  careful  only  not  to  push  the  knife  too  far  in  ;  or  in  allowing  the 
pus  to  escape,  which  it  will  probably  do  by  jets  because  of  the  patient's  breath- 
ing or  coughing.  The  best  point  at  which  to  )»uncture  is  at  the  side  just  in 
front  of  the  latissimus  dorsi  muscle,  certainly  not  lower  than  the  eighth  inter- 
space, and  perhaps  even  as  high  as  the  sixth,  ileic  the  jileura  is  near  the  sur- 
face, and  we  gain  the  advantage  of  gravity  in  draining  the  chest,  while  drain- 


scnai:nv  of  tiii:  lucspinAToiiv  organs.  G41 

age-tubes  at  this  point  cause  little  discomfort.  Of  course  air  enters  the  chest 
through  the  external  opening,  the  air-pressure  on  each  side  of  the  lung  is 
e([uali7A'd.  and  there  is  no  fear  of  distress  from  too  rapid  expansion  of  the  lung. 
The  ])us  from  these  cases  is  freciuontly  fetid,  l)ut  the  fetor  will  usually  disap- 
pear in  a  short  time.  Some  surgeons  advise  washing  out  the  pleural  cavity,  by 
•which  means  pus-clots  are  removed  and  fetor  of  discharge  is  subdued,  but  when 
there  is  neither  fetor  nor  debris  discharged  it  is  perhaps  as  well  to  omit  irriga- 
tion. When  this  latter  is  practised  we  may  use  strong  or  saturated  boric  solu- 
tions or  solutions  of  mercuric  chloride,  1  :  5000,  followed  by  boiled  water  or 
dilute  Labarracjue's  solution.  Through  the  incision  one  or,  preferably,  two 
good-sized  stout  drainage-tubes  are  inserted  and  f;\stened  by  silk  sutures  to  the 
skin.  They  should  be  just  long  enough  to  reach  from  without  fairly  into  the 
pleural  cavity,  and  are  introduced  partly  for  purposes  of  washing  and  drainage, 
and  partly  to  keep  the  opening  from  healing  too  quickly. 

In  some  instances  the  ribs  are  so  close  together  that  any  tube  will  be  col- 
lapsed by  their  pressure  upon  it.  AVhen  this  is  the  case  a  section  of  rib,  prob- 
ably of  the  seventh,  about  an  inch  in  length,  should  be  removed.  After  the 
complete  evacuation  of  an  empyemic  cavit}^  a  large  quantity  of  antiseptic  and 
absorbent  dressing  should  be  placed  outside  the  wound,  and  over  all  this  some 
impervious  covering  such  as  rubber  dam.  Outside  this  an.  elastic  bandage 
around  the  chest  will  be  of  advantage,  provided  it  be  not  too  uncomfortable. 
This  dressing  should  be  renewed  the  following  day.  and  after  that  every  second 
day.  As  soon  as  the  discharge  becomes  serous,  and  has  diminished  to  a  very 
small  amount,  one  drainage-tube  may  be  removed,  and  the  second  when  the 
amount  is  no  greater  than  would  be  caused  by  the  presence  of  the  tube.  Wlien 
the  chest  has  thus  been  opened,  expansion  of  the  collapsed  lung  is  finally  at- 
tained in  many  cases. 

Excision  of  Rib. — In  certain  cases  it  is  evident  at  the  outset,  and  in 
other  cases  it  becomes  patent  later,  that  mere  incision  with  insertion  of  ilraiii- 
age-tubes  will  not  afford  large  enough  and  permanent  enough  vent.  In  such 
cases  it  is  a  common  practice  to  remove  a  section  of  one  or  two  ribs  through  a 
single  external  incision,  the  bony  pieces  being  from  one  to  two  inches  long. 
This  makes  a  somewhat  more  formidable  operation  than  the  foregoing,  and  is 
advisable  mostly  in  cases  of  longer  standing.  Whenever  it  is  necessary  to 
incise  the  chest  for  this  purpose,  we  must  expect  to  find  the  pleura  altered 
from  a  thin  parchment-like  membrane  into  one  which  seems  more  like  leather, 
and  which  may  be  correspondingly  tough. 

THOEACOPLASTY  (ESTLANDER'S  AND  SCHEDE'S  OPERATIONS). 

Finallv,  the  surgeon  is  called  at  times  to  cases  where  the  empyemic  con- 
dition has  existed  for  a  long  time,  or  where  an  encysted  collection  has 
formed,  or  where  spontaneous  perforation  has  occurred,  so  that  he  has  to 
deal  with  a  thoracic  fistula,  discharging  at  times  a  small,  at  times  a  large, 
amount  of  pus.  In  these  instances  the  pleura  has  become  so  rigid  and  inflex- 
ible, and  the  lung  so  fixed  in  its  abnormal  position,  that  even  if  the  cav- 
ity be  widely  opened  by  the  ordinary  method  it  is  impossible  for  it  to  heal, 
since  the  lung  cannot  expand  from  within  nor  can  the  chest-wall  collapse 
from  without.  The  ribs  now  act  like  parallel  hoops,  and  serve  to  preserve 
a  cavity  which  we  urgently  desire  to  obliterate.  This  may  be  somewhat 
diminutive  in  size,  or  may  be  almost  commensurate  with  the  entire  space  nor- 
mallv  occupied  by  one  lung.  It  is  in  these  cases  that  the  thoracoplastic  method 
devised  by  Estlander  has  rendered  the  most  signal  service.     It  is  based  simply 

41 


042 


•  I.V    AMFJilCAX    TEXT-IK K>K    OF   SCUdFin' 


Oil  the  theory  that  inasmuch  as  tlie  inner  wall  of  the  cavity  cannot  (•\j)an(l  to 
meet  the  ribs,  the  ribs  must  be  so  divided  as  to  iierniit  them  to  fall  toward  and 
meet  the  lung  tissue.  It  offers  a  prosjject  of  final  cure  for  cases  which  are  otlier- 
■wise  beyond  such  possibility.  The  smaller  the  cavity  the  simpler  the  operation, 
though  one  may  not  be  deterred  from  resorting  to  it  in  exti-eme  cases.  Before 
deciding  to  operate,  however,  it  would  be  well  carefully  to  examine  the  patient 
and  the  urine,  in  order  to  recognize  such  signs  of  amyloid  changes  as  would 
make  it  unwise  to  give  anesthetics  or  perform  any  sevei-e  operation. 

Inasmuch  as  it  is  usually  necessary  to  attack  several  ribs,  we  must  jilan  our 
incisions  in  such  cases  according  to  the  size  of  the  cavity  and  the  amount  of 
collaj)se  desirerl.  In  the  im^-e  simjile  cases  it  is  enough  to  make  a  long  incision 
from  the  axilla  downward,  and  simply  to  divide  or  perhaps  remove  pieces  from 
the  third  to  the  eighth  or  ninth  rib.  At  other  times  an  incision  is  made  both  in 
front  and  behind,  and  posteriorly  at  the  inner  border  of  the  scapula,  bv  which 
three  or  four  ribs  may  be  divided  in  front  and  from  three  to  seven  behind. 
Such  an  operation  as  this  is  very  severe,  and  leaves  the  patient  witii  a  large 
passage  clear  through  the  chest. 

When  performing  this  operation,  if  the  patient's  strength  hold  out,  it  i.s  well 
to  do  more  than  simply  divide  the  ribs  and  the  enormously  thickened  pleura. 
This  pleura  is  practically  the  wall  of  an  immense  abscess,  and  from  it  shreds 
of  membrane  and  disorganized  tissue  may  hang  like  stalactites  from  the  roof 
of  a  cavern.  These  cases  are  also  usually  tubercular,  and  such  membrane 
is  fraught  with  danger.  It  is  advisable,  therefore,  to  scrape  and  cut  away  from 
both  pleural  surfaces  as  much  of  it  as  can  be  safely  removed  without  excitincr 
too  serious  hemorrhage.  No  fear  need  be  felt  from  the  intercostal  arteries, 
since  it  is  a  simple  matter  to  check  the  hemorrhage  with  catch  forceps  and  to 
pinch  the  bones  sufficiently  to  compress  the  arteries.  The  altered  pleura,  as  a 
rule,  is  not  vascular,  and  it  is  surprising  how  so  formidable  an  operation  can  be 
made  with  so  little  loss  of  blood.  No  attempts  should  be  made  to  suture  or 
close  the  wound,  but  it  is  left  as  widely  open  as  possible,  and  perhaps  packed 
in  order  to  keep  it  so.     As  granulations  spring  up  on  the  freshened  pleural 

surfaces  we  have  a  gradual  process  of  healing 
by  second  intention  or  adhesion  of  granu- 
lating surfaces,  by  Avhich  the  lung  will  be 
gradually  drawn  outward  and  the  chest 
drawn  inward.  Considerable  restoration  of 
function  also  occurs. 

iSchcde's  Operation. — In  old  cases,  in  which 
the  pleura  may  be  an  inch  thick,  Schede  has 
devised  a  still  more  radical  operation.  An 
incision  (Fig.  267)  is  made  from  the  level  of 
the  axilla  in  front  to  the  second  rib  behind, 
the  convexity  of  the  incision  reaching  to  the 
lowest  limit  of  the  pleura.  The  large  flap 
is  dissected  loose  down  to  the  ribs,  the  scap- 
ula being  lifted  from  the  trunk.  The  ribs, 
from  the  second  downward,  from  the  costal 
cartilages  to  the  tubercles,  and  the  entire 
muscular  chest-wall  and  the  pleura,  are 
then  removed  by  large  scissors  or  bone- 
forceps  and  the  flap  is  replaced  on  the  lung 
Any  bleeding    arteries  are  tied.      Healing  gen- 


liicision  for  Schede's  Operation  of  Tho- 
racoplasty (Esmarch  and  Kowalzig). 


after  thorough   curetting. 

erally  takes  place  by  first  intention. 


srii(;i:in-  or  riii:  j:i:si'ii:A'r<tin-  onaANS.  643 

(JAXdKKNi:   OF   THE    LUNGS. 

This  may  bo  oitlicr  idiopathic'  or  traumatic.  It  is  more  coiniiioii  in  the 
h)\vt'r  than  in  tlio  u])))cr  h)hi's.  'I'hore  are  a  (liffusc  and  a  circiiniscrihed  form. 
Tlie  ("ormer  is  usually  of  the  emljolie  variety.  (ianL^ronc  here,  as  elsewhere, 
is  the  result  of  bacterial  invasion  and  putrefaction.  The  lungs  may  be  invaded 
from  -within  by  foreign  bodies  taken  in  by  inhalation  or  by  "  swallowing  the 
wrong  way."  It  occurs  in  marasmic  patients,  in  the  insane,  in  those  that  can- 
not swallow  well  nor  cough,  and  in  those  witli  bulbar  paralysis.  It  may  also 
result  from  necrotic  ])rocesses  in  the  pharynx  or  larynx  ;  also  from  perforation 
of  septic  foci  from  other  tissue,  as  through  the  j)leura  or  dia])hragm,  or  from 
carious  vertebnxi  or  infected  bronchial  glands.  It  develops  secondarily  also 
from  such  conditions  as  fetid  bronchitis  or  croupous  pneumonia  or  bronchial 
dilatation ;  also  by  embolic  processes  from  gangrenous  bed-sores,  puerperal 
septicemia,  etc.  It  furthermore  occurs  as  the  result  of  injuries,  such  as 
lacerations,  compound  fractures,  gunshot  and  stab  wounds,  etc. ;  or  as  the 
result  of  severe  contusions  with  cerebral  concussion  by  which  respiration 
is  interfered  with  and  venous  stasis  encouraged  ;  or  by  such  injuries  as  cause 
endocarditis. 

The  clinical  signs  of  gangrene  of  the  lungs  much  resemble  those  of  fetid 
bronchitis.  The  sj)utum  as  well  as  the  breath  has  a  most  repulsive  odor,  and 
if  the  former  be  collected  in  a  glass  it  forms  usually  three  layers,  the  lower  one 
consisting  almost  wholly  of  pus  and  debris.  When  of  traumatic  origin  we  have 
intense  local  and  prolonged  pain,  severe  initial  chills,  pyrexia,  and,  later,  fetid 
expectoration.  If  the  gangrene  is  localized  in  the  lungs,  ulceration  may  take 
place ;  when  the  pleura  is  involved  it  is  fatal.  By  physical  examination  we 
can  sometimes  easily  map  out  the  extent  of  the  gangrenous  condition.  Some- 
times we  get  even  the  signs  of  a  cavity.  If  such  be  near  the  surface,  we  may 
be  sure  of  adhesion  between  lung  and  chest-wall,  and  may  see  here  a  plain 
indication  for  surgical  interference. 

This  may  be  rapidly  and  successfully  performed  by  free  incision  down  to 
the  pleura,  with  resection  of  one  or  more  ribs  if  necessary,  and  then  the  open- 
ing of  the  gangrenous  pulmonary  cavity,  which  is  usually  performed  with  the 
cautery  knife.  The  danger  of  the  operation  can  be  scarcely  as  great  as  that 
of  the  condition  if  left  unrelieved. 

SUEGERY  OF   THE   LUNG. 

Modern  experimental  methods  have  shown  that  in  certain  cases  and  in  certain 
ways  it  is  not  only  possible,  but  judicious,  to  attack  the  human  lung.  Centu- 
ries of  clinical  observation  have  made  it  clear  that  the  entrance  of  air  into  the 
pleural  cavity  either  from  within  or  from  without  is  by  no  means  fatal,  but  may 
be  an  incident  quickly  recovered  from.  So  long,  then,  as  air  has  access,  it  mat- 
ters little  whether  it  be  through  a  small  opening  or  through  a  large  one  ;  that  is 
to  say,  if  necessary,  we  can  expose  the  lung  by  a  large  incision.  Thus  far, 
the  lungs  have  been  attacked  in  cases  of  wounds,  especially  for  the  relief  of 
hemorrhage,  of  gangrene,  of  abscess  Avhether  due  to  gangrene,  dilated  bronchi, 
or  tubercular  disease,  for  the  drainage  of  cysts,  for  the  removal  of  solid  tumors, 
for  the  excision  of  foci  of  tubercular  disease ;  and  they  may  properly  be 
attacked  in  certain  cases  for  the  removal  of  foreign  bodies.  We  may  distin- 
guish between  simple  incision,  or  pneumotomy,  and  exsection  of  a  portion  of 
lung  tissue,  or  jynt'ianectomif. 

Experiments  on  animals  have  shown  that  two-thirds  or  more  of  one  lung 
can  be  removed  through  an   incision  in  the  thoracic  wall  with  almost  perfect 


044  .4.V   AMERICAN    TllXT-lK X )K    OF  SURGERY. 

impunity-  So  much  as  this  of  a  human  hni;^  has  as  yet  never  heen  safely 
removed,  but  small  portions  have.  Vivisection  teaches  us  that  although  one 
pleural  cavity  be  opened  and  its  lung  collapsed  and  made  temporarily  useless, 
the  animal  can  get  sufficient  oxygen  by  respiring  uith  the  other  lung,  and 
that  in  case  oxygenation  be  deficient  or  respiration  suddenly  sto])ped,  it  may 
be  continued  by  artificial  means  almost  indefinitely.  Consequently,  if  the 
human  patient  must  be  subjected  to  some  such  ordeal  as  this,  the  surgeon 
should  have  at  hand  a  irachea-tube  and  bellows  or  means  for  inducing  arti- 
ficial respiration.  In  the  operations  recorded,  however,  it  has  seldom  been 
necessary  to  resort  to  them. 

PxEUMOTOMY  in  the  presence  of  disease  consists  ))ractically  in  the  measures 
described  above  for  opening  gangrenous  cavities.  This  is  where  we  expect  to 
find  the  lung  adherent  to  the  chest-wall.  Should  we  fail  to  find  it  thus  fixed, 
the  lung  should  be  drawn  up  toward  the  surface  and  snugly  fastened  there  by  a 
row  of  sutures.  Within  a  few  hours  adhesion  will  have  taken  place,  and  the 
cautery  may  be  used  for  penetrating  deeper,  as  above  mentioned.  This  would 
presumably  be  the  Jjetter  method  for  dealing  with  a  foreign  body  in  the  lungs, 
provided  we  can  locate  it,  and  if  it  cannot  be  located  it  will  be  inadvisable  to 
operate  unless  the  chest  has  been  already  widely  opened  and  the  lung  collapsed. 
In  one  instance  after  a  stab  wound  of  the  chest  a  man  was  allowed  to  die 
because  it  was  held  that  a  large  vessel  in  his  lung  had  been  wounded  and  that 
his  condition  was  consequently  helpless.  It  was  found  later,  however,  that 
the  bleeding  all  came  from  an  intercostal  artery,  through  which  the  man  had 
bled  to  deatli  into  his  own  chest.  In  this  case  the  result  might  have  been 
very  different  had  free  incision  been  made  and  the  source  of  the  hemorrhage 
sought  for. 

Pneumectomy  may  be  done  in  a  similar  way,  as  when  a  hernia  of  the 
lung,  recent  or  old,  is  excised ;  or  it  may  be  forced  upon  a  surgeon  when  in 
operating  upoji  a  malignant  tumor  of  the  chest  he  finds  the  lung  adherent 
behind  it  and  involved  in  the  disease.  Success  has  been  obtained  in  such 
cases,  the  wound  in  the  luni;  tissue  beino;  closed  according;  to  usual  methods. 
Or  it  may  be  done  with  deliberation,  as  in  the  case  where  an  Italian  surgeon 
resected  a  tubercular  lobe  from  one  lung  of  his  Jiancie,  and  later  committed 
suicide  because  of  the  fatal  effect  of  his  operation. 

IIemourha<;k  Folloavixu  Wound  of  the  LrN<;. — In  a  case  recently  re- 
ported by  J.  Chalmers  Da  Costa,  secondary  hemorrhage  into  the  pleural 
cavity  occurred  eleven  days  after  the  infliction  of  a  gunshot  wound  of  the 
lun,g.  Several  ribs  were  resected,  and  the  lower  lobe  of  the  lung  was  found 
to  be  lacerated,  sloughing,  and  bleeding  violently.  It  Avas  impossible  to  arrest 
the  hemorrhage  by  ligatures  or  forceps.  On  attempting  to  pack  gauze  against 
the  bleeding  surface,  the  lung  was  simply  pushed  away.  The  entire  pleural 
sac  was  filled  with  sterile  gauze  in  order  to  afford  a  base  of  support,  and 
iodoform  gauze  was  then  packed  against  the  bleeding  lung.  The  hemor- 
rhage was  arrested  and  the  patient  recovered. 

INTRATHORACIC  TUMORS. 

Intrathoracic  tumors  may  spring  either  from  the  thoracic  wall  or  from  the 
thoracic  viscera.  Of  the  former,  the  most  common  are  exostoses  and  enchon- 
dromata,  which  may  develop  in  pedunculated  form  or  as  extensive  sessile  masses 
involving  several  bones  or  cartilages.  Malignant  tumors,  the  most  common  of 
which  are  sarcomata  or  mixed  tumors,  also  develop  in  the  same  way.  Tumors 
springing  from  the  thoracic  wall,  whether  developed  internally  or  externally, 


SLH(li:iiy    OF    TllK    RKSl'HiATOHV    OlidAyS. 


645 


constitute  lo-Mtiinat.'  sul.jocts  for  consideration  ;vith  reference  to  operative  re  lef, 
the  (lecision'lK'in-  gn.m'.ae.l  upon  their  cliaracter,  extent,  and  probable  adhe- 
sion to  the  viscera  of  the  thorax.  Operations  by  Avhich  portu.ns  of  several 
ribs  involved  in  such  tumors  are  excised  have  been  performed  Avitli  success,  as 
weil  as  operations  for  the  removal  of  the  sternum  when  that  is  the  primary 
seat  of  tlie  disease.  Thev  are  extensive  and  most  severe,  and  should  never  be 
made  without  a  statemetlt  of  their  dangers  to  the  patient  and  his  assumption 
of  risks.  In  most  if  n«.t  all  of  them  the  costal  pleura  at  least  will  be  so 
involved  that  free  opening  of  the  pleural  cavity,  with  collapse  of  the  lung  is 
inevitable.  There  would  be  no  object  in  attacking  such  growths  were  the 
overlvin<T  integument  so  involved  as  to  prevent  its  preservation  for  covering 
the  defect.  When,  however,  the  tumor  simply  involves  one  or  two  ribs  only, 
and  is  of  an  osseous  or  cartilaginous  nature,  it  is  quite  possible  in  most  cases 
to  remove  it,  subperiosteally,  without  opening  the  pleura.     But  little  danger 

attends  such  cases.  ,.      ^      ^  4.        f   ^„*^ 

Tumors  involving  the  contents  of  the  thorax  lie,  for  the  most  pait   out- 
side the  present  domain  of  operative  surgery.     Nevertheless    a  few  ot  them 
demand  operative  measures.      Such,  for  instance,  are  substernal  dermoid  cysts, 
hvdatid  tumors  of  the  lung,  actinomycotic  masses,  and  possibly  others  ot  non- 
malignant  character.     The  sternum  may  be  freely  resected  m  ^^-^er  to  reach 
thenf     Even  sarcoma"  of  the  sternum  has  thus  been  successfully  eiadicateri. 
The  diagnosis  is  made  largely  by  a  process  of  ex-clusion,  as  well  as  by 
symptoms  of  pressure  upon  nerves  and  vessels  and  by  a  study  of  physical 
sicrns      The  microscopic  study  of  the  sputum  may  also  yield  valuable  evi- 
de'nce.     If  a  solid  tumor  in  any  way  could  be  recognized  as  involving  a  cir- 
cumscribed part  of  one  lung,  it  might  be  warrantable  to  remove  the  affected 
po  t  on.     It  has  very  recently  been  suggested  to  open  the  thorax  from  behind 
bv  resectincr  ribs  from  a  line  near  their  angles  to  the  inner  side  of  the  scap- 
u  a   by  whfch  reasonable  access  is  permitted  to  the  posterior  mediastinum 
and  tlfe  root  of  the  lung.     Some  such  procedure  as  this  -ay  be  made  ser- 
viceable in  selected  cases.     Possibly  also  certain  aneurysms  within  the  tho- 
rax may  be  attacked  in  this  way. 

INTRA-THORACIC  CYSTS. 
Although  in  America  they  are  very  rare,  the  most  clearly  defined,  and  in 
some  countries  the  most  common,  intra-thoracic  cysts  are  hydatid  or  echino- 
coccus  cysts  within  the  pleural  cavities.  They  may  develop  as  free  cysts  oi 
more  commonly  in  connection  with  the  lungs  or  with  the  thoracic  wall.  Those 
which  have  primarily  formed  within  the  liver  sometimes  perforate  the  diaphragm 
Tnd  involve^  the  pleura  or  even  the  lungs.  For  the  most  part  they  contain 
dauc^hter  cysts  within  themselves,  and  may  attain  a  size  even  as  large  as  that 
of  a  child's  head.  They  cause  usually  considerable  pain,  which  is  increased 
on  Wing  upon  the  aifected  side,  and  are  accompanied  by  dyspnea.  Lnless 
thev  suDDurate  the  course  of  the  disease  is  feverless.  The  veins  over  the 
Sn Tp^minent,  the  chest-wall  may  be  pushed  forward,  and  the  intercostal 
paces  widened  and  fluctuating;  the  liver  and  the  heart  may  be  displaced. 
The  aspirator  needle  will  give  the  most  positive  results,  the  fluid  withdrawn 
beincT  free  from  albumen  and  sometimes  containing  hook  ets. 

While  puncture  will  afford  temporary  relief,  and  ^^Jeetion  of  iodine  may 
possibly  re  ult  in  cure,  the  most  satisfactory  result  is  afforded  by  ^ee  mcision 
if  neceLry  with  resection  of  ribs,  and  packing  the  cavity  with  gauze,  by  which 
free  drainage  is  aff"orded. 


G4«i  .l.V    AMi:RIiAy    TEXT-HOOK    OF   SCJK; KllY. 


CONTUSIONS  OF  THE  CHEST. 

These  may  occur  in  a  fireat  variety  of  ways,  as  by  the  passage  of  vehicles 
over  the  chest,  by  severe  blows,  by  being  caught  between  cars,  etc.  The  chest 
is  constructed  in  a  wonderfully  elastic  way.  and  it  is  surprising  what  contusions 
it  will  coniinonly  resist  without  serious  injury.  Mild  contusions  give  rise  to 
ecchynioses  and  Itruiscs  from  which  sloughing  rarely  mav  occur.  Even  abscess 
following  such  injuries  is  rare.  Fractures  of  ribs  are  the  most  common  serious 
lesions ;  these  are  discussed  under  their  own  heading.  The  chief  symptoms 
attendant  upon  such  injuries  are  pain,  which  sometimes  is  (juite  severe,  and 
such  soreness  as  effectually  for  the  time  being  to  dis(|ualifv  the  muscles  from 
acting.  Consequently,  patients  insensibly  adopt  the  abdominal  method  of  res- 
piration, while  such  involuntary  efibrts  as  coughing  and  sneezing  give  intense 
pain.  They  assume  a  characteristic  attitude,  usually  on  the  back,  lying  far 
enough  upon  the  injured  side  to  rest  it  and  give  freer  play  to  the  other 
side. 

The  treatment  of  these  conditions  is  mainly  the  enforcement  of  rest,  with 
such  compression  of  the  chest-wall  as  will  limit  its  motion.  This  is  best  carried 
out  by  a  snug  bandage,  by  a  broad  binder,  or  by  a  broad  piece  of  adhesive  plaster 
drawn  nearly  or  quite  around  the  thorax.  This  should  be  omitted  only  in  case 
it  adds  to  the  patient's  discomfort  instead  of  relieving  it.  Such  local  treat- 
ment as  may  be  appropriate  may  be  instituted  either  by  anodyne  applications 
beneath  the  bandages  or  by  hot  or  cold  applications  outside. 

Contusions  involving  the  Thoracic  Viscera  may  be  of  the  most 
complicated  character.  The  amount  of  damage  done  within  the  thorax  with- 
out visible  external  evidence  in  certain  cases  is  astonishing.  This  includes 
rupture  of  vessels  of  the  lung,  rupture  of  the  heart  or  pericardium,  or  such 
minor  lacerations  as  lead  to  hemorrhagic  or  inflammatory  results.  The  heart 
appears  to  experience  results  of  concussion  in  many  respects  analogous  to  those 
from  concussion  of  the  brain  ;  indeed,  fatal  results  have  followed  such  injuries 
where  even  on  autopsy  no  alteration  was  discovered.  In  the  more  severe 
injuries  blood  may  be  thrown  out  in  quantity  beneath  the  pleura  or  into  the 
lacerated  lung  substance,  by  which  many  of  the  signs  of  circumscribed  pneu- 
monia will  be  caused  ;  in  ftict,  also,  pleuritis  and  pneumonia  of  acute  form  are 
not  infrequently  met  with  and  sometimes  run  a  fatal  course.  One  sign  of  rup- 
ture of  the  lung  is  the  existence  of  emphysema,  beginning  either  at  the  base 
of  the  neck  or  in  the  epigastric  region  and  extending  thence  upward  or  down- 
ward. It  is  worth  while  to  bear  in  mind  that  such  emphysema  may  occur 
"without  any  fracture  of  the  thoracic  wall. 

Rupture  of  the  lung  may  be  quite  extensive,  and  occurs  in  military  as  well 
as  in  civil  practice,  such  an  injury,  for  instance,  as  a  blow  on  the  chest  by  a 
spent  cannon-ball  having  caused  it.  Rupture  of  the  lung  of  course  implies 
extensive  hemorrhage,  with  expectoration  of  blood  or  bloody  mucus,  and  effu- 
sion of  blood  into  the  chest  in  case  the  surface  of  the  lung  be  torn.  While 
recovery  is  not  impossible,  it  wmII  be  accompanied  by  serious  inflammatory  dis- 
turbances, with  permanent  impairment  of  function.  The  heart  and  pericar- 
dium have  been  also  thus  ruptured,  and  the  heart  has  been  completely  separated 
from  its  attachments,  without  more  serious  injury  to  the  chest-wall  than  a  tri- 
fling abrasion  of  the  cuticle.  In  all  cases  of  rupture  of  the  pericardium  the 
tear  has  been  of  large  size,  and  for  the  most  part  the  injury  has  been  accom- 
panied by  fracture  of  the  ribs  or  the  sternum,  or  of  both.  A  case  is  also  on 
record  where  the  wadding  of  a  small  cannon  struck  a  man  in  the  chest  with- 
out injury  to  its  wall,  and  the  heart  completely  burst  the  pericardium. 


scnaEnv  or  the  hespirat(jry  oitoAys.  647 


WOUNDS  OF  THE  CHEST. 

These  may  be  divided  into  the  non-penetratin<;  and  the  penetrating.  There 
is  practically  no  limit  to  the  amount  of  possible  laceration  of  the  soft  parts 
about  the  chest.  The  immediate  danger  attending  them  is  from  hemorrhage, 
while  septic  disturbances,  including  erysipelas,  gangrene,  and  tetanus,  are 
among  their  possible  consequences.  The  possibility  of  pleurisy  and  pneumo- 
nia as  immediate  sequels  must  not  be  overlooked.  In  rjire  cases  also  peri- 
tonitis or  a  pericarditis  or  endocarditis  develops  in  an  unlooked-for  mariner, 
which  is  to  be  explained  probably  upon  the  theory  of  septic  embolism.  In  such 
wounds,  whether  incised  or  lacerated,  the  routine  should  be  as  elsewhere :  first 
hemostasis,  then  removal  of  all  foreign  material,  and,  if  the  parts  are  rudely 
lacerated,  excision  of  all  torn  and  ragged  tissue,  careful  suture  with  or  without 
drainage,  and  finally  an  antiseptic  di'essing. 

Penetrating  Wounds  of  the  Chest. — These  may  be  of  the  most  vary- 
ing character,  from  the  sliglitest  perforation  Avith  a  minute  instrument  or 
weapon  or  the  smallest  bullet  up  to  the  most  frightful  loss  of  substance.  They 
are  dangerous  in  proportion,  first,  to  the  amount  of  hemorrhage  which  they 
produce,  and,  secondly,  to  the  amount  of  air  and  especially  of  any  foreign  or 
septic  material  which  has  been  introduced  or  permitted  to  enter. 

The  first  mentioned  is  the  most  immediate  danger,  and  its  relative  extent  is 
to  be  judged  of  at  the  time  by  the  direction  of  the  penetrating  substance,  if 
known  or  if  it  can  be  ascertained,  and  by  the  general  condition  of  the 
patient. 

Inasmuch  as  wounds  of  the  heart  are  elsewhere  considered,  we  shall  speak 
here  for  the  most  part  of  injury  to  the  lungs.  If  the  patient  expectorates 
blood,  the  existence  of  a  wound  of  the  lung  may  be  instantly  recognized. 
If  air  can  be  heard  entering  the  chest  or  if  the  lung  on  one  side  is  evidently 
collapsed,  it  is  a  sign  at  least  of  perforation  of  the  pleura  upon  that  side.  If 
collapse  is  extreme  and  if  death  rapidly  ensue,  in  all  probability  a  large  vessel 
has  been  injured.  If  the  diaphragm  is  paralyzed,  it  implies  injury  of  the 
phrenic  nerve ;  if  the  heart  is  tumultuous  in  its  action,  there  has  been  injury 
either  to  it  or  to  the  pericardium,  or  else  to  its  nerve-supply.  If  the  external 
wound  bleeds  freely,  the  blood  probably  comes  from  one  of  the  intercostal  or 
mammary  arteries.  If  a  weapon  has  been  used,  much  information  as  to  depth 
of  perforation,  etc.  may  be  obtained  by  examining  it. 

But  no  such  conclusions  can  be  drawn  in  cases  of  bullet  wounds  unless 
there  be  a  wound  of  entrance  and  none  of  exit,  which  implies  of  course  that 
the  bullet  is  somewhere  within  the  tissues.  A  bullet,  under  these  circum- 
stances, is  not  likely  to  be  arrested  by  the  lung,  although  it  may  be  by  the 
substance  of  the  heart.  Consequently,  if  the  lung  has  been  thus  injured 
it  has  probably  been  perforated.  Careful  search  for  a  wound  of  exit  should 
always  be  made,  since  there  have  been  instances  in  which  careless  prac- 
titioners probed  and  hunted  for  bullets  which  had  passed  completely  through 
the  body,  the  Avounds  of  exit  being  found  upon  simply  turning  the  patient 
over.  Nevertheless,  it  is  necessary  to  ascertain,  if  possible,  when  two  bullet 
wounds  are  found,  whether  one  or  two  shots  have  been  fired.  It  is  not 
every  bullet  or  stab  wound  of  the  chest  that  will  cause  perforation  of  the 
pleura.  A  bullet  or  the  blade  of  a  knife  may  be  deflected  by  the  ribs  or  the 
scapula  in  such  a  way  as  to  pass  perhaps  a  long  distance  through  the  tissues 
without  entering  the  thoracic  cavity. 

Emphysema  is  another  evidence  of  perforation,  at  least  of  the  costal 
pleura,  which  Avill  increase  with  time,  and  which  may  not  exist  at  the  moment 


648  Ay   AMKincW    TEXT- HOOK    OF   Sl'JiaKliY. 

of  first  exaniiiiatioii  if  it  bt'  iiiadc  iiniiicdiatflv  after  iiijiirv.  lit  rnia  of  the 
lun^  of  coiirsc  is  positive  cn  itlciicc  of  jterfuiation  of  the  cliest-valh 

The  treatment  of  peiietiatin^r  wounds  of  the  cliest  must  necessarily  (lei)enJ 
in  large  measure  upon  their  character  and  extent.  Injuries  to  the  large  ves- 
sels are  usually  rapidly  fatal,  and  for  these  surgery  as  yet  has  little  to  offer ; 
but  when  no  such  innnediate  danger  threatens  the  surgeon  should  seek  first  to 
check  hemorrhage,  enlarging  the  wound  by  free  incision,  and  ligating  vessels 
or  tissues  en  masse  according  to  circumstances.  Although  intercostal  vessels 
are  protected  by  the  groove  in  the  lower  border  of  the  ribs  in  which  they  lie, 
it  is  nevertheless  not  difficult  either  to  wound  or  to  secure  them.  A  bleeding 
internal  mammary  vessel  is  much  more  difficult  to  secure,  and  yet  its  course, 
parallel  to  the  border  of  the  sternum  and  a  short  distance  from.it,  though 
inside  the  thorax,  is  well  known,  and  should  other  measures  fail  a  large  stout 
needle  carrying  a  strong  silk  ligature  should  be  passed  into  the  chest  under  it 
and  out  again  in  such  a  manner  as  to  include  it  within  the  loop.  Should  other 
measures  tail,  bleeding  ma}'  be  checked  by  a  compress  of  aseptic  gauze  plugged 
tiffhtlv  into  the  wound. 

Above  all  things,  it  is  needful  to  warn  against  useless  exploration,  espe- 
cially with  the  probe,  in  cases  of  bullet  wound,  since  with  the  probe  nothing  is 
ascertained  which  could  not  otherwise  be  learned,  Avhile  by  its  use  protective 
blood-clot  is  broken  up  and  septic  matter  is  frcfjuently  introduced.  Hemor- 
rhage being  checked  and  the  region  of  the  wound  being  thoroughly  cleansed, 
aseptic  occlusion  is  probably  the  best  course,  at  least  for  the  average  practi- 
tioner, to  pursue.  The  day  has  come  when  the  thorax  may  be  opened  for 
access  to  the  wounded  lung,  pericardium,  and  heart  by  experts.  The  experi- 
mental results  of  Block  and  others  warrant  this  course :  but  the  time  has  not 
yet  arrived  when  a  general  recommendation  of  this  course  is  justifiable.  Such 
blood  as  is  poured  int(j  the  pleural  cavity  ordinarily  coagulates  rapidly  and  is 
subsequently  absorbed.  If  it  still  be  liuid.  or  if  later  it  should  liquefy,  or  if 
serous  effusion  or  purulent  degeneration  takes  place,  its  effects  may  be  over- 
come by  aspiration  or  by  incision  and  drainage. 

COMPLICATIONS  OF  CHEST  INJUEIES  AND  THEIR  SEQUEL.E. 

These  have  been  in  the  main  already  considered  ;  still  one  or  two  of  them 
deserve  distinct  consideration. 

Pneumocele,  or  IIerxia  of  the  Lung,  is  a  rare  result  of  incised  or 
lacerated  wounds  which  penetrate  the  thorax.  It  may  be  ])rimary  or  second- 
ary. The  former  may  occur  in  oblicpie  wounds,  the  margins  of  which  act  as 
valves  to  prevent  the  ingress  of  air,  while  they  permit  a  small  portion  of  one 
lobe  to  be  expelled  by  violent  efforts  in  coughing.  In  another  class  of  cases 
the  lung  may  escape  at  the  time  of  the  infliction  of  the  wound.  The  second- 
ary hernijB  of  the  lung  are  those  in  which  the  wound  is  of  large  size  and  the 
lung  escapes  some  time  after  the  infliction  of  the  injury,  or  in  which  it  occurs 
during  the  removal  of  fragments  or  during  the  cicatrization  of  the  wound. 
When  the  protruding  portion  is  not  adherent  it  should  be  thoroughly  cleansed 
and  restored  to  its  proper  cavity ;  when  fixed  in  place,  ligature  or  excision  is 
to  be  recommended. 

E.MPHY.SEM.\. — This  has  already  several  times  been  mentioned.  By  this 
term  is  meant  the  escape  of  air  into  the  cellular  tissue  outside  of  the  thorax 
proper.  Usually,  when  present,  emphysema  extends  to  a  distance  of  several 
inches  around  tlie  wound,  and  sometimes  involves  the  entire  neck  and  trunk. 
After  compound  fracture  of  the  ribs,  for  instance,  it  has  extended  as  high  a,s 


SURGERY   OF    THE   RESPIRATORY   ORGANS.  649 

the  scalp  and  as  low  down  as  the  thighs.  It  is  in  no  wise  dangerous,  except 
that  it  may  be  so  excessive  as  to  interfere  with  respiration,  or  that  the  air  may 
bo  infected,  in  which  case  cellulitis,  erysij)elas,  a1)sccss,  or  even  gangrene, 
may  be  the  result.  Ordinarily  the  air  is  taken  up  into  the  blood-vessels  by 
osmosis  and  disappcai-s  within  a  few  days.  Should  it  give  rise  to  great  dis- 
turbance, multiple  punctures  in  the  skin  will  facilitate  its  escape. 

The  other  sequehie  of  chest  injuries  are  mainly  septic  or  inflammatory,  and 
are  to  be  dealt  with  according  to  their  nature  and  upon  generally  accepted 
principles.  Cicatricial  contraction  may  cause  deformity,  or  injuries  of  special 
nerves  may  lead  to  vague  or  peculiar  muscular,  sensory,  or  trophic  disturb- 
ances, which,  however,  can  hardly  be  considered  here. 

MEDIASTINAL  ABSCESS. 

This  may  be  idiopathic,  secondary,  or  traumatic.  As  a  purely  idiopathic 
condition  it  is  extremely  rare.  The  secondary  form  may  be  consequent  upon 
abscess  in  the  neck,  burrowing  down  behind  the  deep  cervical  fascia,  or  upon 
tubercular  trouble  either  in  the  neck  or  within  the  thorax.  The  traumatic 
variety  may  follow  contusions,  but  has  been  most  common  after  fractures  of 
the  sternum  or  gunshot  wounds.  Such  abscesses  are  characterized  by  a  sense 
of  weight  in  this  region,  by  pain  on  coughing,  drinking,  sneezing,  etc.,  by  a 
sense  of  being  out  of  breath,  by  more  or  less  cedema  over  the  sternum,  and 
by  the  constitutional  signs  of  the  presence  of  pus.  When  these  signs  are 
present  the  proper  course  will  be  to  trephine  the  sternum,  enlarge  the  open- 
ing freely  by  the  rongeur  forceps,  explore  carefully  with  the  hollow  needle, 
and,  if  pus  be  found,  to  open,  wash  out,  disinfect,  and  drain  the  cavity.  Even 
abscesses  of  the  posterior  mediastinum  have  been  reached  by  a  posterior 
operation. 

SURGICAL    AFFECTIONS    OF    THE    DIAPHRAGM. 

This  muscle  constitutes  the  natural  septum  between  the  thorax  and  abdo- 
men, and  has  fixed  attachments  to  the  spine  and  to  the  lower  portion  of  the 
thoracic  wall.  It  is  capable  of  considerable  displacement  upward  and  down- 
Avard ;  in  forced  expiration  it  rises  to  the  right  third  cartilage,  and  in  forced 
inspiration  descends  to  the  right  fifth  intercostal  space.  On  the  left  side  it  is 
one  or  two  ribs  low^er.  In  cases  of  enormous  abdominal  distention  it  has  been 
found  as  high  as  the  second  rib,  and  in  cases  of  enormous  pleural  effusion  as 
low  as  the  false  ribs.  It,  however,  never  loses  its  convexity.  Most  of  its 
upper  surface  is  covered  by  pleura,  and  most  of  its  lower  surface  by  peritoneum  ; 
these  two  membranes  therefore  come  into  very  close  relation  here.  Still,  there 
is  a  small  surface  where  the  liver  comes  into  actual  contact  with  it,  and  at  this 
point  a  ball  penetrating  from  behind  at  about  the  tenth  dorsal  vertebra  might 
enter  the  liver  without  Avounding  the  peritoneum. 

Congenital  Defects. — The  sternal  portion  of  this  muscle  is  sometimes 
wanting,  and  absence  of  other  portions  is  occasionally  seen,  a  case  being  on 
record  of  a  child  which  lived  ten  days  in  whom  the  left  half  was  entirely  want- 
ing. Through  such  openings  the  abdominal  viscera,  most  commonly  the 
stomach,  may  protrude  into  the  thorax,  constituting  a  diai^liragmatic  hernia 
(q.  v.).  Various  muscular  additions  have  also  been  observed,  but  these  anom- 
alies are  rare. 

Paralysis. — Paralysis  of  the  diaphragm  may  occur  in  the  course  of 
pleurisy,  diphtheria,  disease  of  the  spinal  cord,  or  lead-poisoning;  or  it  may 
be  hysterical,  or  due  to  injury  of  one  or  both  phrenic  nerves,  or  to  the  destruc- 


Gr)()  .Lv  AMi:ni('A.\   riixr-iiooK  of  surgery. 

tion  i)t"  their  roots  in  riipidlv  asfciuliii^  (lcgeii(.i;iii«-ii  i'lKiii  injiirv  to  the  c'ord 
in  cases  of  fracture  or  dislocation  of  the  spine.  It  may  be  unihiteral  or 
luhiteral.  and  eonijilete  or  jjartial.  It  is  cliaracteri/e(l  liy  diflieulty  in  ])reath- 
in<r,  the  abdoiiieii  sinkini;  (hiring  inspiration  and  ]»econiin<:  iuller  in  expiration, 
thus  reversin<;  the  natural  order.  All  eflVtvts  wliieh  recjuire  fixation  or  con- 
traction of  the  diajjliraizni,  sueh  as  cou<rhing,  talking,  etc.,  are  made  difficult  or 
impossible. 

The  prognosis  must  depend  upon  the  cause,  and  treatment  must  be 
directed  to  the  removal  of  the  same.  In  idiopathic  or  non-surgical  cases  the 
faradic  current,  Avith  one  pole  applied  over  the  ])hreiiic  nerve  in  the  neck,  the 
other  over  the  diai)hragni,  is  said  to  have  given  good  results. 

Hernia. — See  Hernia. 

Wounds. — Wounds  of  the  dia})hragm  are  inseparable  fi'om  those  of  the 
abdomen  or  chest,  and  are  of  impoa-tance  according  as  the  viscera  on  either 
side  of  it  have  been  injured.  It  is  occasionally  torn  by  the  jagged  end  of  a 
fractured  rib.  Perforating  wounds  of  the  diaphragm,  however,  are  not  neces- 
sarily fatal,  and  manN'  patients  have  recovered  who  have  been  shot  in  such  a  way 
that  the  bullet  has  first  entered  the  abdominal  cavity,  passed  through  the  dia- 
phragm, and  traversed  the  pleural  cavity,  or  the  reverse.  The  prognosis  of  such 
wounds,  therefore,  is  not  necessarily  bad,  although  they  are  always  of  the  most 
serious  nature. 

The  diaphragm  may  be  perforated  as  the  result  of  abscess,  of  tumor,  especi- 
ally cystic,  or  of  fatty  degeneration.  It  is  not  an  uncommon  thing  for  it  to 
give  way  before  advancing  pus  in  cases  of  abscess  of  the  liver,  profuse  adhe- 
sion of  the  lung  above  it  having  taken  place  in  such  a  way  that  pus  is  evacu- 
ated through  the  bronchial  tubes  and  the  mouth.  The  same  is  true  of  sub- 
diaj)hragmatic  (subphrenic)  abscess. 

Rupture. — T'his  may  occur  as  the  result  of  contusions  either  of  the  abdo- 
men or  of  the  chest,  and  occurs  more  frequently  upon  the  left  side,  the  presence 
of  the  liver  upon  the  right  apparently  affording  protection.  Through  such  rup- 
tures diaphragmatic  hernire  frequently  occur.  When  the  rent  is  small,  it  is 
usually  the  intestine  which  passes  through  ;  when  large,  the  stomach,  or  per- 
haps both  stomach  and  bowel.  The  consequence  of  this  is  sometimes  immediate 
strangulation  of  the  bowel,  at  other  times  great  embarrassment  of  respiration, 
with  vomiting. 

The  diagnosis  of  this  condition  is  too  often  only  made  pnst-murtem. 
When,  however,  it  is  made  probable  by  the  character  of  the  injury,  and  when 
the  condition  of  the  patient  will  warrant  it,  it  is  proper  to  open  the  abdomen 
and  explore.  Still,  in  consequence  of  anatomical  conditions  this  procedure, 
coupled  with  that  for  repair  of  the  damage,  would  be  so  difficult  and  prolonged 
as  to  deter  most  operators,  though  it  has  been  done  successfully. 

A  question  of  medico-legal  interest  has  been  raised  about  these  injuries, 
whether  such  a  hernia  could  be  proved  to  have  resulted  directly  from  such 
inj  ury  or  to  have  antedated  it.  The  presence  or  absence  of  a  hernial  sac  will 
settle  this  question. 


J  > /SILASES   AND    J  XJ  lit  IKS    OF    THE   NECK.  651 

CHAPTER    IV. 

DISEASES   AND    INJURIES    OF  THE   NECK. 

A  roiNT  in  the  anatomy  ot"  the  neck  to  which  too  little  attention  is  ironc- 
rally  directed  is  the  constitution  of  the  so-called  branchial  folds  and  clefts. 
Very  early  in  f(Vtal  life  there  are  found  on  each  side  of  the  head,  behind  the 
rudimentary  aural  cavity,  four  fissures  Avhich  communicate  with  the  upper  end 
of  the  future  alimentary  caruil.  In  the  human  embryo  the  third  and  fourth  of 
them  should  have  disappeared  by  amalgamation  about  the  sixth  week,  and  the 
second  by  the  tenth.  Only  the  first  remains  persistent,  and  appears  as  the 
Eustachian  tube,  tympanic  cavity,  and  auditory  meatus.  Between  these  clefts 
develop  the  so-called  branchial  arches  or  folds.  From  the  first  of  these  is  devel- 
oped Meckel's  cartilage,  whieh  hel])S  to  form  the  lower  jaw;  from  the  second, 
two  of  the  small  bones  of  the  ear,  the  styloid  process,  the  stylo-hyoid  ligament, 
and  the  lesser  cornu  of  the  hyoid  bone.  Its  great  cornu  and  body  develop 
from  the  third.  Of  the  fourth  branchial  arch  there  seem  to  be  no  permanent 
remains.  Most  of  the  congenital  tumors  and  fistulfe  about  the  neck  are  to  be 
explained  by  the  persistence  or  defective  development  of  these  early  foetal 
remains.     (Cf.  p.  664.) 

CONGENITAL  MALFOKMATIONS  OF  THE  NECK. 

Those  Avhich  will  be  considered  here  are  for  the  most  part  cysts  and 
fistula.  They  have  been  termed  branchial  cysts,  deep  dermoid  or  deep 
atheromatous  tumors,  congenital  hydrocele  of  the  neck,  hygromata,  ath- 
eromatous cysts  of  lymph-nodes,  etc.  The  preferable  term,  however,  is 
branchial  cysts,  and  they  may  be  divided  into  mucous,  atheromatous, 
serous,  and  sanguineous.  They  may  be  very  small  or  may  attain  very  large 
size.  They  are  most  common  in  the  region  of  the  second  and  third  clefts,  ^.  e. 
the  vicinity  of  the  pharynx  and  larynx,  and  are  in  intimate  relation  with  the 
sheaths  of  the  large  vessels.  They  occur  more  frequently  on  the  left  side ;  are 
always  globular  or  ovoid,  and  always  fluctuate,  fluctuation  being  detected  by 
bimanual  palpation.  They  are  lined  with  the  same  epithelium  which  originally 
lined  the  clefts.  They  should  not  be  confounded  with  the  pure  dermoid  cysts, 
which  may  be  found  at  various  points  on  the  scalp,  face,  or  neck,  and  are  to 
be  distinguished  from  them  in  that  they  contain  only  epithelial  products  and 
no  hair  or  sebaceous  or  sudoriparous  material,  since  the  branchial  clefts  close 
before  such  material  is  formed. 

To  the  first  class  belong  many  of  the  so-called  ranulae  or  cysts  about  the 
base  of  the  tongue.  The  second  form  is  most  common  about  the  region  of  the 
hyoid  bone,  and  contains  atheromatous  material  not  of  dermoid  origin.  The 
third  or  serous  form  has  very  thin  walls,  and  is  that  sometimes  known  as 
hydrocele  of  the  neck  (Fig.  30).  They  may  be  single  or  multiple.  The  san- 
guineous cysts  may  originally  have  been  connected  with  the  anterior  jugular 
vein.  Their  contained  fluid  is  discolored  b}^  admixture  of  blood.  There  is 
but  one  variety  of  these,  including  those  which  still  communicate  with  the 
interior  of  the  cranium.  This  form  may  be  emptied  by  pressure,  but  will 
quickly  refill.  They  will  be  diagnosticated  mainly  by  the  character  of  the 
fluid  withdrawn  upon  aspiration.  All  these  tumors  lie  so  near  the  vessels, 
and  so  transmit  their  pulsations,  that  they  may  be  easily  mistaken  for 
aneurysms.     They  lack  free  expansile  pulsation,  and  they  are  common  in 


()52  Ay    AM  ERICA  X    TEXT-liOOK    <JF   SlUdKliY. 

youth,  wlifii  aneurysm  is  rare.  No  bruit  is  audible  in  tbeni,  and  expbjr- 
atorj  puneture  gives  widely  different  results.  A  final  dia^^nosis  of  dermoid 
cyst  is  perhaps  to  be  made  only  by  post-operative  examination,  but  usually 
a  dermoid  cyst  will  have  a  thicker  wall.  From  cystic  degeneration  of  one  of 
the  retro-tracheal  lymph-glands  they  will  be  distinguished  jjartly  by  position 
and  partly  by  the  fact  that  (juite  early  in  their  history  the  latter  give  rise  to 
considerable  pain  and  difficulty  in  swallowing.  They  are  to  be  explained  as 
the  result  of  renewed  activity,  often  due  to  pul>erty,  at  a  point  where  there  was 
originally  a  tubular  passage  lined  with  epithelium  which  has  failed  to  be  com- 
pletely obliterated — ''obsolete  canals."  Concerning  the  causes  which  call 
into  activity  the  inherent  developmental  forces  remaining  in  these  histological 
relics  we  are  profoundly  ignorant.  For  such  cysts  the  best  line  of  treatment 
practicable  is  their  extirpation.  When  for  any  reason  this  is  not  feasible  the 
next  best  method  consists  in  antiseptic  incision,  packing  with  gauze,  and 
drainage. 

Congenital  Fistulje. — These  fistulae  are  due  to  the  same  primary  causes 
as  those  which  give  rise  to  the  branchial  cysts  above  described,  being  simply 
persistent  relics  of  the  branchial  clefts,  one  or  both  of  whose  extremities  have 
failed  to  close.  They  may  open  interiorly  into  the  pharynx  or  externally  upon 
the  neck.  In  the  former  case  secretions  may  collect  Avithin  them,  causing 
trouble  by  suppuration,  by  producing  cellulitis,  or  by  giving  rise  to  constant 
discharge.  They  are  not  to  be  confounded  with  congenital  fistulae  of  the 
trachea,  which  are  usually  found  in  the  middle  line  of  the  neck.  The 
former  commonly  open,  Avhen  external,  in  the  lower  third  of  the  neck,  along 
the  inner  border  of  the  sterno-mastoid.  In  rare  instances  the  fistulae  have 
been  complete  from  the  neck  to  the  pharynx.  If  they  are  capable  of  treat- 
ment at  all,  it  must  be  by  cauterization  and  exciting  granulations,  with  or 
without  division  or  dilatation  of  their  external  openings. 

Cellulitis. — This  may  be  primary  or  secondary,  and  superficial  or  deep. 
The  primary  form  iS  usually  the  result  of  exposure  to  cold  or  to  one  of  the 
infectious  diseases,  e.  g.  scarlatina,  while  the  secondary  form  may  be  consequent 
upon  trifling  or  severe  injury,  or  the  extension  of  inflammation  from  already 
affected  teeth,  bones,  lymph-glands,  etc.  The  general  signs  and  symptoms 
of  cellulitis  of  the  neck  are  the  same  as  those  of  cellulitis  of  other  parts, 
modified,  if  at  all,  only  by  anatomical  disposition. 

Any  condition  of  this  kind  which  terminates  by  resolution  is  apt  to  be 
only  annoying;  but,  on  the  other  hand,  such  cases  are  serious  just  in  pro- 
portion as  pus  forms  deeply  and  causes  damage  in  the  endeavor  to  evacuate 
itself.  The  presence  of  pus  in  these  cases  is  to  be  made  out  both  by  local 
and  by  general  signs.  Of  course  fluctuation,  when  easily  recognizable, 
will  dispel  all  doubt.  On  the  other  hand,  most  cases  of  cellulitis  will  be 
accompanied  by  such  brawny  induration,  and  perhaps  by  such  oedema,  as  to 
mask  the  ordinary  local  signs  of  the  presence  of  pus.  In  these  cases  the  occur- 
rence of  symptoms  of  embarrassment  of  respiration,  or  of  extending  deep  pres- 
sure, or  of  chills  or  septic  symptoms,  will  make  it  wise  to  institute  a  careful 
search  even  at  some  depth  for  the  suspected  pus.  This  may  be  done  with  the 
exploring  needle,  but  it  will  be  much  more  satisfactory  and  effective  to  anes- 
thetize the  patient  and  make  free  incisions  over  the  suspected  area,  their  posi- 
tion and  direction  being  guided  by  anatomical  knowledge,  taking  the  pre- 
caution already  mentioned  of  dissecting  with  extreme  care  and  avoiding  all 
deep  small  punctures  for  fear  of  displaced  important  vessels  or  nerves.  "When 
the  collection  of  pus  has  been  reached,  the  opening  should  be  enlarged  suflS- 
ciently  to  admit  at  least  a  finger,  by  which  the  cavity  may  be  explored,  in 


DISEASES  A  XI)    INJURIES   OF    THE  NECK.  653 

order  to  ascertain  wlietlicr  a  coiiuter-opeiiiii;^  is  necessary,  and,  if  so,  to  indi- 
cate the  point  where  such  may  be  made  with  the  greatest  safety. 

A  special  form  of  cellulitis  is  that  known  as  Luchvig's  anrjina,  or 
infectious  submaxillan/  angina,  an  acute  form  of  this  disease  involving  the 
areolar  tissue  around  the  submaxillary  glands.  After  three  or  four  days  of 
local  discomfort  the  neck  becomes  swollen  and  i)ainful ;  the  condition  extends 
to  the  tongue,  which  becomes  fixed  and  swollen ;  there  is  great  difficulty  in 
opening  the  mouth ;  the  anterior  portion  of  the  mouth  is  distended ;  there  is 
great  salivation  ;  and  dyspnea  and  dysphagia  are  caused  by  pressure  and  fixa- 
tion. The  disease  may  be  accompanied  by  very  high  temperature  with  septic 
symptoms,  and  fre({uently  terminates  fatally.  Sometimes  the  disturbance  to  the 
circulation  is  so  great  that  local  gangrene  is  the  result.  It  is  an  unusual  form 
of  cellulitis  of  the  neck,  but  one  which  may  assume  a  terrible  importance. 

Abscesses  and  Consequent  Fistula  of  the  neck  are  virtually  always 
the  result  of  a  previous  cellulitis.  Abscesses  have  just  been  dealt  with. 
Fistulfe  are  best  treated  by  enlargement  of  their  external  openings  and  a 
thorough  scraping  of  their  wall  with  a  sharp  spoon,  but  when  tortuous,  or 
when  they  divide,  counter-openings  or  perhaps  extensive  incision  and  split- 
ting may  be  necessary.  The  majority  of  fistulte  of  this  kind  will  be  found 
connected  Avith  existing  tubercular  foci  in  lymph-glands  or  with  the  incom- 
pletely healed  results  of  operations  for  their  removal.  In  either  case  they 
are  to  be  treated  after  the  same  fashion. 

Cicatrices. — These  are  always  the  result  of  previous  lesion  of  the  skin. 
They  may  be  trifling  in  size,  like  the  irregular,  wrinkled  scars  which  show 
where  tubercular  lymph-glands  hg^ve  broken  down  and  have  caused  more  or 
less  destruction  of  the  overlying  skin,  or  where  syphilitic  disease  has  resulted 
in  the  same  condition ;  or  they  may  be  extensive  and  disfiguring,  being  the 
result  of  more  or  less  widespread  burns  of  the  parts.  (See  Deformities  of  the 
Mouth.) 

Small  and  attached  or  depressed  scars  can  be  excised  and  replaced  by  scars 
which  are  much  more  presentable.  For  the  relief  of  the  extensive  cicatriza- 
tion which  folloAvs  burns  some  one  of  the  various  plastic  methods  must 
in  whole  or  in  part  be  adopted.  This  may  consist  in  a  division  of  the  con- 
stricting bands,  or  in  the  formation  of  flaps  of  dissected  skin  and  their  rear- 
rangement by  sliding  or  by  transplantation,  or  recourse  may  be  had  to  the 
Indian  method  after  a  fashion  much  like  that  described  in  the  formation  of  a 
new  nose,  by  which  a  flap  of  skin  is  raised  from  the  arm  to  be  sewed  on  to  the 
defect  in  the  neck,  while  the  arm  is  fastened  to  the  head  or  thorax  until  the 
flap  can  be  safely  detached ;  or,  lastly,  one  or  other  of  these  methods  may  be 
combined  with  Thiersch's  method. 

The  disappointment  which  may  ensue  after  these  eflbrts  comes  partly  from 
a  failure  of  some  part  of  the  flaps  to  unite  as  w^e  desire,  and  partly  from 
the  formation  of  keloid  tissue  along  the  lines  of  union.  This  frequently 
occurs  in  spite  of  all  care  and  in  consequence  of  unknown  causes,  and  serves 
sometimes  to  undo  half  of  that  which  we  appear  at  first  to  have  accomplished. 
When  this  tendency  to  keloid  is  once  recognized,  further  efforts  should  usually 
be  discontinued,  since  it  cannot  be  overcome. 

INJUEIES  OF  THE  NECK. 

Contusions. — Contusions  of  the  neck  may  be  so  violent  as  to  cause  insen- 
sibility, or  even  death.  The  reputation  Avhich  a  "  blow  upon  the  jugular  "  has 
among  the  laity  is  an  evidence  of  the  severity  of  many  of  these  injuries. 


G54  AN  AMi:i!I(Ay    TEXT- HOOK    OF   SlP^dKUY. 

The  results  of  siu-li  ])l<)vs  may  be  fracture  of  the  livoid  oi-  of  the  caitihtt^es 
<'f  tlie  hivynx,  or  a  rupture  of  the  mucous  meuihraiic.  lollowcd  l)v  a  deep 
(•mj)hysema.  Aspliyxia  may  repeatedly  tlircateii,  and  ior  this  tradieotomy 
may  be  re(|uired.  Aside  from  these  lesions  there  may  be  bloody  effusions  or 
acute  inflamnuitory  swellings.  Avith  all  their  suppurative  possibilities,  while  from 
some  abrasion  or  eruption  of  the  skin  an  erysij»elas  even  of  the  phle<_rnionou8 
variety  may  develop. 

Open  wounds  of  the  neck  may  be  of  all  sizes,  and  be  incised,  punctured, 
or  lacerated  in  character.  A  wound  by  wliicli  the  ilccp  fascia  is  divided  niay 
be  called  a  deep  wound,  and  will  usually  involve  blood-vessels  and  nerves 
of  inii)ortance.  The  frequency  with  which  the  vessels  escape,  especially  when 
the  trachea  is  divided  in  cases  of  suicidal  attempt,  has  already  been  spoken  of. 
The  extent  and  character  of  these  wounds  when  not  at  once  apparent  to 
sight  must  be  recognized  ])artly  by  the  nature  of  what  escapes,  as  air,  arterial  or 
venous  blood,  mucus,  or  ])ossib]y  food,  as  well  as  by  a  study  of  im])aired  func- 
tions, as  of  respiration  or  deglutition,  by  the  occurrence  of  emphysema,  and  by 
a  consideration  of  whatever  can  be  learned  concerning  the  direction  of  the 
wound  and  the  weapon  which  inflicted  it.  If  bleeding  is  profuse,  the  natural 
inference  is  that  an  important  vessel  has  been  divided,  although  serious  hemor- 
rhage may  result  from  wound  of  the  thyroid  body.  If  the  carotids  are 
wounded,  death  will  proba])ly  ensue  raj)idly.  Ndlaton  is  said  to  liave  remarked 
that  it  takes  four  minutes  for  a  man  to  bleed  to  death  from  the  carotid,  while 
two  minutes  are  sufficient  to  tie  it.  Wounds  of  the  large  veins  are  dangerous, 
not  simply  from  risk  of  loss  of  blood,  but  also  of  the  admission  of  air.  Jileed- 
ing  here  is  generally  favored  by  free  anastomosis.  If  seen  in  time,  compression 
can  almost  always  be  successfully  a])plied  to  a  bleeding  wound  in  the  neck,  and 
this  may  be  continued  until  means  are  at  hand  for  operative  relief.  In  case 
of  a  perforating  wound  into  the  larynx,  patients  may  suffocate  by  the  entrance 
of  blood  into  the  air-passages. 

Besides  bullets,  foreign  bodies  like  arrow-heads  or  splinters  of  wood  are 
sometimes  imbedded  in  the  structures  of  the  neck.  Modern  teaching  with 
regard  to  bullet  wounds  inculcates  the  wisdom  of  primary  antiseptic  occlusion, 
without  removal  of  the  bullet,  but  other  foreign  bodies  should  be  removed  as 
soon  as  detected. 

Such  Avounds  as  are  not  quickly  fatal  are  usually  recovered  from.  Danger 
comes  from  complications  rather  than  from  the  injury  itself.  The  first  indi- 
cation in  treatment  is  absolute  hemostasis,  followed  by  rigid  asepsis  or  anti- 
sepsis and  closure  of  the  wound,  with  or  without  draiiuige  according  to  circum- 
stances. In  case  of  a  deep  wound  it  would  be  better  to  close  it  by  two  or 
more  tiers  of  sutures,  if  necessary  for  complete  approximation.  If  the  irsopha- 
gus  be  opened,  it  may  be  sutured  if  conveniently  situated,  otherwise  it  w  ill  be 
better  to  leave  at  least  a  portion  of  the  wound  open  and  pack  it  with  gau/.e. 
Untoward  results  of  such  w^ounds  differ  in  no  wise  from  those  of  injuries 
generally,  and  are  to  be  dealt  with  as  they  may  arise. 

Emphysema. — In  deep  wounds  of  the  neck  perforation  of  the  air-passages 
is  probable.  The  possible  extent  of  this  condition  has  l)een  already  spoken 
of  (see  Wounds  of  the  Chest),  the  anatomical  condition  being  virtually  the 
same.  If  it  be  practicable  to  close  the  tracheal  opening  of  an  emphysematous 
wound,  it  should  be  done,  but  the  external  wound  should  not  be  completely 
closed  or  sealed. 


DISEASES  Ayi>    JNJritlES    (jF    THE  NECK.  655 


TUMORS  OF  THE  NECK. 

Of  tumors  proper  we  find  nearly  every  known  variety  occurring  in  and 
about  the  neck.  The  benifrn  tumors  are  usually  of  slow  growth,  movable,  and 
])uinless,  and  give  rise  mostly  to  nu'chanical  annoyance.  They  may  be  mis- 
taken for  cvsts,  and  indeed  such  tumors  may  be  of  mixed  character.  Malignant 
tumors  of  the  neck  are  not  infreciucntly  of  rajiid  growtii,  proceeding  often  to 
ulceration  (PI.  IX,  Fig.  1),  and  sometimes  to  the  condition  of  fungus  luema- 
todcs.  In  almost  all  instances  of  carcinomatous  growths  the  lymph-glands  in 
the  vicinity  will  be  involved.  This  is  less  likely  to  occur  in  cases  of  sar- 
coma. Malignant  tumor  being  diagnosticated,  the  principal  question  is  as 
to  whether  it  can  be  removed,  and  secondly  whether  operation  is  advisable. 
Shoidd  the  tumor  extend  so  deeply  or  Avidely  as  to  involve  vital  parts,  it  is 
unlikely  that  radical  extirpation  can  be  made  with  safety.  This  is  especially 
true  of  tumors  at  the  base  of  the  neck,  Avhere  the  large  vessels  and  perhaps  the 
thoracic  duct  are  involved.  In  a  certain  class  of  tumors,  also,  where  it  may 
seem  that  extirpation  is  still  possible,  yet,  knowing  the  frequency  with  which 
they  return,  one  may  well  stop  to  ask  whether  it  is  worth  while  to  expose  the 
liatient  to  the  risk  of  operation  when  the  probability  of  recurrence  amounts 
almost  to  a  certainty.  This  is  a  matter  which  may  be  best  submitted  to  an 
intelligent  patient  for  his  own  consideration  and  decision.  Circumstances  at 
times  make  it  expedient  thus  to  gain  a  temporary  respite,  while  at  other  times 
t!iey  render  it  more  important  than  usual  not  to  jeopard  life.  If  a  surgeon 
decides  to  attack  such  a  growth,  he  must  be  prepared  to  sacrifice  everything 
that  is  involved  ;  otherwise  it  is  better  not  to  operate.  Even  the  pneumogastric 
nerve  under  these  circumstances  in  a  few  instances  has  had  to  be  removed 
with  the  rest  of  the  contents  of  the  carotid  sheath.  The  phrenic  nerve 
should  nevertheless  be  spared  if  possible.  Death  is  not  the  inevitable,  but  it 
is  the  common  result  of  division  of  the  phrenic,  but  not  of  the  pneumogastric 
nerve  in  the  human  being. 

Infectious  Granulomata  of  the  Neck. — These  comprise  the  actinomy- 
cotic, glanderous,  syphilitic,  leprous,  and  tubercular  forms  of  infection,  which 
nearly  always  are  located  in  the  lymph-glands.  The  actinomycotic  and  gland- 
erous infections  almost  always  first  appear  about  the  submaxillary  and  the  cer- 
vical glands,  as  the  reader  will  perceive  by  refei'ence  to  these  subjects.  Leprous 
disease  is  even  less  common  in  this  country  than  are  the  other  two,  and  is 
marked  by  equally  characteristic  lesions  in  other  parts  of  the  body.  The 
same  is  true  to  a  large  extent  of  syphilitic  aifections  of  the  neck.  Of  these 
granulomata,  therefore,  the  surgeon  has  to  deal  with  two  forms  mainly :  tuber- 
cular infection  and  enlargement  of  the  lymph-glands,  and  syphilitic  gummata, 
which  may  develop  at  almost  any  point.  This  latter  condition  is  usually  cha- 
racterized by  such  unmistakable  evidences  that  doubt  in  diagnosis  will  scarcely 
arise.  Unless  pus  be  present,  these  cases  are  hardly  suitable  for  the  knife,  but 
should  be  treated  vigorously  by  anti-syphilitic  remedies,  operation  being  post- 
poned until  these  have  proved  themselves  insufficient.  Should  free  pus  be 
present,  a  simple  incision  of  the  abscess,  possibly  combined  with  scraping  and 
cauterization  of  its  walls,  should  be  made  at  once. 

Local  Tubercular  Disease. — The  most  common  of  all  neoplasms  in  the 
neck  which  call  for  surgical  measures  are  those  produced  by  tubercular  disease 
of  the  lymph-glands.  These  were  formerly  included  under  the  term  scrofula  or 
scrofulous  glands  or  swellings,  but  in  the  light  of  modern  pathological  know- 
ledge they  should  always  be  spoken  of  in  their  true  character,  as  tubercular. 
Thev  are  most  common  in  childhood,  but  may  occur  at  any  age,  and  a  distinct 


G5G  AX   AMKIUCAX    TKXT-llOOK    OF  SURGERY. 

senile  form  is  known.  In  these  cases  we  have  to  (U'al  ■with  a  true  tuhercular 
infection,  eitlier  priniarv  or,  )>erliaj)S  more  often,  secondary.  In  a  majority  of 
instances  some  port  of  entry  for  infection  will  be  found  al)0ut  the  head  or  neck 
of  any  individual  thus  sutfering.  It  may  be  a  diseased  tooth,  an  ulcer  in  the 
mouth,  nose,  or  oro-pharynx,  a  diseased  tonsil,  a  suppurative  lesion  in  the 
middle  ear,  a  chronic  eczema,  ulcerative  disease  of  the  skin  or  scalp,  chronic 
conjunctivitis,  or  something  of  this  kind.  The  prime  source  of  trouble  is 
more  often  concealed  from  ordinary  observation,  but  can  in  almost  all  cases  be 
found  if  searched  for  witli  suflicient  care.  One  gland  or  several  may  be  in- 
volved. At  times  a  chain  of  enlarged  glands  may  be  detected  extending  from 
that  behind  the  ear  to  those  at  the  root  of  the  neck,  whence  the  disease  seems 
to  extend  into  the  thorax.  The  most  common  course  for  these  lesions  to  pursue 
is  slow  but  steady  enlargement,  perhaps  with  periods  of  rest,  W'hile  the  slow 
development  of  caseous  changes  is  often  interrupted  by  a  sudden  suppurative 
activity.  Calcification  and  other  changes  are  much  more  rare.  As  these 
masses  become  larger  and  press  nearer  the  skin,  they  not  infrecjuently  perforate 
it  by  a  process  of  granulomatous  infiltration.  On  reaching  the  surface  these 
break  down,  and  we  have  to  deal  with  a  sluggish  fungoid  ulcer  overlying  a 
distinct  hard  mass.  These  changes  are  always  accompanied  by  more  or  less 
periadenitis  or  cellulitis  about  the  principal  focus,  by  which  masses  originally 
quite  movable  become  planted  in  their  places  and  impossible  of  easy  extirpa- 
tion, being  so  fixed  that  it  is  necessary  to  dissect  out  the  entire  mass.  Further- 
more, when  the  masses  are  multiple  the  original  chain  of  lymph-glands  becomes 
altered,  and  merges  into  what  is  much  more  like  a  columnar  mass  of  infected 
and  infiltrated  tissue,  always  lying  near  and  often  adherent  to  the  sheaths  of 
the  large  vessels,  and  making  complete  extirpation  always  difficult  and  some- 
times impossible.  In  such  a  mass  of  tissue  we  usually  meet  with  foci  of  soften- 
ino;  and  defjeneration. 

This  constitutes  a  form  of  disease  often  met  with  in  individuals  of  tuber- 
cular history  and  diathesis  and  of  "scrofulous"  appearance.  The  milder  and 
limited  manifestations  of  such  tubercular  disease  sometimes  fade  away  and 
disappear  spontaneously,  probably  by  atrophic  processes,  leaving  few  or  no 
traces.  Even  those  cases  in  which  spontaneous  perforation  has  occurred  will 
sometimes  slowly  cicatrize,  leaving  unsightly  and  adherent  scars,  but  the  per- 
manent and  more  agtirressive  forms  are  most  troublesome  to  surgeons.  Sum- 
ming  up  in  few  words  the  results  of  centuries  of  experience  with  regard  to 
their  best  treatment,  we  may  say  that  save  what  may  be  done  by  general  con- 
stitutional measures,  and  by  local  applications  in  the  way  of  promoting  absorp- 
tion of  the  peritubercular  infiltration,  no  treatment  has  proved  so  effective  as 
thorough  extirpation,  which,  as  mentioned  above,  is  often  a  most  formidable 
measure.  In  these  cases,  as  well  as  in  the  so-called  malignant  diseases,  both 
surgeon  and  patient  must  be  prepared  for  recurring  manifestations  of  the  dis- 
ease which  may  call  for  a  second  or  a  third  operation.  Such  cases,  however, 
are  not  so  destitute  of  hope  as  are  recurring  cancerous  cases. 

The  results  of  the  injection  of  Koch's  tuberculin  are  still  suh  Jiidice. 
It  is  only  just  to  say  that  in  some  cases  the  treatment  has  yielded  very 
encouraging  results. 

The  injection  of  a  solution  or  emulsion  of  iodoform  into  tlie  infected 
tissue  is  a  measure  which  often  giv^s  more  or  less  satisfactory  results.  The 
amount  must,  of  course,  depend  upon  the  size  of  the  mass  into  which  it  is 
injected.  Most  gratifying  results  have  been  obtained  by  the  internal  use 
of  guaiacol,  of  which  eight  or  ten  drops  in  milk  are  given  after  each  meal, 
though  the  more  palatable  form  of  essentially  the  same  drug  in  the  shape 


DISEASES  AND    INJURIES    OF    HIE  NECK.  657 

of  bcnzosol  is  fireferable,  of  which  five  grains  are  given  at  a  dose  three  or 
four  times  a  day.  It  may  be  put  in  capsule  and  made  perfectly  tasteless  and 
inoffensive. 

Malignant  Lymphoma. — Under  this  term  are  included  the  local  mani- 
festations of  Ilodgkin's  disease,  or  malignant  lympho-sarcoma  (PI.  IX,  Fig. 
2),  This  is  more  specially  a  general  disease,  but  its  local  manifestations 
sometimes  cause  extreme  symptoms  of  dyspnea,  dysphagia,  etc.  It  is  spoken 
of  here  only  because  it  occasionally  calls  for  operations  on  the  neck,  sometimes 
of  an  exacting  character.  In  one  such  case  where  the  glandular  manifestations 
were  extreme,  tracheotomy  was  re((uired  some  months  before  the  patient  finally 
succumbed,  and  toward  the  end  the  size  of  the  glandular  enlargements  became 
a  barrier  against  the  changing  of  the  trachea-tube,  since  if  removed  it  was 
almost  impossible  to  replace  it.  In  these  cases  operation  is  advised  only  for 
relief  of  urgent  symptoms. 

LiPOMATA  occur  very  frequently  in  the  neck.  As  a  rule  they  can  be  easily 
removed  by  enucleation.  Sometimes  they  require  deep  and  careful  dissection, 
exposing  the  vessels  and  nerves. 

THE  SALIVARY  GLANDS. 

The  parotid  gland  occupies  a  position  where  it  is  quite  exposed  to  inju- 
ries, both  contusions  and  open  wounds,  which  are  of  importance  not  so  much 
on  account  of  the  glandular  tissue  itself,  as  because  of  the  vessels  and  nerves 
which  pass  through  or  near  it.  Septic  disturbance  following  such  wounds  is 
not  uncommon,  as  well  as  paralysis  of  the  facial  nerve,  which  latter  may  result 
from  its  division  or  from  the  pressure  of  inflammatory  products.  If  it  is  purely 
from  the  latter  cause,  the  prognosis  is  not  so  bad  ;  if  from  division,  there  is  little 
to  be  hoped  for  in  the  way  of  restoration  of  function.  Fistula  occasionally 
occur  as  the  result  of  injury  to  the  gland  or  to  Stenson's  duct.  Fistulse  of  this 
duct  are  usually  the  result  of  operation  or  accident,  and  are  difficult  to  heal. 
A  variety  of  plastic  operations  have  been  suggested  for  their  closure.  Perhaps 
the  most  feasible  plan  is  that  suggested  by  AgneAv,  which  consists  in  passing  from 
within  the  mouth  a  threaded  needle  around  the  duct  posterior  to  the  fistula, 
entering  and  emerging  as  nearly  as  possible  at  the  same  point  and  including 
the  duct,  but  not  the  skin,  in  the  loop.  This  ligature  is  tightly  drawn  and 
knotted.  Its  immediate  eff"ect  is  to  produce  ulceration  wdthin  the  cheek,  while 
the  suture,  working  its  way  loose,  separates  after  a  few  days,  leaving  a  new 
and  artificial  fistula  bv  which  saliva  is  again  conducted  into  the  mouth. 

Parotitis. — While  a  diphtheritic  form  of  this  aff"ection  is  not  unknown, 
by  far  the  most  common  form  is  that  known  generally  as  mumps,  in 
which  one  gland  is  aff'ected.  sometimes  both,  chiefly  in  young  males  and  dur- 
ing adolescence.  It  should  be  classified  with  the  specific  infectious  diseases. 
It  may  be  ushered  in  by  chills,  nausea,  and  fever,  with  considerable  consti- 
tutional disturbance,  and  causes  local  swelling  which  may  be  extensive,  and 
by  which  mastication  and  deglutition  are  interfered  with.  The  disease  often 
assumes  an  endemic  character,  frequently  spreading  in  schools.  The  pathology 
of  the  disease  is  still  obscure.  Metastasis  from  the  parotid  to  the  mammae, 
ovaries,  or  testes  occurs  in  perhaps  3  per  cent,  of  cases,  or  often  enough  to 
deserve  the  recognition  which  it  enjoys  among  the  laity.  When  this  occurs  in 
the  male,  we  have  to  deal  with  a  true  form  of  orchitis,  and  this  form  is  seldom 
met  with  as  a  primary  aff'ection  of  the  part  under  any  other  circumstances. 
Mumps  is  a  self-limited  disease,  disappearing  usually  spontaneously,  and  leav- 
ing no  bad  results  except  in  a  very  limited  number  of  cases  in  which  suppura- 

42 


658  AN  AJfERICAX   TEXT-BOOK   OF  SURGERY. 

tion  occurs.  Ordinarily  it  needs  l)ut  little  treatment,  saline  laxatives  and 
jxTJiaps  mild  anodyne  apjdieations  being  usually  enough.  In  severe  cases 
leeches  may  be  applied  Avith  benefit. 

Suppurative  Parotitis. — This  may  be  the  result  of  mumps,  or  may  occur 
as  a  secondary  and  mixed  infection  in  debilitated  or  susceptible  subjects  after 
such  infectious  diseases  as  erysipelas,  typhoid,  scarlatina,  variola,  pueiperal  fever, 
etc.  Abscesses  are  also  often  found  in  the  parotid  in  cases  of  pyemia.  The 
parotid,  being  provided  with  a  strong  capsule  and  being  contained  m  ithin  a  firm, 
deep  fjiscia,  we  must  expect  severe  pain  and  much  general  disturbance  when  pus 
thus  forms  within  it.  The  only  exception  to  this  rule  will  be  found  in  some 
of  the  adynamic  fevers.  When  the  ordinary  signs  indicate  the  presence  of  pus, 
or  even  the  probability  of  it,  an  incision  should  be  made  as  early  as  possible, 
if  necessary  under  an  anesthetic,  in  order  to  check  the  course  of  the  disease,  as 
well  as  to  give  it  a  direct  path  toward  the  surface,  since  if  left  to  itself  it  may 
cause  disaster  in  various  directions.  Most  frequently  it  opens  into  the  auditory 
meatus,  but  in  exceptional  cases  it  may  pass  downward  to  the  chest,  or  upward 
along  the  carotid  sheath  to  the  skull,  or  behind  the  pharynx,  or  into  the  neigh- 
boring maxillary  joint.  If  the  pus  be  superficially  located,  the  incision  should 
correspond  with  the  course  of  the  facial  nerve;  but  if  a  deep  incision  is  neces- 
sary, it  should  be  made  in  front  of  the  line  of  the  external  carotid.  Often, 
however,  it  is  much  better  to  make  a  free  incision  and  careful  dissection  with- 
out reference  to  future  scar.  In  these  cases  we  must  expect  involvement  of  the 
surrounding  lymph-glands,  along  with  a  periadenitis  or  even  an  erysipelatoid 
condition.     Pus  from  such  a  source  often  has  a  bad  odor. 

TUMORS  AND  OTHER   AFFECTIONS  OF  THE   PAROTID. 

Salivary  Concretions  or  Calculi  may  form  within  the  parotid  or  ob- 
struct its  duct.  They  have  been  found  as  large  as  a  hen's  egg.  By  such 
obstruction  they  may  cause  retention  of  saliva,  with  inflammatory  phenomena, 
and  these  latter  may  proceed  to  abscess  and  to  spontaneous  evacuation,  with 
salivary  fistula. 

A  positive  diagnosis  can  best  be  made  by  the  insertion  of  a  probe  along 
Stenson's  duct  or  by  puncture  of  a  needle  from  without.  It  may  be  impos- 
sible to  remove  a  small  stone  by  dilatation  of  the  canal.  A  large  one  must 
be  removed  by  incision,  always,  if  possible,  from  within  the  moutii  under 
cocaine. 

Cystic  Dilatation  of  the  duct  or  of  the  gland  itself  may  occur  from 
simple  inflammatory  or  cicatricial  obstruction,  and  suppuration  may  finally 
occur  in  such  a  sac.  Incision  from  within  the  mouth,  aijain,  must  be  made, 
along  with,  possibly,  extirpation  of  the  sac-wall. 

It  is  especially  in  the  carotid  region  that  the  different  blastodermic  layers 
come  into  intimate  relations  with  one  another,  which  will  account  for  the  fact 
that  most  of  the  tumors  of  the  parotid  are  of  a  mixed  character.  Among 
the  benign  forms  are  adenoma,  chondroma,  and  fibroma,  in  which  nearly 
always  myxomatous  elements  will  be  found.  (.)f  the  malignant  tumors,  sar- 
coma and  carcinoma  are  almost  eijually  common.  Just  within  the  parotid 
gland  itself  lies  a  lymphatic  gland  which  sometimes  develops  into  a  tumor 
from  tubercular  or  sarcomatous  degeneration  and  is  generally  easily  removed. 

A  diagnosis  of  tumor  of  the  parotid  is  easy,  but  the  determination  of  its 
exact  character  is  often  difficult.  The  distinction  between  the  l)enign  and 
malignant  forms,  which  is  the  most  important,  is  made  ))artly  by  considering  the 
age  of  the  patient,  the  rapidity  of  the  growth  of  the  tumor,  the  relative  fixity 


DISEASES   AND    INJURIES    OF    THE  NECK.  659 

of  the  neoplasm,  and  tlie  involvement  of  the  neighborinfj  lymphatics.  Benign 
tumors  which  are  causing  inconvenience  or  worse  may  be  excised,  especially  if 
sujjerficial.  Concerning  the  advisability  of  removing  malignant  tumors  in  this 
region  there  is  room  for  wide  ditlerences  of  opinion.  It  is  questionable  whether 
a  cancer  involving  all  or  nearly  all  of  the  gland  can  be  so  radically  extirpated 
as  not  to  invite  speedy  return  of  the  disease.  Still,  in  many  instances  opera- 
tion has  been  followed  by  temporary  relief,  extending  over  such  a  space  of  time 
as  am]>ly  to  reward  the  patient  for  the  suffering  it  has  caused. 

Treatment. — There  are  some  tumors  of  the  parotid  which  can  be  removed 
with  but  little  disturbance  of  the  facial  nerve.  In  such  cases  operation  should 
be  advised  without  the  slightest  hesitation.  But  operation  for  the  entire 
removal  of  the  gland  is  always  difficult,  and  always  followed  by  complete  paral- 
ysis of  that  side  of  the  face,  with  accompanying  inability  to  close  the  eyelid 
and  constant  irritation  of  the  eye  itself,  and  is  not  only  severe  for  the 
patient,  but  frequently  trying  for  the  operator,  that  portion  of  the  gland  which 
is  Avrapped  around  behind  and  concealed  by  the  lower  jaw  being  very  difficult 
of  access,  while  the  danger  of  recurrence  comes  from  the  inadvertent  leaving 
of  some  fragment  in  this  location  rather  than  from  any  other  source.  The 
incisions  for  this  purpose  may  be  made  parallel  to  the  borders  of  the  jaw,  the 
operator  being  constantly  on  his  guard  against  injuring  the  carotid  sheath,  and 
being  prepared,  if  necessary,  to  tie  the  external,  perhaps  even  the  common, 
carotid. 

THE  SUBMAXILLARY  GLAND. 

This  is  much  more  protected  from  injury  than  the  parotid,  but  resem- 
bles it  in  other  respects.  It  has  a  complete  capsule,  which  has  the  same  sur- 
gical importance  as  that  of  the  parotid.  Its  duct,  named  after  Wharton,  may 
be  obstructed  by  calculi,  the  presence  of  which  when  large  may  be  detected  by 
one  finger  in  the  floor  of  the  mouth  and  another  beneath  the  jaw.  The  gland 
is  sometimes  inflamed,  and  often  participates  with  the  parotid  in  cases  of 
mumps.  Cysts  of  benign  character  and  malignant  tumors  may  arise  primarily 
within  it,  and  often  it  is  secondarily  involved,  even  early,  in  cases  of  cancer 
of  the  jaw.  When  involved  in  any  of  these  aff"ections  it  should  be  removed 
without  hesitation,  the  only  neighboring  vessel  of  importance  being  the  facial 
artery,  which  is  easily  tied,  while  the  lingual,  and  the  hypoglossal  and  lingual' 
nerves,  are  easily  avoided. 

The  same  remarks  apply  to  the  sublingual  gland,  which,  however,  is 
seldom  the  seat  of  any  primary  surgical  aff'ection. 


THE  THYROID   BODY. 

This  is  normally  developed  as  a  bilobed  organ,  the  two  portions  of  which 
are  separated  by  a  narrow  bridge  of  similar  tissue,  called  the  isthmus,  which 
lies  normally  near  the  second  ring  of  the  trachea.  The  lobes  are  of  nearly 
the  same  size  under  ordinary  circumstances,  although  they  may  vary  a  little 
within  normal  limits.  The  thyroid  body  is  quite  likely  to  be  accompanied  by 
accessory  masses  of  similar  tissue,  which  may  be  connected  with  it,  or  may 
lie  behind  the  trachea,  or  beneath  the  base  of  the  tongue,  or  elsewhere  about 
the  middle  or  anterior  portions  of  the  neck,  and  which  may  assume  con- 
siderable surgical  importance,  since  they  seem  quite  likely  to  undergo 
changes  that  may  lead  to  errors  in  diagnosis.  Thus  when  these  little  masses 
are  enlarged  they  may  be  mistaken  for  enlarged  lymph-glands. 

Thyroiditis  is  a  rare  form  of  aftection  of  this  body,  which  when  met  with 


(!()()  AN   AAfK/ilCAN    Ti:X'r- li()< >k'    OF   SUIid i: IIY. 

occurs  usually  durin;^  typhoid  and  other  iut'cctious  diseases.  It  is  accoiupanieil 
by  fever,  pain,  swelling,  and  perhaps  serious  venous  obstruction,  by  which 
headache,  vertigo,  epistaxis,  or  cyanosis  may  be  caused.  It  may  possibly  go 
on  to  suppuration.  If  this  occurs,  free  incision  should  be  made  as  early  as 
possible.  Its  treatment  is  for  the  most  ])art  anti))hlogistic.  It  is  jirobably 
of  the  same  general  character  as  the  tttrunu'tis  which  occurs  so  often  in  cases 
of  goitre,  and  consists  in  more  or  less  inflammatory  disturbance  in  the  pre- 
viously diseased  or  enlarged  thyroid  tissue.  Some  authors  have  seen  in  such 
cases  evidences  of  a  constitutional  predisposition.  It  is  easy  to  understand 
how  in  such  affected  tissues  hemorrhages,  thrombi,  and  retrogressive  metamor- 
phoses, often  with  tissue-necrosis,  may  prepare  the  way  for  inflammation 
on  slight  pi-ovoeation.  Under  these  circumstances  even  a  slight  injury,  or 
a  hemorrhage,  whether  apoplectic  or  traumatic,  or  an  irritating  injection,  or 
the  introduction  of  an  unsterilized  needle,  or  the  occurrence  of  some  general 
infectious  disease,  may  bring  about  an  inflammation  in  this  focus  of  least 
resistance.  The  symptoms  of  strumitis  are  similar  to  those  of  thyroiditis,  save 
that  they  are  usually  more  severe  because  of  the  greater  size  of  the  organ,  are 
less  (|uickly  relieved,  and  often  prove  fatal.  Free  evacuation  of  pus,  or  trache- 
otomy, or  possibly  extirpation  of  the  organ,  will  be  called  for  in  such  cases, 
usually  as  emergency  operations. 

GOITRE,   BRONCHOCELE,   OR  STRUMA. 

This  is  a  terra  generally  applied  to  an  hypertrophy  and  hyperplasia  of  the 
thyroid  body;  more  common  on  the  right  side  than  on  the  left;  involving  at 
times  only  a  portion  of  the  organ,  at  other  times  its  entire  mass.  While  it  may 
occur  anywhere,  its  worst  forms  are  met  with  in  the  mountain  regions  and 
valleys  of  Asia  and  Europe,  as  well  as  in  Chile  and  Mexico.  Its  hereditary 
character  is  not  clearly  established.  Its  true  cause  has  not  been  discovered. 
Many  conditions  of  climate  and  surroundings  have  been  described  as  etiolog- 
ical, but  it  is  not  likely  that  they  alone  are  suflficient  to  produce  it.  It 
is  essentially  a  chronic  disease.  It  occurs  oftenest  in  women,  and  rarely 
before  the  tenth  year  of  age.  Several  different  forms  are  described.  Thus 
we  speak  of  hypertrophic  or  parenchymatous  forms,  in  which  the  entire  mass 
seems  to  be  made  up  of  tissue  identical  or  nearly  so  with  the  original.  The 
follicular  form  is  that  in  which  there  is  a  minimum  of  stroma  with  a  large 
proportion  of  mucinous  or  glandular  elements.  The  fibrinous  form  is  the  re- 
verse of  this,  may  be,  in  a  measure,  of  irritative  or  inflammatory  origin,  and 
may  assume  at  times  almost  a  sclerotic  type.  The  vascular  form  is  that  in 
which  the  normal  vessels  of  the  part  are  more  or  less  dilated,  and  in  which 
frequently  new  vessels  are  formed.  In  fact,  this  form  often  assumes  such  a 
phase  as  to  entitle  the  mass  to  be  considered  as  a  cavernous  tumor  of  the 
thyroid.  The  vessels  thus  affected  are  for  the  most  part  the  venous,  but  an 
arterial  form  is  known. 

The  cystic  form  is  the  most  common.  It  consists  in  the  development  of 
one  or  numerous  small  or  large  cysts,  which  may  attain  almost  any  size,  and 
may  be  filled  with  fluid  of  various  degrees  of  consistency.  The  fluid  is 
always  rich  in  soda-albumin,  and  may  be  more  or  less  mucinous.  It  may  also 
contain  cholesterin  in  rich  proportion,  as  well  as  the  products  of  fatty  meta- 
morphosis, together  with  the  residue  of  recent  or  old  hemorrhages. 

A  goitre  may  be  of  any  dimensions,  from  the  slightest  perceptible  increase  in 
size  of  the  normal  thyroid  up  to  a  tumor  which  will  interfere  with  motions  of 
the  head,  and  which  may  even  overhang  the  chest  and  reach  as  far  as  the  navel. 


DISEASES   A XI)    EXJilUES    OF    THE   XECK.  661 

Mild  forms  of  goitrous  enlartroinent  are  mot  with  sometimes  in  pregnant 
women,  and  it  will  often  be  noted  that  a  goitre  will  increase  in  size  with  each 
succeeding  pregnancy.  This  is  but  an  expression  of  the  sympathy  between 
this  organ  and  the  female  pelvic  organs  which  in  many  women  is  shown  during 
or  succeeding  each  monthly  jieriotl. 

The  goitrous  tumor  is  usually  not  difficult  of  recognition.  As  a  rule,  it  is 
chronic  in  its  course ;  it  rises  and  falls  in  the  act  of  deglutition,  is  painless,  is  not 
adherent  to  the  oveidying  skin,  under  which  it  moves  freely,  and  has  no  attach- 
ment to  the  jaw  or  to  the  clavicle  beneath.  The  larynx  moves  with  it,  but  it 
is  not  adherent  to  any  other  parts  in  the  neck.  It  is  usually  covered  by  promi- 
nent veins.  It  is  often  an  impediment  to  respiration,  sometimes  to  deglutition  ; 
when  large,  or  when  developed  in  the  direction  of  the  recurrent  nerves,  it  may 
cause  alteration  or  loss  of  voice.  It  may  also  distort  the  trachea  or  push  it  to 
one  side  and  displace  the  large  vessels.  Its  original  location  is  almost  con- 
stant, and  a  bilobed  or  symmetrical  swelling  of  the  neck  is  nearly  always  a 
goitre.  Some  of  the  vascular  forms  give  rise  to  a  murmur  which  upon  aus- 
cultation will  yield  a  marvellous  blowing  or  rushing  sound.  About  the  only 
difficulty  in  diagnosis  which  can  arise  will  be  with  reference  to  the  innocent  or 
malignant  character  of  the  swelling,  since  tumor  of  almost  every  other  portion 
of  the  neck  is  easily  excluded. 

Treatment. — Internal  remedies  are  of  little  or  no  use,  save  as  they  may 
serve  to  build  up  the  debilitated  individual.  This,  however,  is  not  true  of  thyroid 
extract,  which,  in  the  hands  of  Kocher  and  others,  has  greatly  ameliorated 
many  cases  and  apparently  cured  a  number.  Iodine  in  some  form  has  enjoyed 
a  certain  reputation  in  time  past,  but  is  little  given  at  present.  All  kinds 
of  local  treatment  have  been  resorted  to.  Iodine,  again,  has  been  the  most 
satisfactory  medicinal  application.  In  India  an  ointment  made  of  red  iodide 
of  mercury,  rubbed  in  for  ten  minutes  every  morning,  has  given  good  results. 
After  its  application  the  neck  is  exposed  to  the  heat  of  the  sun.  But  the  only 
treatment  which  can  be  recommended  is  surgical.  Cysts  may  be  tapped,  and 
perhaps  drained.  This  should  be  done  with  aseptic  precautions.  A  favorite 
method  of  treatment  has  been  the  injection  into  the  substance  of  the  organ  of 
a  watery  dilution  of  tincture  of  iodine.  In  the  soft  parenchymatous  or  cystic 
form  this  may  be  of  some  service,  although  accompanied  by  danger.  In  old 
or  hard  goitres  it  is  useless.  Electrolysis  has  yielded  good  results  in  many  of 
the  softer  forms,  one  or  more  needles  connected  with  the  negative  pole  being 
inserted  into  the  substance  of  the  tumor,  while  the  positive  pole  is  applied  by  a 
large  sponge  or  clay  electrode  in  the  vicinity.  The  current  should  be  measured 
with  a  galvanometer,  and  should  not  be  strong  enough  to  cause  severe  distress. 
Such  applications  may  be  practised  once  or  twice  a  week,  and  in  severe  cases 
will  often  be  followed  by  diminution  in  size  of  the  mass,  but  scarcely  ever  by 
its  total  subsidence. 

Of  more  formidable  operative  procedures,  ligature  of  the  thyroid  arteries 
is  perhaps  the  least  severe,  but  is  difficult.  This,  too,  will  sometimes  give  good 
results  in  the  vascular  and  parenchymatous  cases.  When  dyspnea  is  caused 
by  pressure,  a  simple  division  of  the  isthmus  will  sometimes  relieve  it. 

Enucleation  or  Partial  or  Total  Extirpation  of  the  mass  (thyroid- 
ectomy) is  the  radical  ami  final  operation,  which,  especially  in  the  Swiss 
and  German  clinics,  is  done  with  a  death-rate  of  about  1  per  cent.  The 
operation  is  serious  mainly  on  account  of  the  dangers  from  hemorrhage.  The 
most  successful  method  appears  to  be  that  of  incision  of  the  fascial  capsule, 
and  shelling  out  of  the  tumor  or  tumors  from  within  the  fibrous  investment, 
which  usually  can  be  done  without  great  difficulty.     The  parenchymatous 


CG2  .l.V  AMi:i:i(  AX    TKXr-HOOK    OF  srudKHY. 

form  is  to  \\q  dealt  \s\\\\  l>y  partial  (.'xtirpatioii.  The  n-curreiit  laryngeal 
nerves  must  be  carefully  avoided.  A'essels  must  be  tied  as  they  are  encoun- 
tered, and  the  base  of  the  growth  may  be  ligated  en  mmsxe.  Bose  and  Pop- 
]»ert  have  recently  practised  a  "bloodless  "  method  by  lifting  the  gland  from 
its  bed  sufficiently  to  encircle  the  pedicle  witii  elastic  tubing  before  enucle- 
ating the  cysts.  The  expi-rience  of  Swiss  surgeons  shows  that  thyroidectomy 
and  enucleation  are  best  <lone  by  a  large  curvilinear  incision  with  the  con- 
vex side  downward  and  without  ether  or  chloroform.  Eucaine,  cocaine,  or 
Schleich's  fluid  may  be  used  to  deaden  the  pain  of  the  skin  incision  and 
(liminish  the  hemorrhage.  By  engaging  the  patient  in  conversation  any 
threatened  injury  to  the  recurrent  laryngeal  nerves  may  be  instantly  de- 
tected by   hoarseness  or  aphonia. 

The  principal  danger  of  thyroidectomy  is  not  so  much  the  risk  of  immediate 
disaster  as  of  a  peculiar  constitutional  change  which  seems  to  be  inherently 
connected  with  the  loss  of  function  of  this  organ ;  a  subject  concerning  which 
we  have  ample  clinical  demonstration,  with  very  little  knowledge  of  its  cause. 
It  is  known  as  cachexia  strum ipriva,  and  corresponds  almost  exactly  with 
the  idiopathic  condition  known  as  myxoedema.  The  development  of  this 
cachexia  is,  however,  a  matter  of  time.  re(iuiring  several  weeks  or  months. 
A  more  acute  form  of  changes  of  the  same  general  character  results  in  the 
condition  known  as  tetany,  which  is  a  spasmodic  nervous  affection,  in  some 
respects  resembling  tetanus,  but  having  no  infectious  condition  underlying  it. 
It  has  been  shown  by  recent  researches,  both  on  animals  and  in  man.  that  total 
removal  of  tlie  thyroid  is  very  likely  to  bring  about  the  acute  or  chronic  form 
of  cachexia  strumipriva,  whereas  the  danger  of  the  same  amounts  to  little  or 
nothing  when  a  portion  of  the  organ,  even  so  small  as  one-fourth  or  one-fifth 
of  its  total  mass,  is  allowed  to  remain.  The  inference  from  these  experi- 
ments, which  is  amply  borne  out  clinically,  is  that  the  greatest,  though  sec- 
ondary, danger  of  total  removal  of  the  thyroid  is  a  series  of  tissue-changes 
throughout  the  organism  by  which  the  body  and  the  mind  of  the  patient  are 
materially  altered  for  the  worse,  while  partial  thyroidectomies  are  accompanied 
by  little  if  any  such  danger.  While,  then,  total  extirpation  is  an  operation  to 
be  avoided  if  possible,  no  hesitation  need  be  felt  about  removing  a  large  por- 
tion of  a  goitrous  thyroid ;  in  other  words,  so  much  as  will  afford  relief  from 
most  of  its  unpleasant  features.  Especially  when  the  condition  is  unilateral 
or  largely  so,  no  hesitation  need  be  ielt  in  recommending  operation.  Several 
surgeons  have  lately  transplanted  the  thyroid  gland  of  the  slieep,  and  placed 
it  in  the  connective  tissues  or  in  the  abdominal  cavity  ;  others  have  injected 
hypodermatically  the  juice  of  the  gland.  Both  methods  have  met  with  encour- 
aging results.  The  secre^of  these  changes  is  very  probably  connected  with 
the  problem  of  the  distribution  of  mucin  and  other  waste  products  of  the 
system.  Much  benefit  often  accrues  from  the  internal  administration  of  thy- 
roid extract,  now  easily  j»rocured.  It  has  considerable  influence  in  reducing 
the  size  of  many  parenchymatous  goitres,  and  is  of  value  in  certain  other 
conditions,  such  as  obesity.  It  may  be  given  in  doses  of  five  to  ten  grains 
thrice  daily. 

EXOPHTHALMIC    <;OITRE  (gRAVES's  OR  BASEDOW'S    DI.^EASE). 

In  these  cases  the  enlargement  of  the  thyroid  gland  is  usually  accom- 
panied with  rapid  juilse  and  prominent  eyeballs,  though  any  one  or  even  two 
of  these  symptoms  may  be  absent.  Often  a  systolic  bruit  may  be  heard  over 
the  thyroid  region,  and  the  eyelids  may  be  retracted  and  they  do  not  follow 
the  eyeballs  in  the  downward  excursion  (von  Graefe's  sign).     Various  ner- 


DISEASES  AND    INJURIES    OF    THE   NECK.  663 

vous  symptoms  are  apt  to  accompany  the  disease,  and  polyuria,  albuminuria, 
ami  dyspnea  are  fre(|uent  concomitants.  The  cause  of  the  disease  is  uncer- 
tain, l)ut  it  is  probably  due  to  the  toxic  action  of  the  thyroid  internal 
secretion. 

Treatment. — Thyroid  extract  is  to  be  avoided.  The  supra-renal  extract 
has  done  good  in  some  cases,  as  has  also  electricity.  Digitalis  and  measures 
looking  to  the  improvement  of  the  general  health  have  met  with  most  success. 
When  properly  directed  internal  treatment  has  failed  surgical  measures 
should  be  instituted.  Upon  the  plausible  thcf)ry  that  the  disease  is  due  to 
an  excess  of  thyroid  secretion,  normal  or  abnormal,  circulating  in  the  sys- 
tem, the  most  effective  method  of  diminishing  it  would  certainly  be  to  remove 
a  portion  of  the  gland.  In  1896,  Starr  had  collected  190  cases  of  thyroid- 
ectomy for  exophthalmic  goitre.  Of  these,  twenty-three  were  promptly  fatal, 
apparently  from  acute  poisoning,  induced  perhaps  by  unavoidable  handling 
of  the  thyroid  during  the  o[)eration.  Death  may  also  have  been  hastened  by 
ether,  as  that  is  a  notably  dangerous  anesthetic  to  use  during  this  operation. 
Seventy-four  cases  were  reported  as  entirely  cured,  and  forty-five  cases  as 
improved.  In  some  instances  the  rapid  pulse-rate  has  diminished  even  dur- 
ing the  course  of  the  operation.  Exophthalmos  is  the  last  feature  of  the  dis- 
ease to  disappear. 

These  operations  are  often  made  difficult  by  friability  of  the  capsule  and 
the  vessels.  As  substitutes,  have  been  proposed  ligation  of  the  thyroid 
arteries — always  difficult  in  these  cases;  exposure  and  suture  to  the  skin  of 
the  surface  of  the  gland  (Jaboulay),  with  the  expectation  that  it  will  contract ; 
and  bilateral  exsection  of  the  entire  cervical  sympathetic  nerve  (Jonnesco). 
None  of  these,  however,  have  given  the  positive  results  attained  by  thyroid- 
ectomy. 

TUMORS  OF   THE   THYROID. 

The  principal  tumors  proper  of  the  thyroid  are  malignant,  being  sarcoma 
or  carcinoma  according  to  the  tissue  primarily  involved.  All  forms  of  these 
growths  are  met  with  here,  the  soft  forms  of  round-celled  cancer  being  perhaps 
no  more  frequent  than  the  varieties  of  sarcoma.  They  are  all  characterized 
by  rapidity  of  growth,  by  great  pain,  by  distinct  pressure  symptoms,  by  inva- 
sion of  the  surrounding  tissues,  by  involvement  of  neighboring  lymphatics  and 
other  tissues,  by  the  general  appearance  of  cachexia,  and  by  the  other  ordinary 
unmistakable  signs  of  cancers  generally.  They  run  a  course  by  which  they 
are  soon  distinguished  from  the  innocent  enlargement  of  the  thyroid  body,  a 
course  which  is  frequently  rapidly  malignant  from  the  outset. 

The  prognosis  is  always  bad.  If  the  disease  be  apparently  still  limited 
to  the  thyroid  proper  and  radical  operation  be  not  considered  too  fonnidable 
for  the  strength  of  the  patient,  it  should  perhaps  be  performed,  if  only  for  the 
relief  of  pressure  symptoms ;  but,  unfortunately,  it  often  happens  that  by  the 
time  such  a  case  reaches  the  surgeon's  hands  for  any  operative  purpose  it  has 
exceeded  the  limits  of  legitimate  hope  or  even  perhaps  of  possible  performance. 


(>64 


.l.V    AMKIil<'A\    TEXr-llOOK    OF  SlliCKRY. 


CHAPTER   V. 


SURGERY  OF  THE   DIGESTIVE  TRACT. 


Fig.  268. 


PART  I.— DISEASES  AND  INJURIES  OF  THE  MOUTH,  TONGUE,  JAWS,   AND 

PHARYNX. 

Malformations  and  Deformities  of  the  Cheeks  and  Lips. — As 
many  of  the  dcfonnities  and  luiilfdniiations  of  the  cheeks  and  lii)s  are  due 
to. retarded  or  arrested  devehipment,  which  a  study  of  the  embryology  of  these 
parts  will  alone  make  clear,  it  will  be  necessary  in  the  first  place  to  give  a  short 

account  of  the  development  of  the  face. 

At  a  very  eai'ly  period  of  foetal  life  a  series 
of  clefts  appear  on  each  side  of  the  cejdialic 
extremity,  separated  by  rods  of  tissue  called 
hrancliial  arches.  The  clefts  communicate 
with  the  alimentary  canal. 

The  first  branchial  cleft  is  between  the 
mandibular  and  hyoid  arclics.  The  mandib- 
ular arch,  wliich  is  afterward  developed  largely 
into  bone,  consists  of  a  Hxperior  maxUhu'i/  por- 
tion, Avhich  does  not  unite  with  its  fellow  in  the 
median  line,  but  has  the  fronto-nasal  process 
interposed,  and  an  inferior  maxillary  portion, 
which  early  unites  in  the  middle  line  and 
forms  the  lower  jaw.  Between  the  superior 
maxillary  and  inferior  maxillary  processes  of 
the  mandibular  arch  is  the  buccal  cleft.  This 
is  closed  early,  except  where  the  aperture  re- 
mains for  the  mouth  (Fig.  268).  These  various  clefts  have  usually  coalesced 
about  the  ninth  or  tenth  week  of  foetal  life,  but  occasionally  this  coalescence 
fails  or  is  incomplete.  This  leads  to  various  deformities,  the  chief  of  whicii  are 
cleft  palate  and  hare-lij).  In  rare  cases  the  orbital  cleft  remains  open,  and  in 
still  rarer  cases  the  mamlibular  arch  is  undeveloped. 

The  palate,  which  is  in  two  parts,  is  formed  by  the  growth  of  a  horizontal 
septum  backward,  which  shuts  off  the  nasal  cavity  from  the  mouth.  This,  of 
course,  is  in  two  parts.  The  median  union,  which  commences  from  before 
backward,  is  not  complete  until  the  tenth  week.  Imperfect  coalescence  of  the 
parts  produces  cleft  palate  and  hare-lip. 

Jfare-lip  is  produced  by  the  non-union  of  the  mesial  nasal  process  with 
the  superior  maxillary  process.  The  non-union  may  involve  only  the  soft 
parts  or  it  may  be  complete,  there  being  a  fissure  between  the  intermaxillary 
and  superior  maxillary  bones.  This  may  occur  on  one  or  both  sides,  pro- 
ducing the  deformity  of  single  or  double  hare-lip. 

If  the  superior  maxillary  bones  do  not  unite  at  the  palatine  cleft,  which  is 
in  the  median  line,  we  have  the  deformity  of  cleft  palate.      Hare-lip  is  always 
to  one  or  the  other  side  of  the  median  line  following  the  direction  of  the  naso- 
maxillary fissure  between  the  superior  maxillary  and  intermaxillary  bones. 
Hare-lip. — Hare-lip  may  be  single,  double,  or  complicated,  or  may  involve 


Head  of  an  Kmbryo  :  pr.  p!ob.,  plobular 
extremity  of  the  mesial  nasal  process  : 
nw,  maxillary  process:  j/;;;,  mamiibn- 
lar  arch  :  hy,  hyoidean  arch  ;  6c',  first 
branchial  arch  (Quain). 


SUROERV    OF    Tin:    DTaKSriVK    TRACT. 


G»Jo 


only  the  soft  parts,  or  the  hard  ami  soft  parts  at  the  same  time.  In  about 
one-tenth  of  the  cases  hare-lip  is  double,  and  when  double  it  is  not  unfre- 
(juently  complicated  with  cleft  palate  and  failure  of  union  of  the  intermax- 
illary bones.  In  such  cases  the  intermaxillary  bones  will  project,  covered 
by  a  small  jiortion  of  skin,  and  attached  to  the  sejttuni  of  the  nose  or  even  to 
the  tip  itself  (Fi^.  'iOy).  Some  cases  have  been  reported  of  hare-lip  coexist- 
ini^  with  congenital  fissure  of  the  cheek  (Fig.  271).  Single  hare-lip  is  by  far 
the  most  common  defect,  and  is  said  to  occur  more  often  on  the  left  than  on 
the  right  side  (Fig.  270),  and  more  often  in  males  than  in  females ;  the  gap 
is  usually  flattened  to  the  outer  and  rounded  to  the  mesial  side.  It  is  occa- 
sionally seen  in  the  negro  (Fig.  272). 

Age  for  Operation. — There  is  considerable  difference  of  opinion  as  to 
the  proper  age  at  which  the  operation  should  be  performed ;  nearly  all  are 


Fig.  269. 


Fig.  271. 


Double  Hare-lip,  with  cleft  of  the  hard  palate 
and  protruding  intermaxillary  bone  (Koenig). 

Fig.  270. 


Slight  Hare-lip,  with  fissure  of  the  lower 
eyelid  (Kraske). 


Left  Hare-lip  extending  into  the  nose  (Koenig). 


agreed  that  some  time  previous  to  dentition  is  the  best ;  some  say  between  the 
third  and  sixth  months;  others  advocate  its  early  performance.  Fergusson 
and  others  advocated  performing  the  operation  about  the  sixth  week  after 
birth.  Probably  from  the  sixth  week  to  the  third  month  is  the  most  suitable, 
as  the  child's  vitality  is  then  usually  good  and  operation  is  well  borne.  Of 
course,  the  more  severe  operations  are  not  so  well  borne  in  early  infancy  as 
those  for  single  hare-lip,  but,  as  Holmes  remarks,  simple  cases  cannot  be 
operated  on  too  early.  In  some  cases  of  double  hare-lip,  when  the  child  can- 
not take  the  breast  and  has  to  be  fed,  early  operation  is  often  desirable  should 
the  child  be  strong.  At  this  earl}'^  period  the  operation  is  not  Avithout  danger, 
for  very  young  infants  bear  hemorrhage  very  badly. 

Operation. — The  operations  for  the  cure  of  hare-lip  are  numerous  (Figs. 
273-276).     Some  are  very  ingenious,  but  very  complicated,  and  while  look- 


GG)J 


.l^V    AMKRIL'AN    TEXT-JIOOK    OF   ^SCJiC'h'Uy. 


in<j:  well  in  a  (lia^rain  arc  not  easily  carried  out  in  practice.  In  operatinf^ 
for  liare-lip  tiierc  arc  certain  points  to  ])e  kej)t  in  view.  Fir.st,  it  is  necessary 
to  olttain  union  l»y  Hrst  intention,  and  in  oi'der  to  accomplish  this  the  ed^es 
of  tlie  cleft  must  he  accurately  hrou<^ht  together  and  tiiere  must  he  no  tension 
of  the  parts.  It  is  also  of  imf)ortance  that  the  red  line  of  the  lips  shouhl  he 
even  ;  and  when  one  side  of  tiie  cleft  is  shorter  and  flatter  than  the  other 
this  is  by  no  means  easy  to  accomplish.  The  edges  of  the  cleft  should  he 
pared  freely,  and  the  lip  separated  from  its  attachment  to  the  gum.  The 
free  separation  of  the  lij*  from  the  gum  is  a  most  important  proceeding,  for 
it  enables  the  edges  of  the  cleft  to  be  brought  together  without  tension.  The 
best  materials  for  sutures  are  silk-worm  gut  and  horse-hair.  The  advantage 
of  silk-worm  gut  is  that  it  is  easily  sterilized  and  can  be  left  in  situ  a 
week  or  more  without  giving  trouble.  The  sutures  should  be  introduced 
about  a  (juarter  of  an   inch   from   one  edge  of  the  cleft  and   brought  out 


Fio.  272. 


Fi.;.  273. 


Simple  Hare-lip  with  Equiliiteral  Sides. 


Fig.  274. 


Hare-lip  in  a  Negro  (original). 


Methofl  of  Clemont  or  Malgaigne  (N<!'lnton). 


at  the  same  distance  from  the  opposite  edge ;  they  should  be  placed  deeply 
enough  to  prevent  hemorrhage  from  the  coronary  artery,  but  should  not 
penetrate  the  mucous  membrane.  Intermediate  sutures  of  horse-hair  are 
very  useful,  and  before  finishing  the  operation  the  lip  should  be  turned 
lip  and  the  mucous  membrane  sutured  with  horse-hair  or  catgut.  This 
has  the  effect  of  keeping  the  saliva  out  of  the  wound  and  so  preserving  its 
asej)ticity. 

Mr.  Owen  advocates  a  method  introduced  by  Mirault  of  Angers  (Fig. 
27.'))  many  years  ago,  whereby  the  flap  on  one  side  of  the  cleft  is  preserved 
and  brought  across  the  middle  line  and  applied  to  the  raw  edge  of  the  gap  at 
the  lower  part  of  the  opposite  edge  of  the  cleft.  Any  redundancy  of  flap 
can  be  removed  after  the  sutures  are  introduced  ;  the  flap  should  be  left  on 
the  side  on  which  there  is  most  tissue.  In  order  to  take  the  tension  off  the 
stitches  it  is  always  well  to  apply  a  strip  of  rubber  adhesive  plaster  to  each 


SURGERY    OF    TllK    DKiKSTlVE    TRACT. 


667 


cheek  and  make  the  ends  meet  over  the  lip.  Tlie  part  attached  to  the  cheek 
^houhl  be  ])road,  but  the  strip  should  narrow  as  it  approaches  the  lips,  ihc 
two  mesial  ends  may  be  perforated,  and  then  laced  together  like  a  shoe.  By 
this  means  the  cheeks  are  brought  forward  and  the  central  parts  of  the  lips 
relaxed.  If  such  a  simple  arrangement  be  applied,  there  is  no  necessity  for 
more  complicated  and  expensive  trusses.  ,      •     j 

To  describe  the  operation  more  in  detail :  The  child,  having  been  etherized, 
is  wrapped  up  in  a  towel  or  pillow-case  to  confine  the  arms,  and  is  held  by 
an  assistant  in  a  convenient  position.  The  surgeon,  with  a  sharp,  narrow- 
bladed  scalpel,  transfixes  one  edge  of  the  cleft  and  cuts  a  strip  of  tissue  from 
the  mar.nn  of  the  gap.  going  well  up  in  the  angle  and  paring  freely  and 
cleanly.  ^  lioth  sides  should  be  pared,  and  the  strips  may  be  cut  away  entirely 
or  left  attached  as  the  ingenuity  of  the  surgeon  may  suggest,  they  being  often 
made  use  of,  as  the  accompanying  figures  show,  to  make  up  for  deficiencies  in  the 
lip  The  incision  on  each  side  should  be  curved,  the  concavity  being  toward 
the  median  line,  so  that  when  the  two  curves  are  brought  together  there  will 
be  a  slicrht  projection  of  the  prolabium  instead  of  a  notch.  The  strips  from 
the  margins  of  the  fissure  may  also  be  adjusted,  so  as  to  prevent  the  occurrence 
of  the  notch  at  the  point  of  union  of  the  flaps.     There  is  much  less  danger  ot 


Fig.  27-5. 


Fig.  276. 


Method  of  Mirault  (NC'laton). 


Operation  for  Double  Hare-lip  (original). 


cutting  too  little  from  the  edge  of  the  cleft  than  of  cutting  too  much.  Only 
sufficient  pressure  should  be  used  to  control  hemorrhage,  as  too  great  press- 
ure mav  easily  cause  a  slough.  The  frenum  of  the  lip  and  all  connections 
between  the  lip  and  the  gum  are  now  freely  divided.  This  Avill  often  cause 
smart  hemorrhage,  which  soon  stops  when  the  cut  edges  of  the  clett  are 
broucrht  together  and  strapping  is  applied  to  the  cheeks.  The  dressing  ot 
the  wound  should  be  as  simple  as  possible ;  it  should  be  dusted  over  with 
iodoform  or  painted  with  an  iodoform  paint.  If  sutures  are  used,  they  should 
be  removed  about  the  fourth  or  fifth  day,  but  the  strapping  should  be  left  on 
for  a  week  or  ten  days  longer.  As  the  strapping  gets  loose  it  may  be  tight- 
ened bv  lacing  the 'two  sides  together  with  silk  or  other  strong  materia 
Union  'should  be  complete  at  the  end  of  the  second  week,  and  often  will 
be  so  before.  Should  a  portion  of  the  wound  fail  to  unite  by  first  intention, 
careful  approximation  by  strips  of  plaster  may  be  followed  by  union  ;  if  this 
fails,  we  must  repeat  the  operation  later. 

In  double  hare-lip  the  operation  is  the  same,  except  that  it  is  done  on 
both  sides,  and  both  clefts  should  be  closed  at  the  same  operation.  When  the 
central  portion  is  short,  the  portions  cut  from  the  gaps  should  be  united  m  the 
median  line  below  the  central  portion.  In  some  cases  where  the  central  por- 
tion is  narrow  it  is  better  to  take  it  away  altogether  and  treat  the  resulting 
fissure  as  a  single  hare-lip. 

Hare-lip  complicated  with  Protrusion  of  the  Intermaxillary 
Bone.— This  is  a  much  mere  difficult  case  to  treat.  In  the  first  place,  before 
closing  the  clefts  it  is  necessarv  either  to  remove  the  projecting  wedge  of  bone 
or  forSbly  bend  it  back  into  position  and  hold  it  there  by  sutures  or  strap- 


GG«  J.V    AMEIUVAy    TEXT-BOOK    OF  SL'UUKllY. 

ping,  and  then  proceed  to  tleal  witli  the  hare-li|».  In  cases  where  the  project- 
ing bone  is  riulimentary  an<l  attached  to  the  tip  (jf  tlie  nose,  it  shoidd  he 
removed.  Fergusson  many  years  ago  stated  that  if  the  intermaxilhiry  l;one 
be  forced  back,  as  the  child  develops  the  incisor  teeth  will  grow  backward 
into  the  mouth  and  thus  prove  a  source  of  annoyance.  Hence  he  always 
removed  the  projecting  bone.  But  in  many  cases  excellent  results  may  be  got 
by  forcing  back  the  projecting  bone  and  suturing  it  in  ])lace  after  paring  the 
edges  of  the  gaj)  in  the  gums.  The  l)one  is  usually  fractured,  and  can  be 
replaced  without  the  rotation  spoken  of  by  Fergusson. 

AFFECTIONS  OF  THE  LIPS. 

Inflammation  of  the  lips  is  quite  a  common  affection  in  winter,  and  is 
due  to  cold.  "Cracked"  or  "chapped"  lips  are  troublesome  and  often  very 
painfid,  bleeding  on  the  slightest  provocation.  The  fissure  or  crack  is  usually 
in  the  median  line,  and,  if  treated  early  by  the  constant  application  of  simple 
or  rose-Avater  ointment  and  a  strip  of  the  more  durable  form  of  court-plaster 
on  muslin,  gets  well  quickly.  Should  the  fissure  persist,  it  may  need  cauter- 
ization with  a  sharp  point  of  nitrate  of  silver  to  relieve  the  pain. 

In  early  life  such  fissures  are  sometimes  neglected  and  leave  deep  furrows, 
which  are  very  disfiguring.  These  gaps  can  be  easily  remedied  by  paring 
the  edges  and  bringing  them  together.  Cracks  may  occur  in  the  upper 
or  lower  lip;  in  children  they  are  seen  most  frequently  in  the  lower,  and  are 
indicative  of  a  strumous  diathesis.  These  children  usually  have  enlarged 
lymphatic  glands  of  the  neck.  Such  cases  must  be  treated  by  attending  to 
the  general  health.  If  the  fissures  are  painful,  they  should  be  brushed  over 
with  a  solution  of  nitrate  of  silver.  Cocaine  should  be  used  first,  so  as  to  avoid 
pain.  When  fissures  or  ulcers  occur  about  the  corners  of  the  mouth  in  chil- 
dren, they  should  be  carefully  inquired  into,  as  they  are  often  indicative  of  a 
syphilitic  taint.     They  leave  scars  which  persist  throughout  life. 

Many  severe  inflammations  of  the  lips  are  caused  by  injuries,  bites  of 
insects  (bees,  wasps,  mosquitoes,  etc.),  and  should  be  treated  by  the  applica- 
tion of  evaporating  lotions.  The  inflammation  usually  subsides  rapidly. 
Should  it  go  on  to  suppuration,  an  early  and  free  incision  should  be  made. 

Herpes  of  the  lips  occurs  as  "cold  sores"  or  "fever  blisters."  Occa- 
sionally in  weakly  individuals  intense  inflammation  accompanies  herpes  of  the 
lips,  and  it  is  very  apt  to  recur.  It  may  be  checked  on  its  first  appearance 
by  t)ie  application  of  a  little  nitrate  of  mercury  ointment. 

TUMORS  OF  THE   LIPS. 

Epithelioma. — This  form  of  carcinoma  most  frequently  aftects  the  lower 
lip,  and  is  most  common  in  males.  It  is  essentially  a  disease  of  advanced  life. 
As  a  rule,  its  growth  is  slow  and  the  glands  are  not  early  involved.  It  may 
commence  as  a  warty  growth,  as  a  mere  excoriation,  or  as  a  fissure  or  ulcer 
which  will  not  heal.  Sometimes  it  commences  as  a  small  indolent  tubercle, 
which  soon  ulcerates  and  is  covered  by  a  thick  scab.  This,  when  picked  off 
by  the  patient,  grows  again.  Soon  the  ulcerated  surface  enlarges,  deepens, 
and  is  surrounded  by  a  mass  of  induration :  although  not  very  painful,  it  is  a 
source  of  great  discomfort,  especially  when  eating. 

Diagnosis. — Although  the  diagnosis  of  cancer  of  tlie  lip  may  appear  very 
simple,  yet  it  is  occasionally  mistaken  for  chancre,  or  rather  chancre  is  mistaken 
for  it.     Chancre  of  the  lij)  more  frequently  occurs  in  females,  and  may  occur  ;it 


SURGEnV    OF    THE    DKiESTIVK    TRACT. 


669 


all  a-es;  cancer  occurs  in  males,  as  a  rule,  and  after  lorty-five      The  lymphatic 
glands  are  involved  very  early  in  chancre,  late  in  cancer.      J  lie  progress  of 
cancer  is  usually  slow  and  lasts  many  months.     Chancre  lasts  a  few  weeks  only. 
Cancer  never  loses  its  har.l  base  and  never  heals  completely.     Chancre  is  sooner 
or  later  accompanied  by  other  manifestations  of  syphilis,  as  sore  throat,  secondary 
nsh  etc     Cancer  does  not  improve  under  treatment.    Chancre  improves  rapidly. 
Treatment.— There  is  but  one  method  of  treating  epithelioma  of  the  lip, 
and  that  is  by  early  and  free  excision.     If  the  growth  can  be  excised  freely 
before  the  submaxillary  lymphatic  glands  become  involved,  there  is  a  very  good 
chance  of  non-recurrence— more  than  in  any  other  form  of  ciincer.      Caustics 
^llould  be  avoided ;  they  only  temporize  with  the  disease  and  delay  thorough 
extirpation  by  the  knife,  often  causing  the  operation  to  be  postponed  until  the 
cervical  crlands  are  involved;  the  case  is  then  comparatively  hopeless  and  ope- 
ration merely  palliative.     Sores  on  the  lip  which  will  not  heal  readily  occurring 
in  i)ersons  over  forty-five  should  be  excised.  .  .,     v    • 

Operation.— the  removal  of  an  ordinary-sized  epithelioma  of  the  lip  is  a 
simple  matter.  It  is  usual  to  employ  a  V-shaped  incision  with  the  base  up- 
ward,  care  being  taken  to  cut  well  away  from  the  growth,  ihe  edges  of  the 
incision  may  be  brought  together  with  hare-lip  pins  or  deep  sutures  of  silk- 
worm crut.  The  wound  if  properly  closed  heals  by  first  intention  withm  a 
week  "when  the  disease  is  extensive  the  greater  part  or  the  whole  of  the  lip 
may  have  to  be  sacrificed  and  a  new  lip  made  by  a  plastic  operation,  fehould 
the  lower  law  be  involved  in  the  disease,  a  portion  may  have  to  be  removed. 
As  a  rule,  it  is  best  to  remove  the  contents  of  the  submaxillary  triangle  ot 
the  same  side,  including  the  submaxillary  salivary  gland,  m  which  are  em- 
bedded several  lymphatic  glands.  Even  in  the  thinnest  necks  infected 
enlarged  glands  may  easily  escape  detection  by  palpation 

n'evi  are  not  infrequently  seen  on  the  lips  (Fig.  32,  p.  227).  At  first  they 
are  usually  small,  and  may  be  ligatured,  or  treated  by  pin-points  of  the  thermo- 
cautery or  electrolysis.  If  the  growth  is  deeper  and  larger,  it  may  either  be 
dissected  out  or  th^  lip  excised  as  in  epithelioma.  The  latter  proceeding  is 
the  easier,  but  care  should  be  taken  to  cut  into  healthy  tissue.  Subcutaneous 
licrature  may  also  be  used  with  advantage  m  many  cases.  ,.  ,  , 

"^  Cysts  of  the  Lip.— These  generally  occur  in  the  lower  lip,  and  are  due 
to  the  blocking  up  of  the  mucous  follicles  in  the  inside  of  the  hp ;  they  often 
grow  to  a  larSe  size  and  appear  as  tense,  semi-transparent,  shmmg  swellings 
containing  a  viscid  or  clear  mucus.  They  are  always  innocent.  1  hey  should 
be  freely  laid  open,  dried  out  with  lint,  and  the  inside  painted  with  strong 
nitric  acid  or  cauterized  with  a  thermo-  or  electro-cautery. 

Horny  growths  are  occasionally  seen  on  the  lips,  and  should  be  excised. 
Hypertrophy  (Macrocheilia)  is  commonly  seen  in  strumous  children, 
and  may  occur  in  one  or  both  lips.  In  some  cases  the  hypertrophy  is  so  great 
that  an  operation  is  asked  for  to  relieve  the  deformity.  The  removal  of  an 
elliptical  portion  of  the  mucous  membrane  and  submucous  tissue  m  a  horizon- 
tal direction  does  much  toward  remedying  the  unsightliness  of  this  affection. 

WOUNDS  OF  THE  LIPS. 
These  should  be  treated  in  the  same  manner  as  wounds  of  any  other  part. 
Thev  should  be  thoroughly  cleansed  and  the  edges  brought  accurately  together 
with  deep  sutures.  If  there  is  much  hemorrhage  from  the  coronary  arteries, 
they  may  be  tied,  but,  as  a  rule,  the  hemorrhage  ceases  on  tightening  the  sutures, 
which  should  go  down  to  the  mucous  membrane  and  so  include  the  arteries. 


G70 


^l.V  AMERJCAX    TEXT-BOOK    OF  smaKHY. 


MAI.I'OKMATIONS   OF  TUE   Mv)UTII. 


Congenital  contraction  or  com- 
plete closure  of  the  mouth  may 
sometimes  be  seen  as  tlie  result  of 
over-closure  of  the  buccal  fissure. 
This  is  called  microstoma.  Ma- 
crostoma,  or  lar^e  mouth,  is  due 
to  the  buccal  fissure  not  closinor 
completely,  and  in  such  cases  the 
mouth  may  actually  extend  to  the 
ear. 

Of  course  the  most  common  mal- 
formations of  the  mouth  are  the  dif- 
ferent forms  of  hare-lip,  which 
have  already  been  described.  Me- 
dian fissure  of  the  lower  lip  is  a  rare 
condition,  so  rare  that  its  occurrence 
has  been  doubted,  but  recently  cases 
have  been  reported  and  figured. 
These  are  easily  explained  by  the 
non-union  of  the  mandibular  arch 
in  the  central  line.  Median  fissure 
of  the  upper  lip  has  also  been  occa- 
sionally seen. 

Deformities  from  Burns 
and  Scalds. — Deformities  of  the 
lips  the  results  of  burns  are  not  in- 

Fir;.  278. 


Results  of  Operation  in  the  Same  Case  (original). 


Deformity  from  the  Cicatrix  following  a  Burn  (original), 

frequently  seen,  and  when  se- 
vere cause  frightful  disfigure- 
ment. They,  of  course,  in- 
terfere with  speech,  and  saliva 
constantly  dribbles  from  the 
mouth.  They  are  usually  com- 
plicated with  contraction  of  the 
face  and  protrusion  of  the  lower 
jaw.  In  some  cases  the  lower 
lip  is  so  much  everted  that  its 
lower  margin  niay  be  attached 
to  the  upper  ])art  of  the  ster- 
num. A  new  lip  may  be  made 
after  the  manner  recommend- 
ed by  the  late  Mr,  Teale  of 
Leeds.  Figs,  277  and  278, 
from  a  case  recently  operated 
on,  well  illustrate  the  deform- 
ity and  the  hap})V  residts  of 
oj)eration,  the  details  of  which 
are  as  follows : 

Cheilop  I  asty. —  *  The 
everted  lip  is  divided  into 
three  parts  by  two  vertical 
incisions  three-uuarters  of  an 
inch  long  and  carried  down  to 


SURUKllV    OF    THE    DIUESTIVK    TRAi'T. 


671 


the  hone.  These  incisions  are  so  phmned  that  the  nii«hllc  portion  between 
them  occupies  one-half  the  li})  ;  from  the  hiwcr  entl  of  each  incision  the  knife 
is  carrie<l  outward  to  a  point  one  inch  beyond  the  angle  of  the  mouth.  The 
two  flaps  thus  marked  out  are  freely  and  deeply  dissected  up.  The  lateral 
flai)S  are  now  raised  and  united  by  twisted  sutures  in  the  mesial  line,  and 
supported  as  on  a  base  by  the  middle  flap,  to  which  they  are  also  attached  by 
a  few  points  of  suture,  leaving  a  triangular  even  surface  to  granulate."  This 
is  a  most  satisfactory  operation  and  always  gives  good  results. 

Salivary  Fistula  is  usually  seen  in  the  line  of  Stenson's  duct,  and  is  the 
result  of  injury,  operation,  or  abscess  following  obstruction.  Should  Stenson's 
duct  from  any  cause  be  opened  externally,  saliva  trickles  out  of  the  open- 
ing and  a  fistula  is  the  result.  It  may  follow  suppuration  of  the  parotid  after 
injury  or  fever.  It  is  one  of  the  most  troublesome  of  affections,  causing  great 
inconvenience  to  the  patient  during  mastication,  when  the  flow  of  saliva  is 
much  increased.  The  first  point  in  the  treatment  is  to  establish  an  opening  in 
the  mouth.  This  may  be  done  by  passing  a  probe  through  the  external  fistula 
into  the  mouth  in  the  direction  of  the  duct,  and  then  cutting  down  on  it  from 
within  and  passing  a  probe  daily.  As  soon  as  a  free  internal  opening  is  estab- 
lished, the  fistula  may  be  closed  by  touching  it  with  a  thermo-  or  electro-cautery. 
Another  method  of  treatment  is  to  pass  a  seton  through  the  fistula  into  the 
mouth,  bring  it  out  of  the  mouth,  and  tie  the  two  ends.  In  a  few  weeks  a  per- 
manent internal  opening  is  established,  when  the  seton  may  be  withdrawn,  and 
the  external  opening  will  soon  close  (cf.  p.  657).  When  the  fistulous  opening 
is  small  it  may  be  at  once  closed  with  a  fine  point  of  an  electric  cautery.  In 
certain  cases  plastic  operation  is  required  to  close  the  fistula. 

Cancrum  Oris. — This  is  a  form  of  sloughing  phagedena  which  occurs  in 
ill-fed,  sickly  children  who  are  recovering  from  some  of  the  exanthemata,  espe- 
cially measles  and  scarlet  fever.  A  similar  disease  aff'ects  the  pudenda  of 
female  children.     It  commences  as  a  phlegmon  of  the  cheek  and  lips,  and  is 

often  first  seen  as  a  dusky  red  spot  on 

the  outer  surface  of  the  cheek.      The 

child  opens   its   mouth  with    difficulty, 
and  if  the  surgeon  looks  in  the  inside 

he  will    see  a  deep,  sloughy,  unhealthy 

ulcer  opposite   the  dusky  spot.     Large 

portions  of    the    cheek    and    lips   may 

become  gangrenous,  and  the  sloughing 

process  may  even  extend  to  the  bone, 

for  it  spreads  with  great  rapidity.     The 

disease,  Avhich  is  attended  by  consider- 
able fever  and  great  depression,  is  very 

fatal,   the    patient   usually   dying    from 

exhaustion.     "When  recovery  does  take 

place  the  deformity  resulting  from  the 

sloughing  process  is  great  (Fig.  279). 
Treatment. — The  food  should  be  the 

most  nourishing  possible,  and  stimulants 

should  be  freely  administered.      When 

the  disease  is  first  recognized  the  child  _    . 

should  be  put  under  ether  and  the  parts  freely  cauterized  with  strong  nitric 

acid.     Afterward  they  should  be  kept  clean  by  antiseptic  washes  of  Condy's 

fluid,  creoline.  etc.  .  j  ut 

Stomatitis,  or  inflammation  of  the  mouth,  usually  occurs  m  the  debili- 


Fk;.  279. 


Cancrum  Oris  (Albert). 


(IT-J 


AX  AMFJilCAX    TEXT- BOOK    OF  SURGERY. 


tated  wlien  tlie  (li<:;t'stivc  organs  are  out  of  order.  The  simjilest  cases  are 
merely  an  inflammation  of  the  mucous  membrane,  and  may  be  caused  by  any 
irritant,  as  smoking,  carious  teeth,  hot  food,  etc.  This  condition  is  easily 
treated  by  awash  of  borax  or  ciilorate  of  potassium.  In  some  cases  the  inflam- 
mation runs  into  aphthous  ulceration.  This  is  often  painful,  and  has  to  be  cau- 
terized by  the  solid  stick  of  nitrate  of  silver  preceded  by  cocaine.  Where  there 
are  recurrent  attacks  of  a])hthous  ulceration  the  general  health  should  be  im- 
proved by  tonics  and  nourishing  food. 

Mercurial  Stomatitis  and  Mi'rcurial  Glossitis  are  not  uncommon  in  the 
trades  in  Avhich  mercury  is  used,  and  as  a  result  of  mercurial  salivation  from  the 
internal  administration  of  the  drug.  The  cause  should  be  removed,  and  potas- 
sium iodide  avoided,  as  it  increases  the  salivation.  Ordinary  washes  of  borax 
should  be  employed,  with  cooling  lotions.  Ice  is  sometimes  agreeable  to  the 
patient,  though  it  has  no  influence  on  the  disease. 


Fi(i.  liSO. 


MacToglossia  (original). 


MALFORMATIONS  OF  THE  TONGUE. 

Tongue-tie,  or  shortness  of  the  fnenum  lingune.  The  tongue  is  bound 
down  and  cannot  be  [)rotruded  beyond  the  incisors.  This  is  a  congenital  defect 
which  is  not  uncommon,  and  when  it  exists  to  a  high  degree  it  prevents  the 
child  from  suckling,  and  later  may  interfere  with  articulation.  In  such  cases 
it  is  necessary  to  divide  the  tightened  bands  ;  this  should  be  done  with  a  pair 
of  scissors  with  blunt  points.  The  points  should  be  directed  to  the  floor  of 
the  mouth  to  avoid  wounding  the  ranine  arteries.  Cases  are  on  record  of  fatal 
henK)rrhage  occurring  from  accidentally  cutting  these  vessels.  In  dividing  the 
fnionum  only  a  small  cut  is  necessary,  and  then  the  rest  may  be  torn  through 
with  the  fingers.  Even  this  is  generally  unnecessary,  for  the  child,  in  crying, 
still  further  frees  the  tongue.  The  frienum  may  be  congenitally  too  long,  and 
cases  of  death  from  suffocation  have  been  recorded  owing  to  this  condition,  the 
patient  ''  swallowing  "  the  tongue. 


SURGERY   OF    THE   DKlESTIVE    TRACT. 


673 


Macroglossia  is  a  congenital  hypertrophy  of  the  tongue  analogous  to 
elephantiasis.      It  is  of  slow  growth,  and  as  it  enlarges  causes  great  trouble, 
tTL-.  size   intertVring   with   deglutition    and  speech.      The    tongue   may 
p  otrude  over  the  chin  and  reach  even  as  far  as  the  sternum.     The  subjects 
r  Is  affection    frequently   suffer    from    epilepsy.       The    great   enhvrgemen 
causes  deformity  of  the  teeth  and  jaws,  especially  the  lower  jaw       Ihe  teeth 
mav  become  carious  and  fall  out,  and  the  lower  jaw  has  been  known  to  be 
di  ioc^ited  or    distorted   bv   the   pressure.      There    is    constant    dribb hng    of 
saliva    and  the  protruded'  tongue  is  much  altered  in  appearance,   indurated, 
swoUen   a  d  pui4lish  in  color  T  later,  nodes,  irregularities,  and  fissures  appear 
on  its    m-f^.ce\  aid  occasionally  the  tongue  ulcerates.      On  puncturing  it  there 
L  not  much  bleeding,  but  there  is  oozing  of  large  quantities  of  serum.      Tie 
disease  is  not,  as  a  rule,  noticed  for  the  first  two  years,  as^sucking  appeals  to 
delay  the  growth  of  th;  organ  by  continuous  pressure.     The  pathology  of  this 
di  else  waS  first  elucidated  by  Virchow:  he  found  that  there  was  an  overgrowth 
ofTnterstitial  connective  tissue,  with  a  remarkable  infiltration  of  the  whole  organ 
wih  white  cells  collected  here  and  there  in  a  delicate  network  and  foi'ming  true 
rvmphoid  tissue.      The   disease,  no   doubt,  is   due  to  congenital  defect  aggra- 
vated by  frequent  attacks  of  glossitis. 

ThItreaLent  consists  in  the  removal  of  the  protruded  portion  of  the 
toncue.  In  some  cases  the  removal  of  a  V-shaped  portion  will  give  the  best 
resuls.  Ligature  of  the  portion  of  tongue  protruded  has  been  successfully 
p'^ctised  bSt  nothing  is  so  safe  or  simple  as  removal  with  knife,  galvano- 
cauteiT,  or  ^craseur.  The  hemorrhage  usually  is  not  great,  and  the  result  is 
almost^  nvanably  satisfiictory.  When  bleeding  is  feared  in  young  children, 
remova  by  the  ecraseur  shodd  be  preferred,  but  in  adults  the  knife  or  scissors 
setter  as  its  use  is  not  followed  by  sloughing.  The  tongue  should  be  drawn 
fL-wad  by  means  of  ligatures  passed  through  its  substance,  and  the  mcision 
houW  be^made  in  such  a  manLr  that  the  tongue  is  left  somewhat  pointed  ; 
the  bleeding  vessels  should  be  tied  as  cut.  The  after-treatment  is  the  same  as 
that  used  for  partial  removal  of  the  tongue  for  any  other  cause. 

Wounds.— Usually  wounds  of  the  tongue  are  not  serious,  but  Jiiyant 
mentions  a  case  where  death  followed  a  wound  of  the  tongue  ma  small  child 
from  trickling  of  blood  down  the  larynx,  the  child  dying  asphyxiated.  Wick- 
ham  Lec^g  rebates  cases  of  death  following  biting  of  the  tongue  m  persons  the 
subjects  of  hemophilia.  Wounds  of  the  tongue  may  be  produced  in  various 
way^,  but  most  commonly  the  wound  is  caused  by  the  teeth.  Epileptics  not 
infrequently  bite  the  tongue  during  a  fit.  The  tongue  may  be  severely  wounded 
by  a  fall  on  the  chin  o?  by  a  violent  blow  on  the  jaw  when  the  tongue  is 
protruded.     The  protruded  portion  of  the  tongue  may  be  completely  bitten  oil 

or  one  side  only  be  injured.  .       ^^         i 

The  hemorrhage  resulting  from  injury  to  the  tongue  is  seldom  dangerous^ 
and  is  usually  easily  controlled  by  hot  water,  ice  or  exposure  to  the^ir.  bhouid 
the  hemorrhage  be  profuse,  its  source  should  be  sought  for  and  the  bleeding 
vessel,  usually  the  ranine  artery,  tied.  Oozing  from  the  wound  is  genemlly 
arrested  by  bringing  its  edges  together  with  sutures.  In  certain  cases  where 
the  wound  is  far  back,  it  may  be  necessary  to  pass  a  ligature  through  the  tip 
of  the  tongue,  draw  it  out,  and  examine  the  wound  thoroughly  ;  if  the  wound  be 
small,  it  should  be  enlarged  and  the  bleeding  vessel  secured  In  some  cases  it 
may  be  necessary  to  use  the  cautery  to  arrest  the  nemorrhage ;  its  use,  how- 
ever, interferes  with  primary  union.  Sutures  are  not  necessary  if  the  wound 
be  small,  but  if  it  be  large  and  a  portion  of  the  tongue  be  hanging  loose 
the  sides  of  the  wound  should  be  carefully  brought  together  with  deeply-placed 


674  Ay    J.l/AV.'/r.LV    THXT-JiOOK    OF  SlUdFJ;)'. 

silk  or  catgut  tiuturt's.  The'.se  must  be  tied  with  more  than  the  iiMial  care,  or 
they  will  loosen  from  the  moisture  and  constant  movements  of  tlie  tongue. 
The  after-treatment  of  wounds  of  the  tongue  is  similar  to  that  of  other  wounds 
of  the  mouth.  Tlie  mouth  should  he  washed  out  frcijuently  with  weak  Condy's 
fluid,  or  a  ])aiiit  of  iddofonu  and  alcohol  may  be  used. 

Foreign  Bodies. — Wounds  of  the  tongue  may  be  caused  by  foreign  bodies, 
such  as  the  stem  of  a  tobacco-pipe,  crochet-needles,  splinters  of  w'ood,  etc. 
Foreign  bodies  are  occasionally  driven  into  the  tongue  in  cases  of  gunshot 
wounds ;  these  consist  of  teeth,  portions  of  the  jaw.  etc.  A  bullet  mav  also 
lodge  in  the  tongue.  "When  a  wound  of  the  tongue  does  not  readilv  heal,  or 
when  there  is  secondary  hemorrhage,  or,  again,  if  a  sinus  exists  and  an  indo- 
lent swelling  remains,  a  foreign  body  may  be  suspected.  When  it  is  removed 
the  wound  usually  heals.  But  its  removal  does  not  always  bring  about  .so 
happy  a  result ;  in  more  than  one  case  this  procedure  has  been  followed  by 
hemorrhase  which  has  caused  death. 


TUMORS    OF    THE    TONGUE. 

Naevi  are  occasionally  found  in  the  tongue.  If  superficial,  they  may  be 
treated  by  nitric  acid  or  by  puncture  with  thermo-cautery  needles.  When  the 
growth  is  prominent  and  can  be  isolated  it  may  be  excised  with  scissors  or 
treated  with  ligature.  In  excision  the  cut  should  be  made  all  around  in 
healthy  tissue,  the  hemorrhage  then  being  inconsiderable.  The  thermo-cautery 
knife  also  may  be  used.  When  the  growth  is  large  and  more  diflfuse,  excision 
by  the  wire  ecraseur  is  a  valuable  method  of  treatment ;  the  ^craseur  should 
cut  through  healthy  tissue.  Ligature  is  seldom  necessary  in  such  cases,  but 
when  used  should  be  passed  deeply  into  the  substance  of  the  tongue  and  tied 
very  tightly. 

Papillomata,  or  Warty  Tumors,  occur  on  the  dorsum  of  the  tongue,  and 
consist  merely  of  hypertroiihied  papilhe.  The  diagnosis  is  easy  when  the 
affection  occurs  in  early  life,  but  when  it  exists  in  old  people  it  is  sometimes 
difficult  to  diagnosticate  from  epithelioma. 

Treatment. — Removal  by  scissors  is  the  simplest  and  best  mode  of  treat- 
ment when  the  growths  are  small ;  when  large,  ligature  is  more  satisfactory. 
If  there  be  any  induration  at  the  base  or  the  slightest  suspicion  of  the  growth 
being  malignant,  to  ensure  complete  removal  the  healthy  tissue  around  should 
be  excised  as  well  as  the  growth.  Butlin  rightly  states  that  ''  the  treatment 
of  the  larger  and  doubtful  warts  in  persons  over  forty  years  of  age  by  caustics 
and  other  similar  measures  cannot  be  too  strongly  deprecated." 

Ran u la  is  a  large  cystic  tumor  which  is  seen  under  the  tongue  on  one  or 
the  other  side  of  the  friv?num  lingute.  The  tumor  is  semi-translucent,  soft,  and 
has  coursing  over  it  large  dilated  veins.  It  occurs  oftener  in  adults  than  in 
children,  and  is  usually  painless,  but  the  sense  of  fulness  and  the  discomfort 
induce  the  patient  to  consult  a  surgeon.  It  contains  a  clear,  glairy  fluid, 
mucoid  in  appearance,  but  rarely  saliva.  The  exact  cause  of  the  swelling  has 
given  rise  to  much  discussion.  There  is  no  doubt  that  it  may  be  due  to  dilata- 
tion of  the  ducts  of  the  salivary  glands,  as  well  as  to  obstruction  of  those  of 
the  sublingual  mucous  glands. 

The  treatment  is  not  so  satisfactory  as  would  at  first  sight  appear.  If  the 
sac  is  emptied,  it  soon  fills  again,  and  to  prevent  the  return  of  the  disease  it  is 
necessary  to  destroy  the  lining  membrane  of  the  cyst  by  caustics,  after  having 
excised  a  portion  of  the  cyst-wall.  Sometimes  the  injection  of  15  minims  of  a 
mixture  of  tincture  of  iodine  10  parts,  water  10  parts,  and  iodide  of  potassium 


SUIiGERY    OF    THE    DIGESTIVE    TRACT.  (wo 

1  part  will  avail.  Tlie  solid  stick  of  nitrate  of  silver  applied  to  the  interior 
of  the  sac  ;xives  the  most  satisfactory  results.  Butlin  and  Bryant  recommend 
the  old  method  of  treatment  l)y  a  seton  of  strong  silk,  left  for  a  week.  Should 
this  fail,  a  Hap  of  the  cyst-wall  may  be  stitched  back. 

Salivary  Calculus. — A  calculus  may  form  in  the  ducts  of  the  salivary 
glands.  It  has  been  seen  in  Stenson's  duct  and  in  the  ducts  of  the  sublingual 
glands,  but  Wharton's  duct  is  its  more  frequent  situation.  The  calculus  is 
composed  chiefl}'  of  calcium  carbonate  and  phosphate,  and  magnesium  phosphate. 
It  forms  slowly,  Jind  may  have  been  growing  for  years  before  it  gives  trouble. 
Suddenly  inflammation  may  be  set  up,  and  the  patient  consults  the  surgeon  for 
a  large  inflammatory  mass  between  the  tongue  and  the  floor  of  the  mouth.  The 
submaxillary  gland  is  usually  enlarged,  and  a  fistula  may  form  below  the  jaw. 
The  diagnosis  is  not  commonly  difficult,  for  the  hard  mass  can  generally  be  felt 
with  the  finger.  Cases  are  reported  in  which  the  inflammatory  changes  produced 
by  the  calculus  have  been  mistaken  for  malignant  tumor.  The  treatment  is 
removal  by  free  incision  over  the  tumor.  This  is  made  inside  the  mouth. 
Cocaine  anesthesia  is  sufficient,  as  a  rule.  As  soon  as  the  cause  is  removed 
the  swelling  and  inflammation  disappear. 

Sublingual  Cysts. — These  are  usually  congenital,  and  are  rather  infre- 
quent. Being  situated  between  the  tongue  and  the  lower  gum,  they  are  often 
mistaken  for  ranulie.  They  grow  slowly,  and  the  surgeon  is  never  consulted 
until  they  are  of  considerable  size,  and  either  interfere  with  deglutition  or  pro- 
ject externally  into  the  submaxillary  space.  They  are  painless,  and  are  situ- 
ated between  the  muscles  on  the  under  surface  of  the  tongue.  They  have  been 
seen  only  in  adults  under  twenty-five.  These  cysts  contain  a  thick  putty-like 
material,  made  up  of  epithelium,  cholesterin,  and  fatty  matter,  and  have  been 
described  by  some  writers  as  sebaceous  cysts,  but  they  are  really  dermoids,  and 
may  contain  hair,  teeth,  and  bone.  The  contents  are  sometimes  semi-purulent 
and  very  offensive.  They  may  grow  to  a  considerable  size,  but  generally  are 
about  the  size  of  a  small  orange.  The  sac  is  often  tough  and  fibrous,  though 
sometimes  it  is  very  thin  and  easily  broken,  and  its  dissection  is  a  matter  of 
some  difficulty. 

A  sublingual  cyst  is  not  difficult  of  diagnosis.  It  appears  as  a  smooth, 
rounded  swelling  beneath  the  tongue,  and  often  in  the  submaxillary  space,  but 
it  has  none  of  the  translucency  so  characteristic  of  ranula.  Instead  of  being 
actually  fluctuating,  the  swelling  has  a  doughy  feel  and  is  inelastic.  They  may 
be  multiple  or  single,  central  or  lateral.  The  explanation  of  their  occurrence 
is  simple.  During  development  a  portion  of  the  epiblast  gets  folded  in  and 
shut  off  from  connection  with  the  external  surface.  It  remains  as  a  sac  lined 
with  epithelium,  increases  with  the  growth  of  the  individual,  and  is  apt 
suddenly  to  take  on  rapid  growth  if  anything  stimulates  the  epithelial  cells. 
The  involution  of  the  epiblast  occurs  between  the  genio-hyo-glossi  muscles  or 
between  the  genio-hyo-glossus  and  the  mylo-hyoid,  Avhich  explains  the  central 
and  lateral  situation  of  the  cysts  respectively. 

The  treatment  is  by  excision,  and  this  may  be  performed  either  from  within 
the  mouth  or  externally  in  the  submaxillary  space.  The  latter  operation  is 
preferable,  as  the  region  of  the  wound  can  be  kept  aseptic  and  the  surgeon  can 
more  easily  see  Avhat  he  is  about.  A  vertical  incision  is  made  in  the  median 
line  between  the  muscles  below  the  chin,  and  when  the  sac  of  the  cyst  is  reached 
it  is  pulled  out  gently  and  freed  with  occasional  touches  of  the  knife  as  it  pro- 
trudes. If  care  be  taken  there  is  but  little  danger  of  hemorrhage.  Should 
the  cyst  be  large,  the  contents  should  first  be  evacuated.  Many  recommend 
the  removal  of  these  cysts  through  the  mouth,  especially  in  females,  as  thus 


G70  .l.V    AMi:i;UA.\    TKXT-liOOK    OF   SURdKUY. 

a  scar  is  avoided  in  the  subniaxillarv  space.     It  is  simple  in  small  cysts,  but 
when  lar<;e  it  will  be  found  a  difficult  j)roceedin<r. 

Acute  Glossitis,  or  parenchymatous  intlammation  (tf  the  ton<:ue,  is  a 
somewhat  rare  afl'cction.  It  is  much  UKire  common  in  adults  than  in  children, 
and  more  fre([uently  attacks  males  than  females.  It  sometimes  follows  specific 
fevers,  or  may  be  due  to  injury,  cold,  septic  conditions  of  the  mouth,  bites  of 
insects,  etc.  These,  however,  are  special  forms  ;  ordinary  spontaneous  glossitis 
is  said  to  be  caused  by  cold  and  dnnip,  and  is  looked  uj)on  by  some  as  a 
catarrhal  affection. 

At  the  onset  of  the  affection  the  paticjit  complains  of  tenderness  of  the  tongue 
while  uuisticating  solid  food.  The  organ  begins  to  swell  rapidly,  and  within 
twenty-four  hours  it  becomes  twice  its  natural  size  and  protrudes  from  the  mouth. 
The  portion  of  the  tongue  within  the  mouth  is  livid  and  shiny,  but  the  part  pro- 
truding is  dry,  cracked,  and  brown.  Pressure  of  the  teeth  causes  its  edges 
to  become  indented,  articulation  is  impossible,  and  difficulty  in  swallowing  is 
always  present.  Fre([ucntly  there  is  dyspnea.  There  is  also  a  ])rofuse  secre- 
tion of  saliva,  which  continually  dribbles  away  from  the  mouth.  The  termina- 
tion of  the  disease  is  usually  by  resolution  in  four  or  five  days ;  there  may  be 
small  superficial  sloughs  on  the  surface  which  leave  ulcers ;  these,  however, 
heal  rapidly.  Occasionally  the  inflammation  is  so  acute  that  gangrene  super- 
venes. One  of  the  rare  terminations  of  this  affection  is  suppuration.  Some- 
times life  is  threatened  by  suffocation,  and  it  may  be  necessary  to  perform 
tracheotomy.  Constitutional  symptoms,  as  fever,  etc.,  are  always  present. 
Ilemiglossitis  is  a  much  rarer  and  a  much  less  severe  form  of  the  affection 
than  the  preceding,  and  usually  occurs  on  the  left  side.  There  is  not  so  much 
difficulty  in  deglutition,  and  there  is  never  any  dyspnea. 

Treatment. — The  nuijority  of  cases  get  well  in  five  or  six  days  without 
much  treatment.  A  saline  purge,  a  chlorate  of  potassium  wash,  and  the  suck- 
ing of  snudl  pieces  of  ice  form  the  proper  treatment  in  the  milder  cases ;  but  when 
the  symptoms  are  urgent  and  the  distress  great,  surgical  interference  becomes 
necessary.  A  deep  and  long  incision  should  be  made  in  each  side  of  the  ra])h^ 
near  the  root  of  the  tongue,  and  free  bleeding  should  be  encouraged.  The 
bleeding  is  rarely  severe,  and  the  relief  following  free  incision  is  immediate, 
the  tongue  in  a  few  hours  resuming  its  natural  size.  After  incision  suppuration 
is  much  less  likely  to  occur. 

Syphilis  of  the  Tongue. — The  most  common  manifestation  of  syphilis 
in  the  tongue  is  in  the  shape  of  jisHures.  These  usually  indicate  a  tertiary 
period  of  the  disease.  Fissures  are  sometimes  seen  in  the  secondary  stage  on 
the  side  of  the  tongue,  and  are  often  aggravated  by  the  sharp  edge  of  a  carious 
tooth.  The  syphilitic  fissure  is  usually  very  sensitive  to  the  touch  and  a  source 
of  annoyance,  though  not  surrounded  by  an  inlianimatory  condition,  as  other 
fissures  are.  It  may  be  single  or  multiple.  The  diagnosis  is  generally  easy, 
for  there  are  manifestations  of  syphilis  in  other  parts  of  the  body.  It  should 
be  treated  by  the  ordinary  antisyphilitic  remedies  ;  if  secondary  by  mercury, 
and  if  tertiary  by  potassium  iodide.  IJutlin  recommends  }>ainting  the  fissures 
with  a  ten-grain  solution  of  chromic  acid,  which  he  says,  in  coml)inati{)n  with 
mercury,  heals  them  with  great  rapidity.  When  heale(l  they  leave  scars.  Ter- 
tiary fissures  may  be  produced  by  the  breaking  down  of  several  small  gummata, 
and  are  of  some  depth  and  length.  They  may  plough  up  the  dorsum  of  the 
tongue  in  every  direction,  and  heal  under  treatment  very  slowly. 

Ulceration  commonly  occurs  during  the  secondary  stage  along  the  edges  of 
the  tongue.  The  ulceration  is  superficial,  and  a  white  patch  on  the  mucous 
membrane  of  the  cheek  corresponding  to  the  ulcer  on  the  tongue  will  usually 


sriwEjn'  or  tiik  dkikstive  tract. 


G77 


},e  foniul.  Mhoohs  tuberrlr.^  mav  also  ai)i)ear  on  the  tip  and  l)or(ler.s  of  the 
ton^nie  durinj:  the  secondarv  stage,  hut  at  the  same  time  they  are  seen  m  other 
phiJes  •  thev  are  oval,  grayish-colored  masses  covered  with  partly  macerated 
ep'ithelhim/  Gnmwata  arc  seen,  and  may  he  superficial  or  deep,  multiple  or 
siiVde  Thev  mav  he  ahsorhed  or  hreak  down.  The  deejJ  syjihihtie  ulcer  m 
cauled  hy  the  hreaking  down  of  a  gumnia.  and  is  nsnally  situated  on  the 
dorsum  o"f  the  tongue.     It  has  sharp-cut  edges  and  an  indurated  hase. 

It  must  also  he  borne  in  mind  that  the  primary  lesion  of  syphilis— c/iawcre 
-mav  occur  on  the  tongue ;  it  presents  the  appearance  of  primary  sores  in 
other \3arts,  but  its  specific  character  may  easily  be  overlooked  on  Jiccount  ot 
its  rarity.     The  submaxillary  lymphatic  glands  are  usually  enlarged  from  tlie 

first  •  n 

Tubercle  of  the  Tongue.— When  tubercle  attacks  the  tongue  it  usually 
manifests  itself  in  the  form  of  an  ulcer,  though  tubercular  fissures  are  some- 
times seen  on  the  tip  and  borders.     They  are  most  often  single,  and  may  be 

stellate  in  shape.  „  ,  ^  i  xi,     4.:^  ,f  +v.^ 

The  tubercular  ulcer  is  seen  most  frequently  on  or  toward  the  tip  ot  the 
tono-ue,  and  when  extensive  it  may  be  easily  mistaken  for  cancer.  I  he  ulcer 
is  irregular,  with  sharply-cut  edges  and  pale,  flabby  granulations  at  the  base; 
there  i1  little  surrounding  induration ;  in  its  advanced  stages  it  may  eat  deeply 
into  the  toncTue.  It  is  acutely  painful,  so  much  so  that  the  lingual  nerve  has 
been  divided  to  ease  the  sufferings  of  the  patient.  It  may  be  a  primary  mani- 
festation of  tubercle,  but  this  is  rare.  It  much  more  commonly  occurs  as  a 
secondary  lesion.  The  diagnosis  is  often  exceedingly  difficult  The  tongue 
has  been  excised  for  tubercular  ulcer  in  mistake  for  cancer  The  prognosis  is 
quite  as  unfavorable  as  that  of  cancer,  the  patient  succumbing  to  the  disease 
in  from  a  few  months  to  two  years.  .     r^    ...,.    ,•       ^      if 

Cancer  of  the  Tongue  is  always  of  one  variety,  viz.  Epithelion^a.  it 
commences  as  a  small  crack,  nodule,  or  ulcer  usually  on  the  side  of  the  tongue, 
though  no  part  of  the  tongue  is  exempt.  The  posterior  half  is  much  less  com- 
monly affected  than  the  anterior.  It  occurs  more  frequently  m  men  than 
in  women  in  the  proportion  of  247  to  46  (Barker).  It  will  be  found,  on 
examining  the  various  statistics,  that  cancer  of  the  tongue  occurs  most  tre- 
quently  between  the  ages  of  forty-five  and  fifty-five. 

There  is  no  doubt  that  smoking  predisposes  to  cancer  of  the  tongue,  as 
many  cases  are  preceded  by  leucoma  or  the  so-called  psoriasis  of  the  tongue. 
This^  condition  may  be  produced  by  dram-drmkmg,  smoking,  and  also  syphilis. 
In  80  cases  16  were  preceded  by  leucoma  (Butlin).     The  psoriasis  and  scars 
produced  by  syphilis,  injury,  or  any  other  cause  will  P.^'^^ispose  to  cancer ;  any 
irritation,  such  as  a  sharp  tooth,  the  stem  of  a  tobacco-pipe,  a  badly-fitting  tooth- 
plate,  etc.,  will  in  some  persons  excite  ulceration  which  may  take  on  a  cancer- 
ous  action.     There  is  no  doubt,  however,  that  cancer  of  the  tongue  may  orig- 
inate without  any  pre-existing  disease  or  irritation,  but  in  ^l^e  majority  of  cases 
some  form  of  irritation  is  the  exciting  cause  of  the  disease.    Many  practitioners 
who  are  consulted  by  elderly  people  for  ulcers  of  the  tongue  are  in  the  habit 
of  cauterizing  the  sore  repeatedly  with  nitrate  of  silver  or  other  caustic.      Ihis 
is  a  most  pernicious  custom,  and  one  which,  while  it  can  do  no  good  may  do 
infinite  harm  ;  for,  should  the  ulcer  be  cancerous,  it  only  aggravates  it,  and  in 
an  ulcer  which  is  of  a  simple,  non-malignant  character  it  may  excite  cancer  by 
the  continued  irritation.     Again,  it  does  harm  in  cancerous  ulcers  by  causing 
operative  measures  to  be  put  ofl"  until  a  period  when  operation  can  be  of  but  little 
use,  by  soothing  the  patient  with  the  idea  that  somethin|  is  l^emg  done  for 
him.     Ulceration  of  the  tongue  in  people  over  forty  years  of  age  should  always 


678  A^''  AMERICAy    TEXT-liOOK    <JF  SClidKin'. 

be  regarded  with  suspicion,  and  if  there  he  any  doiiljt  us  to  its  nature  flic  uk-er 
and  11  portion  of  healthy  tissue  around  it  should  he  excised.  No  donht  many 
cases  of  leueophikia  terininate  in  e|)ithelionia.  When  the  cancerous  ulcer  is 
well  developed  or  the  induration  at  its  hase  is  marked,  the  diaj^nosis  is  not  so 
difHcult.  hut  if  there  l)e  any  douht  a  portion  should  he  excised,  and  the  niicro- 
sco])e  will  usually  establish  the  character  of  the  disease. 

When  the  ulcer  commences  on  the  border  of  the  tongue,  it  rapiilly  infiltrates 
not  only  the  tongue,  but  also  the  floor  of  the  mouth  and  the  gums,  and  finally 
the  jaw-bone  itself  is  affected.  The  tongue  becomes  fixed,  and  its  motion  is 
so  lin)ited  that  it  cannot  be  protruded.  Should  the  disease  begin  farther  back, 
the  ulceration  or  infiltration  extends  to  the  pillars  of  the  fauces,  the  soft  palate, 
and  the  tonsils.  When  the  disease  has  advanced  thus  far,  the  glands  in  the  neigh- 
borhood become  enlarged.  First,  there  is  tenderness  in  the  submaxillary 
region,  with  pain  which  shoots  up  to  the  ear ;  later,  the  glands  may  be  felt, 
small  and  hard,  but  movable ;  as  they  increase  in  size  they  become  fixed.  If 
the  glands  are  affected  early,  the  case  is  unfavorable,  especially  so  when  there 
is  early  involvement  of  the  cervical  glands  innnediately  outside  the  angle  of  the 
jaw.  As  the  disease  progresses,  deglutition  and  speech  becoiae  difficult,  there 
is  profuse  salivation,  and  a  horrible  fetor  of  the  breath.  Patients  may  die 
from  hemorrhage  due  to  the  growth  ulcerating  into  some  large  vessel,  or  there 
may  be  frecjuent  hemorrhages  from  smaller  vessels,  which  may  hasten  the  end. 
The  usual  mode  of  death,  however,  is  from  exhaustion  due  to  pain,  sleepless- 
ness, starvation,  sloughing,  etc.  The  average  duration  of  the  disease  in 
patients  who  have  had  no  operation  is  from  a  year  to  eighteen  months.  Many 
cases  succumb  in  less  than  a  year,  and  few  live  longer  than  two  years. 

Diac/nosis. — In  the  advanced  stages  of  cancer  of  the  tongue  the  diagnosis 
is  not  difficult ;  the  foul,  deeply  excavated  ulcer  with  everted  ragged  edges  and 
widely  infiltrated  base,  Avith  large  granulations  protruding  fiom  it,  the  pain, 
the  fixation  of  the  organ,  and  the  induration  of  the  submaxillary  glands,  stamp 
the  affection  unmistakably  as  carcinoma.  At  this  stage  operation  is  not  very 
hopeful. 

The  diseases  with  which  carcinoma  of  the  tongue  are  most  likely  to  be  con- 
founded are :  1,  syphilitic  ulceration,  primary  and  tertiary ;  2,  tubercular 
ulcer ;  and  3,  simple  ulcer. 

From  Syphilitic  TJlceration. — The  situation  of  the  ulcer  and  the  history  of 
the  case  will  enable  one  to  form  an  opinion.  Syphilitic  ulcers  are  usually  jire- 
ceded  by  induration  or  the  existence  of  a  lump  at  that  point.  In  cancerous 
ulcers  the  induration  does  not  precede  but  follows  the  ulcer.  There  may  be 
two  or  more  gummata  on  the  tongue.  Cancerous  ulcer  is  always  single.  Can- 
cerous ulcer  occurs  chiefly  on  the  side  of  the  tongue,  syphilitic  ulcer  on  the 
dorsum.  In  the  ulcer  of  tertiary  syphilis  the  lymphatic  glands  are  rarely 
enlarged ;  in  cancerous  ulcer  which  has  existed  for  simie  time  they  are  always 
enlarged.  Many  cases  occur  in  which  the  diagnosis  can  be  satisfactorily  settled 
only  by  the  microscope.  Every  doubtful  case  should  be  submitted  to  a  thor- 
ough trial  of  antisyphilitic  treatment.  Even  this  is  sometimes  at  fault  and 
sometimes  dangerous,  for  cases  of  rapid  spread  of  the  disease  have  been  ob- 
served as  the  result  of  the  cutting  out  of  pieces  of  the  growth  for  purposes 
of  diagnosis. 

From  Tubercular  Ulcers. — In  both  the  lymphatic  glands  are  involved. 
The  age  of  the  patient  and  the  extensive  induration  would  point  to  cancer. 
In  cases  of  tubercular  ulceration  we  can  usually  get  a  history  of  tubercle  in 
the  patient's  family.  Of  course  tubercle  bacilli  should  always  be  sought  for, 
and  if  they  are  found  all  question  as  to  the  nature  of  the  affection  is  set  at  rest. 


siuaimv  OF  the  diukstivi:  tjiact.  ()79 

From  Siniiilr  Ulcer. — Tf  simple  ulcer  he  suspected,  a  cause,  such  as  a 
carious  tooth,  traumatism,  <flossitis,  etc.,  should  be  looked  for.  Simple  ulcers 
have  rarely  uiuch  induration  about  the  base,  but  cancerous  ulcers  are  remark- 
able for  the  deep  infiltration  of  the  surrounding  parts.  Should  the  ulcer  not 
heal  readily  in  a  man  over  forty-five,  it  should  be  excised. 

PrognoHiif. — Cancer  of  the  tongue,  like  cancer  of  other  parts,  if  not  ope- 
rated on,  proceeds-  invariably  to  a  fatal  termination.  It  is  of  the  utmost 
importance  that  tlie  disease  should  be  recognized  in  its  early  stages,  when  it 
is  a  purely  local  affection.  At  this  period,  if  removal  of  the  tongue  be  under- 
taken, the  chances  of  the  patient's  remaining  free  from  the  disease  are  greater, 
and  should  the  disease  recur  the  interval  of  freedom  is  much  increased. 

Treatment. — There  is  but  one  method  of  treatment  of  epithelioma  of  the 
tongue,  viz.  removal  by  surgical  operation.  AVith  regard  to  other  methods  of 
treatment,  by  caustics,  pastes,  etc.,  they  are  not  only  useless,  but  hurtful.  It 
cannot  be  too  strongly  insisted  on  that  the  treatment  of  cancerous  ulcers  by 
caustics  is  bad  treatment,  and  that  the  only  chance  the  patient  has  of  cure  is 
early  removal  of  the  disease  by  surgical  operation.  The  latest  statistics  pub- 
lished by  Butlin  (1898)  give  encouraging  results:  out  of  ^'o  cases  in  which 
the  tongue  was  entirely  or  partially  removed,  in  18  there  was  local  recur- 
rence, 28  died  from  glandular  involvement,  and  20  (30  per  cent.)  remained 
well  more  than  three  years  after  operation. 

OPERATIONS    ox    THE    TONGUE. 

In  operations  on  the  tongue,  jaws,  palate,  tonsils,  and  larynx,  the  advan- 
tage of  the  Trendelenburg  position  is  often  very  great.  In  this  position  the 
head  is  lower  than  the  body,  and  the  blood  escapes  by  the  nostrils  and  mouth, 
instead  of  into  the  lungs  and  stomach.  The  danger  of  an  aspii'ation-pneumonia 
from  the  septic  fluids  of  the  mouth  entering  the  lungs  is  greatly  lessened. 

Removal  of  a  Portion  of  the  Tongue. — Should  epithelioma  of  the 
tongue  be  confined  to  the  tip  or  a  very  small  part  of  the  border  of  the  anterior 
half  of  the  tongue,  and  should  the  submaxillary  glands  not  be  enlarged — in 
other  words,  if  the  ulcer  be  early  recognized  as  cancer — the  removal  of  only 
a  portion  of  the  tongue  is  justifiable,  and  gives  a  fair  chance  to  the  patient  Avith- 
out  submitting  him  to  the  much  more  formidable  operation  of  excision  of  the 
whole  organ.  But  the  complete  removal  of  the  tongue  is  usually  the  better 
operation,  unless  the  ulcer  is  very  small,  for  the  chance  of  recurrence  is  much 
less  than  when  only  part  of  the  organ  is  taken  away.  Partial  removal  of  the 
tongue  may  be  performed  with  galvanic  ^craseur,  wire  ^craseur,  knife,  or  scis- 
sors. The  knife  is  to  be  preferred  when  it  is  necessary  to  remove  only  a  small 
part  of  the  tongue.  The  method  recommended  by  Mr.  Barker  is  very  simple 
and  efficacious.  A  gag  having  been  introduced,  the  tongue  is  draAvn  out  by 
means  of  two  ligatures  placed  one  on  each  side  of  the  median  line  of  the 
tongue  near  the  tip.  The  tongue  is  then  split  down  the  middle,  and  the  diseased 
half  is  freed  from  the  floor  and  side  of  the  mouth  with  scissors.  Needles  are 
now  passed  through  the  tongue  behind  the  disease,  and  the  loop  of  the  ecra- 
seur  is  placed  behind  them,  tightened,  and  the  affected  half  removed.  The 
loop  of  the  ecraseur  should  be  of  wire  or  whip-cord.  The  objection  to  the 
use  of  the  galvano-cautery  is  the  troublesome  slough  which  follows. 

Removal  of  the  Entire  Tongue. — In  cases  where  the  cancerous  ulcer 
involves  the  posterior  half  of  the  organ  or  is  at  all  extensive  it  is  necessary  to 
remove  the  whole  tongue.  In  removing  the  tongue  one  of  the  chief  dangers 
is  hemorrhage,  and  before  proceeding  farther  it  may  be  well  to  mention  a 


680 


A\    AM  Kim  A  y    TEXT-llOOK    <)1     Sllidl.h') 


very  simple  and  reiidy  method  of  anvstiiit:  liciiKMiliage  occurring  either 
accidentally  during  operation  or  afterward.  This  method  -was  introduced  by 
Mr.  Heath  of  London,  and  has  been  adopted  l)y  most  surgeons.  It  is  this: 
'*  Tiie  forefinger,  )»assed  well  down  to  the  cjiiglottis,  is  made  to  book  forward 
the  hyoid  bone  and  drag  it  up  as  far  as  ])raoticable  toward  the  symphysis  nienti. 
The  eiVect  of  this  is  to  stretch  the  lingual  arteries  so  as  to  completely  control 
for  a  time  the  How  of  blood  through  them,  and  in  this  way  portions  of  the 
anterior  part  of  the  tongue  may  be  cut  off  almost  bloodlessly." 

The  points  to  be  kept  in  view  in  operations  on  the  tongue  for  malignant 
disease  are:  (1)  The  removal  of  all  the  disease,  including  all  the  infected 
lymphatic  glands;  (2)  the  prevention  of  hemorrhage:  (8)  the  avoidance  of 
the  entrance  of  l)loo(l  into  the  air-j)assages,  especially  by  jdacing  the  patient 
in  the  Trendelenburg  position,  or  occasionally  by  ])reliminary  tracheotomy  ; 
and,  after  operation,  (4)  the  preservation  of  an  aseptic  condition  of  the  mouth 
and  secretions  until  healing  is  complete. 

The  various  operations  which  have  been  practised  for  the  removal  of  the 
entire  tongue  are  very  numerous.  The  most  popular  operation  with  English- 
speaking  surgeons  at  the  present  da}^  is  that  known  as  Whitehead's,  viz. 
removal  of  the  tongue  by  scissors ;  this  may  be  done  with  or  without  pre- 
liminary ligature  of  the  lingual  arteries.  A  few  years  ago  nearly  every  surgeon 
employed  the  galvanic  or  wire  dcraseur,  but  the  occurrence  of  secondary 
hemorrhage  when  the  slough  separated  was  so  frequent  that  the  ^craseur  has 
been  supplanted  by  the  scissors. 

Whitehead's  Operation. — The  operation  for  the  removal  of  the  tongue 
is  thus  described  by  Mr.  Whitehead :  The  head  being  placed  in  a  good 
light  and  a  gag  introduced,  the  tongue  is  drawn  well  forward  by  a  liga- 
ture through  its  tip:  with  a  pair  of  sharp  scissors  the  frfenum  is  then  divided, 
and,  strong  traction  being  made  on  the  tongue,  its  attachments  are  gradually 
freed  by  a  series  of  short  snips  carried  as  far  back  as  possible.  The  lingual 
arteries  may  be  secured  as  they  are  cut.  The  stump  should  be  kept  under 
control  as  regards  hemorrhage  by  a  strong  silk  ligature  passed  through  the 
remains  of  the  glosso-epiglottidean  fold,  and  retained  for  twenty-four  hours. 
Mr.  Whitehead  states  that  he  has  never  seen  any  trouble  from  hemorrhage. 

Kocher's  Operation  (Fig.  281). — Kocher  has  performed  complete  excision 
of  the  tongue  104  times,  with  20  deaths.  These  deaths  were  chiefly  in  cases 
complicated  with  extension  of  the  disease  to  the  floor  of  the  mouth,  tonsil,  and 
lower  jaw.    In  QQ  uncomplicated  cases  the  mortality  was  only  3  (4.5  percent.). 

This  is  the  only  operation  for  the  removal  of 
the  tongue  which  aims  at  preserving  the 
parts  in  a  thoroughly  asej)tic  condition. 
Tracheotomy  is  first  performed  and  a  well- 
fitting  canula  introduced.  The  pharynx  is 
then  packed  with  a  carbolized  sponge  with 
a  cord  attached,  so  that  it  can  be  easily  re- 
moved when  necessary.  An  incision  is  now 
made,  commencing  a  little  below  the  tip  of 
the  ear  and  extending  down  the  anterior 
border  of  the  sterno-mastoid' muscle  to  about 
its  middle,  then  forward  to  the  body  of  the 
hyoid  bone,  and  along  the  anterior  belly  of 
the  digastric  muscle  to  the  jaw.  The  re- 
sulting flap  is  turned  up  on  the  cheek,  and 
the  lingual  artery  is  ligatured  as  it  passes  under  the  hyoglossus  muscle.     The 


Fig.  281. 


Kocher's  Incision  for  Removal  of  the 
Tongue. 


SURdERY    OR    THE    DlLiESTlVE    TRACT.  081 

fiioial  artery  and  any  veins  that  may  be  in  the  way  are  also  secured.  Com- 
mencing from  behind,  all  the  structures  in  the  submaxillary  fossa  are  removed, 
viz.  the' lymphatic  glands,  the  submaxillary,  and.  if  necessary,  the  sublingual 
glands.  The  opposite  lingual  artery  is  now  tied  by  a  separate  incision  if  the 
•whole  tongue  is  to  be  removed.  The  mucous  membrane  along  the  jaw  and  the 
mylo-hyoid  muscle  are  then  divided,  and  the  tongue  drawn  out  through  the 
incision  and  removed  with  scissors  or  galvano-cautery  ;  the  latter  is  preferred 
by  Kocher,  as  there  is  less  liability  to  after-oozing.  The  after-treatment  is 
m'ost  important :  if  the  operation  be  an  extensive  one,  the  external  wound 
should  not  be  closed.  Kocher's  endeavor  is  to  avoid  the  two  great  after- 
dangers  of  excision  of  the  tongue,  pneumonia  and  general  septicemia.  To  pre- 
venf  the  discharge  from  causing  infection,  the  whole  cavity  of  the  mouth  and 
pharynx  is  plugged  with  carbolized  sponges  and  iodoform  gauze.  The  patient 
is  fed  partly  by  the  rectum,  but  chiefly  by  the  throat  with  a  tube,  twice  a  day, 
when  the  dressings  are  changed.  Thus,  if  all  the  minute  directions  are 
enforced,  the  wound  remains  aseptic  throughout,  and  no  food  or  discharge  from 
the  wound  can  possibly  enter  the  air-passages.  There  is  one  thing  that  the 
operator  cannot  guard  against,  and  that  is  vomiting :  should  the  patient  vomit, 
as  is  so  often  the  case  after  the  administration  of  anesthetics,  ^the  elaborate 
preparations  against  sepsis  may  come  to  naught.  In  Kocher's  hands  this 
operation  has  been  most  successful. 

Removal  of  the  Tongue  after  Dividon  of  the  Lower  Jaw.— This  operation 
was  introduced  by  S^dillot  of  Strasburg.  and  afterward  practised  by  Syme  of 
Edinburgh.  It  consists  in  making  a  vertical  incision  in  the  lower  lip,  sawing 
throutrhlhe  inferior  maxilla  at  the^symphysis.  separating  the  two  sides  of  the 
jaw,  and  drawing  out  the  tongue  and  removing  it  by  scissors,  ^craseur,  or 
knife.  The  divided  portions  of  the  jaw  are  afterward  wired  together.  It  is 
best  to  drill  the  holes  for  the  sutures  before  dividing  the  jaw.  This  ope- 
ration answers  well  when  the  floor  of  the  mouth  is  involved  in  the  disease. 

Results  of  Operation.— The  immediate  results  following  excision  of  the 
tongue  are  fairly  good,  considering  the  severity  of  the  operation.     Whatever 
operation  is  practised,  the  mortality  in  a  series  of  cases  is  about  the  same,  and 
the  method  has  less  influence  upon  the  mortality  than  the  after-treatment,     in 
219  cases  collected  by  the  writer  from  the  tables  of  Agnew,  ^unneley,  Barker, 
Whitehead,  Langenbeck,  and  Kocher  there  were  26  deaths  (11.87  per  cent.). 
The  chief  causes  of  death  are  septic  pneumonia,  pyemia,  shock,  and  exhaus- 
tion.    When  the  tongue  alone  is  excised  the  risk  is  much  less :  the  iatal  cases 
occur  most  frequently  when  other  parts  are  involved,  as  the  tonsil,  jaw,  floor 
of  the  mouth,  glands,  etc.,  such  conditions  requiring  more  severe  operations. 
Operation  always  relieves,  if  it  does  not  cure,  cancer  of  the  tongue,  recur- 
rence bein<^  the  rule.    In  all  cases  where  the  glands  are  involved  these  should 
be  removed  before  amputation  of  the  tongue.     Butlm  recommends  that  alter 
removincT  part  of  or  the  whole  tongue,  as  the  case  demands,  the  surgeon 
should  wait  three  or  four  weeks,  and  then  in  every  case  by  a  separate  opera- 
tion remove  the  glands  in  the  cervical  (carotid  glands),  submental   and  sub- 
maxillary recrions.     An  incision  is  made  along  the  anterior  border  ot  the 
sterno-m'astoid  muscle  from  the  mastoid  process  to  below  the  thyroid  carti- 
lage, and  a  second  incision  from  the  symphysis  menti  to  the  flrst  incision 
ab°out  the  level  of  the  upper  border  of  the  thyroid  cartilage ;  the  flap  is  litted 
up  from  below  and  all  the  glands  in  this  region  thoroughly  removed,  and  the 
flap  replaced  and  neatly  sutured.     The  duration  of  life  in  cases  not  operated 
on  is  about  a  year;   in 'those  operated  on  about  nineteen  months,  a  clear  gain 
of  seven  months. 


(i82  AiY   AMKRICA.X    TEXT-HOOK    OF   SiUGKliY. 

Bangers  of  Excision. — ITemorrliage  formerly  was  niucli  dreaded  in  tlicse 
operations,  but  "with  modern  methods  of  arresting  it  this  fear  has  vanished. 
Seconthiry  liemorrliage  also  is  much  less  frequent  now  that  the  ecraseur  has 
been  almost  discarded. 

The  greatest  danger  connected  with  excision  of  the  tongue  is  without  doubt 
septic  })neumonia  or  other  lung  affections,  produced  by  direct  infection  from 
the  fetid  discharges  of  the  decomposing  wound.  In  some  cases  there  is  gan- 
grene of  a  portion  of  the  lung  or  a  number  of  small,  foul,  circumscribed  ab- 
scesses ;  in  others,  a  condition  of  broncho-pneumonia. 

After-treatment. — The  most  important  jjoint  in  the  after-treatment  is  to 
preserve  a  condition  of  asepsis  in  the  wound,  for,  as  has  been  shown  above,  the 
greatest  danger  is  due  to  direct  septic  infection  from  the  wound  itself.  Again, 
the  swallowing  of  blood  at  the  time  of  operation  tainted  with  the  foul  discharges 
of  the  cancerous  ulcer  should  be  carefully  guarded  against  by  having  the  mouth 
thoroughly  and  frequently  Avaslied  out  with  some  antiseptic  solution,  as  Condy's 
fluid,  carbolic  acid,  etc.,  before  o}»eration,  and  during  operation  avoiding  a  con- 
dition of  too  profound  anesthesia,  and  by  posture  as  far  as  possil)le.  After 
operation  the  wound  in  the  mouth  should  be  packed  with  sticky  iodoform  gauze, 
as  recommended  by  Billroth,  painted  over  with  alcoholic  solution  of  iodoform 
and  resin,  or  at  least  dusted  with  iodoform  crystals.  Whitehead  recommends 
a  varnish  made  of  the  ordinary  constituents  of  Friar's  balsam,  substituting  a 
saturated  solution  of  iodoform  in  ether  for  the  rectified  spirit.  It  is  well  to 
feed  the  patient  as  freely  and  early  as  possible  by  the  mouth :  the  results  of 
this  procedure  are  as  good  as,  if  not  better  than,  when,  as  was  formerly  advo- 
cated, the  patient  is  fed  for  the  first  few  days  by  the  rectum.  For  feeding  by 
the  mouth  a  verv  srood  arrannement  is  a  soft  catheter  with  a  piece  of  rubber 
tubing  attached  to  it,  and  to  this  again  is  attached  a  glass  funnel :  by  ])Ouring 
li(iuid  food  into  the  funnel  the  patient  can  be  easily  and  comfortably  fed. 
Should  any  fetor  appear  in  the  wound,  the  mouth  should  be  frequently  washed 
out  with  a  solution  of  Condy's  fluid  (potassium  permanganate  1 :  500),  car- 
bolic acid,  or  potassium  chlorate.  Whitehead  says  that  instead  of  keeping 
the  patient  in  bed,  he  should  rather  be  encouraged  to  sit  up  the  day  after  the 
operation,  or  even  to  go  out  if  the  weather  be  fine ;  in  this  way  discharges 
of  Idood  from  the  wound  are  less  liable  to  get  into  the  air-passages. 

DISEASES  OF  THE   JAWS. 

Congenital  Deformities. — In  the  description  of  the  development  of  the 
face  the  various  deformities  of  the  jaws  have  been  alluded  to.  These  include 
cleft  palate,  arrest  of  development  of  one  or  both  sides  of  the  lower  jaw,  non- 
union of  the  two  halves  of  the  lower  jaw,  with  median  fissure  of  the  lower  lip, 
and  non-union  of  the  premaxillaries,  with  median  fissure  of  the  upper  lip.  With 
arrest  of  development  of  the  lower  jaw  is  sometimes  associated  a  congenital 
dislocation.  All  these  deformities  of  the  jaws,  Avith  the  exception  of  cleft 
palate,  are  extremely  rare. 

Acquired  Deformities  of  the  jaws  are  not  uncommon.  Hypertrophy  of 
the  tongue  may  result  in  deformity  by  constant  pressure.  Chalk  ref)orts  a  case 
of  dislocation  produced  by  it.  Sucking  the  thumb  has  a  very  marked  influence 
on  the  position  of  the  teeth,  and  if  persisted  in  may  cause  considerable  deform- 
ity of  the  jaw.  Cicatrices  outside  the  mouth  may  produce  deformities.  Burns 
in  childhood  may  be  followed  by  deformities,  such  as  binding  the  lower  lip  to 
the  sternum,  and  hence  ])ulling  forward  the  lower  jaw  to  a  considerable  extent. 

Abscess  of  tine  Gums  and  Jaw,  or  "gum-boil,"  is  a  very  common 
affection,  and  is  due  to  irritation  from  decayed  teeth.     Sometimes  it  is  (juite 


SURGERY    OF    Till-:   DKJ LSTIVE    TRACT.  G83 

su})erficial  and  can  be  cured  by  puncture,  but  at  otlier  times,  Avhcn  connected 
"with  the  diseased  root  of  a  tooth,  it  is  inucli  deeper  and  is  accompanied  by  a 
considerable  swcllin<f  of  the  face  and  severe  pain.  In  such  cases  exit  may  be 
found  for  the  abscess  along  the  surface  of  the  tooth  and  temporary  relief  be 
afforded,  but  the  affection  recurs,  and  nothing  short  of  careful  treatment  by  a 
competent  dentist,  and  sometimes  removal  of  the  tooth,  will  benefit  the  patient. 
When  the  abscess  breaks  externally  it  may  give  rise  to  an  external  fistula, 
■\vhich  Avill  close  ■when  the  offending  tooth  is  cured  l)y  the  dentist.  In  certain 
cases  the  abscess,  when  untreated,  may  lead  to  necrosis  of  bone.  The  treat- 
ment then  is  early  and  free  incision  of  the  gum  and  extraction  of  the  diseased 
tooth,  unless  it  can  be  saved  by  the  dentist. 

Necrosis  of  the  jaw  may  be  the  result  of  very  different  causes.  It  may 
follow  one  of  the  zymotic  diseases,  or  be  produced  by  injury,  ostitis,  periostitis, 
exposure  to  the  fumes  of  phosphorus,  or  mercury.  A  carious  tooth  may  be  the 
commencement  of  a  necrosis  of  the  jaw  if  not  properly  treated.  The  predis- 
posing causes  are  struma,  syphilis,  and  lowered  conditions  of  the  system  from 
disease  or  from  deficient  food.  Necrosis  occurs  nearly  as  often  in  the  upper 
as  in  the  lower  jaw,  and  is  seen  at  any  age.  It  is  always  preceded  by  intense 
and  deeply-seated  pain  and  inflamed  and  swollen  gums ;  the  teeth  become 
loose,  and  soon  sinuses  form  in  every  direction,  giving  exit  to  pus.  On  passing 
a  probe,  dead  bone  is  easily  felt.  Soon  the  health  of  the  patient  deteriorates 
and  a  supporting  treatment  is  necessary.  The  bone  is  bathed  in  pus,  becomes 
loose,  and  is  easily  removed  through  an  incision  in  the  gums,  followed  by  deter- 
gent mouth-washes,  as  noted  above. 

Phosphorus  Necrosis  frequently  exists  without  the  patient's  at  first 
being  aware  of  it.  It  is  very  rapid  and  involves  a  large  extent  of  bone.  The 
symptoms  are  those  of  other  forms  of  necrosis.  The  necrosed  bone  is  usually 
porous  and  is  of  a  dirty  gray  color. 

Treatment. — The  dead  bone  should  be  quite  loose  before  removal  is  under- 
taken, as  tearing  out  a  portion  not  yet  fully  separated  may  lead  to  serious  acci- 
dents, such  as  wounds  of  vessels  and  fracture  of  the  new  bone.  It  is  better, 
if  possible,  to  remove  the  sequestrum  from  the  inside  of  the  mouth,  and  Avhere 
the  necrosis  involves  the  upper  jaw  this  can  usually  be  easily  done,  for,  as  a 
rule,  the  alveolar  process  only  is  involved.  But  in  necrosis  of  the  lower  jaw 
the  surgeon  hiust  be  guided  by  the  situation  and  direction  of  the  sinuses,  which 
often  point  externally.  The  necrosed  bone  in  such  cases  may  often  be  more 
easily  removed  by  an  incision  along  the  line  of  the  lower  jaw. 

Epulis. — This  is  a  term  Avhich  is  applied  to  various  tumors  of  the  gums. 
They  are  really  not  connected  with  the  gums  at  all,  but  Avith  the  periosteum  of 
the  alveolar  process  and  sockets  of  the  teeth.  Two  forms  are  usually  described, 
viz.  simple  or  fibrous  epulis  and  malignant  or  myeloid  epulis. 

Simple  Epulis  is  seen  as  a  smooth,  rounded  growth,  red  in  color,  elastic, 
and  appearing  much  the  same  as  the  gum.  It  soon  ulcerates  and  a  sero-puru- 
lent  discharge  exudes  from  its  surface ;  or  it  may  ossify. 

Malig7iant  or  Myeloid  Epulis  is  a  much  more  serious  affection,  and  is 
generally  connected  with  the  socket  of  the  tooth.  It  is  very  vascular,  of  a 
purplish  color,  grows  rapidly,  and  soon  presents  a  large  fungating  mass,  which 
protrudes  between  the  teeth  and  bleeds  easily  ;  it  never  ossifies. 

Treatment. — Early  and  free  removal  is  the  only  treatment  for  both  ;  not 
removal  of  the  growth  alone,  but  extraction  of  the  tooth  and  removal  of  the 
alveolar  process  with  the  socket  of  the  tooth.  It  is  better  to  make  two  verti- 
cal cuts  with  a  Hey's  or  other  saw,  and  then  with  a  strong  pair  of  cutting 
forceps  remove  the  portion  of  bone  mapped  out.     In  this  way  only  will  a 


084  ^^V   AMKlilCAX    TEXr-lloOK    OF   SilUiKliY. 

succossful  result  ciisiu'.  Without  icmhivmI  of  Iiouc  llic  ilisease  will  ncMily 
alway.'^  roturu,  even   in   siinjilc  cases. 

Hyperostosis  is  a  very  rarr  afVcction.  l^cuiarkahle  cases  have  heeli 
rejiorteil  i'roui  time  to  time.  The  cxcitiiif^  cau.se  of  this  atVeeticni  may  he  a 
hlow  ou  the  face.  The  suj)erior  maxilhe,  as  well  as  the  other  hones  of  the 
hcail.  are  sometimes  the  seat  of  hypertrophy  in  the  condition  known  as  leon- 
tiasis  ossium.  ^\  hen  this  is  a  local  affection,  o])erati<)n  has  been  uiuler- 
takeii    for   its   relief   with   entire   success. 

Dentigerous  Cysts  are  found  in  both  the  uj)per  and  the  lower  jaw,  and 
usually  arise  from  permanent  teeth  as  a  result  of  some  form  of  irritation. 
They  are  frequently  mistaken  for  solid  growths.  In  these  cysts,  from 
some  unknown  cause,  the  teeth  remain  undeveloped  Avitbin  the  jaw  or  may 
be  inverted.  The  cyst-wall  is  generally  very  thick  and  lined  by  a  vascular 
membrane.      The  tooth   may  or  may  not  project  through   this  membrane. 

Dia<i)iosis. — When  a  slow-growing,  painless,  solid  tumor  of  the  jaw  is  seen 
in  a  young  person,  the  surgeon  should  always  examine  the  teeth.  He  will  prob- 
ably find  a  tooth  absent  or  a  temporary  tooth  where  a  permanent  one  ought 
to  be.  Jaws  have  ])ecn  removed  for  this  affection  under  the  supposition  that 
the  tumor  was  malignant.  It  is  better,  therefore,  in  a  young  person,  even  if  the 
disease  is  not  looked  upon  as  a  dentigerous  cyst,  to  cut  into  the  tumor  before 
mutilating  the  patient  by  the  removal  of  the  whole  or  a  portion  of  the  jaw. 

Cysts  of  the  Lower  Jaw. — A  limited  portion  of  the  lower  jaw  may  be 
expanded  gradually  by  a  single  cystic  growth.  Such  a  cyst  grows  slowly,  its 
wall  becomes  thinner  and  thinner,  and  the  tumor  distinctly  fluctuates.  The 
bone  becomes  so  thin  that  it  crackles  on  pressure.  It  is  said  that  these  cysts 
originate  in  connection  with  the  teeth.  Sometimes  a  small  cyst  is  connected 
with  the  root  of  a  tooth,  and  Powers  considers  that  they  are  of  inflammatory 
origin. 

Multilocuiar  Cysts. — These  cysts  are  nothing  but  a  late  stage  of  solid 
tumors,  this  condition  being  due  to  cystic  degeneration  of  sarcomata  and  epi- 
theliomata.  There  is  often  a  development  of  bone  in  the  interior  of  the  cyst. 
They  sometimes  grow'  to  large  size  and  are  of  years'  growth.  Frequently  they 
are  painless.     Excision  of  the  jaw  is  the  only  legitimate  method  of  treatment. 

TUMORS  OF  THE  JAWS. 

Tumors  of  the  jaws  may  be  divided  into  non-malignant  and  malignant. 

The  noi} -malign nnt  are — (1)  Fibroma  :  (2)  Enchondroma  ;  (3)  Osteoma. 

Fibroma. — Fibrous  tumors  of  the  jaws  are  not  uncommon,  and  resemble 
other  fibrous  tumors  as  regards  their  clinical  history  and  appearance.  They 
grow  from  the  periosteum,  especially  of  an  alveolus,  and  resemble  epulis: 
or  they  may  grow  from  the  endosteum  and  expand  the  jaw  by  their  growth. 
Such  tumors  usually  make  their  waj  into  the  antrum  or  nasal  fossie.  They 
may  occur  in  early  life.  Their  growth  is  slow,  but  they  persistently  increase. 
They  seldom  attain  very  large  size  nowadays,  because  being  in  an  exposed 
part  of  the  body  they  are  usually  removed  early.  They  are  ])ainless  and  non- 
maligiumt  when  compared  with  cancer. 

Treatment. — Removal  of  the  tumor  and  of  the  entire  portion  of  the  jaw 
which  gives  attachment  to  it  is  the  only  form  of  treatment  of  any  avail. 
These  tumors  not  infrequently  return  after  an  apparently  complete  removal. 

Enchondroma  is  a  rather  rare  form  of  tumor  of  the  jaw.  It  is  some- 
times of  immense  size,  and  in  certain  ca.ses  has  killed  the  patient  by  suffocation. 
Enchondroma  usually  appears  in  early  life  as  a  tumor  of  the  antrum  or  body 


sriwiJKy  OF  Tin:  J>iui:sTiyE  tuavt.  o«5 

f  tl  lou-.r  i-tw  is  verv  hanl,  sonunvhat  ncxlular,  and  -rows  more  rapi.Uy 
l::'fil!:::;:L^  O^c^s^^^ly  .t  l.^...  ^n^...^^.^^  a.,  very  apt  to  recur 
localW  wlien  removed.  ,.„  consist  simply 

:,'„,:'rothet  a';:..;:  l.-o'lf  r^e  Un>e,i.oa  .........     TI.  ^iy  treatment  .s 

•     ^  '    if  k  unfortuuatelv,  by  no  means  uncommon,  and  may  occur  in  the 
^'-h  tVlllrl        -U    iZi"  aJt'tbu";  llingnishable  from 

mXLnr— fc:'tn  afte/vomoval  bcng  L  rule.  Unless  remove,.  ,n 
*^  iT'T?e:Sst™sTs:rco^ata,  such  as  cystic  myeloid  fibrous,  and 
spiidlcelleraT^Ik  the  jaw,  and  should  be  t-t^l  7  -Ij  -„  ,a 
(]pe.-ation  is  rarely  permanently  «''«=<'^^f''''^^P'1r;f  "^  ™X  grow  from  the 
even  when  the  whole  lower  jaw  is  '■'r™°'«>„,,  J''7^,"^^^^'Lvy  be  mistaken 
periosteum.     In  the  early  stages  a  rapnlly-giowmg  sarcoma  may 

for  an  abscess. 

DISEASES   OF   THE   TEMPORO-MAXILLARY    ARTICULATION. 

Tubercular  disease  of  this  joint  is  very  --ly -™ ' ^^^^h^tides'TTs 
affection  is  Rheumatic  Arthritis  wh.ch  may  fff<=  '  7^^,.°f,X^a  ttlage  and 
a  painful  affection,  and  produces  absorption  of    he  mto^^  g 

±TZl::!^:::^^^]^^^  S:t»o  oL  s.de  .  on^ly  one 
XtdaHon  is  involved.     It  does  not  lea^'o  osseous  ankylos,^^^ 

...Thi:  pr,?sibrL^^e;!r^  -^-^i^z^  ^rz 
t^t:t^:z  :i  ^:j:^z.'^lI^^-^^  p«s  forms 

it  should  be  evax^natecl  early  phenomenon  met  with  in  certain 

Noisy  Mastication.— ihis  is  a  peculiar  I  mastication  are 

individuals,  m  whom  some  ^^vemeiits  of  the  ^^l^^nl^  .^  instances  is 
accompanied  by  a  snapping  or  cracking  ^p/'  ^^^^^.y^'^  i^  ,,hom  this  is 
so  loud  as  to  be  heard  even  -^^^^  ^/.^f  [j^StVing  becom  so  accustomed 
noted  are  usually  quite  unconscious  «.f ^^^^^J^^^  ^j^^^^i,^^  nse  to  it  is  one 

to  it  as  not  to  notice  it  themse  ves.     ihe  ^^^^^^^^^J^^^^^^^  joint,  and 

^?  rratbtgLnignE^  r  ::^v 'h,- 

account  of  its  etiology  it  .s  almost  ■•»P°^^'''ly'>  <";'^^-  ,„ylVlv  and'to  get 
rlrtt  Sit'of  Tee  in! T  ru^^'^^ofTeVawt  ^ kSd  of  tension  wh?ch 
;:;in  ;t:vent  ke  poslbil,ty  of  too  sudden  contact  of  articular  surfaces. 


(;s<)  A.\    AMKliHAS    TKX'l'-HOOK    OF  sriHilJiV. 

• 

Ankylosis  of  the  Jaw  is  usually  confiiK'<l  to  one  side,  but  may  affect 
both,  ami  may  be  bony  or  fibrous.  It  is  not  in{V('(|ucntly  tlif  result  of  siij)))U- 
ration.     Its  reco«^niti(>n  is  easy. 

Operations  for  the  relief  of  this  affection  have  been  devised  by  Jlumijhry  of 
Cambridge,  Esmarch,  Kizzoli,  and  others.  These  operations  all  consist  in  simple 
division  of  the  neck  of  the  jaw  or  in  division  Avith  removal  of  a  portion  of  bone. 
Esmarch  advises  the  formation  of  an  artificial  joint  by  the  removal  of  a  wedge- 
shaped  piece  of  bone  through  an  incision  in  front  of  the  massetcr,  and  Hi/.zoli 
advocates  cutting  through  tlie  jaw  with  forceps  introduced  through  the  mouth. 
Some  of  these  cases  after  operation  do  well  and  have  free  movement  of  the 
jaws  for  a  time,  but  many  relapse  and  movement  becomes  again  limited. 

Closure  of  the  Jaws. — This  may  be  merely  temporary^  due  to  some 
hysterical  condition  or  to  some  reflex  irritation  of  the  muscles  of  mastication. 
The  exciting  cause  may  be  the  cutting  of  a  wisdom  tooth  or  the  failure  to  cut 
one.  This  may  be  due  to  malposition  or  want  of  room.  In  such  cases  the  patient 
should  be  put  under  ether,  the  jaw  thoroughly  examined,  and  an  incision  made 
over  the  affected  tooth,  or  the  next  tooth  extracted.  Sometimes  it  may  be  neces- 
sary to  extract  the  wisdom  tooth  or  to  chisel  away  the  surface  of  bone  over  it. 

Permanent  Closure  of  the  Jaivs  may  be  due  to  ankylosis,  which  has  been 
described  above,  or  more  commonly  to  cicatricial  contraction  from  ulceration  and 
sloughing  the  result  of  gangrenous  stomatitis  in  earl}^  childhood.  The  slough 
not  infrequently  involves  the  whole  thickness  of  tlie  cheek,  and  hence  the 
resulting  cicatrix  is  very  extensive  and  unyielding,  and  the  cheeks  are  blended 
with  the  gums  so  that  movement  of  the  jaw  is  impossible.  Division  of  the 
cicatricial  bands  has  been  followed  by  no  good  results,  and  plastic  operations 
that  have  been  devised  have  proved  almost  useless.  The  best  treatment  is 
division  of  the  jaw  as  for  ankylosis  and  the  forming  of  a  false  joint  in  front 
of  the  cicatrix.  Heath  speaks  highly  of  Esmarchs  operation  for  the  relief 
of  this  condition. 

DISEASES  OF  THE   TEETH. 

Dental  Caries. — This  is  a  very  common  affection,  few  persons  reaching 
adult  life  without  having  suffered  from  it.  It  is  a  decay  on  the  surface  of  the 
tooth  which  causes  the  tissues  slowly  to  soften  and  disintegrate  until  the  pulp- 
cavity  is  reached.  It  may  commence  in  the  enamel  or  in  the  dentine  beneath 
the  enamel.  When  the  enamel  is  attacked,  it  becomes  opaque  and  soon  is  dis- 
colored ;  when  the  dentine  is  reached,  the  progress  is  more  rapid.  The  dis- 
eased portion  may  be  nearly  black,  but  it  is  usually  of  a  dark  brown.  The 
deeper  the  stain  the  slower  the  decay.  Carious  dentine  has  a  smell  ])eculiar 
to  itself.  The  much-disputed  question  of  the  active  cause  of  dental  caries  has 
been  finally  settled  by  Miller,  an  American  dentist,  now  in  Berlin,  who  has 
conclusively  shown  that  dental  caries  is  due  to  the  bacteria  in  the  mouth,  of 
which  there  are  a  large  number. 

The  predisposivr/  causes  of  caries  are  (1)  some  defect  in  the  enamel,  so  that 
the  dentine  is  exposed  to  the  action  of  decomposing  food  and  the  bacteria  in  the 
mouth  ;  (2)  injury  due  to  the  too  great  crowding  of  teeth,  the  pressure  causing 
absorption  of  the  enamel  and  thus  exposing  the  dentine ;  (8)  the  accumulation 
of  decaying  substances  between  the  teeth.  In  certain  diseases,  such  as  fevers, 
etc.,  decay  is  more  liable  to  occur.  Pregnancy  and  the  various  forms  of  ill 
health,  by  deranging  digestion,  are  frequent  predisposing  causes.  Imperfect 
calcification  of  the  teeth  and  hereditary  conditions  may  also  predispose  to 
caries. 

The  Exciting  Causes  of  Caries. — (1)  The  acids  which  are  the  products  of 


sunaKRY  OF  Till-:  1)Ii;kstive   tuact.  687 

fermontation  and  clieinical  decomposition  of  food  and  other  mattors  in  the 
mouth,  also  acid  niiicus  secreted  by  the  gums ;  (2)  when  the  dentine  is 
exposed,  certain  organisms,  such  as  the  Leptothrix  bucvalis,  appear  and  per- 
vade the  dentine  and  grow  at  its  expense.  When  the  pulp-cavity  is  reached, 
severe  pain  is  experienced.  Owing  to  the  pulp  l)eing  confinod  within 
bony  walls,  it  cannot  expand  under  the  iniluence  of  iiitiamiiiation ;  hence 
great  pressure  is  the  result,  and  conse(i[uently  intense  pain.  The  pul})  recedes, 
the  inner  surface  of  the  cavity  is  attacked,  and  the  disease  proceeds  from 
within  outward.  Certain  teeth  are  more  liable  to  decay  than  others.  This 
is  particularly  true  of  the  "sixth-year  molar,"  or  the  first  of  the  permanent 
teeth  to  appear.  Surgeons  ftxMjuently  overlook  this  tooth.  The  same  tendency 
to  decay  exists  in  the  "  wisdom  "  teeth.  The  surgical  importance  of  dental 
caries  lies  in  the  fact  that  the  lymphatic  glands  beneath  the  lower  jaw  are  so 
frequently  infected  by  tubercle  and  other  germs  that  gain  access  through 
diseased  teeth. 

Treatment. — The  treatment  of  caries  comes  more  within  the  province  of 
the  dentist  than  within  that  of  the  surgeon,  and  consists  in  the  removal  of 
the  decayed  tissue,  so  that  a  healthy  surface  is  left,  and  then  filling  the  cavity 
with  gold-leaf,  amalgam,  or  other  suitable  material.  The  preventive  treatment 
consists  in  preserving. perfect  cleanliness  by  toothbrush  and  antiseptic  pow- 
ders and  maintaining  a  good  condition  of  health. 

Dental  Periostitis. — The  periosteum  lining  the  sockets  of  the  teeth  is 
liable  to  become  inflamed,  a  diseased  tooth  being  very  frequently  the  cause. 
The  affection  may  be  acute  or  chronic.  When  it  goes  on  to  suppuration  an 
alveolar  abscess,  or  gum-boil,  is  the  result.  The  tooth  is  very  tender,  espe- 
cially on  pressure,  and  feels  as  if  it  were  too  long ;  it  afterward  becomes 
loose  and  protrudes  from  the  socket.  This  affection  must  not  in  its  first 
stages  be  confounded  with  inflammation  of  the  pulp.  In  this  latter,  although 
the  pain  is  intense,  still  the  tooth  is  not  tender  and  does  not  feel  as  if  it  were 
too  large  for  the  socket.  The  results  following  a  neglected  alveolar  abscess 
have  been  described  above  under  Abscess  of  the  Jaw. 

Treatment. — Removal  of  the  cause  is  the  proper  treatment,  viz.  extraction 
of  the  diseased  tooth.  If  left,  the  inflammation  recurs,  and  in  the  end  the 
tooth  has  to  be  sacrificed. 

SypFiiiitic  Teeth. — The  peculiar  teeth  which  occur  in  children  with  inher- 
ited syphilis,  first  described  by  Mr.  Hutchinson,  have  already  been  mentioned 
in  the  chapter  on  Syphilis. 

Extraction  of  Teeth. — The  extraction  of  the  temijorary  teeth  is  a  sim- 
ple matter,  as  in  the  natural  course  of  events  the  roots  are  absorbed  and  the 
crown  of  the  tooth  is  shed  from  the  gum. 

The  permanent  teeth,  however,  frequently  give  some  trouble,  and  unless 
the  operator  uses  judgment  and  care  in  the  extraction  serious  damage  may 
be  done.  The  surgeon  must  remember  that  skill  is  more  requisite  in  the 
extraction  of  a  tooth  than  strength.  The  best  instrument  for  extraction  is 
the  forceps,  of  which  there  are  many  difterent  kinds,  but  for  all  practical 
purposes  two  or  three  pairs  are  all  that  the  surgeon  will  require,  for  the  upper 
jaw  a  bayonet-shaped  forceps  with  straight  handles,  and  for  the  lower  the 
Universal  lower  molar  forceps.  The  first  two  molars  of  the  upper  jaw  and 
the  canines  are  the  most  difficult  to  extract,  the  easiest  being  the  incisors  and 
bicuspids.  In  extracting  a  tooth  with  a  single  root  it  may  be  first  loosened 
by  rotating  it  before  pulling,  but  this  procedure  is  useless  in  the  bicuspids  and 
molars  ;  here  the  fjings  are  flat  and  cannot  be  rotated,  but  by  a  swaying  move- 
ment, first  outward,  then  inward,  for  the  upper  teeth,  and  inward  and  then 


outward  for  the  lower  molars,  the  tooth  is  loosened  and  conies  away  easily.  The 
tooth  should  be  seized  as  near  to  the  root  as  j)ossible.  Care  is  to  he  taken 
not  to  break  oft"  any  jiortion  of  the  alveolar  process,  for,  thouL'h  serious  results 
rarely  follow,  yet  sometimes  necrosis  occurs.  For  the  removal  of  stumjis  of 
teeth  special  force])s  are  re(iuir('d. 

Irregularities  of  the  Teetin  are  comparatively  common,  and  exist  usually 
in  the  ])ennanent  set  alone.  Thumb-sucking  is  a  frecjuent  source  of  irregu- 
larity, causing  all  the  front  teeth  to  protrude ;  crowding  of  the  teeth  also  is 
often  seen,  and  is  relieved  by  extraction  of  one  or  more  t«eth,  thus  giv- 
ing room  for  the  others  to  develop.  Too  early  extraction  of  the  temporary 
canines  of  the  upper  jaw  may  cause  the  premolars  to  encroach  on  the  territory 
of  the  permanent  canines,  and  thus  produce  deformity.  Teeth  which  when 
first  erupted  apjjear  very  irregular,  as  development  proceeds  often  get  into 
line,  and  are  finally  quite  regular  in  appearance.  Su])ernumerary  teeth  not 
infre(iuently  aj»i)ear.  The  treatment  of  irregularities  is  purely  mechanical, 
and  is  fully  described  in  works  on  dentistry,  and  surgeons  would  do  well  to 
refer  such  cases  to  dentists  for  treatment. 

Toothache. — Usually  this  is  a  symptom  of  dental  caries,  the  ulceration 
having  exposed  the  pulp.  It  may  also  be  due  to  intlammation  of  the  peri- 
osteum covering  the  root,  ossification  of  the  pulp,  or  exostosis  of  the  root. 
Healthy  teeth  may  be  aff'ected  with  severe  pain  from  a  neighboring  diseased 
tooth,  in  the  same  way  as  in  some  cases  of  hip-joint  disease  the  pain  is  in  the 
knee.  In  doubtful  cases  it  is  always  advisable  to  examine  the  teeth  very  care- 
fully in  order  to  see  w^hich  one  is  the  source  of  trouble,  and  so  to  prevent 
extraction  of  the  wrong  tooth.  Occasionally  the  toothache  may  be  due  to 
■neuralgia.  In  cases  of  exposed  pulp  pain  may  be  relieved  by  the  oil  of  cloves, 
creasote,  carbolic  acid,  chloroform,  aconite,  and  other  remedies,  applied  on 
absorbent  cotton  wool.  Painting  the  gums  with  equal  parts  of  tincture  of 
aconite  and  tincture  of  iodine  sometimes  affords  relief.  Extraction  should 
never  be  undertaken  except  as  a  last  resort. 

Hemorrhage  after  Extraction  of  a  Tooth. — ]>leeding  occurs  in  all 
cases,  but  it  is  generally  slight,  and  even  if  the  oozing  goes  on  for  some  time 
there  is  usually  but  little  danger.  In  cases  of  hemophilia  or  purpura  hannor- 
rhagica  the  extraction  of  a  tooth  is  a  serious  matter  and  may  be  fatal.  Slight 
hemorrhage  may  be  arrested  by  cold.  In  severe  cases  the  cavity  should  be 
cleansed  of  the  blood-clots  and  carefully  and  tightly  packed  with  cotton  or  strips 
of  lint  with  tannin  rubbed  into  the  meshes,  and  over  this  a  plug  of  lint,  and 
pressure  made  by  closing  the  jaws  on  the  plug  and  fixing  them  with  a  four- 
tailed  bandage.  It  is  only  in  the  most  severe  cases  that  the  plug  has  to  be 
soaked  in  perchloride  of  iron  or  the  cavity  touched  with  the  actual  cautery. 

Odontomes,  or  Tooth  Tumors. — Broca  first  described  these  tumors  in 
1807.  They  consist  of  very  greatly  hypertrophied  dental  tissue.  Malformed 
teeth  and  teeth  with  warty  excrescences  are  sometimes  included  in  this 
group.  A  true  odontome  is  usually  encysted,  has  no  attachment  to  the  sur- 
rounding structures,  and  rarely  gives  rise  to  much  irritation.  One  variety 
occurs  in  the  lower  jaw  and  contains  the  formative  elements  of  one  or  two 
molars.  It  grows  irregularly  and  bears  no  resemblance  to  a  tooth  in  shape. 
This  tumor,  which  grows  slowly  and  expands  the  bone,  may  be  mistaken  for  a 
true  tumor  of  the  lower  jaw,  and  portions  of  the  jaw  may  be  unnecessarily 
removed.  It  is  important,  therefore,  especially  in  all  cases  of  tumors  of  the 
lower  jaw,  that  the  surgeon  before  sacrificing  a  part  of  the  jaw  should  bear 
in  mind  the  possibility  that  the  tumor  may  be  an  odontome.  ^Vhere  tooth 
tumors  are  attended  by  inflammation  it  is  possible  to  mistake  the  case  for  one 


SVRGKny    OF    THE    DIUKSTIVE    TJiALT. 


689 


of  necrosis.  Son.,  oaonton.c-s  aftct  all  the  tissues  <^  the  teeth  ;  ^^he  s  aflect  the 
.n3 Or  the  dentine  only.      S..n.etin.es  there  is  a  fistulous  conimunieation  ^Mth 

he  exte  naf^^^^  e^^  the  cheek.  The  treatn.ent  is  suflRciently  snnple.  If 
e  'n  Xs       .  n  and  is  mc^rely  unsightly,  it  may  be  removed,  but  m  cases 

n  .1  con  of  a  large  mass  of'^dental  tissue  in.bedded  in  the  Ja.^•  an 

nclo  sh,.ul  be  made  ovJr  the  growth,  and  then  with  a  bone  elevator  or 
forceps  the  tumor  can  be  easily   enucleated  without  serious  damage  to   the 

jaw. 

AFFECTIONS    OF    THE    PHARYNX,  TONSILS,  ANI>    PALATE. 

CoN.iENiTAL  Malformations  of  the  Pharynx  -These  are  not  common 
Fistul"^  occur  in  rare  cases  and  communicate  with  the  pharynx,  trachea,  or 
^^,a  a^us.     They  are  due  to  persistence  of  the  branchial  clefts      Pharyngeal 
fistillle  usually  occur  as  minute  orifices  on  one  or  both  sides  of  the  neck  be  ow 
the  cdottis,  their  direction  being  upward  to  the  pharynx  and  oesophagus.      1  he> 
occm-  in  the  line  of  the  old  bSnchial  clefts,  the  lowest  being  near  the  sterna 
end  of    he  clavicle,  the  next  opposite  the  thyroid  cartilage   and  the  highest 
betNveen  the  thyroid  cartilage  and  the  hyoid  bone    Paget)      ^^  hen  two  in  num- 
ber they  are  Jften  symmetrical.     They  vary  in  length  from  half  an  mch  to 
one  and  a  half  inches,  and  barely  admit  a  probe,  though  the  diameter  of  the 
fistula  is  always  greatei'  than  that  of  the  external  opening.     The  internal  open- 
in^  of  the  fis  ula  is  found  in  the  lateral  wall  of  the  pharynx,  behind  the  cornu 
of'th    hyoid  lone,  or  in  the  pharyngo-palatine  side      The  fistula  are  lined  by 
a  smooth  membrane,  which  secretes  a  mucous  fluid.     They  may  be  cured  by 
cauterization  with  the  actual  cautery.  -^  i  •    r 

Diverticula  from  the  pharynx  and  oesophagus  which  are  congenital  indi- 
cate also  incomplete  closure  o"f  the  branchial  clefts  and  occur  in  the  same 
re-ions  as  the  fistuU^ ;  occasionally  they  are  not  congenital,  but  acquired. 
In"  several  instances  they  have  been  successfully  excised  and  the  margins 
united  by  Lembert  sutures.  ,      .     ■    n  .•  „   ^f 

Tonsillitis  (Quinsy,  Cynanche  tonsillans).— Acute  inflammation  ot 
the  tonsils  sets  in   very  suddenly  with  such  symptoms  as  severe  rigor,  high 
fever,  headache,  and  general  malaise.     The  tonsils  soon  become  swollen,  red 
and  painful,  rendering  swallowing  difficult.     The  glands  beneath  and  behind 
the  an.rle  of  the  jaw  enlarge  and  become  very  tender  on  pressure.     One  tonsi 
is  usually  affected  first,  and  in  a  day  or  two  there  is  a  fresh  onset  of  fever  and 
the  opposite  one  becomes  similarly  inflamed.     When  both  tonsils  are  simulta- 
neously attacked  it  is  generally  an  indication  of  septic  infection      The  patient 
has  -reat  pain  during  swallowing,  not  only  in  the  throat,  but  in  the  ear  and  the 
side'of  the  neck.     Articulation  is  difficult,  and  both  hearin-  and  the  sense  of 
taste  are  impaired.     The  temperature  may  go  as  high  as  104  -lOo    1.      Ihe 
inflammation  most  frequently  terminates  in  resolution  m  the  course  ot  a  tew 
days,  but  occasionally  it  goes  on  to  suppuration,     ^\hen  suppuration  occurs 
the  swellincr  in  the  tonsil  increases  rapidly  and  extends  toward  the  sott  palate, 
the  toncrue^becomes  swollen  and  foul,  the  breath  fetid,  and  swallowing  very 
difficult."    The  patient  sits  up  in  great  pain  and  feels  a  sensation  of  suffocation. 
In  some  cases  pus  forms  rapidly,  in  others  slowly.      Some  hold  that  the  sup- 
puration is  always  peritonsillar,  and  that  incisions  are  useful  only  when  made 
in  front  of  or  behind  the  tonsil,  where  the  pillars  of  the  fauces  are  m  con- 
nection with  it,  and  where  pus  is  formed  in  the  connective  tissue  around  the 

*'''' The  causes  of  tonsillitis  are  many.     A  strumous  diathesis  predisposes  to 


44 


690  AX  ami:  HI  (AX  text- hook  or  surgery. 

it,  and  also  an  arthritic  diathesis,  as  well  as  exposure  to  cold,  impure  air,  sewer 
gas,  worry,  sexual  excitement,  etc.  One  attack  predisposes  to  subseijuent  ones. 
The  tendency  to  tonsillitis  has  been  considereil  hereditary  by  some.  The  sever- 
ity of  the  fever,  which  may  reach  10.5°  F.,  and  tlie  great  prostration  often  leave 
the  patient  very  weak  for  some  time,  especially  if  the  inHammation  has  gone 
on  to  suppuration.  Some  hold  that  all  the  severe  forms  of  tonsillar  inflam- 
mation are  due  solely  to  septic  infection.  This  view  has  not  yet  b^en  fullv 
accepted  by  the  profession. 

Treatment. — For  ordinary  tonsillitis,  after  administering  a  brisk  purge, 
nothing  is  better  than  a  mixture  of  tincture  of  muriate  of  iron  with  chlorate 
of  potassium  and  glycerin,  taken  every  hour  or  two,  with  occasional  applica- 
tions of  a  paint  made  of  sodium  bicarbonate,  applied  with  a  brush,  or  of  silver 
nitrate  gr.  Ix  (a  f.^j.  Guaiacuni,  salicylic  acid,  aconite,  and  many  other  rem- 
edies have  been  recommended  from  time  to  time.  Ten  grains  of  Dover's  pow- 
der administered  at  bedtime  give  great  relief.  Should  suppuration  ensue,  earlv 
incision  is  the  only  treatment:  scarification  may  relieve,  but  will  do  so  only 
temporarily.  The  abscess  should  be  opened  with  a  sharp-pointed  bistoury 
or  tenotomy  knife.  Incision  should  be  from  within  out  and  a  little  in  front 
of  the  tonsils.  If  a  sharp-pointed  bistoury  is  used,  its  edge  should  be  guarded 
by  wrapping  plaster  round  it  to  within  an  inch  of  the  point ;  in  this  way  the 
surgeon  runs  no  risk  of  wounding  tlie  mouth. 

Hypertrophy  of  the  Tonsils. — Chronic  enlargement  of  the  tonsils  is  a 
common  aftection  in  strumous  children.  It  is  caused  l)y  a  chronic  catarrhal 
inflammation  or  may  be  a  simple  hypertrophy  without  any  inflammation. 
Repeated  attacks  of  acute  tonsillitis  not  infrequently  lead  to^  this  condition. 
Boys  and  girls  before  the  age  of  puberty  are  most  frequently  aff'ected,  but  as 
the  patient  gets  older  the  disposition  to  tonsillar  inflammation  decreases.  The 
enlarged  tonsils  appear  in  some  cases  almost  entirely  to  fill  the  throat,  the 
uvula  occupying  the  space  between  them.  Xasal  respiration  is  interfered  with, 
the  child  sleeps  with  its  mouth  open  and  its  rest  is  broken.  It  is  important 
for  the  surgeon  to  understand  that  enlarged  tonsils  are  very  frequently  the 
cause  of  impaired  general  health,  as  nearly  all  the  functions  are'  interfered  Vith. 
The  condition  is  apt  to  be  hereditary. 

Treatment. — There  is  only  one  method  of  treating  hypertrophy  of  the 
tonsils  eff'ectually,  and  that  is  by  excision.  It  is  best  performed  with  some 
form  of  tonsillotome  or  guillotine,  after  carefully  separating  all  adhesions  to 
the  arches  of  the  palate,  as  wounds  of  these  structures  often  cause  severe 
hemorrhage.  No  forceps  are  needed.  The  head  should  be  held  by  an 
assistant,  who  with  his  fingers  presses  in  the  tonsils :  as  much  of  the  gland 
should  be  removed  as  can  be  pressed  into  the  tonsillotome.  The  enlarge- 
ment of  the  tonsil  being  usually  downward,  the  tonsillotome  .should  be 
hooked  over  the  projecting  tonsil  from  below  up.  The  tonsil  may  also  be 
removed  with  a  probe-pointed  bistoury,  the  tonsil  at  the  same  time  being 
pulled  out  with  a  tenaculum,  but  the  u.se  of  the  guillotine  is  advised  in 
preference  to  that  of  the  knife,  as  being  more  expeditious,  safe,  and  easy, 
when  the  tonsil  projects  well  toward  the  median  line.  Jarvis'  snare  (Fig. 
2.53)  is  also  an  excellent  instrument.  Bleeding  after  tonsillotomy  is  some- 
times severe,  and  from  time  to  time  fatal  cases  have  been  reported,  chiefly  in 
patients  suff'ering  from  hemophilia.  Hemorrhage  is  generally  easily  controlled 
ty  pressure  from  within  and  from  without.  If  everything'  else  fails,  tie  the 
external  carotid.  The  bleeding  usually  comes  from  a'«livided  tonsillar  branch 
of  the  facial. 

Caseous    and    Calcareous    Concretions  may  be   developed   in   the 


sunarjiY  of  the  dtgestive  tract.  G91 

crypts  of  the  tonsils.  Tliey  are  sometimes  of  large  size,  and  give  rise  to 
a  considerable  amount  of  inflammation,  fetid  breath,  and  general  discomfort. 
Gruening  states  that  all  tonsillar  concretions  are  of  parasitic  origin  and  com- 
posed of  I('i>totIin/.r  elements.  The  treatment  consists  in  removal  of  the  con- 
cretion, and,  if  tJie  tonsil  is  enlarged,  removal  of  a  portion  of  it. 

Malignant  Tumors. — Both  mrroma  and  carciiKima  occur  in  the  tonsil. 
The  form  of  sarcoma  is  lympho-sarcoma,  and  that  of  carcinoma  is  epithelioma. 
Sarcoma  is  more  frequent  than  carcinoma.  Both  affections  are  equally  malig- 
nant. Sarcoma  forms  a  distinct  prominent  tumor  projecting  into  the  fauces, 
which  finally  ulcerates,  and  if  untreated  usually  proves  fatal  by  hemorrhage. 
Sarcoma  has  been  observed  in  persons  under  twenty.  Epithelioma  of  the 
tonsil  is  rarely  primary.  The  tonsil  may  be  secondarily  involved  by  the 
extension  of  the  disease  from  the  tongue  and  pillars  of  the  fauces.  Epithe- 
lioma of  the  tonsil  rapidly  ulcerates  and  very  early  infiltrates  the  cervical 
glands.     It  is  more  common  in  men  than  in  women. 

Treatment. — Epithelioma  of  the  tonsils,  if  seen  early,  may  be  removed, 
but  in  advanced  cases,  Avith  infection  of  the  glands,  removal  does  not  give 
satisfactory  results  and  is  attended  by  not  a  little  danger.  Sarcoma  of  the 
tonsil,  owing  to  the  fact  that  it  occurs  as  a  prominent  tumor  and  does  not  so 
early  infiltrate  or  ulcerate,  is  more  frequently  attacked  by  the  surgeon  than 
epithelioma.  The  removal  may  be  effected  through  the  mouth,  or  from  the 
outside  by  an  incision  in  the  neck,  as  recommended  by  Cheever  of  Boston. 

Removal  through  the  Mouth. — This  is  sometimes  performed  by  means  of 
the  ^craseur,  galvano-cautery,  or  thermo-cautery.  There  is  usually  very  little 
hemorrhage.  Sarcomatous  tumors  in  their  early  stages  are  usually  encapsu- 
lated, and  may  be  cut  down  upon  within  the  mouth  and  easily  enucleated 
(Butlin).      Unfortunately,   they  are  very  apt  to  recur. 

Removal  hy  Incision  through  the  Neck. — This  operation  is  more  suitable 
for  retro-pharyngeal  than  for  tonsillar  tumors.  It  consists  in  making  an  incision 
about  three  or  four  inches  in  length  along  the  anterior  border  of  the  sterno- 
mastoid  muscle  from  the  ear  to  below  the  level  of  the  tumor.  A  second 
incision,  joining  this,  runs  along  the  lower  portion  of  the  inferior  maxilla,  and  a 
careful  dissection  is  made  down  to  the  tumor,  which  is  then  removed  (Cheever). 

Czerny  and  Mikulicz  have  each  devised  a  very  radical  operation  for  the 
removal  of  growths  of  the  tonsils.  Both  these  operations  require  a  preliminary 
tracheotomy,  and  also  division  of  the  lower  jaw  in  the  region  of  the  molar 
teeth.  The  external  incision  in  Czerny's  operation  reaches  from  the  angle  of 
the  mouth  to  the  anterior  border  of  the  masseter  muscle,  and  thence  down- 
ward to  the  level  of  the  hyoid  bone,  and  in  Mikulicz's  operation  it  reaches 
from  the  mastoid  process  to  the  cornu  of  the  hyoid  bone. 

Retro-pharyngeal  Abscess. — This  affection  occurs  chiefly  in  the  young, 
and  may  be  due  to  various  causes.  It  is  usually  met  with  in  strumous  children, 
and  may  be  an  evidence  of  caries  of  the  cervical  vertebrse.  In  some  cases  it 
folloAvs  scarlatina.  It  may  be  glandular  in  its  origin  or  due  to  extension  of 
inflammation  from  other  parts,  or  it  may  be  idiopathic.  The  abscess  is  situated 
in  the  cellular  tissue  between  the  bag  of  the  pharynx  and  the  cervical  vertebrae, 
and  projects  forward  in  the  throat,  causing  difficulty  in  swallowing.  In  cases 
which  have  lasted  some  time  the  pus  may  extend  laterally  and  cause  a  bulging 
of  the  neck,  usually  behind  the  sterno-mastoid  muscle,  or  it  may  travel  toward 
the  posterior  mediastinum.  On  examining  the  throat  the  diagnosis  is  easy  :  a 
tumor  is  seen  projecting  into  the  pharynx,  which  on  palpation  is  distinctly 
fluctuating  and  does  not  disappear  on  pressure.  The  situation  of  the  abscess 
is  in  most  cases  to  one  side  of  the  median  line. 


692  ^l.V   AMKKIVAy    TEXT-BOOK    OF  SURdKRY. 

TrentuH'nt. — As  soon  as  dia^^'iiosticiited,  the  pus  should  lie  evacuated  by 
incision  cither  in  the  mouth  or  through  tlie  neck.  It  may  he  tapped  through  the 
mouth  by  a  large  trocar  and  canula,  and  after  the  first  evacuation  of  the  pus, 
and  when  all  danger  of  suffocating  the  patient  by  too  free  an  escape  of  pus  is 
past,  the  abscess  should  be  freely  laid  open  with  the  knife.  AVhilst  evacuat- 
ing the  abscess  the  child's  head  should  be  held  forward.  The  opening  through 
the  neck  was  first  recommended  by  the  late  Mr.  Hilton.  The  incision  may 
be  made  eitiier  behind  or  in  front  of  the  sterno-mastoid  through  the  deep 
fascia.  The  abscess  is  reached  by  a  careful  dissection,  especially  in  the 
neighborhood  of  the  great  vessels.  The  cavity  is  then  thoroughly  curetted 
and  either  drained  or  closed.  In  cases  in  which  the  abscess  is  due  to  disease 
of  the  cervical  vertebrae  large  portions  of  bone  have  been  discharged  into  the 
pi  larynx. 

Tumors  of  the  Pharynx. — These  are  of  rare  occurrence.  Papillomata 
of  small  size  are  occasionally  seen.  Fatty  and  fibrous  tumors  have  also  been 
met  with.  Fatty  tumors  have  been  seen  of  large  size,  and  are  pedunculated, 
some  being  reported  as  hanging  over  the  oesophagus.  Fibrous  tumors  originate 
more  often  in  the  vault  of  the  pharynx,  and  perhaps  should  be  described  as 
naso-pharyngeal  tumors.  When  of  large  size  they  may  hang  down  into  the 
pharynx.  Pulsating  tumors  of  the  pharynx  may  be  due  to  aneurysm  of  the 
internal  carotid. 

Carcinoma  of  the  pharynx  is  of  rare  occurrence. 

Retro-pharyngeal  Tumors  occur  in  connection  Avith  the  lateral  (jr  the 
posterior  wall  of  the  pliarynx.  If  left  to  themselves,  these  tumors  will  ulcerate 
and  necrose,  and  probably  the  patient  will  ultimately  die  of  exhaustion  from 
repeated  hemorrhages.  They  may  in  some  cases  be  removed  by  incision 
through  the  mouth,  but  of  radical  operations  that  by  external  incision,  with 
or  without  division  of  the  loAver  jaw.  as  described  above  in  the  paragraph  on 
Tumors  of  the  Tonsils,  is  the  best. 

Congenital  Deformities  of  the  Palate  may  involve  the  uvula  and  the 
soft  and  hard  palate.  The  mildest  form  is  where  the  uvula  is  bifid.  Again,  the 
cleft  may  extend  through  the  soft  palate ;  or  the  soft  palate  and  a  portion  of 
the  hard  palate  may  be  fissured :  or  the  separation  may  involve  the  Avhole  of 
the  soft  and  hard  palate  and  extend  forward  between  the  intermaxillary  bones 
and  the  superior  maxilla.  When  this  occurs  the  deformity  is  always  accom- 
panied by  single  or  double  hare-lip.  In  rare  cases  a  circular  or  oblong  open- 
ing is  seen  in  the  center  of  the  palate,  the  rest  being  closed.  In  the  descrip- 
tion of  the  development  of  the  face  and  mouth  it  was  shown  that  these  deform- 
ities are  produced  by  an  arrest  of  development  of  the  parts  and  persistence  of 
an  early  foetal  condition. 

Cleft  Palate. — AVhen  the  severe  forms  of  this  malformation  occur  they 
give  rise  to  great  trouble :  fluids  pass  freely  into  the  nose,  and  unless  the  child 
is  carefully  fed  by  hand  (preferably  with  the  mother's  milk)  it  will  soon  die,  as  it 
is  quite  unable  to  suck.  In  the  less  severe  forms  the  child  soon  learns  to  swal- 
low prof)erly,  but  as  he  learns  to  speak  his  articulati(»n  is  faulty  and  his  voice 
very  nasal.  For  this  reason  early  operation  is  advisable,  not  so  early  as  for 
hare-lip,  but  certainly  before  the  child  has  learned  to  speak  well,  say  between 
the  ages  of  three  and  four,  when  faulty  articulation  may  be  overcome  by  suc- 
cessful closure  of  the  cleft.  When  undertaken  late,  even  if  the  operation  be 
successful,  the  patient  will  not  be  able  to  overcome  the  bad  habits  of  articula- 
tion acquired  in  his  childhood. 

Operation. — The  operation  is  performed  under  an  anesthetic,  with  the 
mouth  held  open  by  a  gag.      The  patient  should  be  placed  in  the  Trendelen- 


SUliaEIlV    OF    TllK    DliSKSTIVE    TRACT. 


693 


buro;  posture  to  fiieilitate  the  escape  of  blood.    The  best  age  for  the  operation 
is   from    two   to    five   years; 

biter,  as  a  rule,  in  closure  of  Fig.  282. 

the  hard  palate  than  in  clos- 
ure of  the  soft. 

Staphylorrhaphy,  or 
the  operation  lor  the  closure 
of  a  cleft  in  the  soft  palate, 
has  been  practised  for  nuiny 
years.  To  J.  Mason  Warren 
belongs  the  credit  of  improv- 
ing the  operation  by  intro- 
ducing a  procedure  Avhich 
lessened  the  tension  on  the 
flaps  and  so  promoted  union. 
This  was  the  division  of  the 
levator  and  tensor  palati  mus- 
cles of  each  side.  Billroth 
has  recently  introduced  a  new 

procedure,  which  is  to  chisel  away  the  lower  part  of  the  pterygoid  process,  so 
as  to  relieve  the  tension  produced  by  the  tensor  palati  and  palato-pharyngeus. 

Operation. — The  patient  having  been  anesthetized  and  a  gag  introduced, 
the  end  of  one  half  of  the  cleft  palate  is  seized  with  a  pair  of  tenaculum  for- 
ceps and  the  edge  freely  pared  with  a  thin-bladed  knife  (Fig.  283).  The 
same  is  done  on  the  other  side,  especial  care.being  taken  to  freshen  the  upper 
angle  of  the  cleft.  The  parts  are  now  ready  for  the  stitches.  These  should  be 
of  wire,  horse-hair,  or  silkworm  gut,  preferably  the  last.  All  these  materials 
may  remain  some  days  Avithout  causing  trouble,  as  may  also  catgut  and  silk. 
Various  methods  have  been  devised  for  passing  sutures,  such  as  a  needle  with  the 


Whitehead's  Gag  (Koenig). 


Fig.  283. 


Fm.  284. 


The  edges  of  the  cleft  are  being  pared  with  a 
finibe-pointed  t)istoury  after  passing  the  su 
tures.  It  is  t)etter  to  pare  the  edges  before 
paring  the  sutures  (Bernard  and  Huette) 


Method  of  Rink:  The  sutures  dd  and  cc  in  place,  the 
third,  b.  being  inserted  from  behind  forward  by  a 
curved  needle  and  needle-holder,  a:  the  lips  are  held 
tense  with  the  forceps  (Bernard  and  Huettej. 


eye  at  the  point  (Fig.  284),  or  a  tubular  needle.  Special  needles  for  right  and 
left  side,  in  handles,  are  often  useful.  Should  none  of  these  appliances  be  at 
hand,  an  ordinary  sharp-pointed  aneurysm  needle  or  a  half-circle  Hagedorn  needle 
and  a  needle-holder  will  be  sufficient.     On  one  side  the  suture  should  be  double 


«{>4 


J.V    AMKliU'AN    TEXT-iiOOK    OF   SURGERY 


and  the  other  sinjL'lc  :  throujili  the  h»(»j)  of  the  (hdihh-  suture  tlie  single  one  is 
iiassetl,  the  h)Oj»  of  the  douliK'  li^jjature  withdraw  ii,  and  tiie  stit(di  is  ///  aitu. 
Tiiis  procedure  is  necessary  only  when  tlie  needle  cannot  he  pushed  throu;.di 
both  sides  at  once.  After  tlie  stitches  have  been  tied  (not  too  ti«:litly)  and 
the  wound  closed  (Fig.  285),  the  palatal  muscles  may  he  divided  by  pushing 
a  tenotomy  knife  through  the  soft  palate,  immediately  internal  to  the  hamular 
process,  and  cutting  u))ward  until  the  muscles  are  cut  through  (Fig.  280), 
Clutton  advises  that  the  pillars  of  the  fauces  should  be  divided  on  both 
sides,  as  low  down  as  possible  after  the  cleft  has  been  closed.  The  chisel- 
ling away  of  the  lower  end  of  the  hamular  process  may  serve  a  similar  |)ur- 


FiG.  285. 


Y\(\.  286. 


Tightening  of  the  Ligatures  by  a  Serre-Noeud, 
a  (Bernard  and  Huette). 


The  sutures  being  fastencil.  the  lateral  incisions  o  b  are 
made  to  relieve  teiisidii  Ijv  division  ol' the  tensor  pahiti 
muscles  (Bernard  and  lluette). 


pose.  Should  there  be  very  little  tension  this  procedure  may  be  omitted.  The 
hemorrhage,  which  at  first  is  quite  brisk,  soon  ceases  when  pressure  is  well  ap- 
plied. The  wound  should  be  thoroughly  irrigated  Avith  boric  or  salicylic  acid 
solution,  and  then  painted  over  with  an  iodoform  paint,  as  described  in  opera- 
tions about  the  tongue  and  mouth.  The  patient  should  be  fed  on  licjuid  food 
for  three  or  four  days,  and  afterward  on  soft  food  until  the  sutures  are  removed; 
the  less  the  mouth  is  opened  the  better.  The  stitches  should  be  removed 
about  the  sixth  or  eighth  day,  and  the  wound  by  that  time  should  be  com- 
pletely healed ;  frequently,  however,  a  small  point  remains  unhealed,  and  has 
afterward  to  be  closed  by  touching  it  with  the  thermo-cautery  or  a  stick  of  sil- 
ver nitrate.  Care  should  be  taken  to  see  that  the  child  before  operation  is  in 
good  health  and  has  not  been  exposed  to  any  infectious  disease. 

Uranoplasty. — The  ojieration  for  closure  of  cleft  of  the  hard  ])alate  is 
one  of  difficulty,  and  in  cases  where  the  cleft  is  very  wide  it  is  (|uestionable 
whether  it  is  not  better  for  the  surgeon  to  transfer  the  case  to  a  dentist,  so  that 
the  aperture  may  be  closed  by  some  form  of  obturator. 

Operation. — The  most  satisfactory  mode  of  operating  will  l)e  found  to  be  as 
follows  :  The  edges  of  the  cleft  are  first  pared  with  a  narrow-bladed  knife  ;  then 
all  the  soft  tissues  are  raised  from  the  hard  palate  by  means  of  a  })eriosteal  ele- 
vator, avoiding  the  tearing  of  the  vessels  which  run  thiough  the  anterior  and 
posterior  palatine  canals.  The  soft  palate  posteriorly  should  be  freely  separated 
from  the  horizontal  plate  of  the  palate-bone  by  a  cutting  instrument,  as  tearing 
freijuently  causes  sloughing  of  the  parts.  The  sutures  should  now  be  introduced 
in  the  same  way  as  in  staphylorrhaphy,  and  be  of  silver  wire,  horse-hair,  or  silk- 
worm gut.  They  should  not  be  tied  until  the  incisions  have  been  made  on  each 
side  midway  between  the  alveolar  border  and  the  sutures.    These  incisions  should 


SURGKRV    or    Till':    DKiKSTIVi:    TRACT.  695 

be  contiimod  back  into  the  veluiii.  If  tlicre  bo  nnicli  tension,  tbe  muscles  of 
the  ));ilate  slioubl  lie  divided  as  described  in  Sta|)h_vlorrhuphy,  or  tbe  end  of  tbe 
internal  pterygoid  plate  should  be  chiselled  through,  as  recommended  by  Bill- 
roth. (See  ante.)  Chiselling  through  the  hard  palate  on  each  side  of  the 
cleft  has  been  recommended  to  relieve  tension,  but  this  procedure  is  rarely 
necessary.  Tt  has  been  held,  iiowever,  that  if  the  uiuco-])eriosteuui  be  fully 
sejtarated  from  the  posterior  edge  of  the  palate-bone,  the  muscles  will  be 
paralyzed  and  no  further  cutting  will  be  necessary.  Some  surgeons  advise 
that  these  lateral  incisions  should  be  made  first ;  but  in  some  eases  they  are 
not  reipiired.  and  this  Ave  cannot  tell  until  the  edges  are  pared  and  sutures 
iiitr()duce(l.  Tu  this  way,  also,  hemorrhage  is  postponed  until  all  the  imjior- 
tant  steps  of  the  operation  have  been  completed.  It  is  a  good  plan  to  tie  the 
sutures  in  the  soft  ])alate  first.  The  first  suture  should  be  placed  at  the 
junction  of  the  hard  and  the  soft  palate. 

Free  hemorrhage  sometimes  occurs  during  the  operation,  but  this  usually 
can  be  controlled  by  pressure  made  posterior  to  the  incisor  teeth.  In  some 
cases  of  severe  hemorrhage  from  the  palatine  arteries  the  palatine  foramina 
have  been  stopped  with  wooden  plugs  (Marsh).  Secondary  hemorrhage 
occasionally  occurs.  In  this  operation  anesthetics  are  always  used.  The 
after-treatment  is  the  same  as  after  closure  of  the  soft  palate.  Wyeth  has 
fractured  and  advanced  the  maxillary  process  in  very  young  infants  with 
harelip  and  cleft  palate,  where  the  cleft  was  a  Avide  one.  This  procedure  very 
much  simplifies  the  subsecjuent  closure  of  the  hard  palate  by  lessening  the 
width  of  the  defect. 

Ulceration  of  the  palate  is  usually  tbe  result  of  syphilis  or  of  struma. 
SypliiUtic  ulceration  may  occur  in  the  form  of  mucous  patches  with  superficial 
ulceration,  or  of  deep  ragged  ulcers  with  sloughy  bases.  They  generally  heal 
under  specific  treatment,  but  not  seldom  perforate  the  roof  of  the  mouth.  Local 
treatment  by  astringents  and  nitrate  of  silver  is  sometimes  beneficial.  Strumous 
ulceration  is  seen  only  in  the  young  and  feeble,  and  should  be  treated  by  tonics 
and  stimulants,  and  locally  Avith  antiseptic  washes  of  boric  acid,  iodine,  salicylic 
acid,  etc. 

Abscess  of  the  Palate  is  a  rare  occurrence.  When  seen  anteriorly  it 
is  usually  connected  Avith  some  disease  of  the  teeth.  Abscesses  of  the  lateral 
part  of  the  soft  palate  may  foIloAV  tonsillitis.  The  proper  treatment  is  early 
and  free  incision. 

Necrosis  of  the  Palate. — The  bone  exfoliates  very  slowly,  and  occasion- 
ally leaves  a  perforation  in  the  hard  palate.  It  is  nearly  ahvays  the  result  of 
syphilitic  disease,  although  it  may  be  the  result  of  operative,  gunshot,  and 
other  Avounds.  Plastic  operations  for  fissures  folloAving  necrosis  are  of  little 
benefit,  and  the  aperture  should  be  closed  by  an  accurately-fitting  obturator. 

Tumors  of  the  Palate  may  be  cystic  or  solid.  Warty  groAvths  are  occa- 
sionally seen  arising  from  the  mucous  membrane  ;  also  fibro-sarcomata  and  cysts 
containing  glairy  fluid.  Sebaceous  cysts  are  sometimes  found  in  the  substance 
of  the  soft  palate.  They  are  recognized  by  their  yelloAvish-Avhite  color.  Car- 
cinomatous tumors  of  the  palate  are  ahvays  of  the  epitheliomatous  type,  and 
are  rarely  primary,  usually  spreading  from  the  tonsil  or  the  tongue.  Removal 
of  all  these  groAvths  is  the  proper  treatment. 

PART  II.— DISEASES   AND  INJURIES  OF  THE   OESOPHAGUS. 

Malformations. — These  consist  of  fistulie,  diverticula,  and  cystic  growths, 
such  as  have  been  described  in  the  section  on  the  Malformations  of  the  Pharynx, 


696  ^l^V   AMt:i:irAN    TKXT-JiOOK    OF  SURGERY. 

and  are  due  to  incomplete  closure  of  the  hrandiial  clefts.  In  some  cases  there 
mav  be  a  con«:ciiital  thickeninf;  of  the  <e.soj)ha<rus  in  the  situation  of  a  hraiu-hial 
cleft.  This  may  cause  some  narrowin;^.  The  tube  may  be  closed  by  a  mem- 
brane, or  the  whole  tube  may  be  dilated;  large  diverticula  may  jiroceed  from 
it,  or  it  may  be  double  or  absent.  Its  absence  is  incompatible  witii  life  unless 
gastrostomy  be  performed. 

Dilatation  and  Sacculation. — Dilatation  may  involve  a  large  part  of  the 
tubf  or  may  be  localized.  When  localized  it  is  called  a  sacculation  or  diver- 
ticulum. It  is  sometimes  of  immense  size,  but  usually  is  small.  Some  form 
of  narrowing  of  the  (lesophagus  precedes  dilatation,  ami  it  is  this  that  must  be 
treated.  The  dilatation  (when  not  congenital)  is  usually  caused  by  the  arrest 
of  food  at  the  point  of  stricture,  the  continuous  endeavors  to  force  it  onward 
producing  a  dilatation  or  pouching  by  putting  the  parts  on  the  stretch.  At 
the  junction  of  the  pharynx  with  the  oesophagus  a  "'  pressure  pouch  "  may  form 
on  the  i)o<terior  aspect  of  the  tube.  This  pouch  or  diverticulum  has  been 
successfully  removed  through  an  incision  in  the  neck  by  Butlin.  Bergmann, 
Kocher,  and  others.  The  operation  appears  to  be  neither  very  difficult  nor 
dangerous.  After  removal  of  the  pouch  the  opening  in  the  oesophagus  is 
closed  with  sutures. 

Stricture. — This  is  the  most  common  form  of  disease  affecting  the  oesoph- 
agus, and  is  due  to  various  causes.  Strictures  of  the  rjesophagus  may  be  divided 
into — 

Organic — Cicatricial  or  simple  ;  cancerous  or  malignant. 

Non-organic — Spasmodic  or  hysterical. 

Strictures  may  also  be  produced  by  the  pressure  of  tumors,  such  as  enlarged 
thyroids,  aneurysms,  etc. 

Cicatricial  Stricture. — This  may  be  produced  by  any  injury  to  the  tube, 
such  as  ;i  wouml.  by  the  swallowing  of  corrosive  fluids,  or  by  syphilitic  ulcer- 
ation. The  most  common  cause  is  the  swallowing  of  corrosive  li(juids,  such  as 
lye,  acids,  etc.,  in  early  childhood.  The  stricture  comes  on  slowly,  and  there 
is  nearly  always  a  history  of  injury.  If  the  stricture  occurs  in  a  young  person, 
it  is  probable  that  it  is  due  to  cicatricial  contraction.  The  usual  site  is  at  the 
beginning  of  the  oesophagus  opposite  the  cricoid  cartilage. 

Cancerous  or  Malignant  Stricture. — Cancerous  disease  is  a  very  com- 
mon cau.-e  of  stricture.  It  may  l>e  engrafted  on  a  simple  stricture.  It  occurs 
more  often  in  men  than  in  women,  and  usually  at  an  age  over  forty-five.  The 
variety  of  carcinoma  is  nearly  always  epithelioma,  and  it  most  frequently  attacks 
the  lower  third  of  the  tube.  The  symptoms  are  very  plain,  viz.  gradually 
increasing  difficulty  in  swallowing,  especially  solid  food,  in  individuals  over 
forty  :  regurgitation  of  food,  with  .sometimes  a  slight  discharge  of  blood  and 
pus.  and  gradually  increasing  emaciation. 

Spasmodic  Stricture. — This  form  is  associated  with  a  hysterical  condi- 
tion, and  is  usually  seen  in  the  young,  but  it  may  occur  at  any  age.  It  is 
more  common  in  women  than  in  men.  The  previous  history  of  the  patient 
will  help  to  diagnosticate  this  affection.  At  times  swallowing  is  quite  ea.sy, 
an<l  suddenly  the  patient  professes  to  be  unable  to  swallow  anything,  the 
attempt  producing  a  severe  spasm.  The  patient  often  com])lains  of  a  con- 
striction or  the  feeling  of  a  lump  in  the  throat  (i/Iohiia  hyHf*'rii-us).  The 
affection  then  appears  suddenly  and  disappears  as  suddenly.  The  single  pas- 
sage of  an  cesophageal  bougie  often  suffices  to  cure  the  stricture.  When  the 
bougie  is  first  used  considerable  opposition  is  offered  to  its  passage,  but  on  con- 
tinuing the  pressure  this  soon  gives  way  and  the  bougie  slips  easily  down  the 
tube.     The  condition  of  the  linsual  tonsil  should  always  be  examined 


SUROJ'JRy   OF    TJIK   DIHEHTIVE    TRACT.  G97 

n-         .-.    f   ^trirfuri'  — 'n.o  fact  tl.at  a  person  has  difficulty  in  s^vallo^ving 

1       ;?Z    -u  a  i    en  Ic  atin! '   u.Ut  to  be  sufficient  to  n.ake  one  suspect  stne- 

:;r^^  td  t;;::  ;lined  so,ne  hours  and  t|-;l.-e,u^at.  ,  espe- 

.i.^11v  if  the  ocsonhacrus  ahove  the  stricture  l)e  inucli  dda  ed      lain  is  not  a 

stricunc  being  easiyveco^.a^c.^^_pa^^t;cv^^^^^^^^^^^^^ 

i„g  hen,onhage;  ^ut  -ually  the  ,^,cnt  d,cs  of    .  an    o^^^  ^^^^  ^^^^^^  ^^^^ 
Jitnr^pltrofrte:;  )7^T.UU^^y^  Las  a  n,ost  disagreeable  s.eU, 

The  patient  usually  gags,  and  may  vomit,     io  obtain  a 

the  patient  should  be  anesthetized.  ^^^,^   ^      .^^^^ 

Beems  to  have  some  great  advantages.      A  flexible  gum-elastic 


fIflH  J.V   AMERICAN    TEXT-llOOK    ()F  srilCERY. 

four  to  six  inches  long  is  introduced  into  tlie  strictuic  and  jiorniancntlv 
retained  there.  Tlie  upper  end  of  the  tulje  is  e.\f)anded  into  a  funnel  vhich 
rests  on  the  stricture.  The  lower  end  is  closed  somewhat  like  a  catheter, 
having  an  eye  of  large  size  a  quarter  of  an  inch  from  the  end,  through 
which  Ii(|uid  food  passes.  For  the  purpose  of  withdrawing  the  tube,  a  piece  of 
plaited  silk  thread  is  passed  about  three-eighths  of  an  inch  below  the  rim  of  the 
funnel  in  a  single  thread,  and  the  portion  inside  the  tube  drawn  out  and  tied  to 
the  side  pieces  about  two  inches  above  the  funnel.  After  ascertaining  the  exact 
size  of  tlie  stricture,  the  tube  is  placed  in  position  by  an  instrument  called  an 
introdunr,  made  of  whalebone  covered  with  gum-elastic.  Symrtnds  has  left  the 
tube  in  without  removal  for  two  months.  In  the  17  cases  of  stricture  treated  by 
this  method,  9  died  from  the  progress  of  the  disease,  but  the  stricture  remained 
patent  and  the  patient  was  able  to  swallow  to  the  last.  In  some  cases  where 
there  is  cough  on  deglutition,  Symonds  recommends  that  the  short  tube  be 
rey)laced  by  the  long  tube  of  Krishaber  of  Paris,  which  proceeding  renders  the 
operation  of  gastrostomy  unnecessary  ;  or,  better  still,  a  piece  of  red-rubber 
tubing  cut  oblicjuely  at  the  end  and  sewed,  an  eye  then  being  made  as  in  a 
catheter,  should,  with  the  aid  of  the  introducer,  be  passed  through  the  stricture 
and  left  in  situ. 

Sir  Morell  Mackenzie,  in  his  work  on  Diseases  of  the  Xose  and  Tliroat^ 
figures  a  long  permanent  oesophageal  tube  which  he  has  used  with  success  in 
cases  of  absolute  aphagia.  The  tube  is  left  in  five  or  six  days  at  a  time. 
Senator  of  Berlin  dilates  the  stricture  with  a  laminaria  tent  attached  to  a 
string  and  left  in  for  from  half  an  hour  to  an  hour.  The  most  suitable 
strictures  for  this  treatment  are  the  non-malignant. 

Wounds  of  the  oesophagus  are  of  rare  occurrence.  In  cases  of  cut- 
throat the  oesophagus  may  be  wounded  or  severed,  and  it  may  be  wounded 
by  stabs  of  a  knife  or  a  bayonet  or  by  a  bullet.  AVhen  this  occurs  in  the 
thorax,  the  injuries  to  the  neighboring  organs  are  so  great  that  this  injury  is 
ordinarily  overlooked.  It  is  extraordinary  how  few  cases  of  wound  of  the 
(Esophagus  are  on  record.  But  one  case  is  noted  in  the  Medical  and  Surgical 
History  of  the  Civil  War.  and  that  was  found  post-mortem.  Foreign  bodies 
may  wound  the  oesophagus  from  within.  The  passage  of  a  bougie  may  wound 
this  tube,  and  even  perforate  it,  causing  hemorrhage,  pain,  and  emphysema. 
\^  hen  the  oesophagus  is  wounded  in  the  neck  the  patient  may  recover.  The 
wound  should,  if  possible,  be  sutured,  and  the  patient  fed  by  the  rectum  for 
several  days.      A  fistula  may  remain  after  the  healing  of  the  wound. 

Foreign  Bodies. — The  impaction  of  foreign  bodies  in  the  oesophagus  is 
of  comparatively  common  occurrence.  Food  niay  be  arrested  here.  viz.  por- 
tions of  bones,  fish-bones,  meat ;  also  artificial  teeth,  coins,  pins;  in  fact,  nearly 
every  imaginable  substance  has  been  found  in  the  oesophagus.  The  foreign 
body  when  large  is  usually  arrested  at  the  narrowest  part,  viz.  the  commence- 
ment of  the  oesophagus  opposite  the  upper  border  of  the  cricoid  cartilage  ;  but 
there  are  two  other  points  at  which  the  body  may  be  arrested,  viz.  where 
the  nesoj)hagus  is  crossed  by  the  left  bronchus  and  where  it  passes  through  the 
diaphragm.  Small  and  sharp  bodies  may  lodge  at  any  part  of  the  tube. 
Should  the  foreign  body  be  arrested  high  up,  there  will  be  dysphagia  and  pain. 
Some  cases  have  died  suddenly  of  a.sphyxia,  so  great  is  the  spasm.  After  a 
time  the  patient  may  get  used  to  the  foreign  body  and  the  symptoms  almost 
disappear.  Should  the  substance  swallowed  be  sharp,  there  will  be  more  pain 
and  sometimes  hemorrhage.  In  these  cases  the  diagnosis  of  the  exact  position  is 
diflRcult,  the  sensations  of  the  patient  being  a  very  poor  guide.  Even  after  the 
foreign  body  has  been  removed  or  has  passed  down,  the  sensation  of  one  being 


SURdKUy    OF    THE   DIUESTIVK    TUAi'T. 


699 


lod.'cd  in  the  frullet  remains,  and  it  is  sometimes  hard  to  convince  tlie  patient 
that  it  is  not  there.  Larjre  bodies,  especially  when  they  l)lock  iij)  the  i)assafre 
and  prevent  swallowincr,  if  not  removed  within  a  reasonal)le  time,  are  incom- 
patihle  with  life.  If  untreated,  the  foreifin  body  may  ulcerate  into  nei^4i- 
borin<r  structures,  such  as  the  trachea,  pleura,  and  pericardium.  Not  a  lew 
cases '•ire  on  record  where  a  foreign  body  has  ulcerated  into  the  aorta  and  has 
caused  death   bv  heiiiorrliajre.  ,       i     i  •  i    * 

The  ih'<u(uosis  of  these  cases  is  aided,  of  course,  greatly  l)y  tiie  liistoiy,  but 
this  cannot  be  obtained  from  children,  lunatics,  or  determined  suicides.  Exter- 
nal palpation,  or  the  presence  of  a  bulging  in  the  neck,  may  serve  to  detect  a 
hir.re  body,  but  a  probang  catheter  or  an  esophageal  bougie  will  otten  satis- 
factorily solve  the  problem.  Small  objects  have  been  detected  with  the  aid  of 
the  oesophacroscope.  Maiiv  foreign  bodies  can  now  be  accurately  located  by 
means  of  th?  skiagraph  or  tluoroscope.  Interesting  cases  have  been  recorded 
which  afford  the  most  convincing  proof  of  the  value  of  this  new  au  to  diag- 
nosis in  these  cases.  If  any  uncertainty  exist,  no  examination  should  be 
considered  complete  which  does  not  include  a  good  skiagraph  of  that  portion 
of  the  chest  through  which  the  oesophagus  passes. 

TreatnH'tit  —^houU  the  object  be  round  and  smooth,  it  may  be  pushed 
down  with  a  probang,  and  if  high  up  may  be  grasped  with  a  pair  of  oesopha- 
geal forceps  (Fig.  287)  and  extracted.     Pins,  pieces  of  bone,  etc.  may  be 


Fig.  287. 


Forceps  in  position  to  remove  a  foreign  body  from  the  gullet  (Fergusson). 


fished  out  with  a  horse-hair  probang  or  Griife's  coin-catcher.     Vomiting  will 
sometimes  displace  a  foreign  body.     ^      .       ,     ^  ^  ,  .       .,  ^..^^^.f 

In  a  certain  number  of  cases  the  foreign  body  cannot  be  extracted  except 
bv  cutting  down  on  it.  If  the  body  has  passed  below  the  level  of  the  supra- 
sternal notch,  it  cannot  be  removed  safely  by  external  incision,  and  the  .(ues- 
tion  of  effecting  its  removal  after  performing  gastrotomy  must  be  considered 

Csee  p   700). 

Operations  on  the  (Esophagus.— External  CEsophagotorny  is  per- 
formed for  the  removal  of  foreign  bodies  and  for  cases  of  stricture  high  up  in 
the  gullet.     The  incision  is  made  on  the  left  side  of  the  neck,  on  account  ot 


700  AN  AMi:ni<'AX  text-book  of  surgery. 

tlic  inclination  of  the  (L'sopliajjus  to  that  side.  'I'he  incision  is  between  the 
larvnx  and  trachea  on  the  insi(h'  and  tlie  sheath  of  tlie  vessels  externally. 
For  ri'nioval  of  foreign  bodies  the  center  of  the  incision  should  be  o))pi)site 
the  cricoid  cartilage:  by  i)ullin<f  the  trachea  and  thyroid  gland  to  the  inside 
and  the  vessels  to  the  outside,  and  )»ulling  aside  or  dividing  the  omohyoid 
muscle,  the  oesophagus  can  easily  be  reached  and  incised  longitudinally.  If 
the  operation  be  i)erformed  for  the  removal  of  a  foreign  body,  this  is  extracted, 
and  the  wound  in  the  (Cso|»hagus  closed  witli  catgut  sutures,  and  the  rest  of 
the  wound  partly  closed  and  |)acked  with  ioiloform  gauze.  1'he  j)atient  for 
the  first  three  or  four  days  after  oj)eration  should  be  fed  by  eneinata,  or 
through  a  small  gum-elastic  catheter  or  rubber  tube  passed  beyond  the  wound 
before  closing  it.  In  cases  where  this  operation  is  performed  for  relief  of 
stricture  a  pi-rmanent  fistula  is  desired,  and  so  a  rid)her  tube  is  left  in  the 
wound.      This  operation   is  called  (mop/iar/ostoini/. 

Internal  CEsophagotomy. — Instruments  which  are  enlarged  copies  of 
those  used  in  the  urethra,  have  been  devised  for  cutting  oesophageal  strictures. 
This  operation  is  dangerous ;  one-third  of  the  cases  have  succumbed.  It  is 
suitable  only  for  certain  cases  of  annular  stricture. 

Strictures  have  been  incised  through  the  opening  made  in  tlie  oesophagus, 
and  foreign  l)odies  seized  as  low  down  as  the  upper  part  of  the  stenmni  by  the 
oesophageal  forcej)s. 

Gastrotomy  and  Digital  Exploration  of  the  CEsophagus. — M.  II. 
Richardson  has  devised  an  operation  for  the  removal  of  foreign  l)odies  impacted 
low  down  in  the  oesophagus.  He  performs  gastrotomy,  introduces  his  hand 
into  the  stomach,  and  with  his  fingers  explores  the  lower  part  of  the  oesophagus. 
In  this  way  he  removed  a  plate  containing  four  teeth  which  had  been  lodged  in 
the  oesophagus  near  the  cardiac  end  for  eleven  months.  The  man  made  a  per- 
fect recovery.  W.  T.  Bull  removed  by  gastrotomy  a  peach-stone  from  a  child's 
oesophagus,  which  was  arrested  some  six  or  seven  inches  from  the  cardiac  end 
and  had  failed  to  be  dislodged  by  other  means.  In  this  case,  a  small  incision 
having  been  made  into  the  stomach,  the  finger  was  introduced,  which  guided  a 
bougie  through  the  cardiac  orifice,  whence  it  was  pushed  u])ward  until  it  pro- 
jected from  the  mouth.  Attached  to  the  bougie  was  a  double  silk  thread  to 
which  Avas  tied  a  s])onge.  This  Avas  drawn  uj)  through  the  oesophagus,  and 
brought  with  it  the  peach-stone.  The  patient  made  a  rapid  recovery.  In  cases 
where  foreign  bodies  are  situated  at  a  distance  of  thirteen  inches  and  over  from 
the  teeth,  from  numerous  experiments  on  the  cadaver  Richardson  recommends 
searchins  for  them  from  below  throuj^h  the  stomach. 

CEsophagectomy. — Excision  of  a  portion  of  the  (X'sophagus  for  malig- 
nant growths  has  been  performed  several  times.  Czerny  of  Heidelberg  is  the 
only  surgeon  who  has  operated  with  any  degree  of  success.  Five  months  after 
operation  his  patient  was  living,  without  return  of  the  disease,  but  within  a 
year  she  died  of  recurrence  of  the  growth.  The  operation  is  performed  in 
the  same  way  as  oesophagotomy,  but  with  a  larger  incision.  A  portion  of  the 
oesophagus  is  resected,  and  the  lower  end  fixed  to  the  external  wound. 

'i'he  iiKop/iai/dscopc  is  now  not  infreiiuently  used  for  diagnosticating  diseased 
conditions  of  the  oesophagus  and  the  detection  of  foreign  bodies.  It  is  an 
instrument  which  is  illuminated  by  reflected  light  or  electric  light,  and  requires 
considerable  skill  to  handle.  As  yet  but  little  progress  has  been  made  in  the 
diagnosis  by  this  means  of  affections  of  the  oesophagus. 


DISEA^SE.S   AND    INJURIES    OF    THE   ABDOMEN.  701 

CHAPTER   VI. 

DISEASES  AND  INJUKIES  OF  TPIE  ABDOMEN. 
PART  I.— WOUNDS  OF  THE  ABDOMEN. 

The  division  of  wounds  of  the  abdominal  wall  into  penetrating  and 
non-penetrating  is  now  universally  adopted.  Irrespective  of  the  nature  of 
the  implement  wliicli  infiicts  the  wound,  this  division  is  important  in  reference 
both  to  prognosis  and  to  treatment.  A  large  wound  which  does  not  implicate 
the  peritoneal  cavity  is  not  nearly  so  dangerous  an  injury  as  a  small  perfora- 
tion made  by  a  bullet  or  a  small  knife-blade  and  complicated  by  a  visceral 
injury.  The  differential  diagnosis  between  non-penetrating  and  penetrating 
wounds  of  the  abdomen  must  be  made  in  every  case  in  which  the  surgeon  is 
called  upon  to  treat  a  wound  in  this  locality,  as  an  approximately  reliable 
prognosis  and  a  rational  course  of  treatment  must  necessarily  rest  on  a  correct 
diagnosis. 

Non-penetrating  Wounds. — In  large  incised  or  lacerated  wounds  of  the 
abdominal  wall  it  is  not  difficult  to  determine  whether  or  not  the  peritoneum 
has  been  injured,  as  the  deepest  portion  of  the  wound  can  be  made  accessible 
to  visual  inspection  and  digital  exploration.  A  wound  of  the  abdominal  wall 
should  never  be  explored  for  diagnostic  purposes  without  proper  antiseptic  pre- 
cautions, as  the  neglect  of  these  is  often  the  direct  cause  of  the  introduction  of 
septic  material  into  the  abdominal  cavity  in  cases  in  which  the  parietal  perito- 
neum has  been  punctured,  torn,  or  incised.  The  wound  and  its  vicinity  must 
be  rendered  aseptic  in  the  usual  manner,  and  digital  or  instrumental  explora- 
tion must  be  done  under  the  strictest  antiseptic  precautions.  If  after  a  care- 
ful examination  it  is  found  that  the  injury  is  limited  to  the  tissues  outside  of 
the  peritoneum,  the  wound  is  to  be  treated  upon  general  principles,  but  with 
due  regard  to  restoring  the  resisting  capacity  of  the  abdominal  wall  by  accu- 
rate suturing  of  the  incised  or  lacerated  tissues. 

A  large  and  deep  wound  of  the  abdominal  wall,  unless  treated  with  especial 
care,  is  very  liable  to  become  subsequently  the  seat  of  a  ventral  hernia. 
In  order  to  prevent  this  later  and  often  distressing  condition,  it  is  necessary 
to  obtain  healing  of  the  wound  by  primary  union  and  to  unite  the  different 
layers  by  deep  or  buried  sutures.  After  careful  arrest  of  hemorrhage,  and 
cleansing  and  disinfection  of  the  wound,  the  divided  muscular  layers  must  be 
brought  accurately  together  with  a  sufficient  number  of  catgut  sutures,  but  before 
these  are  tied  the  superficial  silk  sutures  are  put  in  place  in  such  a  manner  as 
to  embrace  all  the  tissues,  including  the  skin.  After  the  margins  of  the 
wound  have  been  carefully  coaptated  by  the  tying  of  all  the  sutures,  a  few 
superficial  sutures  are  applied  to  bring  the  margins  of  the  skin  in  accurate 
approximation.  Tubular  drains  should  be  avoided  in  such  cases,  as  the  space 
occupied  by  the  drain  may  become  subsequently  the  starting-point  of  a  ven- 
tral hernia.  If  drainage  is  recjuired,  this  can  be  established  by  the  insertion 
at  one  or  more  points  of  an  absorbable  capillary  drain  composed  of  a  small 
bundle  of  catgut  threads,  or  strips  of  iodoform  gauze. 

External  support  is  furnished  by  a  compress  of  hygroscopic  antiseptic 
gauze  and  absorbent  cotton,  retained  in  place  by  strips  of  adhesive  plaster, 
which  must  embrace  at  least  two-thirds  of  the  circumference  of  the  body. 
Next  to  imperfect  suturing  the  most  frequent  cause  of  the  formation  of  a 
ventral  hernia  after  an  accidental  or  intentional  wound  of  the  abdomen  is  the 


702  .I.V   AMi:i:i('AX    TEXr-llOOK    OF  SURGERY. 

too  early  active  use  of  the  tissues  involveil  in  the  injury.  Ileiic-e  the  patient 
shouM  not  he  aHoweil  to  leave  the  hed  until  the  |)roeess  of  repair  is  completed, 
which  will  require  at  least  from  three  to  four  weeks.  If  the  erect  position  is 
assumed  before  tiiis  time,  the  increased  tension  in  the  abdominal  wall  may  make 
such  an  amount  of  traction  upon  the  wound  that  the  new  tissues  will  yield  to 
the  traction  force,  and  o;ive  way  sufficiently  for  the  parietal  peritoneum  to 
bulge  at  the  point  oft'ering  the  least  resistance.  In  the  after-treatment  of  large 
wounds  of  the  alxlominal  parietes  it  is  necessary  to  maintain  external  support 
by  a  well-fitting  bandage  for  several  months,  the  ])atient  being  cautioned  not  to 
eniiaiie  durini:  this  time  in  anv  violent  exercise  which  miirht  brincr  about  a- sub- 
cutaneous  separation  of  the  different  muscular  layers  at  the  line  of  suturing. 

Penetrating  Wounds. — If  in  cases  of  incised  and  lacerated  wounds  of 
the  abdomen  the  peritoneum  is  laid  open  and  the  viscera  protrude,  their  con- 
dition must  be  observed,  and  if  they  are  not  wounded  they  must  be  care- 
fully cleansed  with  warm  sterilized  water,  or  normal  salt  solution,  dried,  and 
returned.  Hlood-clots  and  other  foreign  botlies  when  present  must  be  removed. 
If  the  intestines  have  escaped  through  such  a  wound,  and  have  become 
strangulated  and  cannot  be  readily  reduced,  the  surgeon  should  enlarge  the 
wound  rather  than  resort  to  any  violence  in  perhaps  fruitless  attempts  at 
reduction.  In  the  closure  of  such  wounds  it  is  advisable  to  suture  the  peri- 
toneum separately,  after  which  they  are  dealt  with  in  the  same  manner  as  non- 
penetrating wounds. 

The  penetrating  wounds  of  the  abdomen  most  frequently  met  with  in  prac- 
tice are  punctured,  gunshot,  and  stab  wounds.  These  must  again  be  divided 
into  those  Avhicli  have  opened  the  peritoneal  cavity  without  being  complicated 
by  any  serious  injury  of  the  abdominal  organs,  and  those  in  which  the  great 
danger  consists  in  the  fact  that  the  missile  or  implement  which  produced  the 
wound  has  caused  at  the  same  time  visceral  injuries  of  a  serious  character.  A 
simple  penetrating  stab  or  gunshot  wound  of  the  abdomen  is  a  more  serious 
injury  than  a  much  larger  non-penetrating  wound,  yet  is  frequently  followed  by 
recovery  without  active  surgical  interference  ;  but  penetrating  wounds  compli- 
cated by  visceral  injuries  of  important  organs  with  few  exceptions  |)rove  fatal, 
unless  the  surgeon  is  able  to  prevent  this  termination  by  timely  operative 
interference  and  treatment  of  the  visceral  lesions. 

In  cases  of  gunshot  and  stab  wounds  of  the  abdomen  the  first  duty  of  the 
surgeon  is  to  determine  whether  or  not  the  abdominal  cavity  has  been  entered. 
This  part  of  the  diagnosis  may  be  easy  or  difficult  according  to  circumstances. 
If  the  bullet  has  passed  through  the  body  and  the  wounds  of  entrance  and  exit 
occupy  such  positions  that  a  direct  line  connecting  them  will  necessarilv  pass 
through  the  abdominal  cavity,  there  can  be  but  little  doubt  that  the  bullet  has 
traversed  that  part  of  the  peritoneal  cavity  interposed  between  them,  and  con- 
sequently that  there  has  been  injury  of  the  viscera  occupying  that  locality.  In 
fat  persons  the  exact  outlines  of  the  peritoneal  cavity  cannot  be  located  with 
absolute  accuracy,  and  on  this  account  some  doubt  may  remain,  in  case  two 
bullet  wounds,  made  by  a  single  bullet,  are  found  over  the  anterior  or  lateral 
aspect  of  the  pendulous  abdomen,  whether  the  peritoneal  cavity  falls  in  the 
track  made  by  the  bullet.  The  existence  of  emphysema  in  the  tissues  around 
the  track  of  a  bullet  or  stab  wound  is  not  positive  evidence  that  penetration  has 
taken  place,  as  it  may  be  caused  by  the  entrance  of  air  from  without.  In  stab 
wounds  prolapse  of  the  omentum  into  the  wound  is  of  frecjuent  occurrence,  and 
when  this  condition  is  present  it  is  a  positive  evidence  that  the  knife  li;is  pene- 
trated the  abdominal  cavity.  If  a  large  bullet  has  entered  the  i)erit()neal 
cavity  by  the  shortest  possible  route  through  a  thin  portion  of  the  abdominal 


DISEASES   Ayi>    INJURIES    OF    THE   ABDOMEN.  703 

vail,  tlie  fact  that  i)eiietrati()ii  lias  taken  place  often  becomes  evident  in  the 


same  manner. 


In  the  majoritv  of  cases  of  penetratinn;  wounds  exi)lovation  ot  the  wound  hy 
a  careful  dissection  is  the  only  positive  and  reliable  procedure  in  determining 
that  the  bullet  or  knife-blaile  has  entered  the  peritoneal  cavity.  Digital 
exploration  of  small  wounds  should  never  be  relied  upon  in  ascertaining  the 
deptli  and  course  of  the  Avound,  as  this  measure  is  not  infallible  in  making  a 
correct  diagnosis,  and  in  case  the  bullet  has  penetrated  the  abdominal  cavity 
the  finger  may  push  before  it  and  into  the  peritoneal  cavity  infected  foreign 
substanc'es.  The  use  of  the  probe  should  be  discarded  in  tlie  examination  of 
punctured  and  gunshot  wounds  of  the  abdomen  for  diagnostic  purposes.  The 
wound-canal  is  often  so  tortuous  from  displacement  of  the  tissues  forming  its 
walls  that  it  cannot  be  followed  with  a  probe  without  risk  of  making  false  pas- 
sages  an  occurrence  which  could  not  fiiil  to  lead  to  erroneous  conclusions  in 

reference  to  the  extent  and  course  of  the  wound  and  in  regard  to  the  presence 
of  visceral  complications  which  might  demand  prompt  operative  interference. 
The  only  safe  plan  to  pursue  is  to  enlarge  the  wound  by  an  incision  at  least  two 
inches  in  length,  which  should  intersect  the  external  opening  through  its  center 
and  in  the  direction  of  the  principal  muscle  involved  by  the  injury.  Before 
this  is  done  all  the  preparations  for  a  laparotomy  should  have  been  completed, 
everything  required  in  the  treatment  of  visceral  wounds  should  be  on  hand, 
and  the  consent  of  the  patient  and  his  friends  obtained  to  do  whatever  may 
become  necessary  in  case  it  is  found  that  the  peritoneal  cavity  has  been  invaded 
and  that  visceral  injuries  dem.and  surgical  interference. 

It  is  often  a  difficult  task  to  follow  the  track  of  a  bullet  with  the  scalpel 
through  a  thick  abdominal  wall.     The  best  method  of  procedure  is  to  insert  a 
grooved  director  as  far  as  it  will  pass  without  resistance,  and  then  divide  the 
tissues  layer  after  layer,  catching  bleeding  vessels  with  hemostatic  forceps  as 
fast  as  they  are  cut,  in  order  to  keep  the  field  of  operation  as  nearly  as  possible 
in  a  bloodless  condition.     The  bullet  frequently  discolors  the  tissues,  and  these 
discolorations  are  often  important  landmarks  in  following  the  wound.     When 
the  point  of  the  director  is  reached,  it  becomes  necessary  to  make  a  close  in- 
spection, and  under  no  circumstances  should  the  knife  be  used  until  the  wound- 
canal  can  again  be  identified  and  followed  with  the  eye  or  the  director.      The 
dissection  is  to  be  made  carefully  and  slowly  until  the  opening  in  the  peritoneum 
is  reached,  which  alone  establishes  beyond  a  doubt  the  existence  of  penetration. 
Quite  recently  the  assertion  has  been  made  by  several  prominent  surgeons 
that  laparotomy  should  be  done  in  all  cases  where  it  can  be  shown  that  a  punc- 
tured Avound  extends  into  the  abdominal  cavity,  for  the  purpose  of  treating 
intra-abdominal  lesions.     It  must,  however,  be  admitted  that,  in  the  absence 
of  serious  visceral  lesions,  penetrating  wounds  of  the  abdomen  are  injuries  from 
which  the  patients  are  very  likely  to  recover  without  operative  treatment,  and 
that  when  such  patients  are  subjected  to  laparotomy  death  may  occur  solely  in 
consequence  of  the  operation.     It  is  undoubtedly  true  that  in  most  cases  of 
spontaneous  recovery  after  punctured  wounds  of  the  abdomen  the  favorable 
termination  has  been  due  to  the  absence  of  serious  visceral  lesions,  which  some 
hold  to  be  invariably  present  in  such  cases.     In  two  out  of  six  cases  of  pene- 
trating gunshot  Avounds  of  the  abdomen  which  came  under  the  observation  of 
Senn  the  absence  of  visceral  injuries  of  the  gastro-intestinal  canal  w^as  demon- 
strated by  the  use  of  the  hydrogen-gas  test,  and  both  of  these  patients  recovered 
Avithout  resort  to  laparotomy.     The  same  absence  of  visceral  lesions  has  been 
also  demonstrated  during  an  operation  or  at  the  post-mortem.     During  the 
Grf«co-Turkish  Avar  several  cases  of  gunshot  wounds  of  the  abdomen  recov- 


7(14  J.V   AMKIiH'AX    TEXT- HOOK    OF  SURGERY. 

ert'd  under  a  consorvative  plan  of  treatment.  In  nearly  all  of  these  cases 
the  hiilk't  entere<l  the  ab(h>nien  above  the  level  of  the  umbilicus,  the  most 
favorable  h)cati«»n  for  the  escape  of  the  intestines  from  the  penetrating 
projectile,  the  patient  being  in  a  standing  position.  Clinical  ex|)erience 
and  the  result  of  experiments  show  conclusively  that  laparotomy  should 
not  be  performed  simply  because  a  bullet  or  a  knife-blade  has  entered  the 
al»dominal  cavity,  but  that  its  performance  should  be  limited  to  the  treatment 
of  intra-abdominal  lesions  which,  witliout  operative  interference,  wouhl  tend  to 
destroy  life.  Stab  wounds  are  not  as  often  complicate*!  by  visceral  injuries  as 
are  bullet  wounds.  A  bullet  which  passes  through  the  lower  part  of  the  abdo- 
men from  side  to  side  or  obliquely  is  almost  sure  to  produce  from  four  to  four- 
teen perforations  of  the  intestines,  while  absence  of  dangerous  visceral  wounds 
may  be  inferred  with  some  degree  of  probability  if  it  crosses  the  abdominal 
cavity  in  an  antero-posterior  direction  at  or  a  little  above  the  umltilical 
level. 

Symptoms. — The  general  symptoms  in  cases  of  penetrating  punctured 
wounds  of  the  abdomen,  with  the  exception  of  those  due  to  profuse  hemor- 
rhage, furnish  absolutely  no  reliable  information  in  the  differentiation  between 
simple  penetrating  wounds  and  penetrating  wounds  complicated  by  visceral 
injuries.  Severe  shock  may  attend  even  a  non-penetrating  wound,  and  it  may 
be  absent,  or  at  least  not  well  marked,  in  cases  of  multiple  perforations  of  the 
intestines.  It  is  not  an  uncommon  occurrence  for  a  patient  who  has  received 
a  penetrating  wound  of  the  abdomen  to  walk  several  blocks,  or  even  a  number 
of  miles,  without  a  great  deal  of  suffering  and  without  showing  any  symptoms 
of  shock,  and  vet  for  a  number  of  intestinal  perforations  to  be  revealed  at  a 
subsequent  operation  or  post-mortem.  Vomiting  takes  place  as  frequently  in 
wounds  of  the  abdominal  parietes  and  in  simple  ])enetrating  wounds  as  when 
the  viscera  have  been  injured,  ^'omiting  of  blood  indicates  the  existence  of 
a  wound  of  the  stomach. 

Pallor  is  present  in  all  penetrating  wounds  of  the  abdomen  soon  after  the 
receipt  of  the  injury,  and  it  is  only  more  pronounced  when  produced,  at  lea.st 
in  part,  bv  sudden  and  severe  internal  hemorrhage.  Pain  is  a  very  unreliable 
and  ofren  misleading  svmptom.  as  it  may  be  moderate  or  almost  completely 
absent  soon  after  the  injury  has  been  inflicted,  even  when  multiple  perfora- 
tions are  present.  The  pulse  at  first  is  slow  and  compressible  in  all  cases, 
and  nothing  characteristic  in  its  qualities  is  observed  even  if  the  stomach  or 
intestines  have  been  injured.  Hemorrhage  caused  by  wounds  of  any  of  the 
large  organs,  as  the  spleen,  liver,  or  kidneys,  gives  rise  to  progressive  acute 
anemia,  small,  rapid  pulse,  cold,  clammy  perspiration,  dilated  pupils,  yawning, 
vomiting,  and.  in  extreme  cases,  syncope  and  convulsions. 

The  local  symptoms  are  of  no  more  value  in  determining  the  existence  of 
visceral  injuries  in  penetrating  wounds  of  the  abdomen  than  are  the  general 
symptoms  just  enumerated.  External  hemorrhage  is  slight  or  entirely  wanting 
unless  an  artery  or  a  vein  in  the  abdominal  wall  has  been  injured.  The  bleed- 
insr  from  visceral  wounds  jrives  rise  to  accumulation  of  blood  in  the  iieritoneal 
cavity:  this  can  be  recognized  by  physical  signs  which  denote  the  j)resence  of 
fluid  in  the  free  abdominal  cavity  and  by  the  general  symptoms  indicating  pro- 
gressive anemia:  increasing  pallor  of  the  face  an<l  of  the  visible  mucous  mem- 
branes, small,  feeble  pulse,  and  dilated  pupils.  Wounds  of  the  stomach  often 
give  rise  to  hemorrhage  into  this  organ  and  hematemesis.  Blood  in  the  stools 
seldom  follows  hemorrhage  into  the  bowels  from  intestinal  wounds  sufficiently 
early  to  be  of  any  diagnostic  value. 

Circumscribed  emphysema  in  the  tissues  around  the  track  made  by  a  bullet 


1)IsI':ases  axj)  lyjuiUKS  of  ihe  abdomen,        705 

has  been  reo-ar.lod  as  an  important  si-n  of  the  existence  of  intestinal  perfora- 
tion. This^'syn.ptom  is  n.isk-u.lino-  and  absolutely  .levoid  of  diagnostic  value 
as  this  condition  has  frequently  been  observed  in  non-penetrating  wounds  ot 

the  abdominal  Avall.  .         ^  •      ^i  -4.1 

'Phe  accumulation  of  any  considerable  quantity  of  gas  in  the  peritoneal 
cavity  sometimes  can  be  recognized  by  the  disappearance  of  the  nonnal  liver 
dulness,  cause<l  bv  the  presence  of  gas  between  the  surface  of  the  liver  and 
the  chest-wall.  This  condition  has  been  sought  for  m  cases  of  perforating 
T^ounds  of  the  abdomen  as  a  diagnostic  point,  and  if  found  has  been  laid  down 
as  a  sure  indication  of  the  existence  of  visceral  wourids  of  the  gastro-intestinal 
canal  This  is  not,  however,  always  the  case.  Adhesions  between  the  liver 
and  chest-wall  may  have  existed  before  the  injury  was  received,  or  the 
amount  of  gas  present  may  be  insufficient  to  give  rise  to  this  sign. 

The  escSpe  of  the  contents  of  the  wounded  stomach  or  intestines  through 
the  external  wound  is  a  rare  occurrence,  and  is  possible  only  when  the  exter- 
nal wound  is  sufficiently  large  and  straight  and  when  it  is  located  directly 
opposite  the  visceral  wound,  or  when  there  are  pre-existing  adhesions  between 
the  abdominal  wall  and  the  injured  portion  of  the  gastro-intestinal  canal. 
It  occurs  more  frequently  in  wounds  of  the  large  than  of  the  small  intestine. 
When  this  symptom  .is  present  it  is  conclusive  proof  of  the  existence  of  a  vis- 
ceral wound  of  the  gastro-intestinal  canal,  and  the  character  of  the  materia 
which  escapes  will  furnish  a  reliable  indication  as  to  what  part  of  this  tract 
has  been  iniured.     With  the  exception  of  the  last-mentioned  symptom  and 
the  indication   pointing  to  the  necessity  of  arresting  internal  hemorrhage, 
there  is  nothing  about  the  local  or  general  symptoms  in  cases  of  penetrating 
wounds  of  the  "abdomen  that  would  enable  the  surgeon  to  decide  with  any 
de-ree  of  positiveness,  even  after  the  injury  was  received,  whether  visceral 
injuries  existed  or  not.  and,  conse.iuently,  whether  celiotomy  should  or  should 

not  be  performed.  i    ^  ,i        v  i      •     i 

Diagnosis.— It  has  already  been  urged  that  the  fact  that  the  abdominal 
cavity  has  been  opened  should  rest  upon  unmistakable  evidence,  such  as  pro- 
lapse of  the  omentum  or  intestines,  or  the  escape  of  the  contents  of  the  gastro- 
intestinal canal,  and  in  the  absence  of  such  evidence  it  must  be  established  by 
followin^r  the  track  of  the  wound  down  to  the  opening  in  the  parietal  peritoneum. 
After  it'has  been  ascertained  that  the  wound  is  a  penetrating  one,  the  course  to 
be  pursued  must  vary  according  to  circumstances.     If  the  local  signs  and  gen- 
eral symptoms  point  to  the  existence  of  dangerous  internal  hemon-hage,  no  time 
should  be  lost  in  further  efforts  to  make  an  accurate  anatomical  diagriosis,  as 
sufficient  evidence  has  been  obtained  to  warrant  a  laparotomy  for  the  purpose 
of  preventing  death  from  hemorrhage  by  the  direct  surgical  treatment  of  the 
visceral  injirries.     If  no  such  urgent  indication  presents  itself,  it  is  desirable 
that  the  existence  of  visceral  lesions  demanding  surgical  interference  should  be 
ascertained  before  the  patient  is  subjected  to  the  additional  risks  incident  to  a 
laparotomy.      Since  a  simple  penetrating  wound  of  the  abdomen  is  an  injury 
from  which  a  large  majority  of  patients  recover  without  operative  treatment, 
and  since  visceral  wounds  of  the  gastro-intestinal  canal  are  attended  by  such 
frio-htful  mortality  without  surgical  interference,  the  practical  value  and  import- 
ance of  a  correct  diagnosis  before  deciding  upon  a  definite  plan  of  treatment 
become  obvious.     It  is  apparent  that  if  some  reliable  diagnostic  tes   could  be 
applied  in  cases  of  penetrating  wounds  of  the  abdomen  which  would  indicate 
to  the  surcreon  the  presence  or  absence  of  visceral  lesions  of  the  gastro-intes- 
tinal  canal,   the  indications  for  aggressive  or  conservative   treatment  would 
become  clear. 


45 


7(»(j  J.V    AMi:i!irAy    TKXT-noOK    Ol     SI  UCEliV. 

Senn  lias  shown  by  his  exjieriraents  on  animals,  and  later  by  his  clinical 
experience  in  the  treatment  of  six  cases  of  gunshot  wounds  of  tlie  abdomen, 
that  rectal  insujflation  of  hi/droin'n  (/as  can  be  for  the  most  part  relied  upon 
in  demonstrating  the  existence  of  intestinal  perforations  before  ojiening  the 
abdomen,  lie  has  demonstrated  conclusively  that  if  the  abdominal  muscles 
are  completely  relaxed  under  the  inHuence  of  an  anesthetic,  hydrogen  gas  or 
filtered  air  can  be  forced  from  the  anus  to  the  mouth  if  no  perforations  exist; 
and  if  such  are  present  the  gas  as  a  rule  will  escajjc  into  the  peritoneal  cavity, 
where  its  presence  can  be  easily  iiscertained  by  tlie  physical  symptoms  char- 
acteristic of  a  free  tympanites,  or  by  the  escape  of  the  gas  through  the  exter- 
nal opening. 

The  use  of  hydrogen,  while  it  has  failed  in  a  few  cases,  and  in  others  has 
made  the  return^  of  the  boAvels  into  the  abdominal  cavity  more  difficult,  is 
nevertheless  occasionally  a  valuable  addition  to  our  means  of  diagnosis  and 
treatment.  Many,  perhaps  the  majority  of,  surgeons,  however,  hold  that 
the  difficulties  and  possible  dangers  it  creates  more  than  offset  its  apparent 
advantages. 

Prognosis. — Penetrating  wounds  of  the  abdomen  without  serious  visceral 
injuries  and  without  the  presence  of  a  septic  foreign  body  in  the  abdominal 
cavity  are  frequently  followed  by  recovery  without  resort  to  intra-abdominal 
treatment.  Penetrating  wounds  complicated  by  visceral  injuries  giving  rise  to 
profuse  internal  hemorrhage  are  serious  injuries  and  call  for  prompt  surgical 
interference.  Penetrating  wounds  complicated  by  wounds  of  the  stomach 
or  of  any  portion  of  the  intestinal  tube  large  enough  to  permit  the  escape  of 
the  contents  of  the  injured  organ  must  practically  be  regarded  as  mortal  injuries. 
In  the  former  instance  death  usually  follows  in  a  short  time  from  hemorrhage ; 
in  the  latter,  from  septic  peritonitis.  In  exceptional  cases,  where  all  the  con- 
ditions are  favorable  for  such  a  termination,  a  spontaneous  recovery  may  take 
place  by  the  wounded  portion  of  the  stomach  or  intestine  forming  speedy  adhe- 
sions with  adjacent  serous  surfaces,  thus  protecting  the  peritoneal  cavity  against 
infection.  One  of  the  most  important  conditions  for  such  a  favorable  termi- 
nation to  take  place  is  that  the  wounded  organ  should  be  empty  at  the  time 
the  injury  is  inflicted  and  should  remain  so  until  the  peritoneal  cavity  has 
been  shut  off  by  adhesions.  These  cases,  however,  are  exceptional :  ex- 
travasation, septic  peritonitis,  and  death  are  the  usual  results  of  such 
injuries. 

Treatment. — The  propriety  of  surgical  interference  in  cases  of  pene- 
trating wounds  of  the  abdomen  will  depend  on  one  of  two  things : 

1.  Dangerous  internal  hemorrhage. 

2.  "Wounds  of  the  stomach  or  intestines  large  enough  to  permit  of 
extravasation. 

The  rational  treatment  of  penetrating  wounds  of  the  abdomen  originated 
in  this  country,  and  its  development  to  a  life-saving  and  legitimate  surgical 
procedure  has  been  brought  about  almost  exclusively  by  the  researches  and 
clinical  work  of  American  surgeons.  Among  those  who  contributed  most 
toward  the  advancement  of  this  branch  of  abdominal  surgery  may  be  men- 
tioned Gross,  Sims,  Kinloch,  McGuire,  Parkes,  McGraw,  Bull.  Dalton,  Ber- 
nays,  Cabot,  Barrows,  Keen,  Stimson,  and  Senn.  The  most  recent  statistics 
show  that  about  30  per  cent,  of  the  cases  operated  on  have  recovered,  thus 
fully  sustaining  the  expectations  of  those  who  urge  not  only  the  propriety  but 
also  the  necessity  of  treatment  by  laparotomy  in  all  cases  in  which  penetrating 
wounds  of  the  abdomen  are  complicated  by  -serious  visceral  injuries. 

1.  Preparation  of  the  Patient. — A  patient  suffering  from  a  perforating  wound 


I)IsI':asi:s  asp  l\j('uii:s  of  the  ajwomkx.        tot 

of  the  abdonirn  should  be  ])ro|)erly  prepared  before  he  is  subjected  to  lapa- 
rotomy. If  the  stomach  is  filled  with  food,  a  salt-water  emetic  should  be  given 
for  the  purpose  of  evacuating  the  stomach,  or,  better  still,  it  may  be  emptied 
by  a  stomach  tul)e.  The  rectum  and  colon  should  be  emptied  by  a  copious 
enema  of  lukewarm  Avater  to  which  may  be  added  a  taldespoonful  of  common 
salt.  A  hypodermatic  injection  of  gr.  J-  of  morphia  and  gr.  -^-^  of  strychnine 
should  be  given  shortly  before  the  anesthetic  is  administered,  as  these  drugs 
in  the  doses  specified  assist  the  action  of  the  anesthetic,  secure  rest  for  the 
intestines,  and  sustain  the  action  of  the  heart.  If  the  patient  is  much  pros- 
trated, two  ounces  of  whiskey  diluted  with  four  ounces  of  warm  water  should 
be  irivcn  bv  the  rectum.  ]>odv  heat  should  be  maintained  and  increased,  and 
the  embarrassed  circulation  aided  by  the  use  of  external  dry  heat.  The 
external   wound  and  the  whole  abdomen   must  be  thoroughly  disinfected. 

2.  Operating  Room. — The  room  in  Avhich  the  examination  is  to  be  made, 
and  possibly  laparotomy  performed,  should  be  prepared  as  directed  in  the  sec- 
tion on  Operative  Surgery. 

3.  Incision. — Great  diversity  of  opinion  still  prevails  in  regard  to  where 
the  incision  should  be  made.  In  the  majority  of  cases  the  median  incision 
affords  advantages  which  give  it  the  preference.  It  should  always  be  selected 
in  cases  of  gunshot  wounds  of  the  stomach,  and  where  the  wound  of  entrance 
is  located  near  the  median  line,  and  where  it  is  known  that  the  bullet  has 
taken  an  antero-posterior  course.  A  median  incision  affords  most  ready  access 
in  the  treatment  of  wounds  of  the  small  intestine. 

If  the  hydrogen-gas  test  is  used,  it  may  sometimes  prove  of  value  in  decid- 
ing the  location  of  the  incision.  If  in  gunshot  wounds  of  the  upper  portion  of 
the  abdomen  direct  inflation  of  the  stomach  through  an  elastic  tube  reveals  the 
existence  of  perforation  of  this  organ,  the  median  incision  should  be  selected. 
If  rectal  insufflation  yields  a  positive  result  before  the  gas  has  passed  the  ileo- 
ciecal  valve,  the  incision  should  be  made  over  the  wounded  portion  of  the 
colon,  which  is  usually  indicated  by  the  course  of  the  bullet.  A  wound  in  the 
transverse  colon  can  be  found  and  dealt  with  most  efficiently  through  a  median 
incision,  perforation  of  the  caecum  or  of  the  ascending  colon  calls  for  a  lateral 
incision  directly  over  the  wounded  organ,  Avhile  a  lateral  incision  on  the  left 
side  is  indicated  if  from  the  direction  of  the  bullet  it  is  evident  or  probable 
that  the  colon  below  the  splenic  flexure  is  the  seat  of  the  visceral  injury.  In 
the  treatment  of  gunshot  wound  of  the  colon  a  lateral  incision  should  be  made 
sufficiently  long  to  facilitate  the  finding  and  suturing  of  the  perforation  and  to 
enable  the  surgeon  to  search  for  and  treat  additional  injuries.  The  external 
wound  is  closed  with  several  rows  of  buried  sutures  :  there  is  but  little  danger 
of  the  occurrence  of  a  ventral  hernia. 

Laparotom}^  performed  for  the  arrest  of  dangerous  hemorrhage  should 
alwavs  be  done  bv  making  a  long  median  incision,  which  will  afford  the  most 
direct  access  to  the  different  sources  of  hemorrhage.  Very  often  it  will  be 
advisable  to  make  the  incision  in  the  line  of  the  wound  of  entrance,  more 
especially  in  cases  where  a  lateral  incision  is  indicated  from  the  location  of  the 
wound,  from  the  course  of  the  bullet,  and  perhaps  from  the  results  obtained  by 
application  of  the  hydrogen-gas  test. 

4.  Arrest  of  Hemorrhage. — In  penetrating  wounds  of  the  abdomen  pro- 
fuse hemorrhage  is  more  frequently  of  parenchymatous  and  venous  than  of 
arterial  origin.  Gunshot  wounds  of  the  liver,  spleen,  kidneys,  and  mesen- 
tery give  rise  to  profuse  and  often  fatal  hemorrhage.  After  opening  the  peri- 
toneal cavity  it  is  often  very  difficult  to  find  the  bleeding  points,  as  the  blood 
accumulates  as  rapidly  as  it  is  sponged  out,  and  it  becomes  necessary  to  resort 


708  .liV^  AMERICAN    TEXT-BOOK    OE  ^LROERW 

to  special  iru'ims  in  order  to  arrest  the  |)rofiise  bleeding  sufficiently  to  find  the 
source  ot"  heiiiorrliage. 

One  of  two  means  should  be  employed:  (1)  digital  compression  of  the 
aorta ;  (2)  packing  the  abdominal  cavity  with  a  number  of  large  sponges. 
Digital  compression  of  the  aorta  below  the  diaphragm  can  be  readily  made  by 
an  assistant  introducing  his  hand  through  the  al>doniinal  incision,  which  in 
such  a  case  must  be  larger  than  under  ordinary  circumstances.  Compression 
of  the  abdominal  aorta  immediately  below  tiie  diapliragm  will  promptly  arrest 
the  hemorrhage  from  any  of  the  abdominal  organs  for  a  sullicient  length  of 
time  to  enable  the  surgeon  to  find  the  source  of  hemorrhage  and  carry  out  the 
necessary  treatment  for  its  permanent  arrest. 

Hemorrhage  from  a  perforated,  lacerated  kidney  may  demand  a  nephrec- 
tomy. A  similar  wound  of  the  liver  is  sutured  with  catgut,  cauterized  with 
the  actual  cautery,  or  tamponed  with  a  long  strip  of  iodoform  gauze,  one  end 
of  which  is  brought  out  of  the  external  Avound.  A  wound  of  the  spleen,  if  the 
hemorrhage  cannot  be  arrested  by  the  antiseptic  tampon,  necessitates  splenec- 
tomy. Very  troublesome  hemorrhage  is  often  met  with  from  wounds  of  the 
mesenteric  vessels. 

When  multiple  perforations  of  the  mesentery  and  visceral  wounds  of  the 
stomach  or  intestines  are  the  source  of  hemorrhage,  it  is  a  good  plan  to  pack 
the  abdominal  cavity  with  a  number  of  large  sponges  or  gauze  compresses  to 
each  of  which  a  long  strip  of  iodoform  gauze  is  securely  tied,  these  strips  being 
allowed  to  hang  out  of  the  wound  in  order  that  none  of  the  sponges  may  be 
lost  or  forgotten  in  the  abdominal  cavity  after  the  completion  of  the  opera- 
tion. The  sponges  or  compresses  make  sufficient  j)ressure  to  arrest  paren- 
chymatous oozing  as  well  as  venous  hemorrhage  if  they  are  placed  at  different 
points  against  the  mesentery  and  between  the  intestinal  coils.  The  sponges 
are  removed  one  by  one  from  below  upward,  and  the  bleeding  points  secured 
as  fast  as  they  are  uncovered. 

The  ligation  of  mesenteric  vessels,  both  arteries  and  veins,  should  be  done 
by  applying  the  ligature  en  masse.  Thornton's  curved  hemostatic  forceps  is 
the  most  useful  instrument  for  this  purpose.  Troublesome  hemorrhage  from 
a  large  visceral  wound  of  the  stomach  and  intestines  is  best  controlled  by 
hemming  the  margin  of  the  wound  with  fine  silk.  If  hemorrhage  is  profuse, 
this  must  be  attended  to  before  anything  is  done  in  the  way  of  finding  or 
suturing  the  visceral  wounds. 

5.  Search  for  Perforations. — If  the  hydrogen-gas  test  has  been  employed 
with  a  positive  result  before  the  abdomen  was  opened,  there  Avill  be  no  dif- 
ficulty experienced  in  finding  the  first  opening.  If  the  stomach  was  inflated 
directly  through  an  elastic  tube,  and  the  test  has  shown  the  presence  of  a  per- 
foration, a  median  incision  is  made  from  the  tip  of  the  ensiform  cartilage  to 
the  umbilicus  and  the  stomach  drawn  forward  into  the  wound.  If  no  perfora- 
tion is  found  in  the  anterior  wall,  the  insufflation  is  repeated,  and  the  escaping 
gas  will  direct  the  surgeon  to  the  perforation.  After  closing  the  perforation 
the  stomach  is  again  inflated,  and  if  a  second  perforation  exists  it  is  readily 
detected  by  this  test.  The  possibility  of  the  existence  of  a  third  perforation 
should  be  remembered ;  consequently  a  third  inflation  may  become  necessary. 
A  second  and  a  possible  third  perforation  can  also  be  detected  by  inflating  the 
stomach  directly  through  the  first  or  second  perforation. 

In  searching  for  intestinal  wounds  by  the  aid  of  inflation  further  inflation 
should  be  suspeniled  as  soon  as  the  lowest  perforation  has  been  found.  If 
possible,  the  perforated  ])ortion  of  the  intestine  should  now  be  brought  for- 
ward into  the  wound,  and  after  emptying  the  intestine  below  the  perforation 


DLSEASKS   AM)    LXJililES    OF    THE    ABDOMEN.  709 

as  far  .ns  possiMc  of  its  fjas,  tlie  bowel  is  coinprossed  })elow  tho  perforation  by 
an  assistant  and  tho  intestine  bi^dier  up  is  inllated  tliron^rli  the  wound.  As 
a  matter  of  eourse,  a  ])erfectly  aseptie  rrlass  tube  shoubl  be  inserted  into  the 
rubber  tube  in  pLaee  of  employing  the  tube  which  was  used  in  the  rectum. 
The  inflation  is  now  carried  as  far  as  the  second  opening,  when  the  first  open- 
ing is  sutured,  and  after  disinfecting  an<l  emptying  the  intervening  portion 
of  its  gas  the  intestine  is  replaced  in  tho  alHlominal  cavity.  Further  infla- 
tion is  now  made  through  the  socon<l  opening,  and  if  a  third  one  is  found  the 
second  is  sutured,  and  so  on  until  the  entire  intestinal  canal  has  been  thor- 
oughly subjected  to  the  test.  By  following  this  plan  extensive  eventration 
is  rendered  superfluous  and  the  overlooking  of  a  perforation  is  made  abso- 
lutely impossible;  at  the  same  time  intestinal  distention  is  guarded  against 
and  the  subsequent  suturing  of  the  wound  greatly  facilitated.  I  ndiscov- 
ered  perforations  and  external  eventration  in  the  search  for  perforations 
figure  largely  as  the  causes  of  death  in  gunshot  wounds  of  the  abdomen 
treated  by  laparotomy,  and  both  of  these  sources  of  danger  are  avoided  by 
a  thorough  and  systematic  employment  of  the  hydrogen-gas  test. 

There  is  good  reason  to  think  that  quite  as  many  lives  have  been  lost  by 
prolongation  of  the  search  for  perforations  as  by  overlooked  perforations,  and 
most  surgeons  now  hold  that  the  search  should  be  made  with  the  aid  of  inflation 
and  by  I'apidly  running  over  the  movable  portion  of  the  intestines,  and  only  so 
much  of  the  fixed  portion  as  lies  in  the  track  of  the  bullet. 

6.  Suturing  of  Wounds  of  the  Stomach  and  Intestine. — Trimming  the 
margins  of  the  visceral  wounds  is  not  only  superfluous,  but  absolutely  harm- 
ful, as  it  requires  a  useless  expenditure  of  time  and  may  become  an  additional 
source  of  hemorrhage.  The  same  can  be  said  of  the  Czerny-Lembert  suture. 
All  that  is  required  in  the  treatment  of  a  visceral  wound  of  the  stomach  and 
intestine  is  to  turn  the  margins  of  the  wound  inward  and  bring  into  apposition 
healthy  serous  surfaces  by  the  continuous  Lembert  or  by  interrupted  sero-mus- 
cular  sutures,  which  should  always  be  made  to  include  fibers  of  the  submucosa. 
Fine  aseptic  silk  should  be  used,  and  from  four  to  six  sutures  to  an  inch  are 
sufficient.  If  possible,  wounds  of  the  stomach  should  be  sutured  in  a  line  paral- 
lel with  the  loner  axis  of  the  organ,  and  wounds  of  the  intestine  should  be  closed 
transversely,  with  a  view  of  preventing  constriction  of  the  lumen.  Defects  an 
inch  and  a  half  in  length  on  the  convex  border  can  be  closed  in  this  manner 
without  fear  of  causing  intestinal  obstruction,  while  much  smaller  defects  on 
the  mesenteric  side  often  necessitate  a  resection,  not  only  because  the  vascular 
supply  in  the  corresponding  portion  of  the  intestine  would  be  inadequate,  but 
also  because  a  suflficiently  sharp  flexion  might  be  produced  at  the  seat  of  sutur- 
ing to  become  the  immediate  mechanical  cause  of  intestinal  obstruction. 

7.  Enterectomy. — Enterectomy  is  often  indicated  in  cases  of  double  per- 
foration and  in  marcfinal  wounds  of  the  mesenteric  border.  If  in  cases  of 
multiple  perforations  it  becomes  necessary  to  make  a  double  enterectomy, 
and  the  intervening  portion  of  the  small  intestine  is  not  more  than  two  or 
three  feet  in  length,  it  is  best  to  resect  the  intervening  portion  itself,  as  the 
immediate  effect  of  the  single  operation  will  be  less  severe  than  that  of  a 
double  resection  with  a  corresponding  double  enterorrhaphy.  The  mesentery 
corresponding  to  the  portion  of  intestine  to  be  removed  should  be  tied  in 
small  sections  with  fine  silk  before  the  bowel  is  excised.  Strips  of  gauze 
are  preferable  to  clamps  in  preventing  extravasation  during  the  operation. 
The  gauze  strip  is  passed  through  a  small  buttonhole  made  with  hemostatic 
forceps  in  the  mesentery  near  the  intestine  and  tied  Avith  sufficient  firmness 
to  prevent  escape  of  intestinal  contents. 


71U  AX   AMKJilCAX    TllXT-HOOK    OF   SURdEllY. 

8.  Oinental  Graftin<:f. — If  tlie  bowel  at  the  seat  of  suturing  shows  evi- 
dences of  contusion,  the  line  of  suturing  and  the  damaged  portion  of  the 
bowel  should  be  covered  by  an  omental  graft,  which  is  fastened  in  its  place  on 
the  mesenteric  side  by  passing  two  catgut  sutures  in  the  line  of  the  mesenteric 
vessels  through  both  ends  of  the  graft  and  the  mesentery  and  tying  them 
loosely.  Before  the  graft  is  planted  the  surface  of  the  bowel  and  the  surface 
of  the  graft  which  is  to  be  brought  in  contact  with  it  are  scarified  with  the  point 
of  an  aseptic  needle. 

9.  Irrigation  of  the  Abdominal  Cavity. — This  is  necessary  only  if  fecal 
extravasation  or  escape  of  stomach  contents  has  taken  place,  an  accident  which, 
if  it  has  not  occurred  before  the  abdomen  was  opened,  should  be  carefully 
avoided  during  the  manipulation  of  the  wounded  intestines.  Flushing  the 
peritoneal  cavity  with  normal  salt  solution,  not  only  clears  it  of  infectious 
material,  but  acts  at  the  same  time  as  a  stimulant  to  the  Hagging  circulation. 
After  completion  of  the  irrigation  the  patient  is  placed  on  his  side,  and  in 
this  manner  the  fluid  contents  of  the  abdominal  cavity  are  poured  out.  The 
cavity  is  then  rapidly  dried  with  largo  sponges  wrung  out  of  a  weak  sublimate 
solution  (1 :  lO.OOn)  or  Thiersch's  solution.  Some  surgeons  have  practically 
abandoned  flushing  of  the  abdominal  cavity,  and  rely  almost  exclusively  on 
sponging  in  removing  pus  and  extravasated  fecal  iuaterial. 

10.  Drainage. — Cases  which  require  irrigation  usually  necessitate  drain- 
age. Other  indications  for  drainage  are  visceral  wounds  of  the  liver,  pan- 
creas, spleen,  and  kidneys,  where  extirpation  of  the  wounded  part  of  the 
organ  or  of  the  whole  organ  is  deemed  unnecessary,  and  the  existence  of 
parenchymatous  hemorrhage  which  cannot  be  remedied  by  any  of  the  differ- 
ent hemostatic  measures.  A  combination  of  a  tubular  and  gauze  drain  is 
most  advantageous.  A  glass  drain  reaching  to  the  bottom  of  the  pelvis 
loosely  packed  with  a  strip  of  iodoform  gauze  answers  an  excellent  purpose. 
Occasionally  multiple  drains  are  indicated.  The  Mikulicz  drain  may  be 
used  in  arresting  surface  oozing. 

11.  Closure  of  the  External  Incision. — Incisions  through  the  median  line 
are  rapidly  closed  by  one  row  of  silk  sutures  which  include  all  the  tissues  of 
the  margins  of  the  wound.  Incisions  made  in  any  other  place  are  to  be  closed 
in  the  same  manner,  or  by  two  or  three  rows  of  buried  catgut  sutures  and  a 
superficial  row  of  silkworm-gut  sutures  including  all  the  tissues  except  the 
peritoneum. 

12.  After-treatment. — Absolute  rest  must  be  strictly  enforced.  Opiates 
must  be  given  in  doses  sufficient  to  quiet  the  peristaltic  action  of  the  intestines. 
No  food  should  be  given  by  the  stomach  for  at  least  forty-eight  hours.  During 
this  time  a  mixture  of  brandy  and  water,  in  small  doses  frequently  repeated,  is 
agreeable  to  the  patient,  as  it  quenches  thirst  and  exerts  a  favorable  influence 
upon  the  circulation.  If  more  active  stimulation  is  required  to  overcome  shock 
and  the  eff"ects  of  hemorrhage,  whiskey,  strychnine,  ether,  musk,  or  camphor 
can  be  injected  subcutaneously  or  by  the  rectum,  while  the  perij)heral  circu- 
lation is  restored  by  applying  dry  heat  to  the  extremities  and  trunk.  The  subcu- 
taneous transfusion  of  one  to  two  pints  of  normal  saline  solution  is  an  excel- 
lent restorative  and  of  special  therapeutic  value  in  cases  where  the  vital  forces 
are  depressed  and  life  is  in  danger  from  the  effects  of  hemorrhage.  Should 
symptoms  of  peritonitis  set  in,  a  brisk  saline  cathartic  should  be  given  at  the 
end  of  forty-eight  hours,  as  at  this  time  the  intestinal  wounds  will  have  become 
sufficiently  united  to  resist  the  peristalsis  provoked  by  the  cathartic,  while  the 
removal  of  the  intestinal  contents  and  the  absorption  of  septic  material  from 
the  peritoneal  cavity  thus  attained  are  not  only  the  most  efficient  means  of 


J)/,Sj:A,Sh\S    AXl)    lyjL'RIKS    OF    THE    ABDOMEN.  711 

avertiii<^  a  fatal  disciise,  but  also  of  placiug  the  wounds  in  tlie  most  favorable 
condition  for  rapid  repair. 

If  the  case  progresses  favorably,  liijuid  food  by  the  stomach  can  be  allowed 
at  the  end  of  the  second  day,  and  digestible  solid  food  at  the  end  of  the  first 
veek.  Under  ordinary  circumstances  no  effort  is  made  to  move  the  bowels 
until  the  end  of  the  third  or  fourth  day.  If  early  feeding  becomes  necessary 
in  marasmic  or  exsanguine  patients,  this  can  be  done  by  rectal  alimentation. 
Patients  should  not  be  allowed  to  leave  the  bed  until  the  external  wound  has 
firmly  united  throughout,  as  any  imprudence  in  this  direction  is  liable  to  be 
followed  l)y  the  formation  of  a  ventral  hernia.  The  sutures  are  removed  on 
the  eighth  day,  and  the  patient  is  directed  to  wear  an  abdominal  supporter  for 
several  months  after  he  has  left  his  bed. 

PART   II.— DISEASES  AND  INJURIES  OF  THE  STOMACH. 

Wounds  and  Contusions. — The  stomach,  when  of  normal  size  and  in  its 
natural  location,  is  so  Avell  protected  by  the  chest-wall  and  the  surrounding 
organs  that  it  seldom  becomes  the  seat  of  injury  from  blunt  force.  Contusion, 
partial  laceration,  and  complete  rupture  may  occur  from  a  severe  blow  or  kick 
applied  over  the  organ  when  distended  with  food.  A  partial  laceration  and 
contusion  will  give  rise  to  circumscribed  pain  at  the  seat  of  injury,  followed 
by  a  limited  inflammation  which  usually  results  in  the  formation  of  adhesions 
between  the  injured  part  and  the  adjacent  surface.  Evidences  of  circum- 
scribed peritonitis  in  the  region  of  the  stomach  after  an  injury  are  suggestive 
of  the  existence  of  a  traumatic  lesion  of  this  organ,  and  should  warn  the  surgeon 
to  secure  rest  for  the  injured  part  by  placing  the  patient  on  an  absolute  diet  for 
four  or  five  days,  withholding  indigestible  food  until  all  danger  of  perforation 
has  passed. 

As  the  peritoneal  investment  is  less  elastic  than  the  muscular  and  mucous 
coats,  partial  rupture  of  the  organ  necessarily  implicates  most  frequently  the 
external  or  peritoneal  coat.  In  complete  ruptures  and  in  lacerations  involv- 
ing the  mucous  coat  hemorrhage  takes  place  into  the  stomach ;  and  if  the 
patient  vomits  blood,  the  existence  of  a  serious  injury  of  this  viscus  may  be 
.fairly  assumed.  A  rupture  of  the  stomach  large  enough  to  permit  the  escape 
of  its  contents  into  the  peritoneal  cavity  is  usually  attended  by  additional  seri- 
ous injuries  which  still  further  complicate  the  case.  Extravasation  of  food  into 
the  peritoneal  cavity  causes  severe  pain  and  symptoms  of  shock,  which,  if  the 
patient  rallies,  is  followed  by  diffuse  septic  peritonitis  and  death  within  forty- 
eight  hours.  In  cases  of  this  kind  the  existence  of  a  complete  rupture  can  be 
readily  demonstrated  by  inflating  the  organ  with  hydrogen  gas  or  filtered  air 
through  an  elastic  stomach-tube.  If  the  rupture  is  incomplete^  the  stomach 
will  be  dilated  and  its  contour  can  be  mapped  out  on  the  surface  of  the  abdo- 
men by  inspection  and  percussion  ;  if  a  complete  rupture  has  taken  place,  the 
organ  cannot  be  distended,  as  the  gas  will  escape  through  the  visceral  wound 
into  the  ai)dominal  cavity,  where  its  presence  can  be  recognized  by  the  physi- 
cal signs  wliich  characterize  a  free  tympanites. 

In  the  treatment  of  a  complete  rupture  of  the  stomach  no  time  should  be 
lost.  The  abdomen  should  be  opened  by  an  incision  from  the  xiphoid  cartilage 
to  the  umbilicus.  If  the  visceral  wound  is  located  where  it  cannot  be  readily 
found,  it  can  be  quickly  pointed  out  by  repeating  the  inflation.  If  extravasation 
has  taken  place,  the  peritoneal  cavity  should  be  carefully  cleansed  by  flushing 
with  normal  salt  solution  and  moj)ping  Avith  a  soft  aseptic  sponge.  If  the 
stomach  has  not  been  emptied  by  vomiting  or  by  the  escape  of  its  contents 


712  .liV   JJ/A/.'/rj.V    TllXr-llOOK    OF   srii(ii:L'Y. 

through  the  rupture,  it  should  be  evacuated  completely  through  the  wound 
before  this  is  closed  with  sutures.  After  careful  arrest  of  hemorrhage  the 
rent  in  tiie  stomach  is  closed  by  applying  two  rows  of  silk  sutures:  the  first 
row.  to  embrace  the  muscular  and  mucous  coats,  is  cut  short,  and  buried  by  the 
second  row,  which  is  made  to  include  the  peritoneum  and  enough  of  the  mus- 
cular coat  to  give  each  suture  a  firm  hold.  Some  surgeons  employ  only  a 
single  row.  If  the  peritoneal  cavity  has  been  contaminated  by  extrava.sation 
for  a  considerable  length  of  time,  it  is  advisable  to  resort  to  drainage.  As  an 
operation  for  such  an  injury  necessarily  requires  a  considerable  length  of  time, 
the  circulation  should  be  maintaine<l  by  a  judicious  use  of  external  heat  and  of 
stimulants  administered  by  subcutaneous  and  rectal  injections.  As  heart  stimu- 
hints,  camphorated  oil,  digitalis,  and  strychnia,  injected  subcutaneously,  are  to 
be  relied  upon.  Whiskey  or  brandy  diluted  with  Avarm  water  should  be  given 
by  the  rectum.  The  patient  is  to  be  nourished  exclusively  by  rectal  alimenta- 
tion for  at  least  three  or  four  days. 

Gunshot  and  Stab  Wounds  of  the  Stomach  are  much  more  frequent 
than  lacerated  wounds.  The  existence  of  a  visceral  wound  of  this  organ  in 
connection  with  penetrating  wounds  of  the  abdomen  is  often  made  evident  by 
hematemesis,  and  less  frequently  by  the  escape  of  the  contents  of  the  stomach 
through  the  external  wound.  If  such  positive  indications  are  wanting,  as  is 
usually  the  case  in  gunshot  wounds,  the  diagnosis  may  be  made  by  resorting 
to  insufflation  with  hydrogen  gas  or  filtered  air. 

A  number  of  cases  have  been  reported  where  the  stomach  had  been  perfo- 
rated by  a  small  bullet,  and  recover}^  followed  without  operative  interference. 
Such  a  favorable  termination  can  be  hoped  for  if  the  visceral  wound  is  small  and 
if  the  organ  was  empty  at  the  time  the  injury  was  inflicted.  Under  such  circum- 
stances the  wound  is  temporarily  closed  by  the  bulging  of  the  mucous  mem- 
brane, w^hich  forms  a  perfect  plug  until  by  a  speedy  process  of  repair  the  wound 
on  the  peritoneal  side  is  permanently  sealed  by  new  tissue. 

In  the  surgical  treatment  of  wounds  of  the  stomach  it  is  important  to 
remember  that  if  the  Avound  is  located  near  the  cardiac  orifice  of  the  organ  or 
in  the  posterior  wall,  it  is  difficult  of  detection  and  not  readily  accessible  to 
direct  treatment.  In  gunshot  wounds  of  the  stomach,  unless  the  bullet  grazes 
one  of  the  bordei^s,  it  is  the  rule  that  the  organ  is  perforated  at  two  points.  If  * 
only  one  perforation  is  found,  this  should  never  be  closed  until  search  has  been 
made  for  additional  perforations  by  inflating  the  organ  through  the  perforation. 
This  diagnostic  test  prevents  the  possibility  of  leaving  an  undiscovered  and 
unsutured  perforation.  Two  cases  may  be  mentioned,  in  each  of  which  one 
perforation  was  overlooked  and  the  patient  died  of  peritonitis  which  could  be 
traced  to  the  unsutured  wound.  In  one  of  the  cases  the  bullet  passed  through 
the  cardiac  extremity  of  the  stomach  in  an  antero-posterior  direction.  The  per- 
foration in  the  anterior  wall  was  readily  found  and  sutured,  and,  as  no  other 
visceral  injuries  could  be  found,  the  operation  was  terminated.  The  patient  died 
of  septic  peritonitis  on  the  second  day.  The  necropsy  revealed  a  second  per- 
foration in  the  posterior  wall  of  the  stomach  and  a  septic  peritonitis  which  had 
plainly  developed  from  this  source,  as  the  large  opening  had  remained  patent, 
establishing  a  free  communication  between  the  interior  of  the  stomach  and  the 
peritoneal  cavity.  The  second  case  is  of  great  interest,  as  it  shows  that  one 
bullet  can  produce  three  perforations  in  the  stomach.  The  bullet  passed  trans- 
versely through  the  upper  part  of  the  abdominal  cavity.  Abdominal  section 
was  made,  and  two  perforations  in  the  stomach,  one  near  the  cardiac  extremity, 
the  other  near  the  pylorus,  were  easily  found  and  sutured.  The  surgeon  had 
every  reason  to  believe  that  he  had  found  and  treated  all  the  perforations. 


DISKA.SES   AND    INJURIES    OF    THE   ABDOMEN.  713 

The  patient  died  of  septic  jieritonitis,  wliicli,  as  the  post-mortem  showed,  was 
caused  by  an  overlooked  j)erfbration  in  the  small  curvature  of"  the  stomach. 
Gunshot  and  stab  wounds  of  the  stomach  are  sutured  in  the  same  manner  as 
lacerated  wounds,  care  being  taken  to  cover  the  perforation  some  distnnce 
beyond  the  margins  of  the  wound  by  applying  the  superficial  or  Lembert 
sutures  at  least  half  an  inch  beyond  the  margins  on  each  side.  The  same 
care  must  be  exercised  in  the  after-treatment  of  such  cases  as  has  been 
detailed  in  describing  the  treatment  of  lacerated  and  ruptured  wounds  of  this 
organ. 

Foreign  Bodies. — Foreign  bodies  which  traverse  the  pharynx  and  oesopha- 
gus usually  pass  through  the  entire  length  of  the  gastro-intestinal  canal  and  escape 
in  a  day  or  two  with  the  fecal  evacuation.  Coins,  buttons,  fragments  of  bone, 
pins,  and  other  small  foreign  bodies  are  usually  disposed  of  in  this  manner. 
The  popular  belief  tliat  the  passage  of  a  foreign  body  through  the  alimentary 
canal  is  facilitated  by  the  administration  of  purgatives  is  erroneous,  as  every 
measure  directed  toward  increasing  peristalsis  will  tend  to  increase  the  risk 
of  its  arrest  and  impaction.  It  has  been  advised  to  restrict  such  patients  to 
an  exclusive  diet  of  bread  and  milk  for  a  number  of  days,  to  be  followed  by  a 
gentle  laxative.  Quite  recently  the  so-called  "Vienna  treatment,"  consisting 
in  an  exclusive  diet  of  mashed  potatoes,  has  received  a  great  deal  of  attention 
and  has  been  employed  to  good  advantage  in  such  cases. 

The  dietetic  treatment  of  foreign  bodies  in  the  alimentary  canal  is 
founded  upon  the  fact  that  during  appropriate  feeding  the  foreign  body  be- 
comes, as  it  were,  encrusted  or  buried,  and  is  thus  rendered  less  dangerous,  and 
its  passage  through  the  pyloric  orifice  of  the  stomach  and  along  the  intestinal 
canal  is  facilitated.  If  the  foreign  body,  such  as  a  knife,  fork,  etc.,  either 
from  its  great  size  or  on  account  of  its  shape,  cannot  pass  through  the  pyloric 
orifice,  it  acts  as  an  irritant  to  the  Avails  of  the  stomach,  causing  catarrhal 
inflammation,  ulceration,  and  even  perforation.  It  is  now  possible,  by  means 
of  the  skiagraph,  to  determine  from  day  to  day  whether  the  foreign  body  re- 
mains impacted  or  whether  it  is  being  passed  onward  Avith  the  fecal  current. 
Bodies  retained  in  the  stomach  may  sometimes  be  shown  by  the  use  of  the 
gastrodiaphane.  Under  such  circumstances  it  becomes  the  duty  of  the  sur- 
geon to  resort  to  the  operative  removal  of  the  foreign  body  before  it  has  in- 
flicted irreparable  damage. 

Gastrotomy  for  the  removal  of  foreign  bodies  is  one  of  the  oldest 
and  most  successful  of  all  abdominal  operations.  The  first  operation  of  this 
kind  was  performed  by  Florian  Mathias  of  Prague  in  1602.  The  stomach  is 
reached  through  a  median  incision,  and,  if  possible,  the  foreign  body  is  located 
before  the  incision  for  its  removal  is  made.  If  this  cannot  be  done,  the  ante- 
rior wall  of  the  stomach  is  brought  forAvard  into  the  Avound  and  retained  in  this 
location  Avith  volsellum  forceps,  and  a  vertical  incision  made  large  enough  to 
admit  one  or  tAvo  fingers  for  digital  exploration  of  the  interior  of  the  vis- 
cus.  After  the  foreign  body  has  been  located,  it  is  grasped  Avith  a  pair  of 
strong  polypus  forceps  in  such  a  manner  as  to  extract  it  Avithout  inflicting 
additional  violence.  The  visceral  wound  is  closed  in  the  usual  manner 
with  Czerny-Lembert  sutures,  and  after  carefully  cleansing  the  exposed  parts 
the  organ  is  replaced  and  the  external  Avound  sutured.  Absolute  diet  must 
be  enforced  for  at  least  three  or  four  days  after  the  operation,  the  time  re- 
quired for  the  formation  of  firm  adhesions  betAveen  the  margins  of  the  visceral 
wound. 

Ulcer. — Until  recently  ulcer  of  the  stomach  had  no  interest  for  the  sur- 
geon, as  treatment  for  this  affection  Avas  regarded  as  the  exclusive  pi'ovince  of 


711  .i.v  AMi:iii('A\   77;.\"/-y;ooA'  or  sri:(n:i:y. 

the  physician.  Recurring  hemorrhage?  from  an  ulcer  of  tliisorgan  liave  brought 
nianv  patients  to  tf»e  brink  of  the  grave,  and  not  infre(|uently  death  has  resulted 
from  this  cause  alone,  while  in  many  other  cases  the  cicatricial  contraction  occur- 
ring during  the  healing  of  an  ulcer  iias  given  rise  to  remote  evil  conscrjuences 
beyond  tiie  range  of  successful  treatment  by  internal  medication.  For  these 
reasons  during  the  last  few  years  ulcer  of  the  stomach  has  become  the  subject 
of  surgical  interest  and  operative  interference.  Perforatingulcerof  thestomach 
and  duodenum  follows  circumscril)ed  necrosis  of  the  walls  of  these  organs  caused 
bv  a  diminished  arterial  blood-supply  of  a  limited  vascular  district.  That  many 
of  these  ulcers  are  of  vascular  origin  is  shown  by  their  funnel-shape  and  their  di- 
rect relation  to  a  terminal  artery.  The  defect  is  in  the  form  of  a  cone,  of  which 
the  base  is  directed  toward  the  lumen  of  the  viscus.  and  the  apex  correspomls 
with  a  small  artery  which  must  have  been  partially  or  completely  obstructed  be- 
fore the  necrosis  occurred.  These  ulcers  are  sometimes  multiple,  and  in  the  stom- 
ach they  are  found  by  )»reference  along  the  lesser  curvature.  After  interru  j)tion 
of  the  arterial  circulation  the  wedge-shaped,  ischemic,  necrosed  portion  is 
removed  by  the  action  of  the  gastric  juice  and  the  ulcer  is  formed.  As  per- 
forating ulcer  of  the  stomach  or  duodenum  never  occurs  in  cases  of  ulcerative 
endocarditis,  and  as  it  selects  in  preference  young  females,  the  causes  of  vascular 
obstruction  must  be  of  a  local  nature.  The  sphacelus  shows  molecular  decay, 
but  no  trace  of  inflammation.  The  more  fi-equent  occurrence  of  perforation  is 
prevented  by  circumscribed  plastic  peritonitis,  which  seals  the  defect  or  estab- 
lishes permanent  adhesion  between  the  affected  j)ortion  of  the  organ  and  an 
adjacent  serous  surface. 

The  principal  symptoms  of  ulcer  of  the  stomach  are  a  fixed  pain,  a  cir- 
cumscribed area  of  tenderness,  and  vomiting  soon  after  eating.  If  in  the 
absence  of  the  usual  symptoms  of  carcinoma  the  patient  vomits  blood,  the 
diagnosis  is  almost  positive. 

The  surgical  treatment  of  ulcer  of  the  stomach  has  for  its  object  one  of 
three  things :  (1)  arrest  of  hemorrhage ;  (2)  e.xcision  of  the  ulcer ;  (3) 
suturing  of  a  perforation.  If  a  positive  diagnosis  of  the  existence  of  an 
ulcer  of  the  stomach,  which  threatens  life  from  recurring  attacks  of  hemor- 
rhage or  which  has  resulted  in  perforation,  can  be  made,  treatment  by  lapa- 
rotomy sliould  be  resorted  to  without  delay.  The  stomach  is  reached  by 
a  median  incision.  The  existence  of  a  perforation,  if  not  easily  seen,  can  be 
readily  demonstrated  by  insufflation  with  hydrogen  gas  through  an  elastic 
oesophageal  tube.  If  no  perforation  is  present,  the  seat  of  the  ulcer  can 
sometimes  be  located  by  a  circumscribed  patch  of  peritonitis  which  corre- 
sponds with  the  location  of  the  ulcer  within  the  viscus.  As  ulcers  are 
most  frefjuently  found  in  the  smaller  curvature  and  in  the  region  of  the  car- 
diac and  pyloric  orifices,  these  localities  should  be  carefully  inspected.  If  the 
ulcer  involves  the  upper  posterior  wall  of  the  stomach,  it  can  be  found  and  treated 
only  through  an  incision  in  the  anterior  wall.  If  the  ulcer  is  located  in  the 
anterior  wall,  it  can  be  readily  excised  and  the  resulting  wound  united  in  the 
usual  manner.  The  closure  of  the  wound  made  by  excision  of  an  ulcer  of  the 
posterior  wall  must  be  done  in  such  a  manner  that  the  superficial  or  Lembert 
sutures  are  inserted  and  tied  before  the  deep  stitches  are  made,  which  are  tied 
last  and  cut  short.  The  woun«l  in  the  anterior  wall  is  then  closed  in  the 
ordinary  manner.  As  in  all  other  operations  on  the  stomach,  the  patient  is 
placed  on  an  absolute  diet  for  a  number  of  days.  Rydygier  was  the  first  to 
subject  an  ulcer  of  the  stomach  to  surgical  treatment,  and  since  his  time  a 
number  of  successful  cases  have  been  reported.  Excision  of  an  ulcer  followed 
by  gastrorrhaphy  will  undoubtedly  prevent    the  remote  consequences  which 


j>/sj:a.sj:s  a.\/>  ixjuries  of  the  ajii>()M1-:x.        715 

would   follow   the   cicatrization  and  spontaneous  licaling  if  the  disease  were 
allowed  to  i)ursuc  its  own  course. 

Cicatricial  Stenosis. — Cicatricial  stenosis  of  either  ot  the  two  ontices 
of  che  stomach,  the  cardiac  and  the  pyloric,  freciuently  follows  as  a  remote 
sequel  the  healing  of  an  ulcer  or  a  traumatic  defect  in  these  localities.  If  it  is 
located  at  the  cardiac  orifice,  the  stricture  interferes  with  the  introduction  of 
food  into  the  stomach ;  if  it  involves  the  pyloric  orifice,  it  interferes  with  the 
escape  of  chyme  into  the  intestinal  canal.  The  development  of  the  stenosis  is 
a  slow  process,  as  it  depends  upon  the  formation  and  contraction  of  cicatricial 
tissue  which  is  formed  at  the  site  of  the  former  trauma  or  ulcer.  The  forma- 
tion of  an  excessive  amount  of  granulation-tissue  in  a  surface  wound  or  ulcer 
of  the  stomach  takes  place  in  consequence  of  the  continual  irritation  caused 
by  the  food  and  digestive  fluids ;  and  it  is  on  this  account  that  cicatricial  con- 
traction so  often  follows  the  healing  of  a  wound  of  the  mucous  membrane  or 

ulcer  of  this  organ.  .  .  ,        .  ,       , 

Diagnosis.— At  the  cardiac  orifice  a  cicatricial  stricture  develops  most 
frequently  after  destruction  of  the  mucous  membrane  by  the  action  of  caus- 
tics or  throucrh  the  injury  caused  by  the  lodgment  of  a  foreign  body  or  by  rude 
attempts  to  remove  it,  whereas  ulcer  constitutes  the  most  frequent  cause  of  cica- 
tricial stenosis  at  the  pyloric  orifice.  A  cicatricial  stricture  at  the  cardiac  orifice 
of  the  stomach  may  be  suspected  if  the  patient  has  experienced  a  gradually 
increasing  difficulty  in  swallowing  solid  food.  As  the  stricture  grows  nar- 
rower, the  oesophagus  above  it  becomes  dilated  and  solid  food  is  regurgitated 
soon  after  it  is  swallowed,  while  liquids  still  enter  the  stomach  through  the 
constricted  orifice.  If  the  patient  has  not  reached  the  age  at  which  carci- 
noma may  be  suspected,  and  if  the  clinical  history  points  to  an  antecedent 
pathological  condition  which  is  known  to  produce  a  stricture,  it  is  almost  certain 
that  a  stenosis  of  a  benign  nature  exists.  The  presence  of  the  stricture  and  its 
exact  location  are  determined  by  the  use  of  an  olive-pomted  oesophageal  bougie 
(p  697).  A  cicatricial  stenosis  of  the  pyloric  orifice  of  the  stomach  gives  rise 
to  obstruction  at  this  point,  retention  of  food,  and  dilatation  of  the  stomach. 
Such  patients  are  usually  treated  for  months  or  years  for  dyspepsia  or  mdiges- 
tion,  until  finally  a  careful  examination  of  the  stomach  reveals  the  existence 
of  tiie  obstruction  and  great  distention  of  the  organ. 

The  diacrnosis  of  stricture  of  the  jjylorus  must  be  based  on  the  history  ot 
the  case,  the  use  of  the  siphon  stomach-tube,  and  inflation  of  the  orgaj.  Ihe 
clinical  historv  will  usually  reveal  the  existence  of  disturbed  digestion  lor  years 
previously,  incident  to  the  presence  of  an  unhealed  ulcer,  and  more  recently 
caused  by  the  obstruction.  For  a  time  compensatory  hypertrophy  balances  the 
mechanical  difficulties  caused  by  the  stricture,  but  when  this  is  no  longer  pos- 
sible the  walls  of  the  stomach  become  attenuated  and  the  cavity  ot  the  organ 
is  enormously  increased  in  size,  containing  remnants  of  food  which  have  been 
retained  for  days  and  often  for  weeks.  Through  the  elastic  siphon  tube  the 
stomach  is  evacuated  and  irrigated,  and  the  quantity  of  fluid  which  it  holds 
furnishes  important  information  in  reference  to  the  size  ot  the  organ.  Air 
can  be  forced  through  the  stomach-tube  after  the  organ  has  been  thoroughly 
emptied  and  irrigated,  and  the  contour  of  the  stomach  then  becomes  visible 
externally  and  its  outlines  can  be  accurately  fixed  by  percussion,  ^eidlitz 
powder  can  be  used  for  the  same  purpose,  the  two  portions  being  dissolved 
separately,  the  bicarbonate  solution  being  swallowed  at  once,  the  tartaric  acid  in 
divided  doses.  It  is  not  uncommon  to  find  the  greater  curvature  of  the  stom- 
ach considerably  below  the  umbilicus  if  dilatation  has  progressed  to  any  con- 
siderable extent.     The  absence  of  a  tumor  in  the  pyloric  region  is  indicative 


71<)  AX  A.]//:/:/(:\y  Ti:xT-iiO(jk'  or  sfnaKRY. 

of  a  cicatricial  stenosis,  but  docs  not  precliule  the  possiltilitv  of"  malignant  dis- 
ease. A  cicatricial  stricture  of  either  orifice  of  the  stomach  is  certain  to  lead  to 
a  fatal  termination  from  marasmus  unless  the  mechanical  difliculty  is  remedied 
hy  sur<fical  interference,  as  a  jjatient  suft'erinii;  from  a  stricture  of  the  cardiac 
■orifice  dies  from  starvation  on  account  of  his  inability  to  inti'oduce  food  into  the 
stomach,  and  a  pyloric  stricture  leads  to  permanent  and  complete  obstruction  to 
the  passage  of  food,  the  patient  finally  succumbing  to  the  combined  effects  of 
inanition  and  the  retention  of  putrefying  and  fermented  food  in  the  stomach. 

Treatment. — Cicatricial  stenosis  of  the  cardiac  orifice  of  the  stomach 
should  be  treated  by  gradual  dilatation  in  all  cases  ■where  it  is  possible  to  pass 
even  the  finest  filiform  bougie  through  the  stricture.  The  different  kinds  of 
urethral  bougies  answer  often  an  excellent  purpose  in  the  early  treatment  of 
narrow  strictures.  Dilatation  should  be  carried  out  gradually,  but  persistently, 
until  the  normal  size  of  the  lumen  of  the  orifice  has  been  restored,  and  the 
largest  dilating  instrument  used  should  be  employed  every  Aveek  or  two  for  a 
long  time  subsequently,  in  order  to  prevent  recurrence  of  the  stricture.  If  the 
stricture  proves  impermeable  to  the  different  kinds  of  dilating  instruments,  the 
only  course  left  is  to  resort  to  a  gastrostomy,  both  for  the  purpose  of  establish- 
ing a  new  route  for  the  introduction  of  food  into  the  stomach  and  in  order  to 
afford  another  opportunity  to  make  an  attempt  to  dilate  the  stricture  from 
below.  Abbe  has  recently  devised  a  new  method  of  treatment  in  cases  of 
oesophageal  stricture.  Afcer  opening  the  stomach  through  an  external  in- 
cision, he  passes  with  an  instrument  a  string  through  the  stricture,  and,  bring- 
ing one  end  out  through  the  mouth  and  the  other  through  the  opening  in  the 
stomach,  divides  the  stricture  by  placing  the  string  on  the  stretch  and  moving 
it  rapidly  upward  and  downward  until  the  stricture  is  divided.  After  the 
oesophagus  has  been  rendered  permeable  in  this  manner  the  visceral  and  ex- 
ternal incisions  are  closed,  and  recurrence  of  the  stricture  prevented  by  the 
frequent  introduction  of  oesophageal  bougies. 

The  operative  treatment  of  a  cicatricial  stricture  at  the  pyloric  end  of  the 
stomach  consists  in  dilating  the  stricture  forcibly  through  a  wound  in  the 
stomach  (Loreta),  or  through  a  gastric  fistula  (Treves),  in  the  formation  of  a 
partly  new  pylorus  by  the  Heineke-Mikulicz  pyloro-plastic  operation,  or  in 
establishing  a  new  outlet  from  the  stomach  into  the  upper  portion  of  the  small 
intestine  by  making  a  gastro-enterostomy.     (See  p.  724.) 

Dilatation  of  the  Stomach  without  Mechanical  Obstruction. — As 
a  rare  pathological  condition  Ave  occasionally  find  an  enormously  dilated  stomach 
without  a  mechanical  obstruction  at  the  pyloric  orifice.  The  cause  of  dilata- 
tion in  such  cases  is  a  chronic  catarrhal  infianimntion  of  the  mucous  membrane, 
which  results  in  a  Aveakenino;  and  attenuation  of  the  muscular  coat  and  gradual 
yielding  of  all  the  tunics.  If  under  dietetic  and  ap])r(i])iiate  medical  treat- 
ment, including  systematic  evacuation  of  the  stomach  through  the  rubber 
siphon  tube  and  the  application  of  the  galvanic  current  directly  to  the  interior 
surface  of  the  stomach  through  an  insulated  oesophageal  tube,  the  function 
and  normal  size  of  the  organ  cannot  be  restored,  a  "  tuck  "  may  be  taken  in 
the  stomach  by  scAving  the  greater  curvature  to  the  lesser  by  several  roAvs  of 
stitches,  as  Bircher  and  Weir  have  done  in  four  cases ;  or  a  ncAv  outlet  from  the 
stomach  into  the  small  intestine  may  1)0  made  by  a  gastro-enterostomy  (p.  7*24). 
Bircher  has  recently  recommendecl  in  such  cases  redujilication  of  the  anterior 
Avail  of  the  stomach,  with  suturing  of  the  fold  by  numerous  catgut  sutures, 
and  has  reported  several  successful  cases.  Weir  and  others  have  resorted  to 
this  procedure  Avith  satisfactory  results. 

Carcinoma. — MA-o-fibroma  and  other  beniirn  tumors  of  the  stomach  are 


DISt:ASE,S   ASn    lyjLIilES    OF    Till-:    ABDOMEN.  717 

extremely  rare,  and  when  present  seldom  necessitate  surgical  interference. 
Sarcoma  as  comj)ared  Avith  carcinoma  is  so  extremely  rare  that  it  is  necessary 
only  to  speak  briefly  of  carcinoma  as  a  tumor  of  the  stomach  which  interests 
the  surgeon.  It  a})pears  that  in  the  stomach  the  general  law  is  observed  that 
this  disease  develops  in  preference  at  points  where  two  kinds  of  epithelial  cells 
meet.  It  is  a  well-known  clinical  fact  that  in  the  stomach  the  disease  has  its 
primary  starting-point  most  fre((ucntly  at  the  pyloric  or  the  cardiac  orifice,  and 
of  these  two  regions  the  pyloric  is  the  more  fre(iuently  aflTected. 

Carcinoma  in  either  of  these  localities  gives  rise  to  a  combination  of  clinical 
symptoms  which  suggest  the  existence  of  ulcer  and  stricture.  As  soon  as 
the  surface  of  the  carcinoma  ulcerates,  hemorrhage  into  the  stomach  is  of  fre- 
quent occurrence,  and  the  tumor,  by  narrowing  the  orifice,  at  the  same  time 
gives  rise  to  obstructioi:^  ^^  tlie  same  manner  as  a  simple  stricture.  It  is  not 
always  easy  or  even  possible  to  ascertain  the  existence  or  exact  location  of  a 
carcinoma  of  the  stomach  by  any  of  the  known  physical  signs.  A  carcinoma 
at  the  cardiac  orifice,  from  its  deep  location,  may  attain  a  considerable  size 
before  its  presence  can  be  demonstrated  by  palpation  or  percussion.  In 
the  majority  of  advanced  cases  of  carcinoma  of  the  pylorus,  however,  a  dis- 
tinct tumor  can  be  felt  in  the  pyloric  region,  but  often  the  weight  of  the 
tumor  has  carried  that  part  of  the  stomach  in  a  downward  direction,  and  the 
tumor  may  be  found  as  low  as  the  level  of  the  umbilicus.  The  size  of  the 
stomach  is  greatly  diminished  in  carcinoma  at  the  cardiac  orifice,  while  if  the 
disease  is  located  in  the  opposite  extremity  the  organ  is  often  found  enormously 
distended  in  consequence  of  the  long-standing  obstruction.  It  is  sometimes 
not  easy  to  differentiate  between  a  carcinoma  of  the  pyloric  extremity  of  the 
stomach  and  a  retro-peritoneal  tumor  in  that  locality.  Inflation  of  the  stomach 
is  the  most  reliable  diagnostic  procedure  in  such  cases.  If  the  tumor  is  retro- 
peritoneal, it  becomes  covered  by  the  distended  stomach  ;  if  it  belongs  to  the 
stomach,  though  it  may  be  displaced  downward,  its  position  relative  to  the 
anterior  wall  of  the  abdomen  remains  unchanged  by  the  inflation.  The  exist- 
ence of  a  carcinoma  at  the  cardiac  orifice  can  be  shown  by  the  oesophageal 
bougie,  and  the  degree  of  contraction  at  this  point  is  ascertained  in  the  same 
manner.  A  carcinoma  of  the  stomach  may  be  suspected  if  a  patient  more 
than  forty  years  of  age  gives  a  history  of  disturbed  digestion  dating  back  for 
several  months  or  a  year,  combined  with  evidences  of  cardiac  or  pyloric  steno- 
sis. The  chemical  examination  of  the  contents  of  the  stomach,  so  much  relied 
upon  during  the  last  feAv  years  in  making  a  differential  diagnosis  between 
benign  and  malignant  affections  of  this  organ,  is  not  always  reliable,  but  will 
often  yield  valuable  diagnostic  information.  Free  hydrochloric  acid  is  not 
infrequently  found  in  the  stomach  contents  in  carcinoma,  and  it  may  be  ab- 
sent in  catarrhal  gastritis  and  non-malignant  pyloric  obstruction.  Hematemesis 
in  persons  beyond  middle  age,  and  enlargement  of  the  cervical  glands,  indi- 
cate malignant  disease.  A  tumor  affecting  the  anterior  wall  of  the  stomach 
can  usually  be  demonstrated  by  the  gastrodiaphanoscope. 

The  surgical  treatment  of  carcinoma  of  the  stomach  consists  either  in  the 
removal  of  the  mechanical  obstacle  which  interferes  with  the  introduction  of 
food  into  the  stomach  or  with  its  escape  from  it,  according  to  the  location  of  the 
tumor,  or  in  the  removal  of  the  disease.  In  carcinoma  of  the  cardiac  orifice  life 
can  be  prolonged  by  keeping  the  strictured  portion  patent  by  the  careful  intro- 
duction of  oesophageal  tubes.  Liquid  and  finely  divided  food  can  be  introduced 
in  this  manner.  If  the  stenosis  has  reached  such  an  extent  that  it  is 
difficult  to  introduce  stomach-tubes,  a  small  rubber  tube  should  be  passed 
through  one  of  the  nasal  passages  and  into  the  stomach,  to  be  retained  in 


718  .i.v  AM /:/:/( A. y  ri:xT-JiooK  of  sunaKRV. 

pliit-e,  and  tlirough  this  licjuid  food  can  be  injected  into  tlie  stomach.  If  this 
method  of  feedini:  is  no  lon<;er  possible,  a  pistrostomy  is  indicated.  A  limited 
carcinoma  of  the  pylorus,  if  it  has  not  resulted  in  secondary  infiltration  of  the 
lymphatic  glands  behind  it,  furnishes  a  legitimate  indication  for  a  radical  ope- 
ration. (See  Operations,  p.  725.)  If,  however,  the  disea.se  has  extended 
beyond  the  walls  of  the  stomach,  pylorectomy  is  contraindicated.  and  the  sur- 
geon must  be  content  to  establish  a  new  outlet  from  the  stomach  into  the  upper 
portion  of  the  small  intestine.  In  pyloric  carcinoma  life  is  greatly  prolonged 
and  much  suffering  prevented  by  placing  the  patient  on  a  carefully  selected 
diet  and  bv  resorting  to  irrigation  of  the  stomach  as  often  as  the  retention  of 
the  undigested  food  may  render  it  necessary. 

Gastric  Fistula. — An  external  gastric  fistula  may  form  as  one  of  the 
results  of  a  perforating  ulcer  of  the  stomach  if  adhesions  between  the  anterior 
surface  of  the  stomach  and  the  abdominal  wall  have  shut  out  the  peritoneal 
cavity  before  perforation  occurred.  It  may  also  develop  after  a  })erforating 
wound  of  the  stomach  if  peritonitis  is  prevented  by  a  speedy  union  between 
the  margins  of  the  visceral  and  parietal  wounds.  An  intentional  gastric  fistula 
may  require  surgical  treatment  for  its  closure  if  the  object  for  which  the  fistula 
was  made  has  been  accomplished,  as  when  it  has  been  undertaken  with  a  view 
of  dilating  a  cicatricial  stricture  of  the  cardiac  orifice  or  the  lower  portion  of 
the  cesophagus. 

Treatment. — If  the  fistula  is  short  and  leads  directly  into  the  stomach, 
an  effort  should  be  made  to  close  it  without  opening  the  peritoneal  cavity. 
The  abdominal  wall  should  be  incised  to  the  extent  of  at  least  two  inches  down 
to,  but  not  through,  the  peritoneum.  This  Aviil  expose  the  opening  in  the 
stomach.  The  lining  of  the  fistulous  track  is  now  freely  excised,  special  care 
being  taken  to  vivify  that  portion  of  the  fistula  which  corresponds  to  the  wall 
of  the  stomach.  In  closing  the  fistula  the  line  of  sutures  must  be  applied  in 
the  direction  off'ering  the  least  traction.  The  first  row  of  sutures  is  made  with 
fine  silk,  and  should  embrace  the  mucous  and  submucous  coats.  The  remain- 
incr  coats  of  the  stomach  are  broujrht  together  with  strong  catgut  sutures.  The 
margins  of  the  wound  corresponding  to  the  abdominal  wall  are  united  Avith  a 
deep  row  of  catgut  and  a  superficial  row  of  silk  sutures.  An  antiseptic  compress 
retained  with  long  strips  of  adhesive  plaster  constitutes  the  dressing.  Nothing 
should  be  given  by  the  stomach  for  at  least  four  or  five  days.  Thirst  is  quenched 
with  fragments  of  ice,  and  food  is  administered  exclusively  by  the  rectum.  If 
this  operation  shouM  fail,  and  in  cases  where  it  is  not  applicable,  the  abdo- 
men must  be  opened,  the  stomach  separated  from  the  abdominal  wall,  and  the 
fistulous  opening  closed  in  the  same  manner  as  a  visceral  wound  of  this  organ. 
Wherever  it  is  possible  to  cover  with  peritoneum  that  part  of  the  Avail  of  the 
stomach  Avhich  has  been  separated,  this  should  be  done,  as  this  Avill  secure  a 
more  speedy  and  certain  union  of  the  sutured  parts.  As  an  additional  precau- 
tion it  might  be  advisable  to  fasten  the  sutured  part  of  the  stomach  to  the 
inner  surface  of  the  abdominal  wound  Avith  a  few  catgut  sutures,  and  drain  the 
external  Avound  Avith  an  iodoform  gauze  tampon  d(»wn  to  this  ])oint.  Avhieh  Avould 
eff'ectually  protect  the  peritoneal  cavity  against  extravasation  should  the  visce- 
ral Avound  fail  in  healing  by  primary  intention. 

OPERATIONS  ON  THE  STOMACH. 

Gastrotomy. — The  term  gastrotomy  Avas  used  for  a  long  time  synony- 
mously Avith  abdominal  section  or  laparotomy,  as  Avell  as  to  designate  the  ope- 
ration of  temporarily  opening  the  stomach  for  the  removal  of  a  foreign  body,  etc., 


DISEASES    AM>    IX/i'Ji/ES    OE    THE   A  Ji DOMEX. 


71 'J 


but  is  now  restricted  to  the  latter  operation,  while  the  opening  ot  the  i)eritoneal 
cavity  is  designated  as  abdominal  section,  laparotomy,  or,  as  has  recently  been 
proposed  by  Harris,  coeliotomy.  As  compared  with  the  operation  whicli  will  be 
described  as  gastrostomy,  the  wound  in  the  stomach,  irrespective  of  its  purpose, 
is  always  closed  ;  that  is  to  sav,  gastrotomy  is  always  followed  by  gastron-haphy. 
Gastrotomv  is  performed  for  the  removal  of  foreign  bodies  which  have  become 
lod-ed  in  the  stomach,  or  for  tiie  rem-.val  of  a  gastrolith  (Thornton,  Schon- 
born,  and  others),  or  for  the  purpose  of  treating  lesions  withm  the  stomach. 
ITnder  the  last  heading  mav  be  mentioned  the  localization  and  direct  treat- 
ment by  excision  of  ulcers  and  the  digital  divulsion  of  cicatricial  strictures  ot 
the  pvloric  or  tbe  cardiac  orifice.  The  stomach  should  be  washed  out  with  a 
weak'aiitiseptic  solution,  such  as  salicvlated  water  or  boric-acid  solution,  im- 
mediately before  the  anesthetic  is  administered,  in  order  to  prevent  extrava- 
sation in  the  vicinity  of  the  wound  after  making  the  incision. 

In  the  majority  of  cases  it  will  suffice  to  make  an  incision  tlirough  tlie 
abdominal  wall  from  the  ensiform  cartilage  to  the  umbilicus,  and  if  more  room 
is  required  a  small  transverse  incision  can  be  added  on  the  side  of  the  median 
line  where  it  will  be  most  needed.     The  anterior  wall  of  the  stomach  is  now 
broutrht  well  forward  into  the  wound,  which,  if  the  organ  is  normal  in  size, 
can  ^eadilv  be  accomplished  without  inflation.      The  peritoneal  cavity  is  then 
protected  by  packing  sterile  gauze  around  the  exposed  portion  of  the  st/^m- 
ach.     The  incision  is  always  made  transversely  to  its  long  axis.      The  best 
method  of  opening  the  stomach  is  to  cut  down  to  the  mucous  membrane  with 
a  sharp  scalpel,  and  then  open  the  organ  between  two  catch-tooth  forceps  and 
enlarr'e  the  incision  to  the  reiiuisite  extent  with  blunt-pointed  scissors.    After 
the  foreign  body  has  been  extracted,  or  the  visceral  lesion  remedied,  the  wound 
is  closed^  in  the  manner  described  below.      Stomach-feeding  should  not  be 
commenced  for  at  least  four  days,  Avhen  small  quantities  of  liquid  food  are  to 
be  given  at  short  intervals.      Up  to  this  time  thirst   is  allayed  by  allowing 
small  fragments  of  ice  to  dissolve  in  the  mouth  and  by  enemata  of  salt  solu- 
tion, and%he  strength  of  the  patient  is  sustained  by  rectal  alimentation. 

Gastrorrhaphy.— Gastrorrhaphy  signifies  the  closure  of  a  woundof  the 
stomach  by  suturing.     It  is  done  in  the  same  manner  as  in  enterorrhaphy. 
After  careful  hemo?tasis,  the  deep  or  buried  sutures  are  first  applied.     These 
should  consist  of  fine  aseptic  silk,  are  made  to  include  all  the  coats  of  the 
stomach  with  the  exception  of  the  peritoneum,  and  are  cut  close  to  the  knot. 
About  four  sutures  to  an  inch  will  be  required    The  superficial  sutures  of  fine 
silk  should  include  the  peritoneum  and  enough  of  the  subjacent  tissue  to  give 
them  a  firm  hold.     An  ordinary  sewing-needle  is  inserted  about  a  quarter  of 
an  inch  from  the  margin  of  the  wound,  and  is  brought  out  near,  but  not  at, 
the  margin,  re-entered  on  the  opposite  side  at  a  similar  point,  and  brought  out 
at  the  same  distance  from  the  wound  on  the  opposite  side.     As  the  superficial 
sutures  are  being  tied  the  peritoneum  is  gently  inverted.     It  is  thought  by 
some  surgeons  (Senn)  that  slight  scarification  of  the  peritoneum   hastens  the 
process  of  repair ;  and  on  this  account  they  deem  it  advisable,  before  the  super- 
ficial sutures  are  tied,  to  subject  to  this  treatment  the  peritoneal  surfaces  which 
are  to  be  brought  into  apposition.     Others  are  of  the  opinion  that  scarification 
adds  nothing  to  the  rapidity  of  union  between  such  opposed  serous  surfaces. 
Gastrostomy. — Gastrostomy  is  an  operation  for  establishing  a  fistulous 
opening  in  the  stomach  through 'the  anterior  abdominal  wall.     A  resort  to  this 
operation  is  indicated  in  cases  of  malignant  or  cicatricial  stenosis  of  the  oesoph- 
a^rus  or  cardiac  orifice  of  the  stomach  advanced  to  such  an  extent  that  the 
introduction  of  food  per  viam  naturalem  or  by  the  use  of  tubes  is  no  longer 


720  A  A  AMi:m(  A.\    I  i:xr- HOOK  o/'  sr  1:01:1:  v. 

possible.  Tlie  results  of  this  operation  in  malignant  dist-ase  have  tlius  far  not 
proved  verv  satisfactory,  as  it  lias  seldom  been  jx-rfonueil  before  the  patient 
had  reached  an  extreme  dejz;ree  of  marasmus  ^vhi^•h  in  itself  proved  the  great- 
est source  of  danger.  As  the  object  of  the  operation  is  to  establish  a  <fastric 
fistula  through  which  food  can  be  introduced  into  the  stomach,  it  is  evident 
that  the  opening  in  the  stomach  sliould  be  made  as  near  as  possible  to  the  car- 
diac orifice.  In  all  instances  in  wliich  the  patient's  strength  warrants  the  per- 
formance of  the  oj>eration  in  two  stages,  as  was  first  suggested  by  Mr.  Ilowse, 
this  method  should  be  practised,  as  it  is  much  safer  than  that  by  Avhich  the 
stomach  is  opened  at  once. 

Forster,  Durham,  and  Verneuil  made  the  abdominal  incision  in  the  line  of 
the  left  linea  semilunaris.  Fenger's  incision  is  the  one  which  has  been  em- 
ployed most  fre(iuently.  This  incision,  from  three  to  four  inches  in  length,  is 
made  to  the  left  of  the  rectus  muscle,  a  little  below  and  parallel  to  the  left 
costal  arch.  The  tissues  are  divided,  layer  after  layer,  with  a  sharp  scalpel 
until  the  peritoneum  is  reached.  This  is  incised  between  two  forceps  and  the 
opening  enlarged  to  each  angle  of  the  wound.  It  is  essential  to  protect  the 
muscular  and  connective  tissues  of  the  belly-wall  against  the  action  of  micro- 
organisms and  the  gastric  juice ;  hence  the  first  thing  to  be  done  after  opening 
the  abdominal  cavity  is  to  suture  the  parietal  peritoneum  to  the  skin  with  fine 
silk  or  catgut  stitches.  If  it  is  difficult  to  find  the  empty  and  contracted 
stomach,  the  next  step  of  the  operation  is  to  inflate  the  organ,  which  will 
bring  its  anterior  wall  into  sight,  Avhen  it  can  be  drawn  into  the  wound. 
By  this  procedure  the  operation  is  greatly  facilitated  and  the  surgeon  will 
avoid  the  eiror  of  opening  the  colon  in  place  of  the  stomach,  as  was  done 
by  Maunder.  The  stomach  should  be  drawn  forward  sufficiently  to  make 
a  small  cone,  and  in  this  position  it  is  fastened  by  suturing  it  to  the  sides 
of  the  Avound.  Langenbeck  made  use  of  two  long  steel  needles  in  anchoring 
the  stomach  more  securely  in  the  wound,  the  needles  transfixing  both  margins 
of  the  wound  and  the  Avail  of  the  stomach.  The  needles  should  not  enter 
the  lumen  of  the  stomach. 

If  the  patient's  strength  can  be  maintained  by  rectal  alimentation  for  four 
or  five  days,  the  opening  of  the  stomach  sliould  be  postponed  until  that 
time,  as  then  the  organ  will  have  become  firmly  adherent  to  the  abdominal 
wound.  If,  however,  the  symptoms  are  very  urgent  and  the  delay  of  stomach- 
feeding  might  endanger  the  life  of  the  patient,  a  small  incision  is  made  at  once  in 
the  stomach,  into  Avhich  a  small  rubber  tube  is  fixed,  and  through  this  at  short 
intervals  licjuid  food  and  stimulants  are  injected.  The  opening  in  the  stomach 
should  never  be  large,  as  there  is  nearly  always  a  tendency  to  the  escape  of 
food  from  the  fistulous  opening.  That  even  five  days  will  not  always  suffice  to 
prevent  separation  of  the  stomach  from  the  abdominal  wound  is  shown  by  a 
case  in  which  the  needles  were  removed  on  the  fifth  day,  and  as  the  stomach 
appeared  to  be  firmly  adherent  it  was  opened  and  stomach-feeding  commenced. 
Two  days  later  the  stomach  was  found  completely  separated,  and  its  contents 
escaped    into   the   peritoneal  cavity,  causing  a  rapidly  fatal  ])eritonitis. 

A  number  of  operations  have  recently  been  devised  for  the  jmrjiose  of 
eflfectually  i»revejiting  leakage  through  the  fistulous  <)j)enings.  The  Ssabana- 
jew-Franck  method  (Fig.  288)  has  j)roved  satisfactory  in  many  cases.  The 
stomach  is  first  exj>osed  by  an  incision  parallel  with  the  left  costal  margin,  its 
anterior  wall  seized  and  a  cone  drawn  out.  A  second  incision  parallel  with 
the  first  is  now  made  one  inch  al)0ve  the  costal  margin,  and  the  two  made  to 
communicate  by  freeing  the  skin  from  the  sulijacent  muscles  by  blunt  dissec- 
tion.     The  portion  of  stonuich  which  had  been  seized  is  carried   under  this 


f)isi:ASEs  Axi)  ly.niur.s  or  riii:  ahdomen.        721 

bridge  of  skin  and  out  of  the  secontl   incision,   wliere  it  is  sutured.     The 
first  incision  is  tiicn   closed.      The  stonnich   nuiy  be  opened  at  once,  or  at  a 


Fk;.  1>8S. 


The  Ssnbanajew-Franck  Method  of  (instrostomy. 

later  time  if  there  be  no  haste.     By  thus  brincring  the  stomach  out  over  the 
border  of  the  costal  cartilages  leakage  is  largely  prevented. 

E.  J.  Senn  relies  on  a  circular  valve,  which  he  forms  by  inverting  and 
ftisteninir  witb  sutures  the  tip  of  the  cone  in  preventing  the  escape  of  the 
food.  The  last-mentioned  procedure  has  yielded  excellent  functional  results 
in  the  hands  of  a  number  of  operators. 


Witzel's  Method  of  Gastrostomy :  a,  first  stage-c,  the  rubber  tube ;  a,  a',  b,  6',  two  folds  of  the  wall  of 
stomach  with  threads  inserted ;  d,  hole  in  stomach  for  insertion  of  tube,  b,  second  stage-tube  buried 
by  tying  the  stitches,  thus  approximating  a  to  h,  and  a'  to  b'. 

Witzel  has  proposed  a  new  method  of  performing  gastrostomy  which  has 
yielded  excellent  results,  and  has  been  quite  generally  adopted  by  the  pro- 
fession. The  external  incision  is  made  to  the  left  of  the  median  line  through 
the  rectus  muscle.  After  bringing  the  stomach  forward  into  the  wound,  an 
opening  is  made  at  the  desirable  point  in  the  anterior  wall  large  enough  to 
permit'the  insertion  of  a  rubber  tube  a  little  larger  than  an  ordinary  lead- 
pencil  (Fig.  289  A,  e).  After  the  introduction  of  the  tube  two  vertical  folds,  one 
on  each  side  of  the  opening,  are  made  (a,  a',  b,  h'\  which  are  united  over  the 
tube  by  a  number  of  muscular  sutures  to  a  distance  of  at  least  two  inches 
(Fig.  289  b).    The  distal  end  of  the  tube  is  brought  out  through  the  upper  angle 

46 


1-22  Ay    AMK1U<JA.\    TKXT-JiOOk'    <)l     SI  lid  Ell  Y. 

)t"  till'  external  incision,  to  which  the  stomach  is  securely  fastened  with  a 
number  of  sutures,  after  which  tlie  balance  of  the  external  wound  is  closed. 
Food  can  be  introduced  at  once  throufjh  the  tube.  The  tube  may  sometimes 
be  removed  after  a  permanent  channel  has  been  established,  and  reinserted 
only  for  feeding  purposes.  The  valvular  construction  of  the  internal  opening 
effectually  prevents  the  escape  of  food.  Keen  and  others  have  reported  suc- 
cessful cases  by  this  method. 

After  the  fistula  has  been  well  established  the  stomach-feeding  is  to  be 
managed  in  such  a  manner  that  the  patient  masticates  all  solitl  food,  which  is 
then  injected  through  a  rubber  tube,  or,  if  the  opening  and  tube  are  large 
enough,  it  is  poured  in  through  a  funnel.  The  act  of  mastication  satisfies  at 
least  in  part  the  sensation  of  hunger,  which  is  not  always  the  case  if  stomach- 
feeding  is  exclusively  relied  on.  Gross  and  Zesas  have  collected  respectively 
207  and  162  cases,  with  surprisingly  different  rates  of  mortality ;  that  of  Gross 
being  only  29.47  per  cent.,  while  Zesas'  mortality  was  GO  per  cent,  for  cica- 
tricial stenosis  and  84  per  cent,  for  malignant  cases.  The  operation  should 
not  be  made  responsible  for  this  bad  showing,  however,  because  we  have  reason 
to  believe  that  in  most  cases  the  disease  would  have  proved  fatal  in  a  short 
time  without  it.  These  unfortunate  results  should  only  remind  us  not  to  post- 
pone the  operation  until  the  patient  has  not  sufficient  recuj)erative  powers  left 
to  rally  from  its  immediate  effects  and  to  secure  satisfactory  repair.  If  gas- 
trostomy is  undertaken  as  a  preliminary  step  in  the  treatment  of  impermeable 
cicatricial  strictures  of  the  cardiac  orifice  or  of  the  lower  portion  of  the  oesoph- 
agus, the  fistula  is  closed  as  soon  as  the  patency  of  the  normal  channel  has 
been  restored  by  rapid  or  gradual  dilatation. 

Digital  Divulsiox  of  Cicatricial  Strictures  of  the  Pylorus. — In 
1883,  Loreta  of  Bologna  introduced  a  new  method  of  treating  non-malignant 
strictures  of  the  pylorus,  which  consists  in  opening  the  stomach  a  little  nearer 
the  pyloric  than  the  cardiac  extremity,  and  passing  first  the  right  index  finger 
through  the  strictured  portion,  and  later  also  the  left,  and  then  separating  them, 
as  he  did  in  the  first  case,  more  than  three  inches.  Considerabk  force  is  usu- 
ally required  in  dilating  the  stricture  to  this  extent,  and  during  such  forcible 
stretching  there  is  always  danger  of  tearing  through  the  entire  thickness  of  the 
wall  of  the  pylorus.  The  wound  of  the  stomach  is  closed  in  the  same  manner 
as  after  gastrotomy  for  other  purposes.  The  stomach  should  be  thoroughly 
emptied  by  irrigation  with  a  boric-acid  solution  before  the  operation,  and  dur- 
ing the  stretching  process  the  visceral  wound  should  be  drawn  well  into  the 
abdominal  incision.  Notwithstanding  the  f^ict  that  a  number  of  successful 
operations  of  this  kind  have  been  reported,  it  is  more  dangerous  and  uncertain 
in  its  results  than  the  pyloro-plastic  operation  of  Heineke-Mikulicz  (see  below). 
To  the  immediate  risks  of  Loreta's  operation,  rupture  of  the  pylorus  and  hemor- 
rhage, must  be  added  recurrence  of  the  stricture,  which  is  certainly  one  of  the 
most  common  remote  consequences  following  the  treatment  of  cicatricial  stenosis 
by  rapid  or  slow  dilatation,  wherever  the  stricture  may  b:  located.  In  this 
particular  it  can  hardly  be  a.«sumed  that  stricture  of  the  pyiorus  constitutes  the 
sole  exception.  The  same  distinguished  surgeon  resorted  to  instrumental  divul- 
sion  of  cicatricial  stenosis  of  the  cardiac  orifice  through  an  incision  of  the  stomach, 
and  the  two  cases  which  he  treated  by  this  method  were  reported  as  cured. 
The  dilatation  was  made  with  an  instrument  resembling  that  of  Dupuytren  for 
lithotomy. 

Forcible  dilatation  of  strictures  of  the  cardiac  orifice  is  a  far  more  difficult 
operation  than  stretching  of  the  pylorus,  but,  as  from  the  inaccessibility  of  this 


JJISKASES   AM)    I.\jriiJi:s    OF    Till':    AJiJXjMEN. 


723 


region  no  plastic  operation  can  be  performed,  the  operation  will  have  a  limited 
field  of  usefulness  in  the  surgery  of  this  part  of  the  stomach. 

Pyloroplasty. — The  operation  for  cicatricial  stenosis  of  the  pylorus 
well  deserves  the  name  pyloroplasty,  as  it  not  only  removes  the  mechanical 
obstruction,  but  at  the  same  time  creates  a  new  pylorus.  This  operation 
was  first  devised  by  Ileineke  of  Erlangen,  and  eleven  months  later  Mikulicz, 
ignorant  of  lleineke's  work,  did  the  oj)eration  in  exactly  the  same  manner. 
The  operation  is  done  by  cutting  through  the  anterior  wall  of  the  pylorus 
and  extending  the  incision  about  an  inch  toward  the  stomach  and  the  same 
distance  in  the  direction  of  the  duodenum,  as  is  shown  in  Fig.  290.  This 
incision  divides  the  stricture,  and  the  contracted  pylorus  becomes  the  pos- 
terior wall  of  the  new  pylorus  by  retracting  the  margins  of  the  wound  on 
each  side  at  the  center  with  a  tenaculum  and  suturing  the  wound  trans- 
versely  to  the  long  axis  of  the  stomach,  as  represented  in  Fig.  290.     The 

Fig.  291. 
Fig.  290. 


Pyloroplasty  :  theuxisof  the  incision  is  changed 
Pyloroplasty:  the  incision.  by  traction  from  horizontal  to  vertical:  su- 

tures in  position  ;  only  one  of  the  two  rows 
of  sutures  is  shown. 

new  pylorus  is  made  up  of  tissue  taken  partly  from  the  duodenum  and  partly 
from  the  anterior  wall  of  the  stomach,  the  posterior  wall  being  composed  of 
the  narrow,  contracted  pylorus.  In  suturing  the  wound  it  is  advisable  to  tie 
first  from  each  angle  of  the  wound,  tying  the  central  sutures  last  (Fig.  291). 
Two  rows  of  sutures  are  employed,  the  same  as  in  closing  a  wound  of  the 
stomach.     Recurrence  of  the  stricture  is  a  physical  impossibility,  as  the  new 

Fig.  292. 


Pyloroplasty  :  aftt-r  tying  the  sutures. 


pylorus  is  composed  mostly  of  healthy  ti.ssue,  and  the  danger  attending  the 
operation  is  not  greater  than  that  which  accompanies  an  ordinary  wound  of 
the  stomach.  The  results  of  this  operation  have  been  very  satisfactorv,  and 
it  is  almost  certain  that  it  will  take  the  place  of  all  other  operations  in  the 
surgical  treatment  of  cicatricial  pyloric  stenosis  ia  which  the  pathological 
conditions  permit  of  mobilizing  tissue  for  the  construction  of  the  new  pylorus. 


7:^4  ^l.V   AMERICAN    TEXT- HOOK    OF   SlJiaEIiV. 

Gastro-extkhostu.mv. — This  operation  is  intended  to  establish  an  anas- 
tomotic openin<2;  between  the  stomach  and  upper  portion  of  tlie  suiail  intestine 
in  eases  of  malignant  stenosis  of  the  ftylorus.  It  was  devised  and  first 
practised  by  WiilHer.  He  made  an  incision  about  three  inches  in  lenffth 
m  the  anterior  wall  of  the  stomach  at  a  safe  distance  from  the  carcinoma  and 
near  the  great  curvature,  and  a  similar  incision  in  the  convex  side  of  the  intes- 
tines about  thirty  inches  below  the  plica  duodeno-jejunalis,  and  united  these 
two  visceral  wounds  with  sutures,  thus  establishing  a  direct  communication  be- 
tween the  stomach  and  the  small  intestine.  In  uniting  the  ppsterior  margins 
of  the  wounds  the  serous  or  superficial  sutures  should  be  first  inserted  and  tied, 
and  then  the  inner  or  second  row  of  sutures  are  tied  and  cut  short  to  the 
knot.  J^ilk  should  be  used  exclusively  as  suturing  material.  It  is  advis- 
able to  insert  and  to  tie  securely  the  posterior  row  of  Lembert's  sutures 
before  the .  visceral  incisions  are  made.  In  Wolfler's  operation  the  move- 
ments of  the  intestine  at  the  point  of  juncture  are  in  a  direction  opposite 
to  the  peristaltic  action  of  the  stomach,  a  condition  which  must  be  unfavor- 
able to  the  easy  escape  of  the  stomach  contents  into  the  intestinal  canal — a 
circumstance  which  led  Rockwitz  so  to  modify  the  operation  that  he  turns  the 
intestinal  loop  one-half  around  its  axis  and  unites  it  with  the  stomach  in  this 
position,  and  thus  brings  the  two  organs  in  such  a  relative  position  that  the 
peristaltic  wave  of  both  is  in  the  same  direction.  Yon  Hacker  has  modified 
the  operation  still  further,  and  establishes  the  communicating  opening  in 
the  posterior  instead  of  the  anterior  wall  of  the  stomach.  This  is  the  opera- 
tion of  choice.  The  portion  of  intestine  which  should  be  united  with  the 
stomach  is  that  which  lies  from  twenty-four  to  thirty  inches  below  the  pylorus. 
Operators  have  experienced  a  great  deal  of  difficulty  in  finding  this  place 
without  too  great  loss  of  time  and  unnecessary  handling  of  the  intestines. 
Luecke  advises  to  seize  and  unite  with  the  stomach  the  first  intestinal  loop 
that  presents  itself  in  the  wound,  and  gives  it  as  his  opinion  and  the  result 
of  his  experience  that  in  doing  so  the  anastomotic  o])ening  will  invariably  be 
made  near  the  desirable  point  and  not  distant  from  the  duodenum.  This 
advice  has  led  to  serious  mistakes.  In  one  case  in  whicli  this  direction  was 
followed,  the  post-mortem  revealed  that  the  opening  had  been  made  eight 
feet  below  the  pylorus,  and  in  one  of  Lauenstein's  cases  the  opening  was 
found  near  the  ileo-Ciecal  region,  conse(|uently  nearly  the  entire  lengtli  of 
the  small  intestine  had  been  excluded  from  participation  in  the  processes  of 
digestion  and  absorption. 

In  searching  for  the  upper  portion  of  the  small  intestine  it  is  not  always 
easy  to  find  the  plica  duodeno-jejunalis.  The  following  plan  of  search  may  be 
recommended.  The  first  loop  that  presents  itself  is  brought  forward  into  the 
wound,  and  is  held  in  this  position  by  an  assistant,  while  the  surgeon  follows 
the  intestine  in  one  direction,  observing  carefully  its  color  and  the  thickness 
of  its  walls  as  loop  after  loop  is  examined.  If  the  intestine  leads  in  an 
upward  direction,  the  color  becomes  paler  and  the  walls  thicker,  and  the  duo- 
denum will  soon  be  reached.  If  he  is  tracing  the  bowel  in  an  opposite  direc- 
tion, the  intestine  becomes  gradually  smaller,  its  walls  thinner,  and  the  color 
is  more  of  a  bright  red.  Should  this  be  the  case,  the  loops  of  the  intestines 
are  returned,  and  the  examination  is  made  from  tlie  loop  held  by  the  assistant 
in  an  opposite  direction,  which  will  soon  lead  to  the  part  that  it  is  intended  to 
unite  with  the  stomach.  As  soon  as  the  desirable  loop  is  reached,  it  should  be 
turned  around,  and  held  in  this  position  by  an  assistant  until  the  anastomosis 
has  been  completed  (Fig.  2'.t8).  According  to  Keen,  from  1891  to  1806,  401 
gastro-enterostoraies  had  been  reported,  with  a  mortality  of  33.91  per  cent. 


DISEASES   A XI)    IXJllilES    OF    THE   ABDOMEN. 


725 


Fio.  293. 


Gastro-enterostomy  (Rockwitz). 


Mikulicz  lias  oj)erate(l  on  74  cases  with  24  deaths  (32.5  ])er  cent.).  Carle 
i-t|)ort8  27  ^astro-enterostoniies  for  non-malignant  stricture,  with  but  two 
deaths,  and  one  of  these  was  due  to 
hemorrhage  from  an  ulcer  of  the  stom- 
ach, and  not  to  the  operation.  The 
mortality  is  due  to  the  deldlitnted  con- 
dition of  the  patients  operated  on  and 
to  the  great  length  of  time  required 
to  unite  the  visceral  wounds.  Unnec- 
essary loss  of  time  is  a  source  of  great 
danger  in  the  class  of  cases  in  which 
it  becomes  necessary  to  make  a  gastro- 
enterostomy. 

Senn  has  modified  Wolfler's  opera- 
tion by  securing  apposition  between 
the  stomach  and  the  intestine  by  means 
of  perforated  decalcified  bone  plates, 
which  he  asserts  greatly  shortens  the  operation  and  brings  the  parts  into  a 
more  favorable  condition  for  speedy  union.  This  procedure  and  its  modifica- 
tions are  fully  described  in  the  chapter  on  Intestinal  Obstruction.  The 
approximation  plates  are  reinforced  by  a  number  of  superficial  sutures  in  the 
same  manner  as  in  establishino;  an  intestinal  anastomosis.  The  serous  sur- 
faces  interposed  between  the  plates  must  be  scarified.  As  the  mucous  mem- 
brane of  the  stomach  shows  a  great  tendency  to  turn  out,  it  should  be  fastened 
in  the  middle  of  the  wound  on  each  side  with  a  fine  catgut  suture  before  the 
viscera  are  approximated.  A  gastro-enterostomy  with  the  aid  of  approxima- 
tion plates  can  be  completed  in  half  an  hour.  At  the  present  time  the  Murphy 
button  has  superseded  most  of  the  other  mechanical  devices  for  approximating 
the  stomach  and  intestine,  as  well  as  different  portions  of  the  intestine. 

The  tendency  of  many  surgeons,  however,  is  to  abandon  mechanical  aids 
of  all  kinds  and  to  rely  on  suturing  exclusively  in  performing  gastro-enter- 
ostomy and  entero-anastomosis. 

Patients  with  carcinoma  of  the  pylorus  who  survive  a  gastro-enterostomy  are 
relieved  of  much  suffering  and  live  in  comparative  comfort  for  from  three  months 
to  a  year  or  more.  The  operation  proves  most  beneficial  in  cii-cular  car- 
cinoma of  the  pylorus  with  great  distention  of  the  stomach.  It  is  contraindi- 
cated  if  the  disease  has  become  diffuse  and  the  organ  is  not  much  dilated.  The 
operation  is  also  not  applicable  if  the  general  strength  of  the  patient  is  so  much 
reduced  that  death  is  likely  to  result  from  the  immediate  effects  of  the  pro- 
cedure, or  if  the  disease  has  extended  to  other  important  organs  and  death 
would  ensue  in  a  short  time  from  this  cause.  In  well-selected  cases  gastro- 
enterostomy is  a  legitimate  operation  which  is  destined  to  relieve  suffering, 
prolong  life,  and  reflect  credit  on  the  achievements  of  modern  surgery. 

Pylorectomy. — Excision  of  the  diseased  pylorus  is  called  pylorectomy. 
This  operation,  first  done  on  animals,  was  suggested  by  Winiwarter  and  Gussen- 
bauer  as  a  remedy  for  carcinoma  of  the  pyloric  end  of  the  stomach,  but  the  first 
operation  on  the  human  subject  was  done  by  Billroth.  The  mortality  in 
cases  with  extensive  adhesions  is  72.7  per  cent.,  while  it  is  but  27.2  per 
cent,  in  those  free  from  the  adhesions.  Of  84  cases  in  the  practice  of 
Kocher,  Kronlein,  Czerny,  and  Mikulicz,  there  were  75  per  cent,  of  suc- 
cesses. Of  those  that  survived  the  immediate  effects  of  the  operation,  all 
but  one  died  in  a  period  varying  from  four  to  eighteen  months.  Gastro- 
enterostomy can  show  a  much  lower  mortality  and  a  prolongation  of  life  of 


■2(j 


AN   AMJ'JJilCAX    TEXT- HOOK    OF   SlIidKnY. 


the  survivors  of  from  two  months  to  a  year  and  more.  Pylorectoniy  .should  Ite 
limited  to  cases  of  circumscribed  annular  carcinoma  of  the  pylorus  in  -which 
the  disease  has  not  extended  beyond  the  wall  of  the  viscus.  Adhesions  of  the 
pylorus  to  other  organs  and  the  presence  of  infected  lymphatic  glands  are  abso- 
lute contraindications.  As  a  positive  diagnosis  of  carcinoma  of  the  pylorus 
cannot  usually  be  made  suflSciently  early  to  justify  this  operation,  the  surgeon 
■will  generally  find,  after  he  has  opened  the  abdomen  and  ascertained  by  direct 
inspection  ami  palpation  the  extent  of  the  disease,  that  he  is  forced  to  abandon 
the  original  intention,  and  Avill  complete  the  operation  by  making  a  gastro- 
enterostomy. In  the  absence  of  regional  metastasis  and  extension  of  the  dis- 
ease by  contiguity  to  adjacent  organs,  a  radical  operation  is  indicated,  provided 
the  patient's  strength  is  sufficient  to  warrant  its  performance.  It  is  to  be  hoped 
that  future  research  will  enable  physicians  to  make  a  sufficiently  early  diagnosis 
to  bring  all  cases  of  pyloric  carcinoma  within  the  reach  of  successful  radical 
surgical  treatment. 

Preparatory  to  the  operation  the  stomach  should  be  placed  in  a  ccndition 
of  absolute  physiological  rest  for  at  least  two  days,  during  whicli  time  it  should 
be  washed  out' daily  through  an  elastic  siphon  tube  with  a  weak  antiseptic  solu- 
tion, such  as  salicylated  water  or  a  solution  of  boric  acid,  and  for  the  last  time 
this  should  be  done  immediately  before  the  anesthetic  is  given.  If  no  contra- 
indications are  present,  chloroform  should  be  given  in  preference  to  ether,  as  it 
is  less  liable  to  be  followed  by  retching  and  vomiting.  In  opening  the  abdo- 
men Billroth  prefers  a  transverse  incision  made  over  the  middle  of  the  tumor, 
if  such  is  present,  and  sufficiently  long  to  secure  ready  access  to  the  seat  of 
operation.  Bleeding  must  be  carefully  arrested  before  the  peritoneal  cavity  is 
opened.  The  pylorus  is  now  brought  well  forward  into  the  wound  with  vol- 
sellum  forceps,  and  the  peritoneal  cavity  is  protected  against  infection  during 
the  operation  by  packing  aseptic  or  iodoform  gauze  around  the  parts  to  be 


Fig.  294. 


Fi(i.  -290. 


Oblique  Division  of  the  Stomach  and  Duod- 
enum in  Pylorectomy  (EJsmarch  and  Kow- 
alzig). 


Duodenum  united  to  the  'irvatir  Curvature:  upper  por- 
tion of  incision  throuf,'h  the  stomach  sutured  before 
the  section  was  completed  lEsmarch  and  Kowalzin). 


excised.  The  omentum  below  the  pylorus  is  tied  in  small  sections  and  divide<l 
between  two  silk  ligatures.  The  other  connections  are  dealt  with  in  a  similar 
manner.  As  soon  as  the  pylorus  is  isolated  it  can  be  drawn  farther  forward  into 
the  wound,  and  a  small  compress  of  gauze  or  a  sponge  is  placed  underneath  it ; 
in  either  case  the  precaution  should  be  taken  to  attach  a  forceps  to  guard 
against  losing  the  compress  or  sponge  in  the  abdominal  cavity.  If  the  stom- 
ach has  been  washed  out  thoroughly,  there  is  no  danger  of  perit(mitis  from 
extravasation,  as  the  small  quantity  of  fluid  which  it  contains  can  be  removed 
with  a  sponge  as  it  escapes  when  the  organ  is  incised,  or  it  is  taken  up  by  the 
underlying  gauze.  The  incision  through  the  duodenum  and  stomach  should 
be  made  at  least  an  inch  from  the  border  of  the  tumor  (Fig.  294).     As  the 


4 

DISEASES   AND    INJURIES    OF    THE    AHDOMEN.  I'll 

incision  thvongli  the  stomach  will  be  much  larger  than  that  through  the  duo- 
denum, Billroth  commences  at  the  upper  border,  and  follows  the  knife  by 
suturing  until  the  remaining  length  of  the  incision  will  correspond  with  the 
section  through  the  duodenum,  wdien  the  section  is  completed,  the  duodenum 
divided,  and  the  part  removed.  The  duodenum  should  always  be  attached  to 
the  larger  curvature  of  the  stomach,  as  shown  in  Fig.  21>r>. 

In  uniting  the  duodenum  with  the  stomach  fine  aseptic  silk  sutures  are 
inserted  by  a  round  needle  in  a  holder,  first  at  the  cut  edge  of  the  stomach 
between  the  mucous  and  muscular  coats,  so  as  to  include  the  muscular  coat 
and  the  ])eritoneum ;  then  inversely  through  the  same  layers  of  the  duodenum; 
and  finally  brought  out  between  these  layers  and  the  mucous  membrane  at  the 
cut  edge  of  the  duodenum.  After  tying  the  posterior  sutures  the  anterior  por- 
tion of  the  wound  is  closed  in  the  usual  manner.  In  bringing  the  cut  sur- 
faces together,  care  must  be  taken  to  avoid  the  formation  of  folds.  Billroth 
warns  not  to  attach  the  duodenum  to  the  lesser  curvature  of  the  stomach, 
as  the  location  of  the  new  pylorus  in  that  locality  is  unfavorably  situated  for 
the  free  escape  of  the  contents  of  the  stomach  into  the  duodenum.  Any  weak 
points  in  the  line  of  suturing  should  be  reinforced  by  superficial  sutures.  In 
some  cases  Billroth  sutured  the  incision  in  the  stomach  completely,  and 
implanted  the  duodenum  into  a  slit  in  the  anterior  wall  of  the  stomach  near 
the  greater  curvature.  In  some  instances  it  may  be  found  advantageous  to 
close  both  incisions  and  follow  the  pylorectomy  by  a  gastro-enterostomy,  a 
method  of  operating  which  has  recently  been  brought  prominently  to  the  atten- 
tion of  the  medical  profession  by  Bulfof  New  York  and  Tuholske  of  St.  Louis, 
the  first  of  whom  reports  two  successful  cases.  The  abdominal  incision  must 
be  carefully  closed  by  several  rows  of  buried  sutures  and  by  superficial  sutures, 
and  tension  relieved  by  at  least  two  button  sutures.  The  after-treatment,  as 
in  all  other  operations  on  the  stomach,  consists  in  withholding  food  by  the  stom- 
ach for  several  days,  relying  during  this  time  exclusively  on  rectal  feeding  and, 
if  need  be,  on  the  hypodermatic  administration  of  stimulants.  After  two  or 
three  days  small  quantities  of  liquid  food  frequently  repeated  are  allowed,  but 
solid  food  must  be  strictly  excluded  from  the  diet  until  the  visceral  wound  is 
healed.     Should  flatulency  occur,  it  is  relieved  by  a  turpentine  enema. 

Gastrectomy. — Gastrectomy  literally  signifies  the  excision  of  the  entire 
stomach,  but  as  the  term  has  been  used  in  surgery  until  recently  it  means  the 
removal  of  only  a  part  of  this  organ.  In  pylorectomy  a  partial  gastrectomy 
is  always  made ;  but  if  a  portion  of  the  stomach  is  removed  Avithout  excision 
of  the  pylorus,  the  operation  is  known  as  a  partial  gastrectomy.  In  the  sur- 
gery of  the  stomach  this  operation  may  come  into  use  in  the  excision  of  an 
ulcer  or  the  removal  of  a  limited  carcinoma  in  the  anterior  Avail  of  the  stom- 
ach or  the  greater  curvature.  In  removing  a  portion  of  the  wall  of  the 
stomach  for  either  of  these  indications  the  incisions  should  be  made  in 
such  a  manner  that  the  resulting  wound  can  be  safely  sutured  with  the 
least  possible  tension  and  without  reducing  the  lumen  of  the  organ  more 
than  is  absolutely  necessary  for  the  complete  removal  of  the  disease. 

When  the  entire  stomach  is  removed  the  operation  is  called  total  ga^strec- 
tomy.  The  first  complete  excision  of  the  stomach  for  malignant  disease 
was  performed  by  Schlatter,  of  Zurich,  during  the  winter  of  1897.  The 
patient,  a  Avoman,  greatly  debilitated  by  the  disease,  recovered  and  lived  for 
fourteen  months.  Digestion  and  assimilation  seemed  to  be  but  little  impaired 
by  the  loss  of  the  stomach.  A  few  other  similar  cases  have  been  reported  by 
Brigham.  Richardson,  and  others,  Avith  some  successes.  Complete  gastrec- 
tomy has  necessarily  a  very  limited  legitimate  application  in  surgery. 


728  J.v  AMi:i;i(Ay   riixr-iiooK  oy  srnai.uy 


PART   irr.-DISEASE8   AND   INJITRIES  OF  THE   INTESTINES. 

Wounds  and  Rupture  of  the  Intestines. — Gunshot  and  stab  wounds 
of  the  intestines  have  been  described  in  a  previous  chapter,  and  it  is  only 
necessarv  here  to  refer  verv  briefly  to  tlie  subject  of  contused  and  hicerated 
wounds  caused  by  external  violence,  but  not  attended  by  a  perforatiiit;  wound 
of  the  abdomen.  Contused  and  lacerated  wounds  of  the  intestine  result  usually 
froni  a  kick  or  blow  or  from  the  passage  of  a  carriage-wheel  over  the  abdomen. 

In  a  contusion  of  the  intestine  all  the  coats  may  be  injured  without 
fecal  extravasation  taking  place.  Such  an  injury  is  followed  by  more  or  less 
inflammation  of  the  injured  part  and  circumscribed  })eritonitis.  If  the  injury 
is  not  extensive,  adhesion  to  an  adjacent  serous  surface  takes  place,  and  the 
patient  recovers.  If,  however,  the  inflammation  is  severe,  gangrene,  perfora- 
tive peritonitis,  and  death  ai'e  almost  sure  to  follow.  Rupture  of  the  intes- 
tine varies  in  extent  from  a  few  lines  to  complete  division  of  the  bowel.  The 
size  of  the  wound  in  partial  rupture  and  of  the  lumen  of  the  intestine  in  com- 
plete laceration  is  diminished  by  bulging  of  the  mucous  membrane.  As  in 
cases  of  stab  and  gunsiiot  wounds  of  the  intestines,  contusion  and  laceration 
of  the  intestines  are  injuries  which  are  seldom  diagnosticated  before  the  abdo- 
men is  opened  or  before  the  diseases  to  which  they  give  rise  make  their  appear- 
ance. In  rupture  of  the  intestine  extravasation  and  hemorrhage  often  cause 
symptoms  resembling  shock,  but  these  are  not  invariably  present  and  are  by 
no  means  pathognomonic.  It  is  possible  that  in  the  future  the  hydrogen-gas 
test  will  yield  valuable  diagnostic  information  in  the  differentiation  between 
contused  and  lacerated  wounds.  If  there  be  an  opening  in  the  intestine,  the  gas 
will  escape  through  it  and  produce  a  well-marked  free  tympanites.  The  prob- 
able diagnosis  must  rest  on  the  manner  in  which  the  injury  was  inflicted,  the 
degree  of  force  applied,  and  a  careful  study  of  the  local  and  general  symptoms. 

Treatment. — Patients  who  have  received  an  injury  of  the  abdomen 
should  be  kept  in  bed  on  an  absolute  diet  for  several  days  if  the  symptoms 
are  such  as  to  make  a  rupture  of  the  intestine  improbable.  Under  this  treat- 
ment a  contusion  of  the  intestine  will  be  followed  by  recovery,  as  a  rule.  If 
the  symptoms  point  to  the  probability  of  a  rupture  of  the  intestine,  immediate 
laparotomy  should  be  performed,  as  by  following  this  course  the  chances  for  a 
favorable  result  are  much  better  than  if  the  0})eration  is  postponed  until  symp- 
toms of  peritonitis  set  in. 

The  external  incision  should  be  made  through  the  linea  alba.  If  intra- 
peritoneal hemorrhage  has  taken  place,  this  demands  the  first  attention.  If 
the  laceration  is  not  readily  found,  rectal  insufflation  of  hydrogen  gas  or  filtered 
air  will  point  out  and  locate  the  visceral  injury  at  once.  Immediate  enteror- 
rhaphy  deserves  the  preference  over  the  formation  of  an  artificial  anus,  as  it  is 
not  attended  by  any  greater  immediate  risk  to  life  and  does  away  with  the 
remote  dangers  incident  to  a  secondary  operation.  Lacerated  wounds  of  the 
intestine  are  closed  in  the  same  manner  as  incised  wounds,  only  that  perhaps 
the  margins  of  the  wound  should  be  more  inverted,  in  order  to  secure  apposi- 
tion between  healthy  serous  surfaces.  If  the  lacerated  wound  presents  contused 
margins,  it  may  become  necessary  to  cover  the  contused  area  with  an  omen- 
tal graft  in  order  more  effectually  to  guard  against  the  occurrence  of  sub- 
sequent perforation.  If  the  mesentery  is  torn  it  also  must  be  sutured.  As 
some  extravasation  always  takes  place  in  lacerated  wounds  of  the  intestines,  it 
is  necessary  to  flush  the  abdominal  cavity  with  normal  salt  .-olution  before 
the  external  wound  is  closed,  and  to  make  ample  provision  for  drainage.  The 
after-treatment  consists  in  stimulation  to  counteract  shock  and  in  securing  rest 


DISK  ASKS    AM)    IXJllilKS    OF    THE   ABDOMEN.  729 

for  the  injured  iute.stine  by  w  ithhuldiug  food  by  the  stoiuacli  for  several  days 
and  by  the  administration  of  opiates. 

Pkufokatiox  from  Typhoid  Fever. — Typhoid  fever  is  one  of  the  causes 
of  perforation  of  the  intestine.  The  mortality  due  to  perforation  is  shown 
by  Fitz's  table  to  l)e  6. AS  per  cent.,  figures  Avhich  i)ractically  represent  the 
freijuency  of  the  condition.  It  is  most  apt  to  occur  during  the  third  week 
of  the  disease.  A  perforation  is  often  preceded  by  marked  leucocytosis,  and 
occasionally  by  pronounced  localized  tenderness.  When  perforation  occurs 
the  individual  passes  into  a  state  of  profouiul  shock.  In  this  state  he  may 
die;  but  he  usually  rallies,  the  rally  being  generally  followed  by  se))tic 
peritonitis  and  death.  After  perforation,  as  a  rule,  the  liver  dulness  dis- 
appears. There  is  no  (piestion  that  it  is  the  duty  of  the  surgeon  to  operate 
in  such  cases.  He  should  not  operate  during  early  shock  ;  but  must  wait — 
but  only  a  reasonable  time — for  the  rally,  hurrying  the  reaction  as  much  as 
possible  by  hot  enemata,  the  hypodermatic  injection  of  strychnia,  wrapping 
the  patient  in  hot  blankets,  hy])odernioclysis,  etc.  The  most  favorable  time 
to  operate  is  within  the  first  twelve  hours.  After  twenty -four  hours  opera- 
tion is  almost  hopeless.  In  83  cases  tabulated  by  Keen  there  were  IG  re- 
coveries. When  a  fair  degree  of  reaction  is  obtained  open  the  abdomen,  the 
incision  being  over  the  seat  of  perforation  if  any  signs  point  to  it ;  otherwise 
in  the  linea  alba.  When  the  point  of  perforation  is  found  the  opening  is 
closed  by  Lembert  sutures  of  silk.  It  is  not  necessary  to  excise  the  edges 
of  the  ulcer.  The  abdomen  is  irrigated  with  plenty  of  hot  salt  solution. 
Wipe  with  care  betw-een  the  liver  and  diaphragm  and  in  the  recto-vesical 
pouch.  Insert  drainage-tubes,  suture  the  abdominal  wound  or  wounds,  apply 
dressing,  and  adopt  proper  means  for  the  treatment  of  shock. 


INTESTINAL  OBSTRUCTION. 

Definition  and  Classification. — Intestinal  obstruction,  occlusion, 
strangulation,  and  ileus  have  been  used  as  synonymous  terms.  Some  authors 
wish  to  draw  a  line  of  distinction  between  cases  of  intestinal  obstruction  and  intes- 
tinal strangulation  upon  an  etiological  basis,  including  under  the  former  term 
all  instances  where  the  obstruction  is  caused  by  a  tumor,  enterolith,  or  intussus- 
ception, while  internal  hernia,  volvulus,  and  constriction  by  a  band  are  included 
under  the  head  of  strangulation.  For  practical  purposes  such  a  distinction  is 
superfluous,  as  any  cause  which  mechanically  interferes  with  the  passage  of 
intestinal  contents  produces  the  symptoms  characteristic  of  intestinal  obstruc- 
tion, and  if  it  cannot  be  removed  by  ordinary  means  should  be  treated  by 
abdominal  section.  The  classification  into  true  and  false  obstruction,  from  a 
surgical  standpoint,  should  also  be  abandoned,  as  operative  interference  is  indi 
cated  only  in  cases  of  obstruction  due  to  the  presence  of  mechanical  obstacles, 
such  as  foreign  bodies,  tumors,  intussusception,  or  to  compression  of  the  lumen 
by  tumors,  flexion,  twisting,  and  bands  of  constriction.  Inflammation  of  the 
tunics  of  the  bowel  and  diftuse  peritonitis  may  give  rise  to  symptoms  resem- 
bling those  of  obstruction,  and  the  indications  for  treatment  are  to  combat 
the  inflammation  and  to  restore  peristaltic  action,  combined  with  mechanical 
means  to  relieve  the  abdominal  distention. 

A  more  important  classification  remains  to  be  mentioned,  in  which  all  cases 
of  true  intestinal  obstruction  are  divided  into  acute  and  chronic.  This  distinc- 
tion must  be  maintained  for  many  reasons.  In  chronic  obstruction  the 
symptoms  usually  develop  very  slowly  as  the  occlusion  becomes  more  complete. 
During  the  early  part  of  the  affection  the  intestinal  wall  above  the  seat  of 


7:50  ^.v  .i.i//;A7r,LV   TExr-iiooK  or  srnarnv. 

obstruction  uii(k'r^of.s  compensatory  liypcrtropliy,  (li):itati(»n  taking  place  very 
slowly  unless  the  chronic  suddenly  merges  into  the  acute  form — an  event  which 
is  always  announced  by  a  coniplexus  of  symptoms  characteristic  of  acute  or 
subacute  obstruction.  Chronic  obstruction  is  more  frequently  met  with  in 
persons  advanced  in  years,  and  tlie  seat  of  the  obstruction  is  usually  located 
in  some  ])art  of  the  laruje  intestine.  The  acute  form  is  caused  by  ])atho- 
logical  conditions  which  suddenly  narrow  or  oI)literate  the  lumen  of  some  por- 
tion of  the  intestine,  usually  above  the  ileo-ciccal  valve,  and  often,  without  any 
premonitory  symptoms,  give  rise  to  a  group  of  acute  symptoms  almost  patJiog- 
nomonic  of  this  affection.  The  sudden  arrest  of  the  fecal  circulation  is  fol- 
lowed by  violent  jieristaltic  action  of  the  bowel  above  the  seat  of  obstruction 
in  a  vain  attempt  to  clear  the  intestinal  tract,  which,  from  muscular  exhaustion 
and  the  increased  pressure  from  within  due  to  the  accumulation  of  intestinal  con- 
tents, finally  gives  rise  to  paresis  and  the.textural  changes  which  accompany 
great  congestion  in  relaxed  and  exhausted  tissues.  In  the  treatment  of  such 
acute  cases  prompt  action  constitutes  an  essential  element  of  success,  as  in  a 
few  hours  or  days  the  patient  ])ecomes  utterly  prostrated,  and  the  bowel  at  and 
above  the  seat  of  obstruction  will  have  undergone  irreparable  i)athological 
changes. 

Surgical  Resources  in  the  Treatment  of  Intestinal  Obstruction. 

Evacuation  and  Irrigation  or  Lavage  of  the  StOxMach. — Accumula- 
tion of  intestinal  contents  above  the  seat  of  obstruction  acts  deleteriously  in 
several  Avays :  1.  It  causes  violent  peristaltic  action  of  the  intestine  above  the 
seat  of  obstruction ;  2.  It  exhausts  the  patient's  strength  by  causing  persistent 
retching  and  vomiting ;  3.  It  is  one  of  the  causes  which  produce  distention 
of  the  intestine  above  the  obstruction  ;  4.  It  favors  fermentative  and  putre- 
factive changes  in  the  intestinal  contents. 

Kussmaul  has  introduced  a  new  and  exceedingly  valuable  measure  in  the 
treatment  of  intestinal  obstruction  by  the  use  of  the  soft-rubber  stomach-tube. 
By  the  siphon  action  of  the  tube,  gas  and  the  fluid  contents  of  the  stomach  and 
upper  portion  of  the  intestinal  canal  are  evacuated,  and  thus  abdominal  dis- 
tention is  relieved  and  the  hydrostatic  pressure  in  the  intestine  above  the 
obstruction  diminished.  In  inserting  the  tube  into  the  stomach  the  patient 
should  be  asked  to  make  swallowing  movements,  which  will  convey  the  tube 
along  the  oesophagus  without  causing  much  gagging,  which  often  prevents  the 
forcible  introduction  of  the  tube.  After  the  stomach  has  been  evacuated  it 
should  be  washed  out  with  a  weak  solution  of  salicylic  or  boric  acid,  a  pro- 
cedure which  cannot  fail  to  diminish  the  fermentative  and  putrefactive  pro- 
cesses in  the  retained  intestinal  contents. 

Distention  of  the  Colon  with  Fluids. — For  evacuation  of  the  colon 
copious  rectal  injections  are  resorted  to  almost  instinctively  in  every  case  of 
intestinal  obstruction.  This  procedure  has  also  been  employed  quite  exten- 
sively with  the  intention  of  utilizing  the  hydrostatic  pressure  as  a  means  for 
the  correction  of  the  mechanical  difficulties  which  have  given  rise  to  the 
obstruction.  For  the  former  pur|)ose  they  should  never  be  omitted ;  for  the 
latter  indication  they  should  never  be  used,  as  fluids  cannot  usually  be  forced 
beyond  the  ileo-ciecal  valve,  and  in  the  treatment  of  mechanical  obstruction 
below  this  point  it  is  far  inferior  to  insufflation  of  air  or  gas. 

Rectal  Insufflation  of  Hydrogen  Gas  or  Filtered  Air. — The  em- 
ployment of  hydrogen  or  filtered  air  in  the  diagnosis  and  treatment  of  some 
forms   of   intestinal   ol)struction   is   occasionally    valuable.      The   inffation    i& 


DiiSEASES  A.\/>    ixjrniKs  or   the  J/.'/^o.I/A.V.         7ol 

made  in  the  same  iiianiicr  as  in  tlic  diagnosis  of  intestinal  wounds.  By  its 
use  the  seat  of  obstruction  beh»\v  the  ileo-cecal  valve  can  be  located  with 
accuracy,  and  above  this  point  at  least  approximately.  The  inflation  will 
distend  the  bowel  below  the  obstruction,  and  the  air  or  gas  will  not  j)ass  be- 
yt»nd  it.  It  is  an  extremely  useful  resource  in  the  treatment  of  invagination, 
and  in  describing  this  form  of  intestinal  obstruction  it  will  again  be  referred 
to  as  a  therapeutic  measure. 

Taxis  and  Massage. — Abdominal  taxis,  so  nmch  lauded  by  Mr.  Ilutcii- 
inson  as  a  means  of  treating  intestinal  obstruction,  is  not  only  unscientific  and 
useless  f(jr  this  purpose,  but  is  attended  by  great  risk  to  life.  Taxis  and  mas- 
sage, scientitically  })ractised,  have  a  limited  range  of  application  in  the  treat- 
ment of  intestinal  obstruction,  but  they  are  a])plicable  oidy  to  cases  where  the 
obstruction  is  due  to  the  presence  of  a  foreign  body,  a  fecal  accumulation,  or 
an  enterolith,  and  should  only  be  resorted  to  before  these  causes  have  devel- 
oped inflammatory  changes  at  the  se'at  of  impaction. 

Uniform  and  Uninterrupted  Compression  of  the  Abdomen. — In  all 
cases  of  intestinal  obstruction,  but  more  particularly  in  the  chronic  form,  uni- 
form support  of  the  abdomen  affords  relief  to  the  patient,  and  is  one  of  the 
best  means  of  preventing  rapid  distention  of  the  intestine  above  the  seat  of 
obstruction.  Fixation  and  equable  compression  are  resorted  to  in  other  parts 
of  the  body  as  the  best  known  means  of  controlling  muscular  spasms.  Uniform 
compression  of  the  abdomen  is  best  secured  by  padding  the  iliac  regions  with 
absorbent  cotton  and  then  enveloping  the  body  from  the  pubes  to  the  tip  of 
the  sternum  with  broad  strips  of  adhesive  plaster,  which  should  be  made  to 
overlap  one  another. 

Puncture  of  the  Intestine. — Advanced  cases  of  intestinal  obstruction 
are  always  attended  by  great  distention  of  the  bowel  above  the  obstruction,  a 
condition  Avhich  causes  increased  intra-abdominal  pressure.  The  distention 
may  be  so  great  as  to  destroy  life  by  the  suspension  of  important  functions 
from  mechanical  pressure.  It  also  aggravates  the  mechanical  difficulties  which 
interfere  with  the  passage  of  intestinal  contents,  as  the  distended  bowel  under 
such  circumstances  forms  numerous  flexions  which  constitute  additional  obstruc- 
tions. If  life  is  threatened  by  the  distention,  and  more  efficiejit  surgical  aid, 
for  any  reason,  cannot  be  rendered,  puncture  of  the  intestine  may  prove  bene- 
ficial. Puncture  of  a  distended  paretic  intestine  is  always  attended  by  some 
risk  of  extravasation,  and  on  this  account  the  needle  puncture  should  be  made 
obliquely  through  the  wall  of  the  intestine,  in  order  to  reduce  this  source  of 
danger  to  a  minimum.  The  best  instrument  for  this  purpose  is  one  of  the 
smaller  needles  of  an  aspirator.  Care  should  be  taken  to  render  the  needle 
aseptic  before  it  is  used.  The  puncture  should  be  made  at  the  most  prominent 
point,  and  the  instrument  pushed  boldly  forward  in  an  oblique  direction  until 
resistance  ceases. 

Enterostomy. — The  formation  of  a  fecal  fistula  above  the  ileo-csecal  valve 
by  operation  should  be  called  enterostomy,  and  not  enterotomy.  This  opera- 
tion was  done  by  N^laton  for  the  first  time  in  1840.  The  mortality  of  the 
operation  has  been  nearly  as  great  as  that  of  laparotomy  with  removal  of  the 
cause  of  obstruction,  and  on  this  score  alone  its  further  application  should  be 
limited  to  exceptional  cases  Avhere  a  radical  operation  is  inadmissible  on  account 
of  the  nature  of  the  obstruction  or  the  enfeebled  condition  of  the  patient.  The 
operation,  which  can  be  made  without  anesthesia,  is  performed  by  making  an 
incision  not  more  than  two  and  a  half  inches  in  length  in  the  right  iliac  region, 
above  and  parallel  to  the  outer  half  of  Poupart's  ligament,  and  all  hemorrhage 
should  be  arrested  before  the  peritoneal  cavity  is  opened.     The  parietal  peri- 


732  AiY   AMKRIL'AS    TEXT-BOOK    OF   SLRUFAlY. 

toiRMun  is  now  sutured  to  the  skin.  Almost  witliojit  exception  a  distended 
knuckle  of  intestine,  readily  recognized  by  its  size  and  color,  presents  itself 
in  the  wound,  and  is  drawn  forward  sufliciently  for  a  surface  the  size  of  a 
quarter  of  a  dollar  to  be  united  with  the  margins  of  the  wound  with  fine  silk 
sutures  closely  placed.  An  incision  large  enough  to  admit  the  tip  of  the  index 
finger  is  now  made  in  the  center  of  the  united  part  transversely  to  the  long 
axis  of  the  bowel,  and  after  the  escape  of  intestinal  contents  and  disinfection 
of  the  surface  of  the  wound  the  margins  of  the  visceral  wound  are  separately 
stitched  to  the  skin  by  a  single  suture  on  each  side,  in  order  to  secure  patency 
of  the  opening.  On  incising  the  bowel  the  surgeon  is  often  disappointed  at 
the  small  amount  of  gas  and  fluid  which  escapes,  and  it  is  frecjuently  several 
hours  before  a  free  escape  takes  place  and  the  abdominal  distention  begins  to 
diminish.  In  exceptional  cases  an  enterostomy  is  followed  by  a  permanent 
cure  bv  the  spontaneous  correction  of  the  mechanical  difficulties  which  caused 
the  obstruction;  in  other  cases  a  radical  operation  is  to  be  done  later;  while 
in  a  third  class  the  fistula  is  allowed  to  remain  permanently  in  case  the  cause 
of  the  obstruction  cannot  be  removed. 

Colostomy. — The  term  eolotomy  has  been  used  to  designate  the  operation 
of  forming  a  fistulous  opening  in  any  part  of  the  colon.  But  this  word,  lite- 
rally, onh'means  cutting  into  or  incising  the  colon  for  the  purpose  of  making 
a  temporary  opening,  as  in  gastrotomy,  enterotomy,  etc.  Hence  the  operation 
of  making  a  more  or  less  permanent  fistula  in  the  colon  should  be  known  and 
described  as  colostomy,  corresponding  to  (/astr ostomy^  enterostomy,  etc.  This 
operation  will  always  retain  its  place  in  operative  surgery  as  a  palliative  and 
life-prolonging  procedure  in  the  treatment  of  carcinomatous  stenosis  of  the 
lower  portion  of  the  colon  and  in  cases  of  inoperable  carcinoma  of  the  rec- 
tum and  in  cases  of  extensive  cicatricial  stenosis  beyond  the  reach  of  more 
conservative  measures.  The  modern  operation  of  colostomy  is  made  by 
opening  the  peritoneal  cavity  in  the  right  or  left  iliac  region,  or  even  in 
the  epigastrium,  according  to  the  location  of  the  obstruction,  and  one 
of  its  principal  objects  is  to  interrupt  the  fecal  circulation  completely  at 
the  artificial  anus,  so  as  to  procure  absolute  physiological  rest  for  the 
portion  of  bowel  below  it — a  condition  not  attainable  by  the  lumbar 
operation.  Inguinal  colostomy  was  first  practised  by  Littre.  In  early 
times  the  mortality  was  even  higher  than  in  lumbar  colostomy,  being 
from  46  to  53  per  cent.  This  was  the  consequence  of  opening  the 
peritoneal  cavity  without  antiseptic  precautions.  The  introduction  of  an- 
tiseptic methods  here,  as  in  all  other  intra-abdominal  operations,  reduced 
the  mortality  to  the  neighborhood  of  5  per  cent.  Kiinig  has  reported 
20  cases  with  only  1  death,  from  peritonitis ;  Cripps,  26  cases  with  only 
1   death. 

A  number  of  operations  have  been  described  for  making  an  inguinal  colos- 
tomy. The  one  devised  by  Maydl  is  done  as  follows :  He  makes  an  incision 
about  four  inches  in  length  over  the  portion  of  the  colon  wliich  is  to  be  opened, 
and  in  the  direction  of  the  fibers  of  the  external  obli(iue  muscle,  and  draws  the 
bowel  forward  until  its  mesenteric  attachment  is  on  a  level  with  the  external 
incision.  Through  a  slit  in  the  mesocolon  close  to  the  gut  is  inserted  a  glass 
rod  with  a  Hange  at  each  end,  iodoform  gauze  being  wrapped  around  the 
ends  to  prevent  displacement  (Fig.  296).  The  rod  prevents  the  return  of 
the  bowel  into  the  abdominal  cavity  before  adhesions  have  formed.  By  means 
of  a  row  of  sutures  ])laced  on  each  side  of  the  prolapsed  gut.  including  the 
serous  and  muscular  coats,  the  two  limbs  of  the  flexure,  so  far  as  they 
lie    in    the    abdominal  .wound,   are    stitched    together  beneath  the  support. 


DISEASES   AND    INJURIES    OF    THE   ABDOMEN. 


733 


The  base  of  the  prolapsed  intestinal  loop  is  sutured  to  the  ])arietal  perito- 
neum with  a  few  points  of  suture  to  shut  off  the  peritoneal  cavity  and  pre- 
vent ])rotrusion  of  the  small  intestine  if  the  patient  should  vomit  or  cough 
after    the   operation.     The    wound   around   the  base  of  the  intestine  should 


Fk;.  2%. 


Maydl's  Operation  for  Inguinal  Colostomy,  show'ing  the  flanged  bar,  and  at  one  end  the  iodoform  gauze : 
a  is  the  line  of  the  later  incision  (modified  from  Esmarch  and  Kowalzig). 

be  sealed  with  strips  of  iodoform  gauze  and  collodion.  If  the  intestine  is 
to  be  opened  immediately,  which  should  be  done  only  Avhen  the  symp- 
toms are  such  as  to  demand  prompt  relief,  it  is  stitched  to  the  parietal 
peritoneum  of  the  abdominal  incision,  and  the  latter  is  protected  by  iodoform 

Fi<i.  297. 


Artificial  Anus  after  the  Maydl  Operation  (from  a  photograph) :  the  patient  has  excellent  control  of  the 

bowels  (original). 

collodion.  If  incision  of  the  bow^el  can  be  postponed  for  a  few  days  until 
firm  adhesions  are  formed,  the  intestine  is  stitched  to  the  peritoneum  and 
surrounded  by  iodoform  gauze  packing  around  and  beneath  the  support.  If 
the  artificial  anus  is  made   for   lesions   incapable  of  subsequent   removal,  a 


734  Ay   A  MK  lire  AX    TEXT-BOOK    OF  SUIidKltY. 

transverse  i)j»enin;i.  including  one-thir<l  of  tlie  ])erij»lierv  <>f  the  Itowcl.  is  made 
bv  the  thermo-cautery,  drainage-tubes  are  inserted  into  the  two  luinina.  and 
the  intestine  is  carefully  washed  out. 

If  it  is  the  intention  to  establish  a  permanent  artificial  anus  and  the  prog- 
ress of  the  case  is  satisfactory,  the  bowel  is  cut  through  completely  in  two 
or  three  weeks,  the  support  serving  a  useful  purpose  as  a  guide  in  making  this 
incision.  A  few  sutures  will  serve  to  secure  the  cut  ends  to  the  skin.  If  the 
direction  of  muscles  has  been  regarded  in  making  the  abdominal  incision,  the 
patient  is  provided  with  so  eflBcient  a  sphincter  that  a  large  drainage-tube  is 
required  to  keep  the  opening  patulous.  Should  the  artificial  anus  be  only  a 
temporary  one,  the  incision  in  the  intestine  is  made  in  a  longitudinal  direction. 
When  it  has  become  desirable  to  close  the  artificial  opening,  the  rubber  sup- 
port is  removed,  after  which  the  bowel  retracts,  and  the  opening  often  closes 
without  any  further  treatment.  If  the  adhesions  are  too  firm  for  this,  they 
are  removed,  the  bowel  is  sutured  and  returned  into  the  peritoneal  cavity,  and 
the  external  wound  is  closed. 

The  modern  operation  of  inguinal  colostomy  is  indicated  in  cases  of  con- 
genital atresia  of  the  rectum  when  the  blind  end  of  the  bowel  cannot  be 
readily  reached  through  the  perineum;  also  in  cases  of  carcinoma  of  any  por- 
tion of  the  colon  and  rectum  not  amenable  to  a  radical  operation.  Finally, 
the  operation  might  become  necessary  in  irreducible  invagination  of  the  colon 
in  which,  for  anatomical  reasons,  resection  or  anastomosis  cannot  be  done. 

Abdominal  Section',  or  Cceliotomy. — In  making  an  enterostomy  or  colos- 
tomy the  abdominal  cavity  is  opened,  but  these  two  palliative  operations  are 
not  classed  under  abdominal  section  in  the  treatment  of  intestinal  obstruction, 
as  this  expression  in  this  connection  is  reserved  for  those  cases  in  which  the 
abdominal  cavity  is  freely  opened  for  the  purpose  of  finding  and  removing  the 
cause  of  the  obstruction.*  A  radical  operation  in  the  treatment  of  intestinal 
obstruction  embraces — 1.  The  detection  and  removal  or  rendering  harmless  the 
cause  of  the  obstruction  :  2.  The  immediate  restoration  of  the  continuity  of  the 
intestinal  canal. 

To  meet  the  first  indication  the  cause  of  obstruction  must  be  found,  its 
nature  determined,  and,  whenever  advisable  or  practicable,  removed — a  step 
in  the  operation  which  may  be  very  easy  or  may  be  a  most  formidable  and 
serious  undertaking,  more  especially  in  cases  where  the  pathological  conditions 
which  have  given  rise  to  the  obstruction  are  of  such  a  nature  as  to  constitute 
in  themselves  an  imminent  or  remote  source  of  danger,  as,  for  instance,  malig- 
nant disease  or  gangrene  of  the  bowel  from  constriction.  Abdominal  section 
in  the  treatment  of  intestinal  obstruction  has  so  far  been  attended  by  a  fearful 
mortality,  owing  to  the  fact  that  most  operations  were  performed  at  a  time 
when  the  patients  were  in  collapse  or  when  the  parts  involved  in  the  obstruc- 
tion had  undergone  advanced  and  often  irreparable  pathological  changes. 

Schramm  has  collected  190  cases  of  intestinal  obstruction  treated  by  lapa- 
rotomy, and  of  this  number  64.2  per  cent,  died,  the  mortality  before  antisep- 
tics were  employed  being  73  per  cent.,  and  since  that  time  08  per  cent.  Curtis 
has  collected  the  cases  of  intestinal  obstruction  treated  by  abdominal  section 
since  the  year  1873,  consequently  since  the  antiseptic  treatment  of  wounds  was 
introduced  ;  the  whole  number  of  cases,  328,  show  a  mortality  of  68.9  per  cent. 
A  more  careful  study  of  these  statistics  shows  the  value  and  importance  of 
earlv  operations,  as  sometimes  delay  of  only  a  few  hours  will  bring  complica- 
tions Ashich  not  only  necessitate  more  time  in  their  removal,  but  will  at  the 
same  time  necessitate  a  resection  or  anastomosis  which,  had  the  operation  been 
performed  earlier,  might  have  been  avoided.     Abdominal  section  in  the  treat- 


DL'SEA.^ES   AMJ    I.XJCRIKS    OF    THE    ABDOMEN.  735 

ment  of  intestinal  obstruction,  both  acute  and  chronic,  is  one  of  the  most  for- 
midable operations  in  surgery.  Tlie  surgeon  ^ho  undertakes  it  should  be  per- 
fectly familiar  Avith  the  anatomy  of  the  abdominal  cavity  and  its  contents,  and 
conversant  with  all  the  pathological  conditions  which  may  give  rise  to  obstruc- 
tion ;  at  the  same  time  he  should  have  a  full  knowledge  of  the  technical  details 
of  the  different  operations,  and  be  supplied  with  the  necessary  instruments  and 
a])pliances.  Keen's  "  Operation  Blank  and  List  of  Instruments  required  in 
Various  Operations"  is  an  excellent  aid  in  making  the  necessary  preparation, 
not  only  for  this  but  also  for  all  other  operations. 

The  first  and  most  important  rule  is  to  make  use  of  the  strictest  precau- 
tions in  securing  an  aseptic  condition  of  everything  that  will  be  brought  in 
contact  with  the  wound  or  the  peritoneal  cavity.  This  includes  the  room, 
patient,  operator,  and  assistants,  instruments,  sponges,  ligatures,  table,  blan- 
kets, towels,  wash-basins,  etc.  Where  the  cheapest  and  most  efficient  antisep- 
tic—heat— cannot  be  emploved  for  this  purpose,  the  disinfection  is  done  with 
warm  water,  potash  soap,  and  an  antiseptic  solution  (1  :  20  solution  of  carbolic 
acid  or  1  :  2000  corrosive  sublimate).  The  operator  must  satisfy  hiraseit  ot 
the  aseptic  nature  of  everything  which  is  used  inside  of  the  peritoneal  cavity. 
As  soon  as  the  abdomen  is  opened,  boiled  water  or  sterile  normal  salt  solution  is 
substituted  for  antiseptic  solutions.  To  secure  the  proper  temperature  boiling 
water  is  cooled  by  adding  cool  pre-boiled  water,  not  by  freshly-drawn  cold  water. 
If  the  patient  is  much  prostrated,  3V  of  a  grain  of  strychnine  and  4  ot  a 
irrain  of  morphia  should  be  given  subcutaneously,  and  four  tablespoontuls  ot 
brandy  in  four  ounces  of  warm  water  by  the  rectum,  before  the  anesthetic  is 
given  Irrigation  of  the  stomach  should  always  precede  inhalation  ot  the 
tnesthetic.  If  no  contraindications  are  present,  chloroform  should  be  given 
until  the  patient  is  fully  under  its  influence,  when  the  narcosis  can  be  con- 
tinued with  ether.  ,  ,      •     i   •     •  • 

If  the  obstruction  has  been  located  beforehand,  the  abdominal  incision 
should  be  made  as  near  it  as  possible  :  when  it  is  in  the  caecum  or  the  ascending 
colon,  it  is  to  be  made  on  the  right  side ;  when  in  the  descending  colon,  on  the 
left  side ;  in  all  other  cases,  and  in  all  instances  where  the  seat  of  the  obstruc 
tion  cannot  be  determined  beforehand,  a  median  incision  is  indicated.      Ihe 
first  incision  should  at  least  be  large  enough  to  admit  the  hand.     It  may  be 
stated  as  a  rule  that  the  ease  of  diagnosis  increases  with  the  size  of  the  incis- 
ion, and  the  danger  which  attends  searching  in  the  dark  for  the  obstruction 
more  than  overbalances  the  slight  increase  of  risk  incident  to  a  large  incision. 
It  must  be  borne  in  mind  that  in  nine  out  of  ten  cases  the  obstruction  is  located 
in  the  lower  portion  of  the  abdominal  cavity,  below  the  umbilicus,  and  that  in 
the  great  majority  of  these  cases  it  will  be  found  in  one  or  the  other  of  the 
iliac" regions.      If  evisceration  is  not  decided  upon,  the  best  plan  to  pursue  is 
to  explore  first  the  lower  segment  of  the  abdomen,  more  especially  the  ileo- 
csecal  region,  the  sigmoid  flexure,  and  the  pelvis,  and  if  the  obstruction  can- 
not be  detected,  a  systematic  search  for  it  must  be  instituted.     Any  distended 
loop  of  the  intestine  that  may  present  itself  in  the  wound  is  an  evidence  that 
the  obstruction  is  located  lower  down.     The  loop  is  withdrawn  and  is  held  by 
an  assistant  while  the  operator  examines  in  one  direction,  and  if  this  does  not 
lead  to  the  obstruction,  the  portion  examined  is  returned,  and  the  bowel  is  then 
explored  in  the  opposite  direction.     As  a  rule,  the  intestine  is  more  dilated  and 
congested  the  nearer  the  obstruction.     If  the  assistant's  hands  are  too  much 
in  the  way,  the  bowel  can  be  fixed  in  place  with  a  strip  of  gauze  passed  through 
a  slit  in  the  mesentery,  which  can  be  held  by  an  assistant  until  the  obstruction 
is  found. 


736  Ai\    AMERICAN    TEXT-BOOK    OF  SCRGERY. 

If  a  lonf^  iiK'dian  iiicisioti  is  made,  the  small  intestines  will  escape  at  once; 
these  should  he  caught  in  warm,  moist,  aseptic  compresses,  su])]»orted  in  this 
position  by  the  hands  of  one  or  two  assistants,  and  ke{)t  warm  by  pouring 
on  warm  boiled  water  from  time  to  time.  Some  operators  j)refer  warm,  dry 
compresses  or  towels  for  this  purpose.  The  surgeon  is  now  able  to  examine 
rapidly  and  accurately  every  portion  of  the  intestinal  canal  with  a  view  of 
locating  the  obstruction,  with  little  or  no  risk  of  inflicting  injury  during  the 
examination.  The  greatest  objection  that  has  been  urged  against  this  method 
is  the  difficulty  of  replacing  the  distended  intestines ;  but  the  proper  way  to 
effect  this  is,  instead  of  making  direct  compression,  to  resort  to  protection 
of  the  intestines  by  covering  the  whole  mass  with  a  warm,  moist,  aseptic  com- 
press, the  margins  of  which  are  tucked  in  under  the  abdominal  incision.  In 
this  Avay  the  bowels  are  protected  against  the  injurious  effects  of  irregular 
direct  pressure,  and  are  guided  back  into  the  abdominal  cavity  as  the  wound 
is  closed  by  tying  the  sutures,  already  in  place,  from  above  downward.  If 
uniform,  diffuse,  gentle  pressure  fails  in  replacing  the  intestines,  the  margins 
of  the  abdominal  incision  should  be  lifted  with  blunt  hooks  and  the  pelvis 
raised  (Trendelenburg's  position) — expedients  which  render  material  aid  in 
effecting  replacement.  Should  the  obstacles  be  so  great  as  to  frustrate  all 
gentle  attempts  at  reduction,  it  is  better  to  resort  to  incision  and  evacuation 
of  the  most  distended  portion  of  the  prolapsed  bowel.  In  cases  where  after 
evisceration  it  is  not  possible  to  find  the  obstruction  by  examination  of  the 
distended  visible  portion  of  the  intestine,  the  contracted  empty  portion  below 
the  obstruction  can  be  brought  into  sight  by  rectal  insufflation  of  hydrogen  gas 
or  filtered  air,  and  a  searcli  made  for  the  obstruction  from  below  upward  by  ex- 
amining the  bowel  as  it  becomes  inflated  until  the  seat  of  obstruction  is  reached. 
This  method  of  examination  will  also  reveal  additional  obstruction  should  such 
exist  below  the  one  which  has  arrested  the  passage  of  intestinal  contents. 

Operative  Treatment  of  the  Obstruction. — Intestinal  Anasto- 
mosis.— This  operation  consists  in  establishing  a  communication  between  the 
intestine  above  and  that  below  the  obstruction,  thereby  permanently  excluding 
from  the  fecal  circulation  the  portion  of  the  bowel  which  has  become  impermeable. 
The  idea  of  making  such  an  anastomosis  originated  with  Maisonneuve,  and  the 
procedure  was  studied  experimentally  by  A'^on  Hacken.  Billroth  resorted  to  it, 
and  Senn  modified  it  by  substituting  for  the  sutures  perforated  decalcified  bone 
plates.  Various  substitutes  have  been  proposed  for  the  latter.  Senn  made 
numerous  experiments  on  animals,  and  he  and  others  have  repeatedly  per- 
formed the  operation  on  the  human  subject  with  results  that  have  proved  most 
satisfactory. 

In  suturing  the  two  visceral  wounds  together  in  establishing  the  continuity 
of  the  bowel  by  the  old  end-to-end  method,  a  great  deal  of  valuable  time  is  lost 
and  only  very  limited  areas  of  serous  surfaces  are  brought  in  contact.  Lateral 
anastomosis  by  absorbable  perforated  plates  can  be  made  in  a  much  shorter 
time,  and  large  areas  of  serous  surface  are  interposed  between  the  clamps,  and, 
being  held  in  uninterrupted  contact,  soon  become  firmly  adherent. 

The  plates  are  now  made  and  used  in  three  sizes,  according  to  the  age  of 
the  patient  and  the  part  of  the  intestinal  canal  to  be  operated  upon.  They 
are  made  of  decalcified  bone,  are  oval  in  shape,  and  the  central  perforation 
should  correspond  in  size  with  the  opening  that  is  to  be  established.  The 
plates  are  to  be  kept  ready  for  use  fastened  between  two  pieces  of  glass  and 
immersed  in  a  solution  composed  of  equal  parts  of  water,  glycerin,  and  alcohol. 
To  the  margins  of  the  perforation  are  fastened  four  double  silk  sutures ;  the 
lateral  or  fixation  sutures  are  armed  with  round  needles  ;  these  strings  are  fast- 


I) TS EASES   A.\J)    lyjrniES    OE    THE   ABDOMEN.  737 

cnoil  to  tlu'  jdate  w  itii  a  lock  stitch  (Fi;^.  'IW).  As  substitiitci^  for  the  bone 
plates,  cat<i;iit  rings  and  mats  have  been  devised  by  Abbe,  Matas,  Davis,  and 
Brokaw.  Robinson  uses  untanned  leather  as  material  for  the  plates,  and 
Stamra  lias  had  o;ood  results  with  cartilage-jdates  made  of  the  scapuhe  of 
calves.  Baracz  has  substituted  for  the  absorbable  animal  substances  plates  made 
of  the  Swedish  turnij),  and  Dawbarn  has  used  j)lates  made  of  raw  potato. 
The  portions  of  the  intestine  between  which  it  is  intended  to  establish  a  com- 
munication should  be  brought  well  forward  into  the  wound  and  surrounded 
on  the  sides  with  aseptic  gauze.  The  incision  is  made  on  the  convex  surface 
of  the  bowel  opposite  the  mesenteric  attachment  and  in  the  direction  of  its 
long  axis.  In  length  it  must  correspond  with  the  greatest  diameter  of  the 
plate.  The  plate  is  inserted  endwise,  and  as  soon  as  it  is  in  the  lumen  of 
the  bowel  it  is  brought  into  proper  position  by  making  traction  on  the  four 
strings.  The  serous  surfaces  corresponding  to  the  size  of  the  plate  are  freely 
scarified.  In  operating  for  intestinal  obstruction  the  proximal  part  of  the 
bowel  will  be  found  distended,  and  its  contents  must  be  freely  emptied  through 
the  incision  before  the  plate  is  inserted.  After  thorough  evacuation  and  irri- 
gation of  the  interior  of  the  bowel,  further  extravasatim  is  prevented  by  an 

Fig.  298. 


Senn's  Decalcified  Bone  Plate  (original). 

assistant,  who  compresses  the  bowel  above  the  place  where  the  incision  is  to 
be  made.  This  can  also  be  done  by  passing  a  rubber  band  or  strip  of  gauze 
through  a  slit  in  the  mesentery  and  tying  it  over  the  bowel,  or  by  catching 
it  with  a  pair  of  lock  forceps  at  the  point  of  crossing  after  tightening  it. 
The  lateral  sutures  are  now  passed  through  the  margins  of  the  wound  near 
the  border  and  equidistant  from  its  angles  (Fig.  299). 

Before  approximating  the  parts,  the  surfoces  are  well  cleansed,  and  if  neces- 
sary, disinfected.  The  superficial  sutures  behind  the  plates  (Fig.  299,  r)  are 
inserted  and  tied  before  the  plate-sutures  are  tied.  An  assistant  now  holds  the 
intestine  in  such  a  manner  that  the  two  visceral  wounds  are  brought  together 
when  the  surgeon  approximates  the  visceral  Avounds  by  tying  the  plate-sutures. 
In  tying  the  threads  attached  to  the  plates  the  posterior  pair  of  the  middle  or 
fixation  sutures  are  tied  first,  and  the  threads  cut  short  to  the  knot.  During 
the  tying  of  all  tlie  sutures  the  plates  are  to  be  held  in  apposition.  The  tying 
is  done  Avith  sufficient  firmness  to  bring  the  parts  in  accurate  apposition,  with- 
out endangering  the  tissues  interposed  betAveen  the  plates.  After  tying  the 
first  pair  of  sutures  the  end  or  apposition  sutures  are  tied,  and  finally  the 
anterior  pair  of  fixation  sutures.      Care  must  be  exercised  to  interpose  the 

47 


738 


AX   AMKRICAX    TKXT-IK )<)K    OF  sriidKUY 


maro;ins  of  the  viscrral  wounds  accurately  l)et\veeii   the  plates.      After  this 
has  been  done,  a  few  stitches  of  the  continued  suture  are  made  at  the  border 

Fir;.  299. 


Ileo-colostomy  with  Decalcified  Bone  Plates,  sho\vin<r  plates  in  position,  one  in  the  ileum,  the  other  in 
the  colon :  a  a!  a',  lateral  or  fixation-sutures  passed  through  the  margins  of  the  wound,  a'  to  be  tied 
to  a' ;  6  6  6'  6',  end  or  apposition-sutures,  to  be  tied  6  to  6  and  6'  to  6' ;  c,  posterior  or  sero-museular 
sutures  (original). 

of  the  plates  anteriorly,  in  order  to  reinforce  the  ])lates  and  bring  in  appo- 
sition a  maximum  area  of  serous  surfaces  (Fig.  300). 

Intestinal  anastomosis  should  take  the  place  of  an  artificial  onus  in  all 
cases  where  the  patient's  strength  warrants  the  procedure  ;  and  a  radical  oj)era- 


Showing  thf  .\nterior  CoriiiiiuiMl  SiTo-iiiusculur  Suture  as  the  final  step  in  ileo-colostomy  (original i. 

tion  is  contraindicated  by  the  general  condition  of  the  patient  or  by  the  char- 
acter and  extent  of  the  local  disease  which  has  caused  the  obstruction. 


DISKASHS    AM)    IXJURIES    OF    TllK   ABDOMEN. 


7;i9 


Fkj.  301. 


The  Murphy  button  (Fi<^s.  SOl-303)  has  been  (juitc  extensively  used  as 
a  means  of  a|)])r().\iniati()n  in  aniistoniosis.  While  this  button  has  been  very 
successfully  used  in  a  large  number 
of  cases,  its  employment  is  attondod 
with  several  dangers  in  that  part  of 
the  intestinal  canal  above  the  ileo- 
cecal valve.  The  orifice  of  the  button 
may  become  plugged,  and  the  button 
itself  has  fallen  into  the  stomach,  or 
has  been  retained  in  the  intestinal 
canal.  These  dangers,  however,  have 
not  been  so  frequent  as  to  prevent  its 
general  use. 

Laplace's  Forceps  for  Intes- 
tinal Anastomosis. — As  -will  be  seen 
by  referring  to  the  accompanying  il- 
lustrations, these  forceps  resemble  two 
pairs  of  hemostatic  forceps,  held  in 
apposition  by  a  clasp  (Fig.  304).  The 
blades  of  each  half  are  semicircular  in 
shape,  so  that  -when  thev   are  placed 

,  .1  ,1  /•  '    1    i       1       I  1  Murphy  Button  (fuliirged I :  A,  open;  B,  closed. 

together  they  form  a  complete  double  ^ 

circle  or  oval,  between  which  the  portions  of  intestine  to  be  united  are  held. 


Fig.  302. 


Fig.  303. 


End-to-end   Union    of  Intestine   bv    means   of  the  End-to-end  Union  with  the  Murphy  Button 

Murphy  Button  :  the  two  portions  of  the  button.  shown  in  section, 

held  in  position  by  purse-string  sutures,  are  ready 
to  be  pressed  together. 

Encl-to-end  Anastomosis. — The  two  ends  of  bowel  to  be  united  are  brought 
together  by  four  .sutures,  the  first  at  the  mesenteric  attachment,  the  second 

Fig.  304. 


Laplace's  Forceps  for  Intestinal  Anastomosis. 

exactly  opposite  this  point,  and  one  on  either  side  midway  between.     The 
forceps  are  then  to  be  introduced  between  any  two  of  these  sutures  and  both 


740 


AN  AMERICAN    TEXT-BOOK    OF  sriiGERY 


sides  opened  simultaneously,  so  that  one  of  the  circles  is  within  either  extrem- 
ity of  the  intestine.     The  forceps  are 
Fig.  305.  then  clamped.    If  the  serous  surfaces  do 

not  tend  to  invert  over  the  blades  as 
the  forceps  are  closed,  they  should  be 


End-to-end  Intestinal  Anastomosis  by  Laplace's  For- 
ceps: by  detaehinp  the  clamp  the  two  blades  are 
successively  removed  as  before  and  the  remaining 
small  opening  sutured. 


Gastro-enterostomy  by  Laplace's  Forceps  :  forceps 
inserted. 


adjusted  so  that  this  result  will  be  accomplished.  A  continuous  or  inter- 
rupted suture  may  then  be  applied  according  to  the  preference  of  the  opera- 
tor. Laplace  uses  two  running  sutures.'  Having  completed  the  line  of 
suture,  the  clamp  is  removed,  and  first  one-half  of  the  forceps  is  slightly 


Fig.  307. 


Sutures  inserted  ;  forceps  still  in  position. 

opened  and  removed,  the  handle  describing  a  semicircle,  and  then  the  other 
half  is  removed  in  the  same  manner.  One  or  two  stitches  to  close  the 
point  occupied  by  the  forceps  complete  the  operation  (Fig.  305). 

Lateral  Anastomosis,  Gastro-enterostomy  (Figs.  306-808),  Entero-entvros- 


nisi:  ASKS   AND    INJUR  FES    OF    THE   ABDOMEN. 


741 


tomij,  etc. — The  ])ortioii.s  of  the  two  viscera  that  are  to  be  united  are  placed  side 
by  side  and  held  between  the  thumb  and  forefinger  of  each  hand  by  the  assist- 
ant, or  the  oi)erator  may  hold  one  part  and  the  assistant  the  other.  xV  sharp- 
pointed  knife  is  then  thrust  tlirou<,fh  all  the  coats  of  the  viscus  and  an  incis- 
ion made,  correspondin<;-  in  len^'th  with  the  width  of  the  forceps  to  be  employed, 
and  a  similar  incision  is  made  in  the  other  viscus.  The  forceps  are  opened, 
one  blade  is  inserted  into  either  opening,  and,  after  ascertaining  that  the 
adjustment  is  accurate,  they  are  closed.  The  sutures  are  then  applied  and 
the  forceps  removed  as  above  described.  In  performing  lateral  anastomosis 
between  two  portions  of  intestine  the  divided  ends  must  first  be  closed  by 
sutures.  For  this  purpose  Laplace  uses  forceps  with  long  and  slender 
blades.  The  divided  extremity  of  the  intestine  is  grasped  between  the 
blades  of  these  forceps  and  invaginated;  a  running  Lembert  suture  is  then 
applied,  the  forceps  unlocked  and  withdrawn,  and  one  or  two  sutures  com- 

Vvi.  .SOS. 


Removal  of  first  blade  of  forceps. 

plete  the  operation.  This  method  has  the  advantages,  that  do  not  obtain 
with  those  heretofore  employed,  of  permitting  rapid  and  accurate  suture, 
without  leaving  behind  any*^  non-absorbable  mechanical   device. 

The  use  of  all  artificiaraids  to  anastomosis  has  of  late  been  abandoned 
by  .some  surgeons,  Avho  have  returned  to  the  old  method  of  suturing,  an  opera- 
tion recently  described  by  Abbe.  His  method,  which  has  given  excellent 
results,  is  as  follows :  After  resection  and  closing  the  two  ends  as  usual,  he 
lays  these  ends  alongside  of  each  other  and  applies  two  rows  of  continuous 
Lembert  sutures  a  quarter  of  an  inch  ajjart  and  an  inch  longer  than  the  pro- 
posed cut  (Fig.  309).  Each  thread  (24  inches  long)  is  left  at  the  end  of  its 
row,  being  still  threaded.  The  bowel  is  then  opened  for  four  inches  a  quar- 
ter of  an  Tnch  from  the  sutures,  both  rows  being  to  one  side  of  the  cut.  The 
vessels  are  temporarily  caught  Avith  hemostatic  forceps.  The  opposite  portion 
of  the  bowel  is  then  opened  in  the  same  manner.  The  two  adjacent  cut  edges 
are  now  united  by  an  overhand  suture,  the  needle  piercing  both  the  mucous 


742 


AN  AMERICAN   TEXT- BO  OK   OF  SURGERY. 


and  the  serous  coat,  and  so  securing  the  bleeding  vessels  (Fig.  310).  The 
forcejts  are  removed  as  they  are  reached.  The  two  free  cut  edges  are  sim- 
ilarly whipped,  after  which  the  serous  surfaces  on  the  opposite  sides  of  the 


Kui.  :}0y. 


Fig 


Suturing  Intestines  in  Apposition  before  Incision 
(Abbe). 


Showing  the  Four-inch  Incision  and  the  Sewing 
of  the  Edges  (Abbe). 


Opening  are  approximated  and  secured  by  tw^o  rows  of  continuous  Lembert 
sutures,  the  first  two  threads  serving  this  purpose.  It  is  asserted  that  this 
method  recjuires  little,  if  any,  longer  time  than  that  with  plates  or  rings  of 
any  kind,  and  is  free  from  many  of  their  disadvantages. 

Maunsell's  Method  of  Intestinal  Anastomosis. — After  the  divided 
ends  of  the  intestine  are  cleansed  two  temporai-y  sutures  are  employed  to  make 
a  preliminary  approximation.  One  suture  is  introduced  at  the  point  of  attach- 
ment of  the  mesentery  and  includes  all  the  coats  of  the  intestine  and  both 
layers  of  the  former,  the  other  suture  is  placed  directly  opposite  and  also 
includes  all  the  coats  (Fig.  311).  These  are  then  tied  and  the  ends  left 
long.  A  longitudinal  incision  an  inch  and  a  half  long  is  next  made  in 
the  larger  segment  of  intestine,  opposite  the  mesentery,  and  tAvo  inches 
from  the  divided  extremity.     This  may  be  made  by  picking  up  the  wall  of 

Fig.  311. 


MaunseU's  Method  for  Longitudinal  Section  of  Gut :  n,  peritoneal  coat ;  6,  muscular  coat ;  c,  mucous 
coat;  d,  temporary  sutures  passed  into  the  bowel  and  out  through  the  longitudinal  slit  made  in  the 
larger  intestinal  segment;  e,  mesentery. 

the  intestine  by  the  thumb  and  finger,  transfixing  at  the  base  of  the  cone, 
and  cutting  outward.  Through  this  opening  a  pair  of  forceps  is  passed,  the 
free  ends  of  the  sutures  caught,  and  the  cut  ends  of  the  bowel  brought  out 
at  this  point  (Fig.  312).  The  two  temporary  sutures  are  held  by  an  assist- 
ant, while  the  ends  of  the  intestine  are  united  by  through  and  through  su- 
tures (Fig.  313) — about  twenty  being  introduced.  The  temporary  sutures  are 
removed,  the  invagination  reduced,  and  the  edges  of  the  longitudinal  incision 
closed  by  Lembert  sutures  (Fig.  314).    A  V-shaped  section  of  the  mesentery 


DISEASES   AND    IXJVIinCS    OF    THE   ABDOMEN. 


743 


should  first  be  removed  corresponding  to  the  amount  of  intestine  excised, 
bleeding  ))oints  ligated,  and  the  two  surfaces  united  by  sutures,  as  in  other 
methods  of  anastomosis. 

Intestinal  anastomosis  is  indicated — 

1.  In  cicatricial  stenosis  of  the  intestines. 

2.  In   inoi.erable   carcinoma  of  the  intestine   if  the   disease  is  located 

Fui.  312. 


TeritoneaJ.  cvaJ 


tJ-j^.M' 


-J- 


^.31^^0Tfy^eraon^^  co^-^ 


lon 


Mflunsoirs  Method  for  Longitudinal  Section  of  Intestine,  showing  relative  position  of  the  peritoneal 
*  coats  of  bowel  invaginated  at  the  longitudinal  opening  (Wigginj. 

sufficiently  high  up  in  the   colon  to   permit   the   formation   of  an   opening 

below  it.  a-        ^ 

3,  In  irreducible  volvulus  and  invagination  uhen  the  parts  aitected  pre- 


FiG.  313. 


Fig.  314. 


Maun^elTs  Method:  the  needle  passed 
through  both  sides  of  the  bowel  and 
through  all  the  intestinal  coats  :  one 
passage  of  the  needle  places  two  su- 
tures. 


Maunsell's  Method :  intestine  after  completion  of  the  anasto- 
mosis and  reduction  of  the  invagination  :  «,  point  of  union 
between  the  ends  of  the  bowel,  showing  that  the  peritoneal 
coat  is  well  turned  in,  and  that  the  sutures  and  knots  are 
all  inside  the  gut;  6,  longitudinal  slit  in  bowel,  closed  by 
Lembert  sutures. 


sent  no  external  evidences  of  gangrene,  and  resection  is  impracticable  on 
account  of  unfavorable  general  or  local  conditions. 

4.  As  a  substitute  for  circular  enterorrhaphy  when  the  lumina  of  the 
resected  ends  differ  greatly  in  size. 

5.  In  congenital  atresia  of  the  intestine. 

The  use  of  bone-plates  in  gastro-enterostomy  has  been  referred  to  in  the 
chapter  on  Injuries  and  Surgical  Diseases  of  the  Stomach. 

Laparo-enterotomy. — Incision  of  the  bowel  for  the  removal  of  obstruc- 
tion durincT  laparotomy  is  indicated  when  the  obstruction  is  due  to  the  presence 
of  a  foreign  body,  a  concretion,  an  enterolith,  a  gall-stone,  or  a  pedunculated 
benign  polypoid  tumor ;  also  in  cases  in  Avhich  the  bowel  has  become  paretic 
by  distention  from  the  accumulation  of  gas  and  feces.  In  the  removal  of  a 
foreign  body,  a  concretion,  a  gall-stone,  or  an  enterolith  not  amenable  to 
removal  by  submural  crushing  or  fragmentation  with  a  needle,  the  incision 


741  AX   AMEh'K'AX    TEXT- HOOK    OF  SURGERY. 

for  extraction  should  not  bo  made  (tver  the  seat  of  impaction,  as  this  part  of 
the  intestine  has  undergone  changes  unfavorable  to  the  satisfactory  healing 
of  the  visceral  wound.  It  is  much  better  in  such  cases  to  make  the  incision 
opposite  to  the  attachment  of  the  mesentery,  in  a  healthy  j>art  of  the  intes- 
tine, an  inch  or  two  below  the  impaction,  and  then  crush  the  foreign  ])ody 
by  instruments  introduced  through  the  incision.  The  removal  of  a  non- 
maliiTuant  pedunculated  polypoid  tumor  is  to  be  accom])lished  by  making  an 
incision  on  the  convex  side  of  the  bowel  large  enough  to  admit  of  the  drag- 
giniz  of  the  tumor  through  it,  after  which  the  base  of  the  pedicle  is  trans- 
fixeil  with  a  needle  armed  Avith  a  stout  ligature  which  is  tied  on  each  side, 
the  tumor  cut  ott",  and  the  Avound  closed  in  the  usual  manner.  Incision  of 
the  bowel  for  overdistention  is  indicated  when  the  intestinal  wall  has  become 
paretic  from  distention  or  inflammation.  A  transverse  incision  at  least  an 
inch  in  length  on  the  convex  side  is  preferable  to  puncture.  Through  such  an 
incision  tiie  intestinal  contents  can  be  forced  out  from  both  sides  and  several 
feet  of  intestine  can  be  unloaded  in  this  manner.  After  evacuation  the  inci- 
sion should  be  closed  in  the  usual  manner.  Cases  may  present  themselves  in 
-which  it  is  advisable  to  make  more  than  one  visceral  incision.  For  the  pur- 
pose of  stimulating  the  paretic  intestine  McCosh  recommends  the  injection 
of  a  solution  of  magnesium  sulphate  through  the  incision  before  suturing  the 
wound,  a  practice  which  seems  to  have  been  attended  by  excellent  results. 

Enterectomy. — The  indications  for  excision  in  injuries  of  the  intestine 
have  been  already  discussed.  In  the  treatment  of  intestinal  obstruction  this 
operation  becomes  necessary  when  the  obstruction  is  due  to  a  malignant  tumor 
if  it  is  possible  to  remove  the  disease  completely,  also  for  the  removal  of  benign 
tumors  which  cannot  be  excised  by  enterotomy,  and  in  all  cases  in  which  gan- 
grene has  been  caused  by  constriction,  comj)ression,  or  over-distention. 

In  incomplete  enterectomy  only  a  portion  of  the  circumference  of  the  bowel 
is  excised.  This  can  be  done  with  safety  only  on  the  convex  surface  of  the 
bowel,  as  partial  enterectomy  on  the  opposite  side,  by  cutting  off'  the  blood- 
supply,  might  cause  gangrene  or  result  subsequently  in  intestinal  obstruction 
from  flexion.  In  making  a  complete  enterectomy  not  more  than  three  or  four 
feet  of  the  small  intestine  should  be  removed,  as  resection  of  a  larger  portion 
is  likely  to  give  rise  to  progressive  marasmus  should  the  patient  recover  from 
the  operation.  The  intestine  on  each  side  of  the  proposed  section  should  be 
tied  with  a  rubber  band  passed  through  a  slit  in  the  mesentery.  The  mesentery 
is  tied  in  small  sections  with  fine  silk  ligatures  before  the  bowel  is  excised. 
After  excision  enterorrhaphy  or  lateral  anastomosis  is  done. 

The  mortality  of  this  operation  thus  far  has  been  very  great.  In  a  series 
of  35  resections  of  the  large  intestine  for  obstruction  which  Weir  collected, 
it  amounted  to  100  per  cent.  Reichel  has  also  shown  that  resection  of  the 
small  intestine  for  conditions  giving  rise  to  obstruction  gave  a  mortality  of 
75  per  cent.,  whereas  in  secondary  resection  for  artificial  anus  the  mortality 
is  reduced  to  37  per  cent.,  a  statement  which  is  supported  by  Makins  in  his 
report  of  13  deaths  in  3!>  resections  for  artificial  anus. 

Enterorrhaphy. — The  closure  of  a  wound  of  the  intestines  with  sutures, 
and  also  the  joining  of  the  ends  of  the  intestine  by  sutures  after  resection,  is 
called  enterorrhaphy.  End-to-end  restoration  of  the  continuity  of  the  intestinal 
canal  after  resection  is  termed  circular  enterorrhaphy. 

The  appalling  mortality  after  intestinal  resection  is  due  principally  to  the 
fact  that,  as  a  rule,  the  operation  is  delayed  too  long  ;  besides,  the  inunediate 
effects  of  so  grave  an  operation  are  serious  and  often  result  in  death  from 
shock,  while  many  cases  have  proved  fatal  from  leakage  at  the  ])lace  of  sutur- 


DISEASES   AXI>    IXJIRIES    OF    THE   A B DOMEX. 


7-15 


Fig.  315. 


Lembert's  Suture :  u.  .-ierous  coat :  6,  muscular  coat; 
c,  submucous  fibrous  layer. 


ing.  Suturing  of  an  intestinal  wound  is  a  verv  delicate  operation,  and  every 
studenti  of  surgery  should  prepare  himself  carefully  by  working  on  the  intes- 
tines of  dead  and  living  animals  and  the  cadaver. 

The  subject  of  the  suturing  of  intestinal  wounds  is  one  of  tlie  most 
bewildering  topics  of  surgery,  as  hardly  a  year  passes  without  the  descrip- 
tion   of  some   new   suture.      It   will   be   well,    therefore,    to   limit  our  study 

to  the  two  kinds  of  suture  now  al- 
most universally  employed,  the  super- 
ficial and  the  deep,  or,  as  usually 
termed,  Lembert's  and  Czernys 
sutures.  Lembert  was  the  first  to 
point  out  that  in  order  to  obtain 
union  of  an  intestinal  wound  it  is 
absolutely  necessary  to  bring  the 
serous  surfaces  in  contact ;  accord- 
ing to  his  teachings,  it  is  only 
necessary  to  include  in  the  suture 
the  peritoneal  coat,  but  later  it 
was  suggested  to  include  enough 
of  the  muscular  coat  to  give  the 
suture  a  safe  hold.  Halsted  has 
clearly  pointed  out  that  it  is  unsafe 
to  rely  on  the  serous  and  muscular 
coats  in  giving  the  necessary  hold  to  the  sutures,  and  insists  that  the  needle 
should  penetrate  more  deeply  and  catch  some  of  the  fibers  of  the  firm  sub- 
mucous coat,  which  he  has  so  well  de- 
scribed. In  applying  the  Lembert  suture 
the  edges  of  the  wound  are  turned  in  a 
little,  and  the  folds  sewed  together  with 
a  fine  round  sewing-needle  carrying  a 
fine  aseptic  silk  thread.  The  stitches  are 
placed  at  intervals  of  about  one-eighth  of 
an  inch  (Fig.  315). 

In  order  not  only  to  approximate  these 
serous  surfaces  more  perfectly,  but  also  to 
bring  together  accurately  the  margins  of 
the  mucous  membrane,  Czerny  reinforces 
the  Lembert  suture  by  a  row  of  deep  su- 
tures (Fig.  816).  These  sutures  to  serve 
their  purpose  best  should  not,  as  Czerny 
advised,  include  all  the  coats,  as  it  is  much 
better  to  make  this  stitch  extraperitoneal 
:ind  cut  the  threads  short  to  the  knot. 
The  deep  row  of  sutures  is  then  buried 
by    the    Lembert    sutures.       In    circular 

enterorrhaphy  the  double  or  Czerny- Lembert  suture  should  always  be 
employed. 

If  time  is  an  object,  the  Lembert  suture  can  be  applied  in  the  form  of  the 
continued  suture,  but  when  this  element  does  not  enter  into  consideration  the 
interrupted  suture  should  be  invariably  employed.  In  circular  enterorrhaphy 
the  greatest  difficulty  encountered  is  at  the  mesenteric  attachment,  where  the 
bowel  for  a  small  space  is  not  covered  by  peritoneum.  It  is  necessary  either 
to  cover  this  space  with  peritoneum  by  stitching  the  two  peritoneal  layers  of 


Fig.  316. 


Czerny-Lembert,  or  Double  lutestiual  Suture, 


746  AX  AMKRICAX    TEXT-BOOK  OF  SURGERY. 

the  mesentery  over  it  with  a  fine  catgut  suture,  or  carefully  to  r.djiist  the  mes- 
entery on  each  side  with  the  licmhcrt  stitch.  The  safety  of  a  circular  r-nteror- 
rhaphy  is  increased  by  covering  the  line  of  suturing  with  a  strip  of  omentum, 
which  is  fastened  on  the  mesenteric  side  of  the  bowel  with  two  fine  catgut 
sutures  passed  through  the  mesentery.  Although  completely  detached,  such 
omental  grafts  retain  their  vitality  and  become  firmly  attached  to  the  serous 
surface  of  the  bowel  within  from  twenty-four  to  forty-eight  hours,  thus  form- 
ing an  additional  safeguard  against  subsecjuent  leakage  at  the  seat  of  suturing. 

Conditions  may  present  tliemselves  after  excision  of  the  intestine,  more 
especially  the  colon,  which  do  not  admit  of  bringing  the  resected  ends  together. 
In  such  circumstances  it  may  become  necessary  to  establish  a  permanent  arti- 
ficial anus ;  but  if  it  is  possible  to  establish  the  continuity  of  the  intestinal 
canal  by  lateral  anastomosis,  this  method  of  treatment  should  be  adopted.  It  is 
possible  that,  in  the  future,  experimental  research  will  prove  the  practicability 
of  restoring  such  defects  by  a  plastic  operation,  consisting  of  transplantation 
of  a  corresponding  portion  of  the  small  intestine  between  the  separated  ends,  a 
procedure  which  would  necessitate  circular  suturing  at  three  different  points. 
Until  it  has  been  shown  that  some  such  plan  is  feasible,  the  surgeon  must  con- 
tent himself  with  establishing  an  anastomosis  between  the  proximal  and  the  dis- 
tal end  by  lateral  apposition  by  any  selected  method.  If  the  two  lumina  of 
the  intestine  after  resection  do  not  correspond  in  size,  and  do  not  diU'er  so 
much  as  to  render  circular  enterorrhaphy  impossible,  the  section  of  the 
smaller  end  should  be  made  oblicjuely  at  the  expense  of  the  convex  side  of 
the  bowel,  which  will  increase  the  surface  to  be  united.  Madelung  in  resect- 
ing the  bowel  always  makes  his  incisions  somewhat  obli(|uely  in  the  same 
direction,  for  the  purpose  of  guarding  more  effectually  against  gangrene  on 
the  Convex  side  of  the  bowel.  If  the  mechanical  difficulties  cannot  be  over- 
come in  this  manner,  the  convex  surface  of  the  smaller  intestinal  end  is  incised 
longitudinally  to  the  requisite  extent,  which  will  then  enable  the  surgeon  to 
unite  the  ends  without  the  remotest  fear  of  causing  a  mechanical  obstruction. 

Lateral  Implantation. — If  for  any  reason  circular  enterorrhaphy  is  out 
of  the  ([uestion  restoration  of  the  continuity  of  the  intestinal  canal  is  secured 
either  by  closing  both  ends  and  establishing  between  the  bowel  above  and 
that  below  the  site  of  resection  an  anastomotic  opening,  or  by  implanting  the 
smaller  end  into  an  incision  on  the  convex  surface  of  the  larger  end  an  inch  or 
two  above  the  sutured  end,  and  fixing  the  implanted  portion  in  its  place  by 
Lembert  sutures.  Billroth  has  resorted  to  this  expedient  with  good  success  in 
several  cases  of  excision  of  the  caecum  for  malignant  disease.  In  two  similar 
cases  Senn  obtained  excellent  results  by  intestinal  anastomosis. 

Direct  Treatment  of  Obstruction  or  Strangulation  by  a  Band  or 
Diverticulum,  Flexion,  or  Adhesion  of  Intestines. — Ligamentous 
bands  as  a  cause  of  intestinal  obstruction  usually  indicate  an  antecedent  at- 
tack of  peritonitis.  Such  bands  when  found  are  either  divided  or,  preferably, 
extirpated,  and  if  the  strangulated  loop  has  not  suffered  gangrene,  this  simple 
procedure  answers  the  indications  for  which  the  abdominal  section  was  under- 
taken. If  the  constricting  band  is  a  diverticulum,  this  appendage  should  not 
be  divided,  but  extirpated,  and  the  opening  in  the  intestine  carefully  sutured. 
If  an  adherent  long  appendix  is  the  cause  of  the  obstruction,  it  is  dealt  with 
in  the  same  way.  If  flexion  of  the  bowel  has  produced  tlie  obstruction,  the 
flexed  part,  which  is  almost  without  exception  adherent,  should  be  separated, 
and  the  flexion  corrected  by  straightening  the  bowel  or  by  excising  the  apex 
of  the  flexion  by  a  V-shaped  excision  and  closing  the  resulting  wound  with 
sutures  in  the  usual  manner.     When  intra-abdominal  hemorrhage  is  followed 


DISEASES   AND    /X./CRIES    OF    THE    ABDOMEN.  747 

bv  a  complcxiis  of  synijitoms  indicative  of  the  presence  of  intestinal  obstruc- 
tion, the  ab(h)iiieii  shi)uhl  be  o])ene(l  ami  the  coagiihited  l)loo(l  removed  by 
spon<fin_i!;  and  Hushing  tlie  peritoneal  cavity  with  norinal  salt  solution,  and 
the  recurrence  of  the  same  condition  prevented  by  arresting  further  hemor- 
rhage. If  a  mass  of  intestinal  coils  has  become  firmly  adherent  and  has 
caused  the  obstruction,  it  is  often  impossible  to  unravel  them,  and  in  such 
cases  the  whole  mass  is  excised,  as  was  done  successfully  by  Baum  and  Koe- 
berl(?,  followed  by  circular  enterorrhaphy  ;  or  if  this  cannot  be  done,  an  anas- 
tomosis is  established  between  the  portions  of  the  intestines  above  and  below 
the  seat  of  obstruction. 

Von  Hacker  has  advised,  in  cases  of  intestinal  obstruction  caused  by 
conditions  which  do  not  admit  of  resection,  to  exclude  the  affected  part  of 
the  bowel  from  the  fecal  circulation  by  dividing  the  bowel  above  and  below 
the  obstruction,  closing  both  ends  by  suturing,  and  restoring  the  continuity 
of  the  bowel  by  circular  enterorrhaphy  or  lateral  anastomosis.  For  the  pur- 
pose of  preventing  the  harmful  effects  of  secretions  or  pathological  products 
which  might  accumulate  in  the  excluded  portion  of  the  bowel,  this  procedure 
has  been  modified  by  stitching  the  ends  of  that  portion  to  the  corresponding 
aniiles  of  the  external  incision. 

Toilet  of  the  Peritoneal  Cavity. — If  everything  that  has  come  in  con- 
tact Avith  the  abdominal  cavity  during  a  laparotomy  for  intestinal  obstruction 
has  been  rendered  aseptic  by  the  most  absolute  antiseptic  precautions,  and 
the  local  conditions  found  have  caused  no  infection,  and  no  soiling  of  the 
peritoneal  cavity  with  intestinal  contents  has  taken  place  during  the  operation, 
the  abdominal  cavity  is  aseptic,  and  can  be  safely  closed  after  the  removal  by 
gentle  sponging  of  any  blood  that  may  have  collected.  If,  however,  infection 
from  any  source  has  occurred,  the  peritoneal  cavity  should  be  flushed  with 
normal  salt  solution.  In  such  cases  drainage  is  a  necessity.  A  large  glass 
drain  inserted  into  the  bottom  of  the  pelvis  and  loosely  filled  with  strips  of 
iodoform  gauze  best  answers  the  purpose.  In  some  cases  multiple  drains  are 
necessary.  An  aseptic  napkin  or  a  small  compress  of  gauze  should  protect 
the  intestines  during  the  time  required  for  the  introduction  of  the  sutures. 
The  omentum  should  be  drawn  downward  sufficiently  to  line  the  whole  in- 
cision. When  the  sutures  are  all  in  place  they  are  tied  from  above  down- 
ward. If  tension  is  considerable,  it  is  necessary  to  add  two  or  more  button 
sutures,  which  are  passed  down  to,  but  not  through,  the  peritoneum,  and  are 
to  be  removed  as  soon  as  the  tympanites  disappears. 

After-treatment. — Food  bj  the  stomach  is  not  to  be  allowed  for  at  least 
two  days.  Thirst  is  quenched  by  small  fragments  of  ice,  and  stimulants  and 
liquid  food  are  administered  during  this  time  by  the  rectum.  Hypodermatic 
injections  of  camphorated  oil  and  strychnine  are  exceedingly  useful  in  counter- 
acting the  immediate  effects  of  the  operation.  The  abdominal  walls  should  be 
well  supported  with  strips  of  adhesive  plaster  and  a  bandage  applied  over  the 
dressing.  Greig  Smith  states  distinctly  that  "  no  case  of  operation  for  intestinal 
obstruction  is  properly  concluded  until  the  distended  bowels  are  relieved  of  their 
contents."  One  of  the  most  favorable  symptoms  after  a  successful  operation  for 
intestinal  obstruction  is  a  spontaneous  action  of  the  bowels,  as  it  not  only  proves 
that  the  cause  of  the  obstruction  has  been  removed,  but  is  also  an  evidence  that 
peristaltic  action  has  been  restored.  The  retention  of  fecal  material  in  the 
distended  paretic  intestines  after  operations  of  this  kind  not  only  retards 
recovery,  but  is  in  itself  a  grave  source  of  danger.  Mr.  Tait  has  taught  us 
the  value  of  saline  cathartics  in  the  prevention  of  peritonitis  after  abdominal 
operations.     It  appears  reasonable  that  the  same  treatment  would  be  useful  in 


748  .l^V   AMKIUCAX    TKXT-liOOK    OF  Sl'llCEllY. 

tlic  manuixeinent  of  cases  after  oj)eratioiis  for  intestinal  ol)struction.  Exami- 
nation of  the  intestine  above  the  seat  of  obstruction  will  satisfy  the  sur<reon 
that  it  will  respond  slowly  but  surely  to  mechanical  irritation,  and  it  is  only 
loi^ical  to  conclude  that  the  same  effect  would  be  produced  by  the  administration 
of  a  brisk  saline  cathartic.  Its  use,  however,  should  be  delayed  until  after 
the  intestinal  wound  is  well  united — till  the  third  day  if  possible.  Dangerous 
as  the  use  of  cathartics  must  be  before  the  ol)struction  is  removed,  their  judi- 
cious emi)loyment  may  be  beneficial  after  the  continuity  of  the  intestinal  canal 
has  been  restored  by  operative  treatment.  Stimulating  rectal  enemata  should 
be  given  to  assist  the  action  of  the  cathartics  if  the  seat  of  operation  has  been 
above  the  ileo-ciBcal  valve.  Opiates  should  be  given  only  to  relieve  pain,  and  as 
sparingly  as  possible,  so  as  not  to  impair  the  ])eristaltic  action  of  the  intestines. 

Anatomico-pathological  Forms  of  Intestinal  Obstruction. — IJefore 
considerin"'  tlie  special  forms  of  intestnuil  obstruction,  it  nnist  be  understood  that 
clinically  they  all  belong  either  to  tlie  acute  or  to  the  chronic  variety  of  ob- 
struction. 

The  forms  which  give  rise  to  ACUTE  symptoms,  and  terminate  in  a  few  days 
either  in  death  or  in  recovery,  are  those  in  which  the  mechanical  difficulties  that 
interfere  with  the  passage  of  the  intestinal  contents  arise  suddenly,  or  at  least  in 
a  short  time.  As  illustrations  of  acute  intestinal  obstruction  may  be  enumerated 
the  sudden  blocking  of  the  lumen  of  the  intestine  by  a  gall-stone  or  other  foreign 
body,  invagination,  the  incarceration  of  an  intestinal  loop  under  or  over  a  con- 
stricting band,  and  volvulus.  In  all  such  cases  the  lumen  of  the  intestine  at  the  seat 
of  obstruction  becomes  impermeable,  completely  arresting  the  passage  of  feces. 

The  most  conspicuous  clinical  symptoms  of  acute  intestinal  obstruction  are 
absolute  constipation,  the  fecal  diseliarges.  if  any  take  place  after  the  obstruction 
has  occurred,  consisting  of  intestinal  contents  from  below  the  seat  of  obstruc- 
tion ;  vomiting,  which,  as  a  rule,  appears  early  and  is  most  distressing  if  the 
obstruction  is  high  up  in  the  small  intestine ;  and  tympanites,  Avhich  is  most 
marked  if  the  obstruction  is  low  down  in  the  intestinal  canal.  Peritonitis 
frequently  gives  rise  to  the  adynamic  form  of  intestinal  obstruction  by  arrest- 
ing the  peristaltic  action  of  the  bowels,  and  it  is  often  difficult  to  differentiate 
between  the  inflammatory  or  adynamic  and  the  mechanical  form  of  obstruction. 

As  important  diagnostic  points  it  may  be  mentioned  that  peritonitis  is 
attended  by  more  severe  and  continuous  pain,  tenderness,  and  rigidity  of  the 
abdominal' muscles  and  a  more  decided  rise  in  temperature,  as  a  rule,  from  the 
very  beginning,  than  is  obstruction  due  to  mechanical  causes,  in  which  the 
pain  is  paroxysmal,  tenderness  is  either  absent  or  less  marked,  the  aljdominal 
muscles  are  not  rigid,  and  the  temperature  in  the  beginning  is  either  normal 
or  only  slightly  increased. 

Acute  intestinal  obstruction,  unless  treated  by  surgical  interference,  with 
few  exceptions  results  in  death  in  from  tw^o  days  to  two  weeks.  Spontaneous 
recovery  in  such  cases  is  the  exception,  death  the  rule.  If  recovery  takes  jdace 
unaided  by  surgical  interference,  the  mechanical  o])struction  is  removed  or 
corrected,  as  when  an  impacted  gall-stone  becomes  dislodged  and  is  forced  into 
a  larger  portion  of  the  intestinal  canal,  when  a  twist  of  the  bowel  is  corrected 
in  volvulus,  when  an  intussusceptuni  sloughs  and  is  eliminated,  or  when 
spontaneous  reduction  of  a  strangulated  intestinal  loop  is  effected. 

In  the  treatment  the  administration  of  cathartics  is  absolutely  contra- 
indicated  in  such  oases,  as  they  invariably  aggravate  the  symptoms  and  local 
conditions  which  have  caused  the  obstruction.  Absolute  diet,  and  the  use  of  the 
rubber  stomach-tube,  combined  with  irrigation  of  the  stomach  and  ^mall  doses 
of  opium  to  diminish  the  violent  peristalsis,  are  the  measures  wdiich  should  be 


DISEASES   A XI)    IXJUniES    OF    THE   ABDOMEN.  749 

relied  upon  in  assisting  the  tendencies  to  recovery,  and  to  hridge  over  the  time 
until  it  is  deemed  necessary  to  interfere  surgically. 

In  CHRONIC  cases  of  intestinal  obstruction  the  clinical  history  usually 
points  to  a  gradually  increasing  stenosis  of  the  intestine ;  an  increasing  diffi- 
culty in  procuring  a  normal  passage  by  the  usual  laxatives ;  frequently  diar- 
rhea, owing  to  a  catarrhal  inflammation  of  the  nmcous  membrane  above  tiie 
seat  of  obstruction  ;  colicky  })ains,  caused  by  increased  peristaltic  action;  and, 
finally,  a  gradually  increasing  tympanites  and  vomiting. 

Chronic  obstruction  is  caused  most  frequently  by  malignant  disease  of  the 
bowel  at  or  below  the  ileo-csecal  valve,  cicatricial  stenosis  affecting  the  same 
portion  of  the  intestinal  canal,  fecal  impaction,  and  chronic,  slowly-progress- 
ing invagination.  Spontaneous  recovery  in  such  cases  is  possible  only  if  the 
obstruction  is  due  to  non-maligiiaut  causes  and  an  intestinal  anastomosis  is 
established  between  an  intestinal  loi>p  below  the  obstruction  and  the  intestine 
above  it  by  ulceration.  It  is  not  uncommon  in  cases  of  chronic  obstruction 
for  acute  symptoms  to  develop  suddenly,  and  the  primary  condition  is  usually 
found  only  after  opening  the  abdominal  cavity  in  search  for  the  cause  of  the 
acute  obstruction. 

Treatment. — With  the  exception  of  chronic  invagination,  which  some- 
times can  be  reduced,  the  causes  which  give  rise  to  chronic  obstruction  make 
it  necessary  to  perform  either  enterectomy  or  intestinal  anastomosis,  or  to 
establish  an  artificial  anus. 

ExTERO-LiTiiiASis. — Entcro-lithiasis  is  due  in  the  majority  of  cases  to  the 
impaction  of  a  gall-stone  or  the  formation  of  an  enterolith,  the  nucleus  of 
which   is  frecjuently  a  gall-stone,  in  the  lumen  of  the  bowel. 

Biliary  Calculus. — Rokitansky  asserted  that  a  calculus  the  size  of  a 
hen's  egg  may  pass  through  the  bile-ducts.  It  is  now  generally  believed  that, 
as  a  rule  at  least,  such  large  concretions  can  escape  from  the  gall-bladder  only 
by  ulceration  through  its  walls,  and  that  a  gall-stone  of  smaller  size,  after  it  has 
passed  through  the  bile-ducts,  subsequently  becomes  larger  by  the  formation 
of  concentric  concretions  during  its  retention  in  the  intestinal  canal.  Leich- 
tenstern  has  found  that  out  of  1541  cases  of  intestinal  obstruction  from  different 
causes,  tabulated  by  himself,  41  were  produced  by  gall-stones.  Of  51  cases  of 
intestinal  obstruction  caused  by  the  impaction  of  a  gall-stone,  collected  by 
Wising,  38  died.  In  some  of  these  cases  the  calculi  were  of  great  size.  In 
the  cases  reported  by  Smith  and  Fagge  they  measured  four  and  a  half  by  two 
and  a  half  inches  in  circumference.  The  calculus  may  become  impacted  in 
any  portion  of  the  small  intestine  from  the  duodenum  to  the  ileo-ctecal  valve, 
but  most  frequently  it  becomes  lodged  in  the  duodenum  or  the  lower  portion 
of  the  ileum  and  just  above  the  ileo-ctecal  valve.  * 

The  clinical  history  of  such  cases  points  to  a  previous  attack  or  passage 
of  gall-stone,  or.  if  the  calculus  has  gained  entrance  into  the  intestine  by  ulcer- 
ation, to  an  antecedent  attack  of  circumscribed  peritonitis  in  the  region  of  the 
gall-bladder.  If  the  calculus  has  become  impacted  in  the  duodenum  or  the 
upper  portion  of  the  jejunum,  scanty  urine,  obstinate  vomiting,  and  the  ab- 
sence of  tympanites  indicate  that  the  obstruction  is  located  high  up  in  the 
intestinal  canal.  If  the  impaction  has  taken  place  in  the  lower  portion  of  the 
ileum  or  above  the  ileo-caecal  valve,  the  symptoms  will  be  the  same  as  in 
obstruction  from  other  causes  in  these  localities.  The  administration  of  pur- 
gatives even  in  this  form  of  intestinal  obstruction  is  exceedingly  hazardous, 
as  the  foreign  body  in  a  short  time  produces  textural  changes  at  the  seat  of 
impaction  which  render  dislodgment  impossible  by  this  method  of  treatment. 

Treatment  by  laparotomy  should  not  be  postponed  until  irreparable  path- 


750  .4.V   AMKIilVAX    TEXT-liOOK    OF   Si'RGEltV. 

ological  changes  liave  been  produeeil  by  the  foreign  body.  After  the  abdomen 
has  been  opened  and  the  seat  of  impaction  located,  an  eft'ort  shouhl  be  made  to 
crush  the  stone  by  pressure,  provided  the  wall  of  the  intestine  is  in  such  a  con- 
dition as  to  warrant  such  an  attempt.  If  this  does  not  succeed,  enterotomy  is 
indicated.  The  stone  should  never  be  attacked  at  the  seat  of  impaction,  but 
should  be  pushed  in  an  upward  or  downward  direction,  and  then  removed,  if 
possible,  by  breaking  it  up  by  manual  pressure,  or,  if  this  fail,  the  method 
suggested  by  Tait,  of  passing  a  stout  steel  needle  obliijuely  thn)ugh  the  in- 
testinal wall  and  attacking  the  calculus,  may  be  tried.  After  the  stone  has 
been  crushed  and  the  debris  within  the  gut  has  been  pushed  into  a  healthy 
segment  of  bowel  below,  the  puncture  in  the  serous  coat  should  be  closed  by 
drawing  the  peritoneum  over  it  with  a  fine  superficial  suture  for  the  purpose 
of  guarding  against  leakage.  If  the  stone  cannot  be  displaced  and  has  to  be 
removed  by  enterotomy,  the  site  of  operation  after  suturing  should  be  covered 
by  an  omental  graft.  If  the  intestine  at  the  seat  of  impaction  presents  evi- 
dence of  gangrene,  it  must  be  resected  and  the  continuity  of  the  intestinal 
canal  restored  by  circular  enterorrhaphy. 

Intestinal  Concretions. — "We  have  already  seen  that  a  small  gall-stone 
when  retained  for  a  sufficient  length  of  time  in  the  intestinal  canal  mav  become 
the  nucleus  of  an  intestinal  concretion,  which  by  the  addition  of  concentric 
layers  gradually  increases  in  size  until  it  fills  the  lumen  of  the  bowel,  and 
after  its  impaction  gives  rise  to  intestinal  obstruction.  Enteroliths  causing 
obstruction  have  been  described  in  which  a  variety  of  foreign  bodies  have  been 
found  as  nuclei.  According  to  the  analysis  made  by  Virchow  of  two  entero- 
liths, the  concretions  are  composed  principally  of  phosphate  of  ammonia  and 
organic  substances,  especially  of  the  derivatives  of  the  biliary  acids  known  as 
dysUsin.  In  one  case  Langenbuch  removed  an  enterolith  by  enterotomy  from 
the  jejunum,  but  the  patient  died  a  few  hours  later,  and  at  the  post-mortem  a 
second  mass,  still  larger,  was  found  in  the  pyloric  region  of  the  stomach.  The 
surgical  treatment  of  intestinal  concretions  is  the  same  as  that  of  impacted 
gall-stones. 

AscARiDES. — Halina,  Saurel,  Pockels,  Stepp,  and  others  have  reported 
cases  in  which  intestinal  obstruction  was  produced  by  masses  of  ascarides 
becoming  impacted  in  the  small  intestine.  The  patients  were  invariably 
children.  "When  the  surgeon  is  called  upon  to  treat  a  case  of  intestinal 
obstruction  in  a  child,  such  a  cause  should  be  borne  in  mind,  as  in  a  case  of 
tjiis  kind  a  timely  anthelmintic  remedy,  followed  by  a  brisk  cathartic,  may 
prove  efficient  in  removing  the  cause  of  obstruction.  If  such  treatment  should 
prove  unavailing,  no  time  should  be  lost  in  resorting  to  operative  treatment 
by  abdominal  section,  which  should  be  conducted  in  the  same  manner  as  in 
operations  for  intestinal  concretions. 

Fecal  Obstruction. — This  is  almost  without  exception  met  with  only  in 
the  large  intestine,  and,  in  preference,  in  the  caecal  region  or  in  the  sigmoid 
flexure.  Cases  have  been  reported  where  a  congenital  dilatation  of  some  part 
of  the  colon  predisposed  to  this  affection.  The  acquired  form  of  dilatation 
which  attends  all  cases  is  the  result  of  prolonged  over-distention,  resulting  in 
paresis  of  the  distended  segment  of  the  bowel.  Impaction  of  feces  sometimes 
gives  rise  to  dangerous  complications.  Ulceration,  and  even  perforation,  may 
take  place  from  this  cause.  Distention  of  the  bowel  often  takes  jilace  to  an 
enormous  extent.  Cruveilhier  found  on  making  a  necropsy  on  an  old  man  the 
transverse  colon  so  dilated  that  it  measured  35  cm.  in  circumference,  and  the 
crecum  had  attained  the  size  of  a  child's  head.  One  of  the  most  important 
diagnostic  points  is  to  give  an  anesthetic  and  make  pressure  over  the  swelling. 


DISEASES   AM)    IXJURIES    OF    THE   ABDOMEX.  751 

when  the  fecal  masses  can  he  indented,  tlie  pressure  leaving  a  permanent  de- 
pression. Patients  who  have  once  suffered  from  fecal  impaction  are  very  prone 
to  suffer  from  a  recurrence  of  tlie  same  condition  at  intervals. 

If  the  impaction  is  within  reach,  its  removal  should  be  accomplished  by 
the  use  of  a  scoop,  assisted  by  copious  injections.  If  the  bowel  at  the  seat 
of  impaction  has  lost  its  contractility,  cathartics  are  useless,  and,  if  it  is  in 
a  state  of  inflammation,  positively  hurtful.  In  such  cases  massage  and  high 
injections  are  indicated.  After  the  mechanical  removal  of  the  fecal  accumula- 
tion a  recurrence  should  be  prevented  by  the  administration  of  extract  of 
belladonna,  gr.  ^,  with  an  equal  dose  of  extract  of  nux  vomica,  combined  with 
half  a  grain  of  aloes  and  a  grain  of  sulphate  of  iron  in  pill  after  each  meal. 
Massage  and  electricity  will  render  material  assistance  in  restoring  normal 
peristalsis.  Perforation  and  suppurative  inflammation  in  the  connective  tissue 
or  the  peritoneal  cavity  must  be  met  by  prompt  surgical  treatment.  In  cases 
where  all  ordinary  measures  fail  to  remove  the  fecal  accumulation  and  the 
symptoms  of  obstruction  continue  unabated,  it  would  be  not  only  justifiable, 
but  good  surgery,  to  cut  down  upon  the  distended  bowel  and  break  up  the 
mass  within  the  gut,  and  push  it  along  to  a  portion  of  the  intestine  below, 
where  peristaltic  action  has  not  been  suspended.  In  cases  where  the  patho- 
logical conditions  contraindicate  such  a  course  of  treatment  it  mav  become 
necessary  to  resort  to  colotomy  and  remove  the  fecal  mass  through  the  wound, 
and,  according  to  circumstances,  either  close  the  visceral  wound  by  suturing  or 
establish  a  temporary  artificial  anus  in  the  corresponding  inguinal  region. 

Invagination  or  Intussusception  is  that  form  of  intestinal  obstruction 
caused  by  the  telescoping  of  one  section  of  the  bowel  into  another.  A  trans- 
verse section  through  an  invaginated  portion  of  the  bowel  reveals  three  intesti- 
nal walls,  of  which  the  outer,  or  sheath,  is  called  the  intussuscipiens,  and  the 
two  inner  the  intussusceptum.  The  usual  form  of  invagination  is  when 
the  intussusceptum  is  directed  downward,  when  it  is  called  a  descending  invagi- 
nation, to  distinguish  it  from  a  rare  form  in  which  the  intussusceptum  is  directed 
upward,  which  is  called  ascending  invagination.  It  is  estimated  that  30  per 
cent,  of  all  forms  of  intestinal  obstruction,  exclusive  of  hernia  and  congenital 
malformations,  are  cases  of  invagination. 

The  direct  causes  of  invagination  are  not  well  understood.  Some  main- 
tain that  descent  of  the  bowel  takes  place  into  a  paretic  section  below  it, 
while  others  assert  that  the  intussusceptum  is  drawn  into  the  intussuscipiens 
by  active  peristaltic  action  of  the  latter.  The  cause  of  a  chronic  invagination 
is  often  a  tumor  att-ached  to  the  inner  surface  of  the  bowel.  In  more  than  50 
per  cent,  the  patients  are  under  ten  years  of  age.  Invagination,  according 
to  Heusner,  is  the  cause  of  obstruction  in  three-fourths  of  all  cases  of  intesti- 
nal obstruction  in  children.  The  disease,  as  a  rule,  is  more  acute  in  children 
than  in  adults,  and  the  mortality  is  correspondingly  greater.  The  average 
mortality  without  surgical  interference  is  more  than  80  per  cent.  Death  is 
caused  by  exhaustion  or  gangrene  and  perforation  at  or  near  the  neck  of  the 
intussuscipiens.  Spontaneous  recovery  is  possible  only  if  reduction  takes  place 
or  if  the  intussusceptum  sloughs  away  after  the  bowel  above  has  become  firmly 
adherent  to  the  neck  of  the  intussuscipiens.  In  this  way  patients  have  event- 
ually recovered  after  the  elimination  of  several  feet  of  gangrenous  intestines. 
In  the  ileo-colic  and  colic  varieties  it  is  not  uncommon  for  the  apex  of  the 
intussusceptum  to  descend  as  far  as  the  rectum,  where  it  can  he  discovered 
by  digital  examination,  and  sometimes  the  bowel  is  protruded  some  distance 
beyond  the  anus. 

In  the  diagnosis  of  this  affection  the  greatest  weight  should  be  placed  on 


752  .I.V   AMEIUCAX    TKXT-IiOOK    OF  SURaKIiV. 

the  existence  of  an  elongated  cylindrical  swellinf;;,  tenesmus,  eoliekv  )»ains.  and 
the  jtrescnce  of  niueus  and  Mooil  in  the  discharges  from  the  rectum.  Another 
important  symi)t<»ra  wliich  distinguishes  invagination  from  other  mechanical 
causes  which  jiroduce  acute  obstruction  is  the  al>sence  of  complete  constipa- 
tion, gas  and  licjuid  feces  finding  escape  through  the  narrow  lumen  of  the 
intussusceptum. 

The  first  indications  in  the  treatment  (d'  invagination  are  to  withhold  food 
by  the  stomaeh  and  to  administer  opiates  to  diminish  the  jx-ristaltic  action  of  the 
bowel  above  the  seat  of  obstruction,  after  wh-ich  no  time  should  be  lost  in  effect- 
ing disinvagination  by  mechanical  measures.  The  simplest,  safest,  and  most 
efficient  of  these  is  distention  of  the  bowel  below  the  obstruction  with  hydrogen 
gas  or  filtered  air,  which  is  done  in  the  same  manner  as  rectal  insufflation  for 
diagnostic  purposes.  Before  insufflation  is  made,  the  colon  should  be  thor- 
oughly washed  out  with  a  high  enema  by  Hegar's  method,  in  which  an  ordinary 
enema  nozzle  connected  with  a  funnel  by  a  rubber  tube  about  two  feet  long  is 
inserted  in  the  rectum.  Warm  water  is  then  poured  into  the  funnel  and  fills 
the  rectum  and  colon.  From  two  to  four  quarts  may  be  injected.  This  should 
be  done  without  an  anesthetic,  so  that  jtain  may  warn  us  when  to  desist.  Insuf- 
flation must  always  be  practised  while  the  patient  is  thoroughly  under  the  influ- 
ence of  an  anesthetic  and  with  the  jiatient  nearly  or  completely  in  the  inverted 
position.  In  recent  cases  of  invagination  below  the  ileo-cwcal  valve  this  method 
of  treatment  will  frequently  succeed  in  effecting  reduction.  If  reduction  cannot 
be  accomplished  in  this  way,  operative  treatment  must  be  resorted  to  at  once. 
In  patients  too  mucli  prostrated  to  bear  a  laparotomy,  an  enterostomy  or  colos- 
tomy should  be  performed,  according  to  the  location  of  the  invagination.  Lap- 
arotomy is  indicated  after  rectal  insufflation  has  been  faithfully  and  thoroughly 
tried  with  negative  result,  in  all  instances  in  which  the  general  condition  of  the 
patient  is  such  as  to  justify  this  procedure.  Treves  gives  the  mortality  in  183 
recorded  radical  operations  for  invagination  as  72  per  cent.  ;  when  reduction 
was  easy  it  was  30  per  cent.,  and  when  difficult  91  per  cent.  The  difference 
between  the  mortality  of  early  and  that  of  late  operations  is  the  most  con- 
vincing argument  in  favor  of  early  operative  interference. 

As  a  rule  to  which  there  should  be  few  exceptions,  the  incision  should  be 
made  in  the  median  line,  as  it  furnishes  the  most  ready  access  to  the  invagina- 
tion and  enables  the  operator  to  apply  the  various  surgical  resources  with  the 
greatest  facilit}'.  For  special  indications  a  second  lateral  incision  may  be  made 
later.  In  recent  cases  the  difficulty  encountered  in  reduction  consists  in  an 
(Edematous  condition  of  the  intussusceptum,  and  on  this  account  the  invagi- 
nated  bowel  should  be  firmly  compressed  between  both  hands  of  the  operator 
before  direct  attempts  at  reduction  are  made.  Reduction  is  then  trie<l  by  mak- 
ing gentle  traction  on  the  bowel  with  one  hand  above  the  obstiniction,  while 
with  the  other  the  bowel  is  compressed  below  at  a  point  corresponding  with  the 
apex  of  the  intussusceptum.  in  such  a  manner  as  to  force  this  in  an  upward 
direction,  while  the  intussuscipiens  is  at  the  same  time  drawn  in  a  downward 
direction.  Reduction  is  sometimes  facilitated  b}'  assisting  the  traction  from 
above  by  elastic  pressure  from  below,  made  by  rectal  insufflation  of  hydrogen 
gas  or  filtered  air.  If  adhesions  exist,  they  can  be  separated  by  inserting  and 
passing  around  the  bowel  Kocher's  director  or  a  small  probe.  If  reduction 
has  been  accomplished,  the  necessary  precautions  should  be  taken  to  prevent 
reinvagination,  consisting  in  shortening  the  mesentery  at  the  point  of  invagi- 
nation by  folding  it  upon  itself  in  a  direction  parallel  to  the  bowel  and 
securing  it  in  this  position  by  a  few  catgut  sutures.  Should  repeated  attempts 
at  reduction  fail,  one  of  three  methods  of  treatment  may  be  pursued :  1.  The 


J>/S/JASES   AND    rXJiJIilKS    OF    THE   ABDOMEN.  753 

formation  of  an  anastomosis  between  the  bowel  above  and  below  the  intussus- 
ceittion:  2.  Keseetion  of  the  invaginated  portion,  to  be  followed  by  eircular 
enterorrha|)hy  ;  3.  Formation  of  an  artificial  anus  ;  4.  Resection  of  intussus- 
ceptum.  Partial  resection  of  the  invaginated  portion  of  the  bowel  by  the 
removal  of  the  intussusceptum  is  advisable  in  the  absence  of  gangrene  of  the 
intnssuscipiens.  The  intussusceptum  is  removed  through  a  longitudinal 
incision  in  the  intnssuscipiens  near  the  neck  after  preliminary  ligation  near 
its  base.  The  opening  is  utilized  in  making  an  anastomosis  between  the 
boAvel  above  and  below  the  neck  of  the  invagination,  as  in  Maunsell's  method. 

Volvulus. — Volvulus,  or  the  tAvisting  of  a  loop  of  intestine  around  its 
axis,  constitutes  a  well-defined  form  of  intestinal  obstruction.  This  pathological 
condition  can  occur  only  where  the  mesentery  of  the  bowel  is  of  considerable 
length,  and  is  therefore  most  frequently  met  with  in  the  lower  portion  of  the 
ileum  and  at  the  sigmoid  flexure  of  the  colon.  The  condition,  as  compared 
with  some  other  forms  of  intestinal  obstruction,  is  quite  rare.  The  immediate 
cause  of  the  volvulus  has  been  ascribed  by  Grawitz  to  accumulation  of  intesti- 
nal contents  above  a  constricted  portion  of  bowel,  while  Nieberding  has  traced 
it  in  a  few  cases  to  adhesions  of  an  omental  stump  to  an  intestinal  loop. 

The  symptoms  of  volvulus  will  vary  to  some  extent  according  to  the 
location  of  the  twist.  If  it  affects  the  small  intestine,  early  and  persistent 
vomiting  is  the  most  important  symptom.  This  symptom  appears  later,  and  is 
less  persistent  if  the  sigmoid  flexure  has  become  twisted  around  its  axis.  Wahl 
has  called  attention  to  a  condition  which  he  considers  almost  pathognomonic 
of  volvulus — a  circumscribed  area  of  tympanites  corresponding  to  the  location 
of  the  twist  and  caused  by  gaseous  distention  of  the  twisted  loop. 

Treatment. — Of  all  forms  of  intestinal  obstruction,  volvulus  leads  most 
rapidly  to  a  fatal  termination.  This  fgict  alone  is  a  sufficient  warning  to  lose  no 
time  in  temporizing  measures.  We  have  reason  to  believe  that  a  volvulus  after 
it  has  caused  symptoms  of  obstruction  is  very  seldom  reduced  without  direct 
surgical  interference.  On  the  other  hand,  it  mav  be  stated  as  a  fact  that  if  an 
early  laparotomy  is  done  the  prognosis  Avill  be  more  favorable  than  in  almost 
any  other  form  of  intestinal  obstruction.  It  is  necessary  to  make  a  long  median 
incision,  for  the  purpose  of  both  detecting  and  correcting  the  volvulus.  The 
untwisting  in  recent  cases  can  be  done  without  difficulty;  where  adhesions 
have  become  firm  and  numerous  it  may  be  impossible.  If  the  bowel  can 
be  untwisted,  a  recurrence  of  the  same  lesion  and  at  the  same  place  can  be 
prevented  by  shortening  of  the  mesentery,  which  is  to  be  done  in  the  same 
manner  as  has  been  described  in  the  operative  treatment  of  invagination.  If 
the  untwisted  bowel  shows  evidences  of  gangrene,  resection  becomes  a  necessity. 
If  no  such  changes  have  taken  place,  but  reduction  is  found  impossible,  the 
distended  twisted  loop  is  incised,  emptied,  and  washed  out  with  a  mild  anti- 
septic solution,  the  wound  sutured,  and  an  intestinal  anastomosis  established 
between  the  intestine  above  and  that  below  the  volvulus. 

Flexions  and  Adhesions. — Flexions  and  adhesions  as  a  cause  of  intes- 
tinal obstruction  are  almost  without  exception  the  remote  consequences  of  a 
previous  peritonitis.  An  adherent  intestinal  loop  may  gradually  become  flexed 
by  the  cicatricial  contraction  of  the  inflammatory  material  deposited  between 
the  bowel  and  the  adjacent  serous  surface.  Immobilization  of  a  section  of  the 
intestinal  tube  in  a  mass  of  inflammatory  exudation  may  cause  intestinal  ob- 
struction by  arresting  peristaltic  action  of  that  part  of  the  intestine.  The 
obstruction  may  remain  incomplete  for  an  indefinite  period  of  time,  until  the 
compensatory  hypertrophy  of  the  intestinal  wall  on  the  proximal  side  of  the 
obstruction  can  keep  pace  no  longer  with  the  increasing  mechanical  difficulties, 

•48 


7o4  AiX  AMi:in<A.\  i'i:xr-ii()()K  of  ,si'ii(,'i:in'. 

wlu'U  syuiptoms  of  acute  obstruction  set  in,  wliicli  may  be  tlie  first  intimation 
of  the  existence  of  an  old-standing  obstruction. 

Treatment. — If  abdominal  section  is  undertaken  for  the  correction  of 
such  patholo^^ical  conditions,  an  effort  should  be  made  to  preserve  the  con- 
tinuity of  the  intestinal  canal  by  isolating  the  adherent  loop  or  loops  and 
.straightening  out  the  tube,  and,  if  possible,  displacing  it  in  such  a  manner  a.s 
to  prevent  it  from  subsequently  resuming  the  same  relations.  Wherever  it  is 
possible  to  cover  a  raw  surface  by  stitching  over  it  the  surrounding  healthy 
peritoneum,  this  should  be  done  to  prevent  a  recurrence  of  the  adhesions  and 
malposition.  If  a  section  of  the  intestine  is  so  firmly  imbedded  that  it  cannot 
be  liberated  without  great  violence  or  perhaps  rupturing  its  wall,  it  should  be 
allowed  to  remain  and  tlie  fecal  circulation  be  restored  by  establishing  an  anas- 
tomotic opening  between  the  bowel  above  and  that  below  the  adherent  portion. 
The  same  can  be  done  in  case  a  flexion  has  caused  the  obstruction  and  is  simi- 
larly imbedded  in  a  plastic  exudation.  If  the  flexed  portion  can  be  easily 
separated,  the  flexion  is  removed  by  the  excision  of  a  V-shaped  piece,  which, 
after  suture  of  the  wound,  leaves  the  intestine  in  a  straight  and  permeable  con- 
dition. 

Strangulation  by  Ligamentous  Bands  or  Diverticula. — Ligament- 
ous bands  resulting  from  old  adhesions  are  usually  found  in  those  parts  of  the 
abdominal  cavity  which  are  most  frequently  the  seat  of  peritonitis,  viz.  in  the 
pelvis  and  the  ileo-caecal  region.  Their  formation  can  generally  be  traced  to 
a  broad  parietal  adhesion  which  by  the  movements  of  the  free  portion  of  the 
intestine  has  become  elongated  and  often  narrowed  to  a  delicate  cord.  It 
becomes  a  cause  of  obstruction  when  the  migrating  or  free  end  forms  an  at- 
tachment to  some  fixed  point,  which  then  renders  the  band  tense  and  unyield- 
ing. In  case  a  loop  of  intestine  becomes  ensnared  underneath  it,  strangulation 
takes  place  in  the  same  manner  as  in  strangulated  hernia,  the  constricting  cord 
by  its  pressure  causing  venous  engorgement  below  the  constriction  and  retention 
of  intestinal  contents  in  the  afferent  limb  of  the  loop.  As  in  hernia,  an  intes- 
tine may  have  become  adherent  and  fixed  underneath  such  a  band  for  an  indef- 
inite period  of  time  without  strangulation  taking  place,  so  long  as  the  immediate 
causes  of  strangulation  are  absent.  Any  cause  which  disturbs  the  mechanical 
relations  still  further  in  such  a  case,  as  a  fall,  lifting,  coughing,  the  administra- 
tion of  an  active  cathartic,  etc.,  may  bring  on  an  acute  attack  of  intestinal 
obstruction.  A  displaced  neck  of  a  hernial  sac  may  cause  obstruction  in  the 
same  manner  as  a  ligamentous  band.  A  band  of  constriction  can  also  be 
formed  by  the  margins  of  an  opening  in  the  mesentery  or  omentum,  through 
which  a  loop  of  intestine  may  pass  and  become  strangulated.  An  adherent 
portion  of  omentum  in  the  course  of  time  may  become  drawn  out  into  a  narrow 
twisted  cord  which  may  become  a  cause  of  internal  strangulation.  Another 
frequent  location  for  bands  is  in  the  umbilical  region,  where  the  remains  of  the 
umbilical  artery  may  cause  constriction. 

A  considerable  number  of  cases  of  intestinal  obstruction  are  on  record  in 
%vhich  the  obstruction  was  caused  by  a  Meckel's  diverticulum,  and  in  several  of 
these  the  strangulation  was  successfully  treated  by  laparotomy.  To  the  same 
category  belong  bands  the  remains  of  obliterated  omphalo-mesenteric  vessels. 
Diverticula  are  found  most  fre(iuently  in  the  lower  portion  of  the  ileum,  and 
are  supplied  with  a  mesentery  when  they  spring  from  the  lateral  aspect  of  the 
intestine  or  near  the  mesenteric  attachment.  Diverticula  on  the  convex  sur- 
face of  the  bowel  are  free,  and  are  supplied  with  vessels  from  the  intestinal  wall. 
From  a  surgical  standpoint  the  appendix  verraiformis  must  be  regarded  as  a 
diverticulum.     This  appendage  may  become  a  cause  of  obstruction  when  it  is 


i>isi:a>ses  AM)  jy.Ji  JUEs  of  riii:  aiuxjmex.        755 

of  abnormal  lencrtli  and  supplle*!  with  a  long  mesentery,  and  when  at  the  same 
time  it  is  transformed  into  an  unyieldintr  band  by  fixation  of  its  free  extremity 
to  some  firm  ])oint  by  adhesive  inflammation. 

Treatment. — The  operative  treatment  of  the  obstruction  in  this  form  of 
intestinal  strangulation  is  usually  not  attended  by  any  difficulties,  provided  the 
operation  is  not  postponed  until  the  strangulation  has  produced  gangrene.  The 
band  of  constriction,  whatever  its  location  or  mode  of  origin  may  be,  is  traced 
to  both  the  fixed  points  of  attachment  and  excised  between  two  ligatures. 
The  excision  of  the  constricting  band  not  only  relieves  the  strangulation,  but 
also  prevents  a  possible  recurrence  of  a  similar  attack  from  the  same  cause.  If 
gangrene  has  occurred,  it  will  become  necessary  to  make  a  partial  or  complete 
enterectomy  acconling  to  the  location  and  extent  of  the  gangrene.  In  oper- 
ating for  obstruction  caused  by  an  elongated  adherent  appendix  vermiformis 
or  a  diverticulum  it  is  necessary  to  remove  these  appendages  near  their  attach- 
ment to  the  intestine  and  to  prevent  extravasation  by  carefully  inverting  the 
margins  of  the  wound  and  closing  it  by  suturing.  If  this  cannot  be  done, 
a  ligature  is  applied  near  the  attachment,  and  after  amputating  the  appen- 
dage the  stump  is  buried  by  suturing  the  peritoneum  over  it.  Bands  com- 
posed of  remains  of  the  omphalo-mesenteric  vessels  are  divided  or  excised 
between  two  ligatures  :  if  this  precaution  of  ligating  them  is  omitted,  trouble- 
some hemorrhage  may  be  encountered. 

NON-MALIGNANT  STENOSIS. 

Congenital  Stenosis. — Congenital  narrowincr  of  the  bowel  varies  in 
degree  from  a  slight  contraction  to  complete  atresia.  If  the  stenosis  is  com- 
plete or  sufficiently  well  marked  to  prevent  the  passage  of  intestinal  contents, 
symptoms  of  intestinal  obstruction  will  develop  soon  after  the  birth  of  the  child. 
Even  if  the  narrowing  is  considerable,  the  bowel  remains  permeable  and  no 
serious  symptoms  are  produced  until  some  foreign  body  becomes  lodged  above 
the  seat  of  constriction  and  causes  obstruction  from  fecal  arrest.  The  surgical 
treatment  is  the  same  as  in  the  next  form. 

Acquired  or  Cicatricial  Stenosis. — Cicatricial  stenosis  is  one  of  the 
remote  consequences  of  deep  ulcerative  lesions,  such  as  are  caused  by  dysen- 
tery, typhlitis  stercoralis,  tuberculosis,  and  typhoid  fever.  The  most  frequent 
cause  of  cicatricial  stenosis  is  tubercular  enteritis.  The  tubercular  intestinal 
ulcer  is  usually  circular,  and  in  the  event  of  healing  the  cicatricial  contractions 
result  in  the  formation  of  a  circular  stricture.  Strictures  from  such  a  cause 
are  not  infrequently  multiple.  They  are  found  most  commonly  in  the  ileo- 
cecal region  and  lower  portion  of  the  ileum,  and  are  often  complicated  by 
tuberculosis  in  other  organs,  notably  the  lungs.  The  cicatrix  which  forms 
during  the  reparative  stage  of  the  ulceration  contracts  slowly  and  causes  ste- 
nosis and  chronic  intestinal  obstruction.  As  in  cases  of  congenital  stenosis, 
the  obstruction  often  becomes  complete  and  gives  rise  to  acute  symptoms 
when  a  foreign  body  or  solid  feces  become  impacted  above  the  seat  of  con- 
striction. Xot  infrequently  the  causes  which  have  led  to  cicatricial  stenosis  are 
located  at  the  same  time  or  appear  successively  in  different  parts  of  the  intes- 
tine, producing  consequently  multiple  strictures.  Cicatricial  stenosis  of  the 
small  intestine  is  caused  most  frequently  by  tubercular  ulcers ;  the  same  con- 
dition in  the  colon  results  commonly  from  dysentery,  while  stricture  of  the 
rectum  often  appears  as  a  syphilitic  lesion. 

The  clinical  history  of  cases  of  cicatricial  stenosis  must  be  traced  to  the 
primary  lesions  which  produced  the  stricture,  and  terminates  with  the  well- 


7oG  AN   AMAJiJCAA    TKXT-IiUUK    OF  SL'UL! KliY. 

known  symptoms  characteristic  of  chronic  oh.stniction.  It  is  not  uncommon 
in  these  cases  to  see  the  ohstruction  assume  siuMenly  an  acute  form. 

Treatment. — Enterectomy  should  be  performed  only  if  the  bowel  at  the 
seat  of  obstruction  presents  pathological  conditions  which  necessitate  this  ope- 
ration, otherwise  the  continuity  of  the  intestinal  canal  is  restored  by  an  entero- 
plasty  or  by  intestinal  anastomosis.  Enteroplasty  is  performed  in  the  same 
manner  as  pyloroplasty,  and  is  applicable  in  narrow  circular  strictures.  If  the 
stricture  is  wider,  and  especially  if  several  strictures  are  close  together,  an 
intestinal  anastomosis  is  safer  and  much  more  easily  executed  than  enterectomy 
and  circular  suturing. 

Intestinal  Tumors. — A  tumor  can  give  rise  to  intestinal  obstruction  in 
different  ways,  according  to  its  location  and  anatomico-pathological  character. 
A  tumor  or  swelling  outside  of  the  intestinal  tube  may  cause  obstruction  by 
compression.  A  polypoid  groAvth  springing  from  the  mucous  or  sul)mucous 
tissue  interrupts  the  fecal  circulation  either  by  blocking  the  lumen  of  the  bowel 
by  its  size  or  by  causing  an  invagination  or  flexion.  A  circular  carcinoma 
produces  a  stenosis  which  leads  to  chronic  obstruction,  but  is  also  frequently 
the  indirect  cause  of  acute  intestinal  obstruction. 

Benign  Tumors. — Benign  polypoid  tumors  seldom  attain  sufficient  size  to 
give  rise  to  intestinal  obstruction  unless  they  cause  additional  mechanical  dis- 
turbances, such  as  invagination  or  flexion,  conditions  wdiich  have  already  been 
described.  If  the  tumor  alone  is  the  cause  of  obstruction,  it  is  to  be  removed 
by  laparo-enterotomy.  If  the  tumor  has  caused  invagination  or  flexion  of  the 
intestine,  its  operative  removal  must  be  preceded  or  followed  by  removal  of 
the  mechanical  difficulties  to  which  it  has  given  rise.  Buchwald  and  Kulen- 
kampff  have  reported  cases  of  intestinal  obstruction  caused  by  cysts  of  a 
benign  character  which  had  evidently  originated  in  the  intestinal  wall  and  had 
caused  obstruction  by  flexing  the  bowel  at  an  acute  angle.  If  in  such  cases 
the  cyst  cannot  be  enucleated  without  opening  the  lumen  of  the  bowel,  and 
with  a  prospect  that  the  flexion  will  be  corrected  by  its  removal,  resection  and 
circular  enterorrhaphy  will  become  necessary. 

Malignant  Tumors. — Malignant  stenosis  of  the  intestine  mav  be  caused 
either  by  a  sarcoma  or  by  a  carcinoma,  of  which  the  former  is  more  frequent 
above,  and  the  latter  below,  the  ileo-csecal  valve.  A  sarcoma  of  the  intestine 
always  has  its  starting-point  in  the  wall  beneath  the  mucous  membrane,  while 
carcinoma  commences  either  in  the  mucous  membrane  or  in  its  glandular 
appendages. 

A  sarcoma,  as  a  rule,  does  not  give  rise  to  glandular  infection,  but  to 
extensive  regional  infection  in  the  course  of  the  blood-vessels  and  connective- 
tissue  spaces,  and  obstruction  is  caused  more  frequently  by  flexion  than  by 
circular  constriction  of  the  bowel.  As  a  sarcoma  of  the  intestine  usually  gives 
rise  to  symptoms  of  obstruction,  and  consequently  comes  under  surgical  treat- 
ment, usually  after  extensive  infiltration  of  the  mesentery  and  retro-peritoneal 
tissues  has  taken  place,  it  is  questionable  if  it  is  prudent  to  attempt  a  radical 
operation,  as  in  case  the  patient  recovers  from  the  operation  an  early  recurrence 
is  almost  inevitable.  If  a  sufficiently  early  diagnosis  were  possible,  resection 
could  be  made  with  a  fair  prospect  of  a  permanent  result ;  but  if  infection 
has  extended  to  the  tissues  around  the  bowel,  it  is  more  judicious  to  leave  the 
sarcoma  and  to  exclude  the  obstruction  by  an  intestinal  anastomosis. 

Carcinoma  is  found  most  frequently  in  the  region  of  the  sigmoid  flexure, 
the  cjtcum,  and  the  rectum.  The  disease  either  appears  as  a  circumscribed 
circular  affection,  in  which  case  the  lumen  of  the  bowel  is  narrowed  gradually, 
giving  rise  to  symptoms  indicative  of  chronic  obstruction  ;  or  diffused  infiltra- 


/)/s/:asks  a.xi)  injuries  of  the  abdomen.        7^7 

tioii  of  the  intestinal  wall  takes  place  at  an  early  stage,  in  ^vliicli  case  obstruc- 
tion sets  in  later  and  the  symptoms  are  less  marked.  A  malignant  stenosis 
may  have  existed  for  montiis  without  symptoms,  when  suddenly  symptoms  of 
acute  obstruction  set  in.  In  cases  of  acute  intestinal  obstruction  in  elderly 
people,  where  no  cause  for  it  can  be  found  in  the  abdomen,  a  thorough  rectal 
examination  should  never  be  neglected.  While  sarcoma  may  occur  in  chil- 
dren, carcinoma  is  seldom  met  with  in  persons  under  thirty-five  years  of  age. 
Carcinoma  at  an  early  stage  is  attended  by  regional  infection  in  which  the 
mesenteric  and  retro-peritoneal  glands  arc  principally  involved.  If  the  tumor 
has  attained  considerable  size,  it  can  be  felt  through  the  abdominal  wall,  and 
its  location  and  relations  to  surrounding  organs  can  be  accurately  determined 
by  rectal  insufflation  of  hydrogen  gas  or  atmospheric  air.  If  ulceration  has 
taken  place,  hemorrhage  into  the  bowel  may  occur,  and  this  symptom  when 
present  should  be  taken  into  careful  consideration  in  the  differential  diagnosis. 
Catarrhal  inflammation  of  the  raucous  membrane  above  the  scat  of  obstruction 
is  an  almost  constant  occurrenci,  and  constipation  alternates  with  diarrhea. 

In  malignant  stenosis  of  the  small  intestine  resection  with  circular  enteror- 
rhaphy  can  be  done  with  comparative  ease.  While  excision  of  a  corresponding 
portion  of  the  mesentery  is  not  only  unnecessary,  but  even  harmful  in  enterec- 
tomy  for  non-malignant  lesions,  this  should  never  be  neglected  in  malignant 
cases,  as  by  it  the  mesenteric  glands,  Avhich  arc  most  liable  to  become  infected 
first,  are  removed.  In  resection  of  the  caecum  the  retro-peritoneal  glands 
should  be  removed  as  far  as  possible,  and  the  continuity  of  the  bowel  restored 
either  by  circular  suturing  or  by  making  an  intestinal  anastomosis  a  few 
inches  above  the  closed  ends  of  the  ileum  and  colon,  or  by  implanting 
the  resected  end  of  the  ileum  into  a  slit  in  the  ascending  colon  a  few- 
inches  above  its  closed  end.  If  after  resection  of  the  lower  portion  of  the 
colon  it  is  found  impossible  to  approximate  the  two  ends  of  the  bowel, 
and  the  distal  end  is  not  sufficiently  accessible  to  make  an  intestinal 
anastomosis,  it  should  be  closed  and  dropped  into  the  abdominal  cavity, 
while  the  proximal  end  is  brought  out  through  a  wound  in  the  left  groin, 
where  it  is  secured  by  deep  and  superficial  sutures,  making  thus  a  per- 
manent artificial  anus.  If  on  account  of  the  extent  or  location  of  the 
carcinoma  it  is  found  impossible  to  make  a  radical  operation,  one  of  two  things 
may  be  done.  If  the  bowel  below  the  obstruction  is  accessible,  an  intestinal 
anastomosis  is  made,  or  the  ileum  is  divided  just  above  the  ileo-caecal  valve,  the 
distal  end  invaginated  and  closed  with  sutures,  and  the  proximal  end  implanted 
into  the  bowel  below  the  seat  of  obstruction.  If  on  account  of  the  location  of 
the  obstruction  either  of  these  operations  cannot  be  done,  an  artificial  anus 
should  be  established  in  one  of  the  inguinal  regions  according  to  the  location 
of  the  carcinoma,  and  if  the  first  incision  was  made  through  the  middle  line, 
this  is  closed  and  dressed  separately. 

Retroperitoneal  Tumors. — Tumors  and  sAvellings  in  the  retroperitoneal 
space  present  to  the  surgeon  many  points  of  diagnostic  and  operative  inter- 
est. In  the  diagnosis  of  such  pathological  conditions  it  is  important  to  con- 
nect the  tumor  with  its  anatomical  starting-point.  The  retroperitoneal  loca- 
tion of  a  palpable  tumor  can  sometimes  be  definitely  ascertained  by  rectal 
insufflation  of  air.  If  the  tumor  is  in  contact  with  the  anterior  abdominal 
wall,  the  area  corresponding  with  its  circumference  will  be  dull  on  percus- 
sion. If  the  colon  is  distended  with  air,  the  dulness  disappears  if  the  tumor 
is  retroperitoneal,  as  the  distended  colon  separates  it  from  the  abdominal 
wall ;  if  the  tumor  is  intraperitoneal,  it  is  often  displaced  by  the  distended 
colon,  but  the  disappearance  of  the   tumor    and  dulness    is   less   marked. 


758  Ai\  ami:l'i<'AX  'nixr-iiooK  of  sunaj:in\ 

Tumors  in  the  retropcritoiu'al  space,  uitli  lew  exceptions,  are  of  niesoblastic 
origin.  Dermoids  in  tliis  locality  are  exceedingly  rare.  Inflammatory 
swellings  take  their  starting-point  most  frequently  in  the  bodies  of  the  verte- 
brne,  lymphatic  glands,  and  connective  tissue. 

The  operative  treatment  of  retroperitoneal  tumors  is  attended  by  much 
more  risk  to  life  than  the  removal  of  intraperitoneal  tumors.  'J'he  surgeon's 
eftbrts  fretfuently  cease  with  an  exploratory  laparotomy. 

Fatty  tumors  develop  most  frc(iuently  in  connection  with  tlie  j»ararenal 
cushion  of  fat  along  the  ilio-psoas  muscle  and  in  the  obturator  foramen  and 
crural  canal.  Usually  they  do  not  reach  large  size;  in  a  few  cases  they  have 
attained  an  enormous  size.  They  often  undergo  sarcomatous  degeneration. 
Their  growth  is  slow%  and  the  symptoms  which  they  produce  are  due  almost 
exclusively  to  pressure.  Their  removal  is  effected  through  a  median  abdomi- 
nal incision  by  splitting  the  peritoneum  over  the  center  of  the  tumor  in  a 
vertical  direction,  followed  by  enucleation.  After  careful  arrest  of  hemor- 
rhage the  peritoneal  incision  is  sutured  before  closing  the  abdominal  incision. 

Retro-peritoneal  Struma. — This  tumor,  of  a  malignant  or  semi-malignant 
nature,  has  its  origin  in  the  supra-renal  gland  or  foetal  rests  of  this  gland. 
Such  a  tumor  is  closely  allied  to  or  almost  identical  with  sarcoma  histolog- 
ically and  clinically.  It  is  rapid  in  growth  and  soon  infects  tlie  kidne3^  A 
number  of  successful  radical  operations  have  been  recorded ;  but  unless  thor- 
oughly removed  speedy  recurrence  is  certain  to  take  place. 

Sarcoma  in  the  retroperitoneal  spaces  springs  either  from  one  of  the 
bodies  of  the  vertebras,  the  pelvic  bones,  lymphatic  glands,  or  the  connective 
tissue.  Lympho-sarcoma  of  the  retroperitoneal  glands  fre((uently  appears  as 
the  result  of  regional  dissemination  of  sarcoma  of  the  testicle.  As  a  primary 
and  secondary  affection  of  the  lymphatic  glands  it  presents  itself  in  the  form 
of  a  multiple  rapid-growing  tumor.  Fascial,  periosteal,  and  bony  sarcomas  are 
characterized  clinically  by  a  rapid-growing  tumor  in  the  retroperitoneal  space. 

Serous  cysts  have  been  found  in  the  retroj)eritoneal  space  that  originated 
from  remains  of  either  the  Wolffian  body  or  Miiller's  ducts.  Cysts  of  such 
histoo-enetic  origin  have  thin  walls  and  contain  a  clear  fluid  in  which  albu- 
min,  chlorides,  and  traces  of  urea  and  uric  acid  can  be  found.  In  some  of 
these  cases  the  kidney  on  the  corresponding  side  was  either  absent  or  in  a 
rudimentary  form.  In  a  foAV  cases  retroperitoneal  serous  cysts  in  the  renal 
region  have  successfully  been  removed  through  a  lumbar  incision. 

Tubcrrulosis  of  the  retroperitoneal  I//mj)/iatic  glands  is  frei[uently  one  of 
the  remote  results  of  a  similar  affection  of  the  testicle.  By  an  extraperito- 
neal incision  a  chain  of  tubercular  glands  extending  from  the  internal 
inguinal  ring  to  the  bifurcation  of  the  common  iliac  artery  have  been 
removed.  Progressive  extension  is  one  of  the  typical  clinical  features  of 
glandular  tuberculosis  in  this  as  well  as  in  other  regions.  Caseation  and 
abscess-formation  occur  if  life  is  sufficiently  prolonged.  The  abscess  usually 
points  above  the  crest  of  the  ilium. 

Chronic  abscesses  which  develop  in  the  course  of  tubercular  spojidylitis 
often  appear  as  retroperitoneal  swellings,  and  have  freiiuently  been  mistaken 
for  pyonephrosis  and  paranephric  abscess.  A  careful  study  of  the  clinical 
history,  combined  -with  a  painstaking  examination  to  locate  the  swelling 
properly,  aided,  if  necessary,  by  an  exploratory  puncture  in  the  lumbar 
region,  Avill  usually  enable  the  physician  to  make  a  correct  diagnosis.  Retro- 
peritoneal tubercular  abscesses  of  glandular  or  osseous  origin,  accessible 
through  the  lumbar  region,  should  be  treated  by  tapping,  followed  by  injec- 
tion of  a  10  per  cent,  iodoform-glycerin  emulsion. 


DISEASES   AND    INJURIES    OF    THE   ABDOMEN.  759 

Adynamic  Intkstinal  Obstruction  caused  by  Arrest  of  Peri- 
stalsis.— A  number  of  pathological  conditions  are  known  to  produce 
symptoms  which  so  closely  resemble  those  of  intestinal  obstruction  due 
to  mechanical  causes  that  the  abdomen  has  been  repeatedly  opened  in 
such  cases  with  the  expectation  of  removing  the  cause  of  obstruction,  yet 
no  occlusion  of  any  kind  could  be  found.  These  are  the  cases  that  have 
caused  the  t^rejitest  difficulty  in  diiignosis,  and  have  often  brought  dis- 
appointment and  reproach  upon  the  surgeon.  The  obstruction  in  these  cases 
is  not  caused  primarily  by  a  narrowing  of  the  lumen  of  the  intestine,  but  by 
suspension  of  the  forces  which  propel  the  intestinal  contents,  and  which  results 
in  the  accumulation  of  feces  and  gases  in  the  paralyzed  portion  of  the  bowel ; 
this  is  followed  by  distention  of  the  intestines,  constipation,  and  obstinate 
vomiting,  which  in  rare  cases  may  become  fecal.  Circumscribed  or  diffuse 
paresis  of  the  intestines  is  often  caused  by  an  inflammatory  affection,  such  as 
peritonitis  or  enteritis,  which  produces  suspension  of  muscular  contractions  in 
the  same  manner  as  when  an  inflammatory  process  in  any  other  organ  affects 
directly  the  muscular  tissue ;  or  the  tunics  of  the  intestines  may  be  in  an  intact 
condition,  and  paralysis  result  from  reflex  causes.  In  either  case  the  most 
striking  symptom  is  an  extensive  tympanites.  While  in  obstruction  from 
mechanical  causes  the  peristaltic  action  of  the  intestines  can  sometimes  be 
seen  on  the  surface  of  the  abdomen,  paralysis  from  over-distention  not  having 
taken  place,  in  the  paralytic  form  the  abdominal  surface  is  smooth  and  the 
outlines  of  the  intestinal  coils  are  not  perceptible.  In  this  form  of  obstruction 
expulsion  of  gas  and  the  passage  of  intestinal  contents  are  prevented  by  the 
formation  of  numerous  flexures,  owing  to  the  great  distention  of  the  intestines, 
which  is  followed  by  compression  of  some  parts  of  the  intestines  by  the  dis- 
tended loops. 

The  diseases  which  cause  adynamic  intestinal  obstruction  are  rapid  accumu- 
lation of  gas  from  fermentative  or  putrefactive  processes  in  the  intestines,  peri- 
tonitis, and  catarrhal  and  ulcerative  enteritis.  A  paretic  condition  of  the  bowels 
has  also  been  observed  following  prolonged  laparotomies,  especially  when 
evisceration  has  been  necessary. 

In  rare  cases  the  intestinal  paresis  is  caused  either  by  embolism  of 
branches  of  the  mesenteric  arteries  or  thrombosis  of  the  mesenteric  veins. 
In  either  case  the  impaired  circulation  is  almost  sure  to  give  rise  to  gangrene 
or  sloughing  of  the  intestine,  to  an  extent  corresponding  with  the  vascular 
district  affected. 

if  a  positive  diagnosis  of  adynamic  obstruction  can  be  made,  the  treat- 
ment consists  in  relieving  the  distention  by  puncturing  the  bowel,  external 
support  by  enveloping  the  abdomen  with  strips  of  adhesive  plaster,  tubage  of 
the  colon,  a  rigid  diet,  and  the  administrat;jon  of  such  remedies  as  naphthaline 
to  procure  an  aseptic  condition  of  the  intestinal  canal.  If  under  such  circum- 
stances a  laparotomy  is  made  upon  the  supposition  that  a  mechanical  cause 
exists,  the  intestine  should  be  emptied  through  one  or  more  incisions  at  least 
an  inch  or  more  in  length,  which  are  at  once  sutured,  the  intestines  returned, 
and  the  external  wound  closed,  after  which  a  treatment  is  adopted  which  is 
directed  toward  the  removal  of  the  primary  cause  and  the  prevention  of  the 
production  of  gas  in  the  intestines. 

APPENDICITIS. 

Appendicitis,  or  inflammation  of  the  appendix  vermiformis,  is  now  a  well- 
recognized  surgical  lesion,  and  is  regarded  as  the  primary  lesion  in  the  cans- 


7(io  ,i.v  AMi:i:i(  A.\   TKxr-iiooK  or  suhgery. 

ation  of  the  ruiiiiorous  loriiis  (»t"  inllaiiiiuatiun  in  the  ileo-civcal  re;:;iun  known 
!vs  typhlitis,  perityphlitis,   paratyphlitis,  and  appendicular  peritonitis. 

Etiology.  —  As  re«:ar<ls  etiology,  we  may  first  consider  (<?)  the  predisposing 
causes.  The  exjilanation  of  the  great  fre(|iien<y  with  which  the  ap]»endix 
becomes  the  seat  of  inHanmiatory  and  tlestructive  lesions  as  compared  with 
the  other  jiortions  of  the  digestive  tract  is  undoubtedly  to  be  found  in  its 
embrvologv  and  in  its  anatomical  relations.  There  can  be  no  question  that 
those'  structures  which  remain  to  us  as  functionless  vestiges  of  parts  once 
useful  in  our  prehistoric  ancestors  are  possessed  of  low  vitality  and  but  feeble 
resistant  powers.  This  is  as  true  in  the  life  of  the  race  as  in  that  of  the  indi- 
vidual. It  doubtless  explains  in  part  the  special  su.sceptibility  of  the  appen- 
dix to  inflammation,  as  it  does  that  of  the  uterus  and  the  female  brea.st  to 
cancer  during  the  post-sexual   ])eriod  of  life. 

In  addition,  its  dependent  position,  its  communication  by  an  orifice,  often 
more  or  less  narrowed,  with  that  portion  of  the  intestine  in  which  inspissation 
of  intestinal  contents  first  occurs,  Avhile  at  the  same  time  it  is  removed  from 
the  direct  fecal  current — all  appear  to  be  conditions  so  markedly  predisposing 
to  inflammatory  attacks  that  we  need  look  no  further  for  a  suflicient  explana- 
tion of  the  extraordinary  frequency  of  appendix  trouble. 

(h)  ExciTiNU  Causes. — Putting  aside  the  comparatively  rare  cases  in 
which  tubei'cular  or  other  general  disease  localizes  itself  in  the  appendix,  we 
have  two  chief  classes  of  exciting  agencies,  clinical  differentiation  of  which 
is  to  be  earnestly  aimed  at :  the  mechanical  and  the  bacterial  or  infective. 
The  latter  comes  into  play  usually,  perhaps  almost  constantly,  as  a  sequel  of 
the  former,  which  may,  however,  exert  its  action  alone  from  first  to  last  in  a 
given  instance,  and  does  so  in  some  cases. 


^ 


Sections  of  two  Appendixes,  showing  Obstruction  of  ilie  l.uiuen. 
(Original.)  (Richardson.) 

The  following  anatomical  points  must  be  remembered :  The  location  and 
direction  of  the  appendix  are  variable.  In  the  majority  of  cases  the  base  of 
this  organ  is  situated  at  or  near  McBurney's  point ;  but  it  has  been  found  in 
exceptional  cases  in  the  left  side  and  beneath  the  diaphragm.  Its  direction 
may  be  upward,  downward,  or  to  either  side.  Its  length  varies  from  one  to 
six  inches  or  more.  The  appendix  is  commonly  found  curved  upon  itself, 
because  its  mesentery,  derived  from  the  inferior  layer  of  the  mesentery  of 
the  ileum,  is  too  short  for  it.  In  the  fnetal  type  of  the  cecum  and  appendix 
the  latter  has  a  mesentery  which  runs  to  its  tip  :  but  in  the  majority  of  adults 
it  ends  about  the  center  of  the  appendix  or  at  the  junction  of  its  middle  and 
distal  thirds.  Along  the  free  concave  border  of  the  mesentery  runs  a  single 
vessel,  a  branch  of  the  ileo-colic,  and  from  this  branch  the  appendix,  as  a 
rule,  derives  almost  its  entire  blood-supply.  Another  peritoneal  fold  runs 
from  that  part  of  the  ileum  most  remote  from  its  mesenteric  attachment  and 
is  united  with  the  mesentery  of  the  appendix.  It  carries  no  blood-ves.<?els.  It 
is  the  remains  of  the  true  mesentery  of  the  appendix  (Treves).  It  is  inter- 
esting to  note  the  fact  that  in  the  different  types  of  cecum  found  in  our 
species  those  which  involve  its  disproportionate  growth  show  that  it  derives 
its  peritoneal  covering  partly  at  the  expense  of  the  mesentery  of  the  appen- 


APPENDICITIS. 


Plate  XVTIT. 


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DISEASES    AM)    fXJURIES    OF    THE   ABDOMEN.  761 

<li.\.  wliii-h  becomes  more  an<l  more  scanty  and  more  vertical  in  dircc-tion  the 
larger  the  rehitive  size  of  the  cecum. 

We  here  have  the  factors  Avhich  enter  into  the  production  of  a  large  number 
of  cases  of  appendicitis.  Distention  of  the  ileum  with  gas  or  of  the  caput  coli 
with  'ras  or  fecal  matter  will  cau.se  dragging  on  one  or  the  other  of  these 
folds. '^ilready  too  scanty,  increase  the  torsion  of  the  appendix,  interfere  with 
the  blood-suYplv  through  its  single  vessel,  and.  according  to  the  degree  of 
torsion,  produce  congestion  and  tumefaction,  catarrhal  iiiHammation.  ulcera- 
tion, or  gangrene,  with  the  clinical  symptoms  that  belong  to  each.  The 
anatomical  conditions  are  so  simple  and  easily  understood,  and  explain  so 
completelv  various  well-known  types  of  the  disease,  that  we  may  assume 
them  to  be  sufficient  in  many  cases  to  account  for  all  the  symptoms. 

It  seems  ])robable  that  the  bacterial  cause  of  appendicitis  is.  as  a  rule,  the 
bacterium  coli  commune.  It  is  almost  invariably  to  be  found  in  the  intestinal 
tract,  and  seems  in  the  presence  of  sound  mucous  membrane  to  have  little  or 
no  power  for  evil ;  but  it  is  equally  well  demonstrated  that  if  the  epithelium 
is  once  dcstroved,  it  has  both  pathological  and  pyogenic  properties. 

Ex])eriments  have  shown  that  even  a  moderate  degree  of  constriction  of 
the  intestinal  canal  may  be  followed  by  the  [lenetration  of  its  walls  by  this 
bacterium,  and  also-  that  its  virulence  is  much  increased  by  the  presence  of 
irritative  conditions,  such  as  exist  in  advanced  constipation  or  marked 
diarrhea,  even   when  produced  experimentally  by  tartar  emetic. 

Other  micro-organisms  are  exceptionally  associated  with  acute  appendi- 
citis, but  the  most  reliable  observations  seem  to  show  that  in  82  per  cent,  of 
infective  cases  this  bacterium  is  the  active  agent  (Tavel  and  Lanz). 

Barbacci  found  that  in  perforative  peritonitis  cultures  from  the  exudate 
yield  onlv  one  microbe  in  the  vast  majority  of  cases,  the  bacillus  coli  com- 
munis. Fowler,  who  has  studied  the  bacteriology  of  appendicitis  on  an 
extensive  scale,  almost  invariably  found  this  bacillus,  but  in  many  cases  asso- 
ciated with  other  microbes  such  as  the  streptococcus  pyogenes,  diplococci, 
micrococcus  Havus  liquefaciens,  etc. 

A  third  class  of  causes  which  may  be  regarded  as  both  predisposing  and 
exciting  must  be  made  to  include  fecal  concretions  and  foreign  bodies.  The 
latter,  once  thought  to  be  the  chief  factors  in  producing  the  disease,  are  now 
known  to  be  of  great  rarity,  occurring  in  only  about  4  per  cent,  of  operative 
<3ases  (Matterstock.  Fowler).  Fecal  concretions  are  found  in  15  to  20  per 
cent,  of  such  cases,  and  there  is  evidence  to  show  that  they  may  occasionally 
by  their  presence  give  rise  to  the  lesion  of  the  mucous  coat  which  precedes 
infective  processes ;  but  they  are  so  often  absent  in  cases  of  all  grades  of 
severity,  and  so  often  preseiat  in  autopsies  on  persons  who  have  died  from 
other  diseases,  that  they  should  not  be  considered  of  primary  importance. 

Catarrhal  appendicitis  may  be  caused  by  an  extension  of  catarrh  of  the 
cecum  bv  continuity  of  the  mucous  membrane  into  this  structure;  in  a  few 
oases  traumatism  has  been  thought  to  have  caused  the  disease. 

The  effect  of  age  'must  be  taken  into  account  in  summing  up  the 
etiological  factors.  It  is  certain  that  the  two  extremes  of  life  are  nota- 
bly exempt,  but  the  explanation  of  this  fact  is  thus  far  purely  theoretical. 
It'is  asserted  that  in  very  early  life  the  funnel-shaped  appendix,  apex  down- 
ward, offers  fewer  opportunities  for  the  formation  and  retention  of  masses 
of  inspissated  feces,  while  in  old  age  atrophy  of  the  mucous  membrane 
about  the  cecal  orifice  of  the  tube  again  widens  it ;  but  we  lack  positive 
knowledge  upon  these  points.  The  very  existence  of  the  fold  of  mucous 
membrane  known  as  the  valve  of  Gerlach  is  disputed,  and  in  any  event  it  is 
so  imperfect  mechanically  as  to  be  presumably  of  slight  importance. 


702  ^l^V    AMERICAN    TEXT- HOOK    OF   SI  IK! Ell  Y. 

The  disproportion  between  the  sexes  re(iuires  explanation.  If  we  accept 
the  usual  description  of  tlif  anatomy  of  the  parts  concerned,  there  seems  to 
be  no  good  reason  Avhy  api)endicitis  should  be  found  in  men  four  or  five  times 
morefrei(uently  than  in  women;  but  if  future  observations  confirm  the  asser- 
tion of  Clado,  that  a  fold  of  i)eritonenm  passes  from  the  right  ovary  to  the 
meso-appendix — the  appcndiculo-ovarian  ligament — and  if  this  fold  carries  a 
blood-vessel,  an  obvious  and  sufficient  exj)lanation  has  been  found.  It  has 
been  shown  (Bryant)  that  the  male  appendix  is  four-tenths  of  an  inch  longer 
than  that  of  the  female ;  that  its  caliber  is  slightly  larger  ;  and,  possibly  as 
a  result  of  the  latter  fact,  that  it  contains  fecal  concretions  in  a  larger  per- 
centajje  of  cases.  But  these  circumstances  do  not  seem  to  throw  much  li<:ht 
on  the  subject. 

The  manner  in  which  constipation  or  diarrhea  and  digestive  disturbances 
generally  favor  the  development  of  appendicitis  is  now  evident.  We  have  a 
vestigial  structure  of  relatively  poor  vitality  and  low  resistant  power,  so  situated 
mechanically  that  its  one  source  of  blood-supply  is  greatly  interfered  with  by 
twisting  or  dragging,  and  connected  by  short  or  scanty  folds  of  serous  mem- 
brane with  portions  of  the  digestive  tract  especially  liable  to  changes  of  form 
and  size,  which  thus  easily  produce  such  torsion  or  tension.  Furthermore,  a 
micro-organism,  capable  of  great  virulence  if  epithelial  exfoliation  occurs  or 
if  any  area  of  lessened  resistance  exists,  is  almost  constantly  present. 

Pathology. — In  an  appendix  the  seat  of  inflammation,  the  mucous 
membrane  is  usually  very  vascular  and  considerably  tliickened,  and  as  the 
opening  into  the  cecum  is  narrowed  by  the  same  cause,  accumulation  of  a  viscid 
or  muco-purulent  product  takes  place,  which  distends  the  lumen  of 
the  appendix.  The  ulcers,  which  are  often  multiple,  present  sharp,  well- 
defined,  infiltrated  margins,  and  in  depth  vary  from  a  slight  superficial 
abrasion  to  complete  perforation  of  the  appendix.  The  examination  of 
cadavers  made  with  special  reference  to  determine  the  relative  fre- 
quency of  disease  of  the  appendix,  by  Kraussold,  Toff"t,  Tiingel,  Fer- 
gu.sson,  Ransohoff",  and  others  shows  that  almost  always  a  jtrimary  appen- 
dicitis precedes  an  attack  of  perityphlitis  or  paratyphlitis.  From  the  ana- 
tomical structure  of  the  appendix  and  its  relations  to  the  peritoneal  cavity 
we  have  reason  to  believe  that  the  peritoneal  cavity  is  implicated  more  or  less 
in  almost  ever^^  case  in  which  appendicitis  leads  to  perforation.  A  diffuse  cel- 
lulitis or  pldegmonous  inflammation  of  the  connective  tissue  behind  the  cjvcum, 
without  participation  of  the  general  peritoneal  cavit}^  will  occur  if  before 
perforation  takes  place  that  part  of  the  appendix  has  become  firmly  adherent 
to  the  parietal  peritoneum,  the  perforation  in  such  cases  not  opening  into 
the  peritoneal  cavity,  but  into  the  loose  retro-peritoneal  connective  tissue,  and 
leading  to  a  localized  extra-peritoneal  abscess.  Such  an  abscess  may  present 
itself  near  the  anterior  superior  spine  of  the  ileum,  above  Poupart's  ligament, 
or  even  in  the  lumbar  region,  in  the  latter  instance  simulating  a  ])erinephritic 
abscess,  or  it  may  dischai'ge  its  contents  into  the  caecum,  an  adjoining  adherent 
loop  of  the  small  intestine,  the  bladder,  the  vagina,  or  even  the  rectum.  In 
cases  of  this  kind  a  localized  peritonitis  always  precedes  the  phlegmonous  inflam- 
mation and  suppuration.  In  other  cases  perforation  takes  place  into  the  peri- 
toneal cavity,  but  the  extension  of  the  infection  is  limited  by  the  formation 
of  an  abscess-wall  composed  of  loops  of  the  small  intestine  which  liave  become 
firmly  adherent  by  plastic  exudation,  and  the  resulting  abscess  is  the  pro(hu;t 
of  a  limited  suppurative  peritonitis.  The  gravest  form  of  appendicitis  is  deter- 
mined if  the  whole  appendix  becomes  gangrenous  or  if  the  ])erforation  com- 
municates with  the  free  peritoneal  cavity.  Total  gangrene  is  usually  the 
inevitable   conseijuence  of  thrombosis  of  the   princii)al    artery  or   thrombo- 


1)Isi:asI':s  axd  jnjuries  of  the  audomiix.        liv.i 

plilchitis  ot"  the  veins  of  the  ineseiiterioliini  [or  iii('S()-;n)j)cii(li.\],  or  of"  siiiiul- 
tanooiis  or  consecutive  thrombosis  of  both  sets  of  vessels.  If  no  .ittempt  at 
localization  occurs,  the  sej)tic  material,  becoming  diffused  over  the  whole  peri- 
toneal cavity,  gives  rise  to  a  diffuse  septic  peritonitis  which  results  in  death 
within  two  or  three  days.  Identical  conditions  with  the  same  result  follow 
the  rupture  of  a  limited  paratyplditic  or  })erityphlitic  abscess  into  the  peri- 
toneal cavity.  In  a  considerable  )»ereentage  of  cases  a  perityphlitis  or  ])!ira- 
typhlitis  docs  not  terminate  in  suppuration,  but  the  inflammatory  swelling 
disappears  within  a  few  Aveeks.  This,  the  most  favorable  termination  of 
appendicitis,  is  most  likely  to  folloAv  if  perforation  does  not  occur  or  if  the 
perforation  is  small  and  tlu>  appendix  surrounded  by  a  mass  of  plastic  exu- 
dation. Rupture  of  an  abscess  into  the  cecum  is  tisually,  but  not  always, 
followed  by  permanent  relief.  In  recurring  a])i)endicitis  a  limited  swelling 
forms  in  the  region  of  the  appendix,  and  disappears  after  the  acute  symptoms 
subside,  to  reappear  later.  In  this  form  of  appendicitis  flexions  and  stric- 
tures are  almost  constantly  found. 

Symptoms. — Let  us  suppose  that  we  have  a  case  in  which  constipation, 
which  is  usually  present,  or  diarrhea,  or  at  least  some  digestive  derange- 
ment, has  caused  intestinal  distention  with  fecal  matter  or  with  gas,  or 
irregular  and  excessive  peristalsis  in  the  ileo-cecal  region.  The  meso-appen- 
dix  is  dragged  upon,  the  torsion  of  the  appendix  increased,  the  return  of 
blood  interfered  with ;  the  arterial  supply,  more  difficult  to  disturb  than  the 
venous  current,  is  but  little  affected.  If  we  could  see  such  an  appendix,  we 
would  undoubtedly  find  swelling  and  congestion,  hypersecretion,  nerve-irrita- 
tion. It  seems  theoretically  unreasonable  to  suppose  that  in  every  such  case 
there  is  necrosis  even  of  epithelium  or  infection  even  of  low  grade.  It  is 
probable,  however,  that  there  is,  even  in  the  mildest  cases,  an  exudate  under 
pressure  into  the  submucous  and  muscular  coats  of  the  wall  of  the  appendix, 
and  a  slight  adhesive  peritonitis  of  very  moderate  extent.  The  post-mortem 
findings,  which  show  that  in  one  person  out  of  every  three  there  has  been 
some  pathological  condition  present  in  the  appendix,  are  so  out  of  propor- 
tion to  the  clinical  percentage  of  frequency,  large  as  that  is,  that  it  seems 
evident  that  some  such  minor  attacks  must  take  place,  and  often  with  phe- 
nomena so  slight  that  they  scarcely  attract  attention. 

The  usual  symptoms  of  such  a  case  as  we  are  considering  are :  pain,  at 
first  general  and  diffused  over  the  abdomen,  because  the  superior  mesenteric 
plexus  of  the  sympathetic,  Avhich  supplies  the  appendix,  also  largely  supplies 
the  intestines,  and  because  irritative  nerve-pain  is  apt  to  be  referred  to  the 
peripheral  extremities  of  nerves ;  next  and  within  a  very  short  time  it  is  felt 
in  the  umbilical  region,  because  as  such  pain  increases  in  intensity  it  is  often 
referred  to  the  nearest  nerve-centre,  and  the  great  sympathetic  ganglia  of  the 
abdomen  are  situated  in  that  region. 

The  pain  at  this  time  is  often  colicky  in  nature,  and  a  discussion  has 
arisen  as  to  whether  or  not  the  circular  muscular  fibers  in  the  appendix  have 
actually  been  observed  in  alternate  spasm  and  relaxation  when  exposed  in  a 
wound  (Morris);  but  it  seems  unimportant,  as  appendix  irritation  may  result 
in  colicky  spasm  of  neighboring  portions  of  either  small  or  large  intestines. 

After  a  few  hours  the  pain  is  felt  in  the  right  iliac  fossa,  because  then  a 
neuritis  has  developed  of  sufficient  grade  to  cause  tenderness  on  pressure. 
It  is  a  localized  tenderness  in  all  the  varieties  of  appendicitis,  because  while 
the  appendix  itself  is  movable,  it  always  arises  from  the  same  part  of  the 
cecum,  and  the  mobility  of  the  latter  is  much  more  restricted.  The  point 
of  pain  on  pressure  known  as  McBurney's  point,  situated  about  two  inches 
from  the  anterior  superior  spine  toward  the  umbilicus,  indicates,  therefore. 


li]\  A\    AMEIiK'AX    TEXT-IiOOK    O/'   sr IK ! Eli  Y. 

vitli  iiioiU'vate  accuracy  tlic  l)asc,  not  the  ti]i.  of  the  M])|»('ii(|i.\.  and  is  rarclv 
absent  even  in  ganj^reiious  cases,  because  that  jiortion  of  the  a]»j)en(li\  is 
usually  the  last  to  be  atlectcd  by  interference  with  the  blood-supplv. 

Vomitino;  coniinonly  follows,  with  little  relation  to  gastric  conditions,  and  is 
ordinarily  reHex  and  due  to  reversed  peristalsis,  as  the  ejeeta  show  a  degree  of 
digestive  change  correspontling  to  the  time  which  has  elapsed  since  the  last  meal, 
"^  Moderate  fever  (lt0.5°  to  101°  F.)  and  slightly  increased  pulse-rate  (90  to 
110)  are  usually  present,  and  are  doubtless  due  to  the  same  sort  of  absorption 
of  intestinal  ])roducts  as  gives  rise  to  the  same  symptoms  in  constipation  or 
in  true  bilious  colic,  for  which  cases  of  this  kind  are  sometimes  mistaken. 

There  is  slight  rigidity  of  the  right  rectus  muscle,  and  later  of  the  abdom- 
inal muscles  over  the  right  iliac  fossa,  often,  but  perhaps  not  necessarily,  due 
to  peritonitis,  and  in  any  event  arising  from  the  fact  that  those  muscles  re- 
ceive their  nerve-supply  from  the  seven  lower  intercostals,  while  the  suj)erior 
mesenteric  plexus  gets  its  splanchnics  from  the  same  seven  intercostals. 

As  long  as  the  disease  is  limited  to  the  appendi.x  the  swelling  is  not 
distinct,  and  if  the  appendi.x  is  located  behind  the  cecum  it  often  eludes 
detection. 

The  swelling  sometimes  increases  ({uite  rapidly  within  a  few  days,  and 
varies  in  size  according  to  the  extent  of  the  disease  and  the  character  of  the 
tissues  involved.  It  appears  early,  and  attains  considerable  dimensions  as 
soon  as  the  connective  tissue  behind  the  cecum  is  extensively  involved  in  the 
inflammatory  process.  Even  if  a  large  abscess  has  formed,  fluctuation  is 
generally  absent  or  indistinct,  on  account  of  the  rigidity  of  the  abdominal 
wall  covering  the  inflamed  area. 

Diagnosis. — As  to  the  diagnosis  of  the  mild  class  of  cases  tending  to 
recovery,  it  is  to  be  made  chiefly  from  stercoral  typhlitis,  a  condition  which 
has  been  so  overshadowed  during  the  advance  of  our  knowledge  in  regard  to 
appendix  disease  that  we  are  in  danger  of  acting  as  if  it  were  non-existent. 
In  some  elaborate  reviews  of  the  diagnosis  of  appendicitis  it  is  hardly  men- 
tioned, and  yet  a  very  moderate  clinical  experience  ought  to  convince  any 
careful  observer  that  it  is  occasionally  present.  It  has  many  features  in  com- 
mon Avith  appendicitis,  and  it  is  quite  possible  that  to  some  degree  this  is 
present  in  most  cases  of  stercoral  typhlitis,  but  the  independent  existence  of 
the  latter  condition  has  apparently  been  shown  both  at  autopsies  and  at 
operations,  where  it  is  asserted  that  severe  forms  of  typhlitis  and  perityph- 
litis have  been  found  to  be  dependent  on  stercoral  ulcers  of  the  cecum,  and 
the  appendices  were  normal.  Some  surgeons  of  large  experience  have  never 
seen  this  condition,  and  there  is  still  much  diff'erence  of  opinion  about  it. 
It  is  true  that  in  the  vast  majority  of  cases  of  severe  inflammation  and 
suppuration  in  the  right  iliac  fossa  the  appendix  is  at  fault,  but  it  should 
not  be  forgotten  that  in  many  of  them  the  original  trouble  is  a  constipation, 
associated  with  distention  of  the  cecum  by  fecal  masses  often  containing 
undigested  food,  and  exciting  both  mechanical  and  chemical  irritation.  The 
relation  of  the  mild  attacks  of  appendicitis  to  digestive  derangement  is  unmis- 
takable, and  it  is  not  very  uncommon  to  find  in  relapsing  aj)pendicitis  that 
one  particular  article  of  food  is  the  especial  exciting  cause  of  an  attack. 

If  in  many  cases  fecal  distention  of  the  cecum  is  the  starting-point  of 
appendicitis,  it  is  reasonable  to  believe  that  in  some  of  them  the  trouble  does 
not  pass  beyond  the  cecum,  and  it  is  important  to  recognize  these  cases, 
because  the  prognosis  is  so  much  more  favorable,  and  operative  measures  need 
not,  as  a  rule,  be  thought  of. 

They  occur  chiefly  at  the  times  of  life  when  appendicitis  is  less  common, 
and  more  especially  in  children.     They  can  be  recognized  with  certainty 


DISEASES   AND    INJURIES    OF    THE    A 11  DOM  EX. 


7G5 


only  l.v  thu  initial  presoiue  of  a  tloughy,  sausage-shaped  swelling  in  the  cecal 
re.Mon".  assoc-iatt-d  with  the  usual  symptoms  f.f  appendicitis  ina  modified  form. 
The  localized  tenderness  is  not  so  great ;  the  fever  is  very  moderate ;  vomit- 
ing is  rarelv  a  prominent  svmptom  ;  constijiation  is  almost  invariable,  thougli 
occasionally  a  spurious  diju-rhea  (analogous  to  the  "  incontinence  of  reten- 
tion "   in  bladder  cases)  may  make  its  appearance. 

The  discovery  of  a  swelling  at  the  very  beginning  of  an  attack  ot  apparent 
appendicitis  of  obviously  mild  type  would,  perhaps,  justify  the  diagnosis  of 
stercoral  typhlitis,  but  in  the  absence  of  that  sym])tom  it  would  be  safer  to 
consider  doubtful  conditions  as  almost  certainly  indicating  appendicitis. 

A  differential  diagnosis  between  an   inflammatory  lesion  m  the  ileo-cecal 
retrion  and  intestinaf  obstruction  in  the   same  locality  is  sometimes  difficult. 
Appendicitis  is  almost  always  attended  by  a  rise  of  temperature  from  the  very 
becrinnin«^  while   an   intestinal   obstruction    uncomplicated  by  inflammatory 
lesions  is^iot  attended  by  fever.     The  history  of  the  case  is  often  valuable  in 
making  an  early  and  correct  diagnosis,  as  it  is  well  known  that  a  person  who  ha& 
once  sufteredfrom  appendicitis  is  prone  to  subsequent  attacks  unless  the  primary 
cause  is  removed  by  operative  measures ;  hence  if  a  patient  has  passed  through 
an  attack  of  appendicitis  at  some  previous  time,  however  remote  this  may  be, 
if  he  airain  presents  •  evidences  of  iBflammation  in  the  ileo-cecal  region  it  is 
very  probable  that  he  is  suff'ering  from  a  recurring  attack  of  appendicitis.     If 
durincr  the  course  of  an  attack  of  appendicitis  the  patient  experiences  a  sudden 
diffuse  pain  and  presents  evidences  of  shock,  frequent,  small,  and  wiry  pulse, 
and  a  subnormal  or  high  temperature,  it  is  almost  certain  that  an  ulcer  of  the 
appendix  or  a  peritvphlitic  or  paratvphlitic  abscess  has  ruptured  into  the  peri- 
toneal cavitv.       Incomplete  intermission  of  symptoms,   especially  pain  and 
tenderness,  is  almost  a  sure  proof  of  the  existence  of  a  mechanical  obstruction 
in  the  appendix  in  the  form  of  stenosis  or  flexion,  or  a  combination  ot  both. 
Hepatic  colic  is  to  be  distinguished  from  appendicitis  by  the  history  of  pre- 
vious attacks  and  of  jaundice  (if  obtainable),  in  conjunction  with  the  symp- 
toms   which  are  :   Sudden,  severe,  cutting  pain  in  the  upper  right  half  ot  tfie 
abdomen,  which  extends  to  the  back  or  shoulder  of  the  same  side;  there  may 
or  may  not  be  jaundice.     In  many  cases  the  patient  has  a  chill,  and  vomiting 
is  the  rule.      There  may  be  tenderness  over  the  gall-bladder,  and  an  absence 
of  signs  in  the  right  iliac  fossa. 

In  renal  colic  the  pain,  as  in  the  preceding  disease,  is  intense  and  unre- 
mittincr:  it  extends  to  the  genitals  ;  the  bladder  is  apt  to  be  irritable  ;  the 
testicle  of  the  aff-ected  side  is  usually  drawn  up  toward  the  external  abdom- 
inal ring.  The  urine  almost  invariably  contains  blood,  which  may  be  de- 
tected bv  the  microscope  if  not  by  the  naked  eye.  Fever  and  the  board-like 
tension  of  the  abdominal  wall  on  the  right  side  are  absent,  and  vomiting  is 
exceptional ;  there  may  be  a  previous  history  of  renal  colic. 

Acute  indiqestion  mav  closely  simulate  a  beginning  appendicitis.  Any 
doubt  will  be'  removed  speedily,  however,  as  the  symptoms  of  the  former 
rapidly  disappear  under  rational  treatment. 

In  women  the  discrimination  between  fi/^o-ovanVm  disease  and  appendi- 
citis is  frequently  necessary.  This  usually  may  be  done  by  a  very  careful 
attention  to  the  previous  historv  and  to  the  manner  of  onset  and  progress  ot 
the  symptoms.  Vaginal  or  rectal  examination  may  establish  the  diagnosis. 
In  rare  cases  the  appendix  lies  in  contact  with  the  tube  and  ovary,  and  in- 
flammation of  any  one  of  these  structures  will  naturally  spread  to  all  and 
give  rise  to  symptoms  more  or  less  confusing.  •  ,     i   ■ 

Other  intra-abdominal  surgical  conditions  are  to  be  distinguished  m  tlie 
same  manner,  by  a  minute  study  of  the  history  and  the  individual  symptoms. 


7<)6  AX  J j//;/.'/r.LV   rr.x'j'-JKjoK  or  sina i:nY. 

Prognosis. — Tin-  moitality  of  appendicitis  and  the  attendin^r  jxTit  yplditi.s  or 
paratyphlitis  is  about  one  out  of  seven  or  eight  cases.  Witliout  ])ronipt  surgi- 
cal interference  death  is  almost  sure  to  ensue  if  the  general  peritoneal  cavity  is 
invaded.  Life  is  in  great  peril  if  the  resulting  abscess  opens  into  the  pleural 
cavity  or  the  bladder.  The  prognosis  is  favoral)le  if  the  peritonitis  is  of  the 
plastic  type,  as  in  such  cases  the  disease  remains  circumscribed  and  the  general 
peritoneal  cavity  is  protected  against  infection.  In  recurring  appendicitis  the 
danger  to  life  increases  with  each  successive  attack,  as  every  subsequent  attack 
bv  aggravating  the  local  lesion  may  give  rise  to  perforative  peritonitis. 

Treatrnent. — The  medical  treatment  of  appendicitis  should  aim  at  the 
prevention  of  ])erforation  and  at  giving  the  peritonitis  a  plastic  character. 
During  the  incipient  stage  it  would  be  advisable  to  administer  saline  cathar- 
tics in  such  doses  and  at  such  intervals  as  to  secure  an  early  and  free  evacua- 
tion from  the  bowels,  and  in  this  manner  remove  the  fecal  accumulation  in 
the  cecum  which  is  so  frequently  present  in  these  cases.  A  warm-water 
enema  containing  an  ounce  of  magnesium  sulphate  should  be  given  for  the 
same  purpose.  Externally,  hot  antiseptic  fomentations  and  the  use  of  mus- 
tard or  turpentine  relieve  pain,  and  at  the  same  time  rather  favor  a  plastic 
peritonitis.  Onlv  li([uid  food  in  extremely  small  amounts  is  to  be  given 
(luring  the  acute  stage.  The  use  of  blisters  and  other  potent  counter-irri- 
tants is  more  harmful  than  beneficial.  About  80  to  85  per  cent,  of  all  cases 
recover  under  such  treatment. 

In  a  large  majority  of  cases  judicious  surgical  treatment  will  become  neces- 
sarv  if  the  inflammation  does  not  yield  to  the  treatment  detailed  above.  Ulcer- 
ative, gangrenous,  and  jterfora  ting  ap))endicitis  are  surgical  affections,  and  should 
be  treated  as  such.  The  propriety  of  surgical  intervention  in  acute  suppurative 
appendicitis  was  first  established  by  AVillard  Parker  of  New  York  in  1867.  The 
treatment  of  recurring  catarrhal  and  ulcerative  appendicitis  by  laparotomy  and 
removal  of  the  appendix,  either  during  an  attack  or  after  the  acute  symptoms 
have  subsided,  has  been  placed  on  a  sound  surgical  basis  by  McBurney,  Treves, 
Senn,  KUmmell,  and  others.  As  it  is  often  necessary  in  these  cases 
to  open  the  abdominal  cavity,  the  strictest  antiseptic  precautions  must  be 
observed.  The  abdominal  incision  may  be  made  directly  along  the  outer 
border  of  the  rectus  muscle  from  the  level  of  the  umbilicus  nearly  to  the 
middle  of  Poupart's  ligament,  or  it  may  be  a  curved  incision  nearer  the 
spine  of  the  ilium  with  its  center  on  the  omphalo-s])inous  line,  or  in  the 
presence  of  a  tumor  it  may  be  directly  over  the  most  ])rominent  ])art  of  the 
swelling.  McBurney's  plan  of  incising  the  abdominal  wall  has  found  much 
favor  with  the  profession.  It  consists  in  dividing  the  muscles  in  the  direction 
of  their  fibers  ;  that  is,  the  external  oblique  and  internal  oblicjue  are  divided 
in  opposite  directions,  more  by  tearing  than  by  cutting.  Retractors  become 
necessary  to  keep  the  wound  open  during  the  operation.  After  the  operation 
the  opening  is  closed  by  the  muscular  fibers  resuming  tlieir  former  position, 
the  resisting  power  of  the  abdominal  wall  is  but  little  imj)aired,  and  the 
occurrence  of  a  ventral  hernia  is  more  effectually  prevented  than  by  cutting 
in  one  direction  through  the  muscular  plane  of  the  abdominal  wall.  The 
margins  of  the  wound  are  retracted  by  an  assistant,  and  prolapse  of  the 
small  intestine  is  prevented  by  packing  the  abdominal  cavity  around  the 
cecum  with  a  compress  of  antiseptic  gauze.  If  the  ajipendix  cannot  readily 
be  found,  the  anterior  longitudinal  band  of  the  cecum  is  taken  as  a  landmark  ; 
if,  as  is  frequently  the  case,  the  appendix  is  located  behind  the  cecum,  this 
must  be  lifted  forward  and  the  band  followed  to  the  appendix.  Tiie  appen- 
dix is  then  freed  from  all   adhesions,  ligated  with  aseptic  silk  or  catgut  close 


DISEASES  AND    INJURIES    OF    THE  ABDOMEN.  767 

to  the  cecmn,  aii-l  cut  oH'  below  the  ligature.  The  stump  is  buried  with  a  few 
Leinbert  sutures.  The  mucous  meml)raiie  of  the  cut  surface  should  be  disin- 
fected with  the  cautery  or  pure  carbolic  acid.  Subserous  amputntion  of  the 
appendix  is  now  generally  practised  when  this  method  is  applicable.  A  tew 
lines  from  the  cecal  end  of  the  appendix  a  circular  incision  is  made  through 
the  peritoneum,  wliicli  is  reflected  in  the  form  of  a  cuff.  The  denuded  part 
of  the  appendix  is  then  tied  with  a  fine  silk  ligature  and  cut  off  a  line  or  two 
below,  after  which  the  mucous  membrane  is  cauterized  with  pure  carbolic  acid, 
the  stump  iodoformized,  and  the  peritoneal  cuff  sewed  over  it  with  fine  cat- 
gut sutures.  As  in  all  lateral  incisions,  the  external  wound  is  to  be  closed 
by  deei)  and  superficial  sutures. 

'  If  an  ulcer  of  the  appendix  or  an  abscess  in  its  vicinity  has  perforated  into 
the  free  peritoneal  cavity,  a  lateral  incision,  such  as  has  been  described,  should 
be  made,  as  it  affords  better  access  to  the  parts  which  retiuire  direct  surgica 
treatment  than  a  median  incision.  In  such  cases  the  abdominal  cavity  should 
be  freely  irrio-ated  with  warm  sterilized  water  or  Thiersch's  solution  (salicylic 
acid  o-r'.  xivf  and  boric  acid,  gr.  Ixxxiv  (a),  Oj  of  water)  before  the  appendix 
is  reinoved,  and  the  flushing  repeated  after  the  removal  has  been  effected. 
Adenuate  provision  for  drainage  is  an  absolute  necessity  in  all  cases  where 
pus  or  fecal  matter  has  obtained  access  to  the  abdominal  cavity. 

If  the  appendicitis  has  resulted  in  the  formation  of  a  circumscribed  abscess 
in  the  ric-ht  iliac  fossa,  a  slightly  curved  incision  from  four  to  six  inches  in 
lencrth,  commencing  just  above  the  middle  of  Poupart's  ligament  and  extend- 
inAoward  the  anterior  superior  spine  of  the  ilium,  will  answer  m  the  majority 
of^cases.     The  deeper  tissues  are  divided  and  retracted  m  the  same  manner  as 
thoucrh  the  operator  were  about  to  ligate  the  external  iliac  artery.     This  incis- 
ion leads  down  to  and  behind  the  ctecum,  the  most  frequent  location  ot  an 
incipient  abscess  resulting  from  appendicitis.     The  use  of  the  exploring  needle 
as  a  means  of  locating  the  pus  before  the  operation  is  to  be  condemned.     ±.x- 
ploratory  puncture  made  at  the  time  of  operation  is  attended  by  less  danger  and 
may  give  valuable  information  in  regard  to  the  location  of  the  abscess,     it  tlie 
peritonitis  has  become  limited,  it  must  be  the  great  object  of  the  surgeon  to  reach 
the  abscess  and  to  remove  its  primary  cause  without  invading  the  general  peri- 
toneal cavity,  and  on  this  account  the  utmost  care  must  be  exercised  not  to 
penetrate  the  abscess-wall  on  the  peritoneal  side  during  the  search  for  the  ap- 
pendix and  its  removal.     As  soon  as  the  abscess  is  reached  its  contents  should 
be  washed  out  with  a  weak  antiseptic  solution,  and  gentle  search  made  for  lec^il 
concretions  and  foreign  bodies  if  the  appendix  is  found  to  be  perforated.     In 
some  cases  the  appendix  will  be  found  completely  detached  from  the  cjBcum 
and  adherent  to  the  surrounding  tissues  or  lying  m  the  abscess  as  a  gan- 
grenous slough.      It  will  generally  be  impossible  to  cover  the  stump  witfi 
peritoneum  in  these  cases.     In  many  cases  of  circumscribed  abscess,  and  espe- 
cially in  those  in  which  the  appendix  is  bound  down  by  adhesions  m  the 
depth  of  the  wound,  the  surgeon  should  be  content  with  evacuation,  irrigation, 
drainao-e,  and  packing  with  iodoform  gauze.     Persistent  search  for  the  appen- 
dix and  attempts  at  its  removal  in  these  cases  are  attended  with  such  danger 
of  opening  the  general  peritoneal  cavity  that  they  are  not  to  be  recommended. 
When  it  is  impossible  to  enucleate  and  remove  the  appendix,  it  may  sometimes 
be  laid  open  by  an  incision  in  its  long  axis  and  drained,  as  advised  by  lait. 
If  the  abscess  presents  anteriorly  underneath  the  abdominal  wall,  it  is  opened 
by  an  incision  which  will  afford  the  best  drainage,  and  after  flushing  it  with 
an  antiseptic  solution  it  is  well  drained  and  the  drainage  maintained  until  the 
surgeon  is  satisfied  that  healing  is  taking  place  from  the  most  remote  portions 


7«J8  A.\  A.)fi:in<'AX  ri.xT-nooK  or  si'iiaEHV. 

of  the  abscess.  The  too  early  removal  ol"  drains  is  often  followed  by  recun-fiiee 
of  the  abscess.  If  the  abscess  does  not  heal,  it  is  a  sicrn  either  that  sinuses 
have  formed,  which  nnist  then  be  scraped  out  with  a  sharp  spoon  and  tiior- 
ou^'hh^  disinfected,  or  that  a  perforated  appendix  has  to  be  removed,  which  can 
be  done  either  by  enlarging  the  sinus  Avhich  leads  down  to  it  f)r  through  the 
peritoneal  cavity. 

Ohmtekatixg  Appendicitis;  Appendicitis  Obliterans  is  a  name 
recently  given  by  Senn  to  a  form  of  appendicitis  in  which  the  lumen  of 
the  appendix  at  difierent  points  is  gradually  obliterated  by  cicatricial  contrac- 
tion. The  obliteration  begins  as  a  stricture  which  may  appear  at  any  point  in 
the  lumen  of  the  appendix,  and  leads  to  its  complete  closure.  Occasionally 
the  entire  appendix  is  transformed  into  a  solid  cord,  in  which  event  the  symp- 
toms disappear  completely  and  a  permanent  spontaneous  cure  is  the  result. 

Recurrent  Appendicitis. — A  patient  who  has  had  even  a  mild  attack 
of  appendicitis  is  more  prone  to  others,  and  these  may  vary  in  type  from  the 
mildest  to  the  most  severe.  It  is  probable  that  after  a  second  attack  opera- 
tion during  the  interval  would  be  recommmended  by  most  surgeons  as  offer- 
ing less  risk  than  further  delay.  But  it  cannot  be  denied  that  many  persons 
who  have  had  several  such  attacks  have  recovered  under  judicious  medical 
treatment.  If  the  condition  in  the  first  instance  was  at  all  serious  as  regards 
danger  to  life,  or  if  the  second  attack  was  distinctly  of  a  graver  type,  there 
would  be  practically  no  difference  of  opinion  among  surgeons,  operation 
being  certainly  indicated. 

Chronic  Relapsing  Appendicitis. — In  chronic  relai)sing  appendicitis 
the  case  is  somewhat  different.  The  interval  then  is  not  one  of  entire 
health  ;  there  are  digestive  disorders,  flatulence,  constipation  or  diarrhea, 
and  pain  in  the  right  iliac  fossa,  aggravated  by  motion  or  exercise  or 
fatigue.  The  attacks  themselves  are  of  a  higher  grade  of  severity,  are 
accompanied  by  the  appearance  of  a  tumor,  which  often  never  entirely  disap- 
pears, and  by  distinct  evidence  of  localized  peritonitis.  The  general  health 
suffers  severely,  and  the  patient  is  apt  to  be  anemic  and  emaciated. 

In  the  majority  of  these  cases  which  finally  require  ojteration,  especially 
in  those  in  which  the  persistence  of  the  local  symptoms  during  the  interval 
is  marked,  pus  is  present  in  small  (quantity  and  is  surrounded  by  thick,  firm 
adhesions. 

The  diagnosis  may  usually  be  made  by  the  history,  the  localized  pain, 
the  variable  tumor,  etc.  Not  infreijuently,  especially  where  the  early  stage 
of  a  malignant  neoj)lasm  is  suspected,  the  only  possible  diagnosis  is  by 
exploratory  incision. 

Even  these  cases  do  not  invariahlji  require  operation.  Treves,  who 
originally  proposed  the  operation  in  1877,  has  thought  it  necessary  to  call 
attention  to  the  fact  that  it  has  been  performed  recently  without  proper 
discrimination,  and  adds:  "  The  circumstances  which  would  justif\-  an  opera- 
tion in  these  cases  must  be  precisely  defined,  and  it  cannot  be  too  em])hat- 
ically  stated  that,  in  a  fair  proportion  of  instances  in  which  the  trouble  has 
relapsed,  no  surgical  interference  is  called  for.  I  am  aware  of  many  cases 
in  which  a  patient  has  had  three  or  more  attacks  of  typhlitis,  and  has  then 
ceased  to  be  troubled  with  any  further  outbreaks.  In  some  examples  of  the 
relapsing  form  much  can  be  done  by  medical  means,  by  diet,  by  attention  to 
the  bowels,  and  by  placing  the  patient  under  conditions  more  favorable  to  a 
state  of  peace  Avithin  the  abdomen." 

There  is  good  reason  for  believing  that  the  mortality  of  the  operation  in 
skilful  hands  will   be  a  low  one.     If  the  indications  for  operation  are  clear, 


DISEASES   AND    INJURIES    OF    THE   ABDOMEN.  769 

the  (luestion  as  to  wliether  it  shall  be  done  between  or  during  attacks  must 
be  unhesitatingly  decided  in  favor  of  the  period  of  quiescence,  the  operative 
difficulties  being  tlien  much  less,  especially  as  regards  the  important  question 
of  possible  general  infection.  In  the  recurrent  type,  if  operation  is  to  be 
considered  at  all,  it  might  be  well  to  take  the  risk  of  waiting  for  another 
attack,  which  may  never  come. 

In  the  chronic  relapsing  cases,  however,  if  the  surgeon,  in  deciding  upon 
operation,  limits  himself  to  the  following  indications  formulated  by  Treves, 
he  had  far  better  take  advantage  of  the  interval.  Operation  is  indicated 
when — 1.  The  attacks  have  been  very  numerous.  2.  The  attacks  are 
increasing  in  frequency  and  severity.  3.  The  last  attack  has  been  so  severe 
as  to  place  the  patient's  life  in  considerable  danger.  4.  The  constant 
relapses  have  reduced  the  patient  to  the  condition  of  a  chronic  invalid  and 
have  rendered  him  unfit  to  follow  any  occupation.  5.  Owing  to  the  per- 
sistence of  certain  local  symptoms  during  the  quiescent  period  there  is  a 
probability  that  a  collection  of  pus  exists  in  or  about  the  appendix. 

White  has  recently  summarized  his  conclusions  upon  the  general  subject 
of  appendicitis,  which  must  be  regarded  as  one  still  open  to  discussion  : 

1.  The  explanation  of  the  great  frequency  of  inflammation  of  the  appen- 
dix is  to  be  found  in  the  following  facts : 

(a)  It  is  a  functionless  structure  of  low  vitality,  removed  from  the  direct 
fecal  current ;  it  has  a  scanty  mesentery,  so  attached  to  both  cecum  and  ileum 
that  it  is  easily  stretched  or  twisted  when  they  become  distended ;  it  derives 
its  blood-supply  through  a  single  vessel,  the  caliber  of  which  is  seriously 
interfered  with  or  altogether  occluded  by  anything  which  produces  drag- 
ging upon  the  mesentery. 

(6)  In  addition,  there  is  almost  always  present  a  micro-organism — the 
bacterium  coli  commune — capable  of  great  virulence  when  there  is  constric- 
tion of  the  appendix  or  lesions  of  its  mucous  coat  or  of  its  parietes. 

2.  The  symptoms  in  a  case  of  mild  catarrhal  appendicitis — general 
abdominal  pain,  umbilical  pain,  localized  pain,  and  tenderness  on  pressure  in 
the  right  iliac  fossa,  vomiting,  moderate  fever,  and  slightly-increased  pulse- 
rate — cannot  at  present  with  any  certainty  be  distinguished  from  the  symp- 
toms, apparently  precisely  identical,  which  mark  the  onset  of  a  case  destined 
to  be  of  the  very  gravest  type. 

3.  It  must  be  determined  by  future  experience  Avhether  or  not  operation 
in  every  case  of  appendicitis,  as  soon  as  the  diagnosis  is  made,  would  be 
attended  by  a  lower  mortality  than  would  waiting  for  more  definite  symptoms 
indicating  unmistakably  the  need  of  operative  interference.  At  present  such 
indication  exists  in  every  case  if  the  onset  is  sudden  and  the  symptoms  mark- 
edly severe,  and  Avhenever  in  a  mild  case  the  symptoms  are  unrelieved  at  the 
end  of  forty-eight  hours,  or,  a  fortiori,  if  at  that  time  they  are  grow'ing  worse. 

4.  It  must  be  determined  by  fut?ure  experience  whether  cases  seen  from 
the  third  to  the  sixth  day,  which  present  indications  of  the  beginning  cir- 
cumscription of  the  disease  by  adhesions,  and  which  tend  to  the  formation  of 
localized  abscesses,  will  do  better  with  immediate  operation  with  the  risk  of 
infecting  the  general  peritoneal  cavity,  or  with  later  operation  when  the  cir- 
cumscribing wall  is  stronger  and  less  likely  to  be  broken  through.  At  pres- 
ent operation  is  certainly  indicated  whenever  a  firm,  slowly-forming,  well- 
defined  mass  in  the  right  iliac  fossa  is  to  be  felt,  or,  on  the  other  hand,  when 
a  sudden  increase  in  the  sharpness  and  the  diffusion  of  the  pain  and  tender- 
ness points  to  gross  perforation  of  the  appendix  or  breaking  down  of  the 
limiting  adhesions. 

49 


77<i  J.v  amj:i;i<a.\   ti.xt-iiook  or  sii:(u:i:y. 

o.  In  the  bei^inniiifr  of  general  .suj)|)urative  peritonitis  operation  offers 
some  hoj)e  of  siieces.s.  In  the  ])resence  of  general  jieritonitis  with  septic 
paresis  of  the  intestines  operation  has  thus  far  been   useless. 

6.  Recurrent  apj)en(licitis  of  mild  type,  like  acute  appendicitis,  frefjuently 
results  from  digestive  derangements.  Several  attacks  may  occur  followed  by 
entire  and  permanent  recovery,  but  it  is  as  yet  impossible  to  diff'erentiate 
these  cases  accurately  from  those  which  do  not  tend  to  spontaneous  nire. 
Operation  is  certainly   indicated  whenever    the   attacks  are  very  fref|uent. 

7.  Chronic  relapsing  appendicitis  is  characterized  by  the  persistence  of 
local  symj)toras  during  the  intervals  and  by  more  or  less  failure  of  the 
general  health.      Operation  is  usually  to  be  advised  in  these  cases. 

8.  It  is  well  for  surgeons  to  be  slow  in  recommending  oyioration  in  all 
cases  in  which  during  tlie  first  attack  an  abscess  formed  and  discharged  into 
the  cecum.  It  is  in  such  cases  that  a  spontaneous  recovery  occurs  very  fre- 
(juently. 

Fecal  Fistula. — A  fecal  fistula  is  a  communication  between  any  portion 
of  the  intestinal  tract  and  the  external  surface  of  the  body  or  some  hollow 
internal  organ  through  which  gas  and  the  solid  or  liquid  contents  of  the  intes- 
tine escape.  In  the  majority  of  cases  the  external  opening  will  be  found  in 
one  of  the  inguinal  or  lumbar  regions.  The  pelvic  organs  through  which  an 
outlet  is  most  frequently  established  are  the  bladder,  uterus,  and  vagina.  An 
artificial  anus  made  for  tlie  purpose  of  relieving  an  intestinal  obstruction  becomes 
a  fecal  fistula  if  the  cause  of  the  obstruction  is  not  removed  subsequently,  either 
spontaneously  or  )jy  operative  interference.  Fecal  fistulae  are  established  spon- 
taneously most  frequently  after  strangulated  hernia  where  the  strangulation  has 
resulted  in  gangrene  of  the  bowel,  or  in  case  of  perforation  of  an  intestine  or 
of  the  appendix  vermiformis  by  an  ulcer  after  the  inflamed  part  has  become 
adherent  to  the  abdominal  wall  or  some  of  the  internal  organs,  or  they  may 
result  from  the  rupture  of  an  abscess  into  an  intestine,  the  external  opening 
being  established  later.  An  intestinal  fistula  may  also  be  caused  by  a  malig- 
nant tumor  located  in  the  intestinal  wall  or  reaching  it  from  an  adjacent  organ. 
Traumatic  fecal  fistula  caused  by  a  perforating  gunshot  or  stab  wound  of  the 
abdomen  generally  heals  without  surgical  interference.  In  the  history  of  a 
number  of  these  cases  it  has  been  noticed  that  the  openings  have  closed  once 
or  twice  and  opened  again  before  the  final  closure  has  taken  place. 

Anatomically  and  from  a  practical  standpoint  it  is  important  to  divide 
fecal  fistuloe  into  two  varieties.  In  the  first  variety  the  perforated  intestine 
has  become  or  will  become  adherent  to  the  abdominal  parietes  or  to  an  adjacent 
organ  over  a  considerable  surface,  while  the  affected  segment  of  the  gut  remains 
straight ;  consequently  the  lumen  of  the  intestine  is  not  diminished  and  the 
fecal  circulation  is  not  impaired.  For  these  reasons  only  a  small  quantity  of 
intestinal  contents  escapes  through  the  fistula,  while  the  rest  passes  per  viam 
naturalem  (Fig.  317).  A  fistula  of  this  kind  often  heals  without  operative 
treatment. 

In  the  second  and  more  troublesome  variety  the  opening  in  the  gut  is  larger, 
und,  in  case  a  whole  loop  of  the  intestine  has  sloughed,  represents  the  entire 
circumference  of  the  lumen  of  the  bowel,  the  afferent  and  efferent  tubes  lying 
side  by  side  like  the  parallel  tubes  of  a  double-barrelled  gun  (Fig.  318).  The 
feces  are,  in  consequence,  diverted  toward  the  external  opening  incessantly  and 
w^ith  force,  renderinj;  the  case  incurable  so  long  as  this  condition  remains.  If 
the  bowel  has  not  been  destroyed  in  its  entirety,  but  has  suffered  a  lateral 
defect  of  considerable  dimensions,  the  affected  loop  becomes  flexed,  the  apex 
of  the  flexion  corresponding  with  the  opening  in  the  gut :  the  wall  opposite 


j)/s/:asks  a\/>   ixjriui:s  or  the  abdomen.        771 

the  oiu'iiiiiu^  is  thru   thrown   into  :.  projection   technically  called  a  septum  ov 
snur.  which   directs   the  contents  of  the   intestine  toward  the  opening,   and 


KiG.  317.  J''^-  ='!«• 


IntestinalFistuhawithoutLinin.M.f  MUCOUS  Mem-  Artittciul   -^""«  ■    «-^^^»'-  = /„-/^«^"""  '''  ''"'■^ 

brane:  a,  abdoiiiinal  wall;   /-,  intestinal  wall;  current  isenn;. 

c,  mucous  membrane  ;  (/,  listnla  (Senn). 

according  to  the  length  and  direction  of  this  spur  a  large  part  or  the  whole 
of  the  contents  escape  through  the  fistula. 

The  len<Tth  of  the  fistulous  tract  from  the  external  opening  to  the  intes- 
tine varies  fT-om  half  an  inch  to  eight  or  more  inches,  its  direction  often  being 
circuitous  and  difficult  to  follow.  This  is  especially  the  case  if  the  intestine  has 
become  adherent  to  the  floor  of  the  pelvis  and  the  perforation  has  given  rise  to 
extensive  phlegmonous  inflammation,  the  formation  of  an  abscess,  and  finally 
a  fecal  fistula.  °The  location  of  the  fistulous  opening  in  the  intestinal  canal  is 
often  not  easily  determined.  If  the  perforation  exists  below  the  ileo-caecal 
opening,  the  discharge  consists  of  feces ;  if  it  is  above  this  point,  the  discharge 
is  more  fluid,  is  devoid  of  off"ensive  odor,  and  on  closer  examination  is  found  to 
be  not  feces,  but  chvle  from  the  small  intestine.  Rectal  insuflftation  of  hydro- 
gen gas  may  be  an  "important  aid  in  locating  the  intestinal  opening.  If  it  is 
below  the  ileo-csecal  valve,  the  gas  will  escape  from  the  fistulous  opening  under 
slight  pressure,  without  much  distention  of  the  abdomen,  and  prior  to  the  sound 
indicating  that  the  gas  is  passing  through  this  valve. 

No  specific  rules  can  be  laid  down  for  the  surgical  treatment  of  intestinal 
or  fecal  fistula.     The  treatment  must  necessarily  vary  according  to  the  location 
and  size  of  the  opening  in  the  gut,  the  length  of  the  fistulous  tract,  and  the 
condition  of  the  intestine  at  the  seat  of  perforation.     If  the  opening  in  the 
bowel  is  small  and  no  obstacle  exists  to  the  passage  of  the  intestinal  contents, 
healincr  frequently  takes  place  without  surgical  interference.     A  spontaneous 
cure  is^hastened  in  such  cases  by  clearing  out  the  intestinal  canal  thoroughly 
by  cathartics  and  injections  and  placing  the  patient  subsequently  for  several 
weeks  on  a  liquid  diet,  with  rest  in  bed.     The  fistulous  tract  should  at  the 
same  time  be  rendered  as  nearly  aseptic  as  possible  by  the  use  of  the  curette 
and  peroxide  of  hydrogen,  and  the  external  opening  protected  against  intec- 
tion  from  without  by  an  antiseptic  hygroscopic  compress.     If  the  intestine  has 
become  adherent  to  the  abdominal  wall,  and  if  the  opening  m  the  gut  can  be 
easily  reached  by  an  incision  through  the  abdominal  wall  without  opening  the 
peritoneal  cavity,  an  attempt  should  be  made  to  close  it  by  suturing,      ihe 
fistulous  tract  is  excised  carefully  and  the  whole  wound  closed  by  at  least  four 
rows  of  sutures.     The  first  row  of  fine  silk  sutures  should  embrace  the  mucous 
and  submucous  coats  of  the  bowel,  while  the  second  row  approximates  the 
remaining  coats,  after  which  the  abdominal  wall  over  the  intestine  is  carefully 
closed  by  two  rows  of  sutures.     If  the  external  fistulous  opening  communicates 
with  an  abscess-cavity  interposed  between  it  and  the  intestinal  perforation,  the 
abscess  should  be  treated  before  an  attempt  is  made  to  close  the  opening  in  the 
bowel.     If  several  external  openings  are  present,  these  should  be  united  by 
incisions  which  will  expose  the  suppurating  or  granulating  cavity  between  the 


772  AN  AMERICAN    TEXT- BOOK    OF  SURGERY. 

bowel  iind  the  external  surface  for  effective  treatment,  and  at  lea.'^t  tninsfoim 
the  abscess  into  a  simple  fistulous  tract,  if  the  fistula  is  not  closed,  as  will  be 
the  case  occasionally.  Treves  has  successfully  dissected  out  the  entire  fistulous 
tract  with  its  walls,  sewed  up  the  opening  into  the  gut,  and  closed  the  abdomi- 
nal wound. 

In  the  second  variety  a  cure  is  impossible  without  removal  of  the  mechan- 
ical obstruction  to  the  fecal  circulation  at  a  point  opposite  the  opening  in  the 
bowel.  The  introduction  of  a  rubber  tube,  as  suggested  by  Banks,  for  the 
purpose  of  gradually  forcing  the  spur  out  of  the  way,  has  not  yielded  satisfac- 
tory results.  Dupuytren  sought  to  destroy  the  septum  by  an  instrument  which 
he  devised  and  which  he  called  an  "  enterotome."  This  consists  of  a  couple 
of  steel  forceps-like  blades,  which,  being  introduced  into  the  canals,  are  made 
to  compress  the  septum  by  the  action  of  a  screw.  For  the  sake  of  safety  it  is 
necessary  that  the  instrument  should  be  made  to  cut  its  way  through  the  tis- 
sues very  slowly,  so  that  union  may  take  place  between  the  apposed  serous 
surfaces  before  the  section  is  completed.  In  the  hands  of  careful  surgeons  the 
use  of  this  instrument  has  been  followed  by  good  results,  but  its  employment 
is  not  devoid  of  danger,  neither  does  the  fistula  always  close  after  the  septum 
has  been  divided.  Senn  has  described  a  method  of  dealing  Avith  fecal  fistulte 
and  artificial  anus  in  cases  in  which  the  mucous  membrane  of  the  intestinal 
opening  is  continuous  with  the  skin,  which  greatly  diminishes  the  danger  of 
peritonitis  and  increases  the  certainty  of  the  result.  It  consists  in  closing 
the  intestinal  opening  by  a  row  of  sutures  placed  transversely  to  the  long 
axis  of  the  bowel.  After  this  preliminary  closure  of  the  wound  the  field  of 
operation  is  thoroughly  disinfected.  As  no  intestinal  contents  escape,  the 
abdomen  can  be  opened  and  the  intestine  separated  without  fear  of  producing 
peritonitis.  The  preliminary  sutures  are  then  buried  by  Lembert  sutures, 
the  intestine  reduced,  and  the  external  incision  closed  throughout.  In  four 
cases  complete  closure  of  the  intestinal  opening  and  satisfactory  primary 
healing  of  the  external  wound  were  secured.  If  the  intestine  is  completely 
detached,  the  spur  will  soon  disappear  spontaneously  after  this  method 
of  operating.  The  treatment  of  intestinal  fistula  by  laparotomy,  resec- 
tion, and  enterorrhaphy  under  strict  antiseptic  precautions  has  been  most 
encouraging.  Unless  special  indications  are  present,  the  abdomen  is  to  be 
opened  in  the  middle  line  for  fistulix;  communicating  with  the  small  intestine, 
and  laterally  for  fecal  fistulas.  The  adherent  perforated  portion  of  the  bowel 
is  then  separated,  special  care  being  taken  to  prevent  fecal  extravasation  dur- 
ing this  step  of  the  operation.  If  no  spur  is  present  and  the  opening  is  small, 
it  can  be  closed  by  suturing.  If  the  opening  is  large  and  a  spur  has  formed, 
and  especially  if  the  adherent  loop  is  much  flexed,  enterectomy  and  circular 
enterorrhaphy  or  a  lateral  anastomosis  will  be  necessary  for  the  cure  of  the 
fistula  and  the  restoration  of  the  continuity  of  the  intestinal  canal. 

PART  IV.— INJURIES  AND   DISEASES  OF  THE   PERITONEUM,  OMENTUM,  AND 

MESENTERY. 

The  peritoneal  cavity  is  anatomically  and  physiologically  a  large  lymph-sac 
which  is  noted  for  its  capacity  of  absorption.  Large  amounts  of  absorbable 
aseptic  fluid  and  solid  substances  are  removed  from  it  in  this  manner  in  a 
remarkably  short  time  when  the  peritoneum  is  in  a  healthy  condition.  During 
the  pre-antiseptic  period  this  cavity  was  a  noli  me  tangerc  to  the  surgeon,  as 
it  was  well  known  that  open  wounds  usually  gave  rise  to  fatal  peritonitis. 
Recent  researches  have  shown  that  the  peritoneum  is  not  so  susceptible  to 
the  action  of   pathogenic    microbes  as  many  of  the  other  tissues,   provided 


DISEASES'   AND    INJURIES    OF    THE   A  B DO 31  EN.  773 

the  abdoiniiuil  cavity  can  be  kept  free  from  fluids  which  serve  as  a  nutrient 
medium  for  ])athogenic  micro-organisms  and  the  peritoneum  itself  is  in  a  healthy 
condition. 

Wounds. — Wounds  of  the  peritoneum  heal  with  remarkable  rapidity  if  the 
peritoneal  surfaces  are  kept  in  uninterrupted  contact  by  mechanical  means. 
Within  a  few  hours  firm  adhesions  will  take  place  by  the  interposition  of 
plastic  material,  and  the  definitive  healing  is  often  nearly  completed  within 
a  week  or  two.  Tlie  process  of  repair  may  be  hastened  by  scarification. 
Wounds  of  the  peritoneum  should  always  be  closed  by  suturing  wherever  this 
is  possible,  as  otherwise  it  is  very  prol)able  that  organs  })rought  in  contact 
with  them  will  become  permanently  adherent,  and  unsutured  wounds  of  the 
parietal  peritoneum  might  become  the  starting-point  of  a  ventral  hernia.  In 
the  treatment  of  all  visceral  wounds  of  the  abdominal  organs  it  is  important 
that  they  should  be  made  as  nearly  extra-peritoneal  as  possible  by  suturing 
the  peritoneum  over  them  after  uniting  separately  their  deeper  portions.  If  it 
is  deemed  necessary  that  the  operation  should  be  completed  as  speedily  as  pos- 
sible, this  can  be  done  by  the  continued  suture.  Wounds  in  the  mesentery 
should  be  closed,  for  if  this  is  not  done  a  loop  of  intestine  may  become 
ensnared  in  the  rent,  causing  acute  intestinal  obstruction. 

Foreign  Bodies. — The  tolerance  of  the  peritoneum  to  the  presence  of 
aseptic  foreign  bodies  is  remarkable.  It  has  been  shown  by  experiments  on 
animals  that  large  fragments  of  aseptic  tissue  are  removed  by  absorption  within 
a  short  time.  Aseptic  fluids,  such  as  blood,  serum,  and  saline  solutions,  are 
promptly  removed  by  the  same  process.  Aseptic  metallic  and  other  substances 
incapable  of  removal  by  absorption  become  encapsulated  and  remain  harmless 
in  the  peritoneal  cavity.  Bullets  should  be  removed  only  in  case  they  can  be 
found  without  extra  loss  of  time  and  can  be  extracted  Avithout  involving  addi- 
tional risk.  If  the  patient  recovers  from  the  injury,  the  bullet  becomes  encysted 
and  seldom  causes  further  mischief. 

In  the  treatment  of  penetrating  wounds  of  the  abdomen  by  laparotomy 
it  is  essential  to  search  for  and  remove  septic  foreign  bodies,  as  fragments  of 
clothing,  splinters  of  wood,  etc.,  w^hich,  if  allowed  to  remain,  will  become 
the  cause  of  septic  peritonitis;  but  no  time  should  be  lost  in  search  for  bullets 
and  other  small  projectiles. 

PERITONITIS. 

For  good  reasons  the  existence  of  primary  or  so-called  idiopathic  peritonitis 
is  considered  more  than  doubtful  by  most  modern  surgeons,  and  it  has  become 
the  routine  practice  to  search  for  a  local  cause  in  every  instance,  with  a  view 
of  adopting  a  rational  course  of  treatment.  The  pathology,  prognosis,  and 
treatment  of  peritonitis  vary  according  to  the  causes  which  produce  it.  The 
most  favorable  cases  are  those  in  which  the  inflammation  is  produced  by  an 
aseptic  cause,  such  as  a  trauma  or  the  action  of  a  chemical  irritant,  and  an 
inflammation  of  this  type  is  termed  plastic  peritonitis. 

Plastic  Peritonitis  is  a  purely  regenerative  process,  and  should  not  be 
classed  with  the  inflammatory  affections.  It  is  produced  by  aseptic  causes, 
remains  limited  to  the  seat  of  trauma  or  chemical  irritation,  and  does  not  extend 
much  beyond  the  surface-area  to  which  the  stimulus  was  applied.  The  general 
febrile  disturbance  which  accompanies  it  is  caused  by  the  introduction  into  the 
circulation  of  the  products  of  coagulation-necrosis  or  metabolic  tissue-changes. 
A  plastic  peritonitis  attends  every  healing  of  an  aseptic  wound  of  the  perito- 
neum or  subcutaneous  injury  of  this  structure  unattended  by  infection.  The 
existence  of  this  form  of  peritonitis  is  indicated  by  circumscribed  pain  and 


771  .l.V    AM/:/i'/(A.\    TEXT- HOOK    OF   sriUlKRY. 

tenflerncss  and  ri^xidity  of  the  abdominal  wall  correspondinfT  to  the  inflamed 
area.  It  leads  to  the  formation  of  firm  adhesions,  whieh,  however,  in  the  course 
of  time  may  tlisapj)ear  in  j)art  or  completely.  The  proL^iosis  is  favorahle.  In 
the  treatment  rest  and  opiates  to  relieve  pain,  and  a  limited  diet,  are  of  the 
greatest  importance.  Hot  fomentations  are  more  agreealde  to  the  patient  tlian 
the  use  of  cold,  and  have  a  favorable  influence  in  limiting  the  disease. 

Septic  Peritonitis. — All  forms  of  progressive  peritonitis  can  be  said  to 
owe  their  origin  to  a  septic  cause,  but  the  adjective  septic  is  here  used  to  desig- 
nate a  form  of  peritonitis  which  destroys  life  before  the  peritoneum  has  under- 
gone any  serious  pathological  changes.  Death  results  in  a  short  time,  sometimes 
within  twelve  hours,  from  the  absorption  of  septic  material  from  the  peritoneal 
cavity.  The  peritoneum  in  such  cases,  aside  from  increased  vascularity,  pre- 
sents no  well-marked  macroscopical  changes.  This  disease  is  well  known  to 
obstetricians  as  the  most  virulent  form  of  puerperal  fever,  resulting  from  infec- 
tion through  the  lymphatic  vessels  of  the  uterus.  It  is  also  frequently  caused 
b}'  perforation  of  an  intestinal  ulcer  or  an  abscess  into  the  free  })eritoneal  cavity, 
and  by  gangrene  of  an  intestinal  loop  caused  by  internal  strangulation  and 
after  abdominal  section.  It  is  ushered  in  by  a  chill  or  symptoms  resembling 
those  of  shock  ;  the  pulse  runs  up  to  from  140  to  160  beats  per  minute  within 
a  few  hours,  and  remains  constantly  high.  The  temperature  is  often  subnor- 
mal, and  remains  so  during  the  whole  course  of  the  disease.  Retching  and 
vomiting  are  prominent  and  distressing  symptoms.  Abdominal  distention  is 
often  well  marked  ;  in  other  cases  it  is  completely  absent.  In  perforative  sep- 
tic peritonitis  (from  appendicitis)  the  pain  is  usually  very  intense  and  diffuse, 
but  in  the  septic  form  of  peritonitis  after  abdominal  section,  and  when  the  dis- 
ease occurs  during  the  puerperal  state,  it  is  not  unfrequently  entirely  absent. 
Delirium  and  dry  tongue  are  almost  always  present.  The  duration  of  the  dis- 
ease seldom  extends  beyond  a  week.  Death  is  caused  by  toxemia.  Patients 
are  often  pulseless  for  twentj^-four  hours,  with  cold,  livid  extremities  and 
bathed  in  a  clammy  perspiration  before  death. 

As  this  form  of  peritonitis  almost  uniformly  proves  fatal,  the  treatment 
should  be  prophylactic  rather  than  curative.  As  it  is  caused  by  infection  with 
pus-microbes,  it  can  be  prevented  only  by  guarding  against  their  entrance  into 
the  peritoneal  cavity  through  a  Avound,  and  by  the  early  removal  of  suppura- 
ting foci  Avhich  threaten  to  rupture  into  the  peritoneal  cavity.  After  the  dis- 
ease has  once  become  fully  developed,  even  flushing  of  the  abdominal  cavity  is 
powerless  to  check  its  progress.  The  treatment  must  be  purely  sym])tomatic. 
If  septic  material  has  accumulated  in  the  abdominal  cavity,  it  should  be  removed 
by  flushing  with  Thiersch's  solution  of  salicylic  acid,  and  reaccumulation  pre- 
vented by  securing  drainage.  The  heart's  action  is  to  be  kept  up  by  alcoholic 
stimulants,  champagne  or  brandy,  up  to  a  point  just  short  of  intoxication,  and 
by  subcutaneous  injections  of  camphorated  oil  or  strychnine;  in  short,  life 
should  be  supported  until  elimination  of  the  septic  micro-organisms  can  be  ac- 
complished through  the  excretory  organs,  while  the  surgeon  assists  the  system 
in  the  process  of  elimination  by  drainage  and  flushing  of  the  abdominal 
cavity. 

FiBRiNO-PLASTic  PERITONITIS. — This  is  a  combination  of  plastic  perito- 
nitis and  septic  peritonitis,  and  was  first  accurately  described  by  Mikulicz. 
An  attempt  at  localization  takes  place  by  the  formation  of  numerous  adhesions 
between  the  intestinal  coils  and  between  them  and  the  parietal  peritoneum  and 
adjacent  organs.  It  results  from  the  same  causes  as  septic  jieritonitis,  only 
that  probably  the  quantity  of  septic  micro-organisms  introduced  is  less  or  that 
the  resisting  powers  of  the  peritoneum  or  the  system  are  greater.     If  life  is  suf- 


DISEASES   AND    INJURIES    OF    THE   ABDOMEN.  lib 

ficientlv  prolonged,  the  disease  oltm  tcnirmiitcs  in  a  circiiniseribed  suppura- 
tive  peritonitis. 

In  sueli  cases  mnltiple  a))seesses  are  often  found,  a  pathological  condition 
wliich  must  be  remembered  wlieJi  an  operation  is  perforincd,  as  it  is  necessary 
to  find,  open,  and  drain  the  ditterent  foci  of  suppuration. 

Suppurative  Pkritonitis. — Etiologically,se[)tic  peritonitis  and  .sui)j)ura- 
tive  peritonitis  are  identical;  clinically,  they  differ  in  so  far  that  septic  perito- 
nitis is  generally  diff'use  and  leads  to  a  rapidly  fatal  termination,  while  what  is 
known  as  suppurative  i)eritonitis  is  more  fre(|uently  circumscribed  and  n)orc 
amenable  to  surgical  treatment.  Both  forms  are  caused  by  infection  with  pus- 
microbes.  The  microbe  most  fre(i[uently  found  in  the  inflammatory  product 
of  suppurative  peritonitis  is  the  bacillus  coli  communis,  when  the  disease 
occurs  as  a  secondary  aff'ection  to  perforative  appendicitis.  In  the  purely 
septic  variety  death  results  from  sepsis  before  suppuration  has  occurred, 
wliile  in  su])]iurative  peritonitis  the  pyogenic  microbes  are  either  fewer  in 
number  or  meet  with  conditions  less  favorable  to  the  production  of  a  fatal 
dose  of  ptomaines,  or,  finally,  the  peritoneum  is  in  a  condition  which  is  un- 
favorable for  the  entrance  of  pyogenic  microbes  or  their  ptomaines  into  the 
circulation. 

Experimental  research  has  demonstrated  that  in  the  causation  of  suppura- 
tive peritonitis  two  conditions  must  be  present  at  the  same  time:  1,  the  pres- 
ence of  pyogenic  bacteria ;  2,  a  wound  of  the  peritoneal  surface  or  an  ante- 
cedent pathological  condition  which  diminishes  the  absorptive  capacity  of  the 
"peritoneum.  The  microbic  cause  is  the  essential  etiological  factor,  as  Avithout 
it  the  other  conditions  would  not  result  in  this  form  of  peritonitis.  Serum  or 
blood  in  the  peritoneal  cavity  prevents  the  speedy  removal  of  pyogenic  microbes 
by  absorption,  and  if  they  remain  they  multiply  and  produce  their  specific 
pathogenic  effect  on  the  peritoneum. 

In  suppurative  peritonitis  pain,  as  a  rule,  is  more  pronounced  and  constant 
than  in  the  septic  variety,  and  the  disease  is  usually  attended  by  a  rise  in  the 
temperature  to  102°  or  104°  F.  Rigidity  of  the  abdominal  muscles  is  a  con- 
stant symptom  in  all  forms  of  acute  peritonitis.  Vomiting  and  obstinate  con- 
stipation are  often  such  prominent  symptoms  that  it  becomes  difficult  to  make 
a  differential  diagnosis  between  peritonitis  and  intestinal  obstruction.  Arrest 
of  the  fecal  circulation  may  be  caused  by  tympanites  alone,  while  perforative 
peritonitis  is  attended  by  a  local  and  general  shock,  causing  intestinal  paresis 
by  the  inhibitory  action  on  the  sympathetic  nerves.  In  differentiating  betw'een 
these  two  conditions  it  must  be  remembered  that  in  the  absence  of  a  swelling 
absolute  constipation  and  fecal  vomiting  are  the  most  characteristic  symptoms 
of  obstruction,  and  that  in  most  cases  of  peritonitis  the  pain  is  severe  and  con- 
tinuous, with  diffuse  tenderness,  tympanites,  and  absence  of  visible  intestinal 
coils.  In  mechanical  obstruction  of  the  bowels  the  temperature  is  usually  not 
above  normal  unless  complications  have  set  in,  while  in  peritonitis  a  rise  in 
temperature  is  the  rule,  although  in  some  of  the  gravest  cases  the  temperature 
is  subnormal.  Many  cases  of  alleged  recovery  from  intestinal  obstruction 
without  operation  undoubtedly  were  cases  of  adynamic  obstruction,  and  the 
recovery  was  either  entirely  spontaneous  or  facilitated  by  means  which  assisted 
in  the  restoration  of  peristaltic  action. 

In  perforative  peritonitis  and  peritonitis  with  putrefaction  the  presence  of 
gas  in  the  free  peritoneal  cavity  gives  rise  to  an  important  physical  sign. 
In  tympanites  from  peritonitis  without  perforation  and  intestinal  obstruction 
the  distended  intestines  push  the  liver  in  an  upward  direction ;  hence  on  per- 
cussion the  liver  dulness  remains,  but  is  transferred  higher  up.     But  under 


776  AN   AMJJi'/CAA    y/.A  7-/.'OOA     <JJ'   Sl'iaiKIiY. 

the  circuinstanccs  mentioned  above  the  gas  in  the  free  al)(loininal  cavity  occu- 
pies the  space  between  the  liver  and  the  chest-wall  ;  conse(|uently  the  liver 
dulness  has  disa]>peareil  and  the  whole  rijiht  side  of  the  chest  is  tympanitic  on 
percussion.  Tympanites  is  often  a  most  distressing  symj)tom  in  circumscribed 
peritouitis,  but  may  be  entirely  absent  in  the  most  fatal  form  of  this  disease. 
In  suppurative  peritonitis  the  presence  of  pus  in  consideriil)le  quantity  is  indi- 
cated by  the  physical  signs  arising  from  the  accumulation  of  fluids  either 
in  the  free  peritoneal  cavity  or  in  a  circumscribed  ])ortion  of  it.  If  the  pus  is 
not  confined  by  adherent  intestines  and  plastic  exudation,  it  will  gravitate 
toward  the  most  depeiulent  portion  of  the  peritoneal  cavity,  and  on  this  account 
the  area  of  dulness  will  vary  according  to  the  position  of  the  patient.  In  circum- 
scribed suppurative  peritonitis  (peritoneal  abscess)  the  pus  is  confined  in  a  limited 
space  by  adherent  abdominal  organs  and  fibrinous  exudation,  and  Avill  then  pre- 
sent all  the  signs  and  symptoms  of  a  deep-seated  abscess. 

Treatment. — For  years  it  was  the  universal  practice  to  resort  to  the  use 
of  opium  in  the  prevention  and  treatment  of  peritonitis,  until  Tait  showed  the 
fallacy  of  this  treatment  and  recommended  saline  cathartics  in  threatened  cases 
of  peritonitis.  The  explanation  of  the  beneficial  eftect  (jf  this  treatment  con- 
sists in  the  fact  that  a  brisk  saline  cathartic  promotes  the  absorption  of  fluids 
from  the  peritoneal  cavity,  and  by  so  doing  removes  the  indirect  cause  of  peri- 
tonitis and  at  the  same  time  favors  the  elimination  of  pyogenic  microbes. 
Intra-abdominal  wounds  and  dead  tissue  of  all  kinds  favor  the  development 
of  jieritonitis  in   the  same  way  as  blood  or  serum. 

The  proper  prophylactic  treatment  of  peritonitis,  therefore,  consists  in 
guarding  against  the  ingress  into  the  peritoneal  cavity  of  pyogenic  microbes 
by  following  the  strictest  antiseptic  precautions  in  all  operations  which  neces- 
sitate abdominal  section,  and  by  preventing  the  accumulation  of  putrescible 
material  in  the  abdominal  cavity  by  a  careful  toilet  of  the  peritoneal  cavity 
after  the  completion  of  the  operation;  and,  when  the  conditions  are  such  that 
reaccumuiation  is  likely  to  ensue,  by  establishing  free  drainage. 

In  perforative  peritonitis  cathartics  are  absolutely  contraindicated,  as 
increased  peristalsis  would  aggravate  the  existing  conditions  by  increasing 
the  extravasation  and  by  preventing  limitation  of  the  infection.  Of  the 
beneficial  eflect  of  the  use  of  such  drugs  in  the  prevention  and  treatment  dur- 
ing the  early  stage  of  septic  and  suppurative  peritonitis  from  other  causes 
mention  has  been  made  above.  In  perforative  peritonitis  opium  should  be 
administered  to  diminish  the  peristalsis,  to  relieve  pain,  and  to  diminish  shock- 
Unless  the  location  of  the  perforation  can  be  ascertained  beforehand,  the  incis- 
ion should  be  made  in  the  median  line.  If  on  opening  the  peritoneal  cavity 
the  jjcrforation  cannot  be  readily  found,  rectal  insufHation  of  hydrogen  gas 
may  be  resorted  to,  and  will  probably  show  not  oidy  that  a  ])erf()ration 
exists,  but  also  its  exact  location.  The  perforations  are  treated  in  the  same 
manner  as  an  incised  wound.  Care  must  be  taken  to  suture  the  oj)ening  in 
a  direction  that  will  interfere  the  least  with  the  lumen  of  the  intestine.  After 
suturing  the  perforation  the  abdominal  cavity  is  washed  out  freely  with  warm 
sterilized  water  or  Thiersch's  solution.  Drainage  in  these  cases  must  never 
be  omitted,  as  the  operator  has  no  assurance  that  the  peritoneal  cavity  has 
been  rendered  perfectly  aseptic.  A  threatened  septic  peritonitis  after  lapa- 
rotomy ,can  often  be  aborted  by  giving  half  an  ounce  of  magnesium  sul- 
phate, dissolved  in  a  glassful  of  water,  upon  the  appearance  of  the  first 
symptom.  The  action  of  the  saline  cathartic  can  be  hastened  and  its  bene- 
ficial effects  increased  by  the  administration  of  a  turpentine  enema.  After 
the  bowels  have  been  thoroughly  moved,  a  minute  (pumtity  of  opium  may  be 


DISEASES   AND   INJURIES    OF    THE   ABDOMEN.  777 

<riven  l)ut  only  to  relieve  severe  pain.  If  the  symptoms  do  not  subside  under 
Tlii^  treatment",  the  abdominal  wound  should  be  opened  sufficiently  to  permit 
free  irri>;ation  with  salicylated  or  sterilized  water,  a  Keith  dram,  loosely 
packed  witii  iodoform  jra"u/.e,  inserted,  and  a  copious  antisei)tic  hyjrroscopic 
dressing  applied.  In  -eneral  suppurative  peritonitis  -au/e  drains  may  be 
passed  between  the  coils  of  intestine  in  diftcrent  directions,  l^inney  has  had 
excellent  results  from  systematic  wiping  of  the  bowel  with  gauze  sponges. 

In  oi)enin^  the  abdiimen  for  the  evacuation  of  pus  the  surgeon  must  look 
for  a  primary'^lesion  ;  but  he  will  not  always  find  it,  as  it  is  not  invariably 
present.    If  the  primary  cause  is  found,  it  should  be  removed,  if  possible  ;  and 
if  this  cannot  be  done,' free  drainage  from  the  primary  focus  must  be  estab- 
lished.    If  the  intestinal  disturbance  is  great,  the  bowel  should  be  emptied 
bv  makino-  one  or  more  transverse  incisions  on  the  convex  side.     To  do  this 
safelv  the"  patient  must  be  placed  on  the  side,  and  the  intestinal  loop  to  be 
incited  brought  well  forward  into  the  wound.     After  evacuation  the  visceral 
wound  is  sutured  in   the  usual  manner.      Localized  sui)purative  peritonitis 
broutrht  about  by  curable   causes  is  amenable  to  successful  surgical  treat- 
ment*!    An  operation  is  always  indicated  as  soon  as  tlie  presence  of  pus  is 
ascertained.      Delay  is  dangerous  in  these  cases,  as  the  delicate  walls,  com- 
posed of  plastic  exudation,  may  yield  to  the  pressure,  and  the  extravasation 
of  pus  infect  a   new  portion  of  the  peritoneal  cavity  or  perhaps  its  entire 
extent.      In  circumscribed  suppurative  peritonitis  the  incision  is  to  be^made 
^t  a  point  where  the   pus  is  in  contact  with   the  abdominal  wall.     If,   on 
cutting  through  the  peritoneum,  no  pus  is  found  and  the  free  peritonea 
cavity  has  been  opened,  it  is  not  safe  to  evacuate  the  pus  until  the  peritoneal 
cavit'y  has  been  shut  out  by  gauze  pads  or  by  suturing  the  abscess-wall  to 
the  parietal  peritoneum  or  packing  the  wound  for  a  few  days  with  iodoform 
gauze,  postponing  the  opening  of  the  abscess  until  firm  adhesions  have  formed 
between    the    margins   of  the  wound   and    the    surface  of  the    abscess-wall. 
This  method  of  operating  in  two  stages  must  be  frequently  resorted  to  m  the 
treatment  of   pelvic  and  visceral  abscesses.     All  operations  for  suppurative 
peritonitis  are  to  be  conducted  upon  rigid  antiseptic  principles,  and  antiseptic 
measures  are  to  be  followed  without  relaxation  during  the  entire  after-treatment. 
As  patients  suffering  from  peritonitis  are  always  greatly  debilitated  from  the 
effects  of  the  disease,  as  well  as  from  lack  of  solid  food,  which  for  obvious 
reasons  must  be  withheld,  every  effort  should  be  made  to  sustain  strength  by 
the  systematic  administration  of  liquid  nourishment,  by  nutritive  enemata,  and 
by  alcoholic  stimulants.     Absolute  rest  must  be  enforced,  for  the  purpose  of 
limiting  the  extension  of  the  disease  and  with  a  view  of  aiding  the  process  of 

repair.  .  .  „    , 

Tubercular  Peritonitis.— Tubercular  peritonitis  occurs  as  one  of  the 
lesions  of  acute  general  tuberculosis,  with  chronic  pulmonary  phthisis,  with 
tubercular  inflammation  of  the  genito-urinary  tract,  and  as  a  local  inflamma- 
tion. The  form  of  tubercular  peritonitis  which  interests  the  surgeon  is  the  local 
form,  in  which  the  disease  occurs  in  the  peritoneal  cavity  as  a  primary  lesion. 
Klimmell  regards  this  form  as  a  purely  local  aff"ection,  amenable  to  surgical 
treatment  in  the  same  sense  and  to  the  same  extent  as  a  tuberculosis  of  joints. 
The  source  of  infection  in  these  cases  is  the  intestinal  canal.  Undoubtedly, 
in  manv  instances  of  this  kind  the  peritoneal  aff"ection  is  preceded  or  attended 
by  tubercular  ulceration  of  the  intestines.  A  considerable  number  of  such 
cases  have  been  permanently  cured  by  abdominal  section  :  in  one  of  the  first 
cases  operated  upon  by  Sir  Spencer  Wells  the  patient  remained  in  perfect 
health  for  twenty-six^  years  after  the  operation.     The  effect  of  the  bacillus 


778  A\  AMi:ni(.\.\   rr.xr-iinoK  of  srucEiiv. 

(if  tubcM'cuIosis  on  \\w  pcritoiiemii  is  not  uniform,  and  the-  conditions  found 
in  peritoneal  tuberculosis  are  variable  :  as  a  result  a  number  of  forms  of 
loeali/.i^l  tuberculosis  of  the  peritoneal  cavity  liave  been  ilescribed.  Of  tliese 
till'  followino;  may  be  mentioned  :  but  only  the  first  variety  of  tubercular  peri- 
tonitis here  described  is  amenable  to  successful  surf^ical  treatment. 

Tuhfrcular  Ascites. — In  this  form  the  peritoneum  is  tliickene<l,  hyper- 
emic.  and  stud<led  with  masses  of  tubercle-tissue  in  the  form  of  miliary 
nodules.  If  the  effusion  is  general,  occupying  the  whole  peritoneal  cavity,  the 
adhesions  are  few  and  slight.  If  the  fluid  is  encapsulated,  the  walls  of  the 
cavity  are  formed  by  intestinal  loops  which  are  adherent  among  themselves 
and  to  the  surrounding  structures.  The  circumscribed  form  usually  takes  its 
origin  from  the  floor  of  the  pelvis,  and  often  gives  rise  to  a  swelling  which 
simulates  an  ovarian  cyst  to  perfection.  The  fluid  which  causes  the  dropsy  is 
either  a  clear,  transparent  serum  or  serum  in  Avhich  small  flocculi  are  suspended, 
or  which  has  become  slightly  turbid  from  the  admixture  of  the  products  of  retro- 
grade tissue-metamorphosis.  Coagulation-necrosis  and  caseation  of  the  nodules 
appear  to  be  retarded  for  a  mucli  longer  time  than  in  cases  of  glandular  tuber- 
culosis. The  amount  of  fluid  may  vary  from  a  teacupful  in  the  circumscribed 
form  to  from  four  to  six  gallons  in  diffused  tubercular  ascites.  Secondary  infec- 
tion is  found  most  frequently  in  the  spleen,  pleura,  and  lymphatic  glands. 

Fihrino-plastie  Tubercular  Peritonitis. — In  this  variety  of  tubercular  peri- 
tonitis no  serum  is  found  in  the  peritoneal  cavity.  The  peritoneal  surfaces, 
which  are  studded  with  miliary  tubercles,  are  covered  by  a  thick  layer  of  gelat- 
inous fibrin  which  cements  together  all  the  adjacent  serous  surfaces,  so  that 
the  whole  abdominal  cavity  api)ears  to  be  filled  witli  a  large,  boggy  mass  com- 
posed of  all  the  viscera  adherent  to  one  another,  and  with  the  interspaces  filled 
■with  fibrin. 

AdJtesice  Tubercular  Peritonitis. — In  this  form  the  i)rimary  inflammatory 
exudation  is  slight,  but  the  endothelial  cells  proliferate  and  form  new  tissue, 
which  undergoes  cicatrization,  giving  rise  to  firm  and  extensive  adhesions. 
The  plastic  peritonitis  may  be  so  extensive  as  to  cause  intestinal  obstruction 
from  perfect  immobilization  of  a  large  portion  of  the  intestinal  tract.  In  this 
35  well  as  in  the  foregoing  form  of  tubercular  peritonitis  ulceration  of  the  intes- 
tine may  take  place,  resulting  in  the  formation  of  a  bimucous,  internal  fistula 
if  the  openings  in  two  adjacent  loops  correspond,  or  in  the  formation  of  a  fecal 
abscess,  terminating  later  in  an  external  fecal  fistula. 

Diagnosis. — the  diftuse  variety  of  tubercular  drojtsy  of  the  peritoneal  cav- 
ity might  be  mistaken  for  ordinary  ascites  or  for  a  large  single  cyst  of  the  ovary 
or  some  other  abdominal  organ.  Ordinary  ascites  is  usually  caused  by  cirrhosis  of 
the  liver,  malignant  disease  of  the  omentum  or  peritoneum,  and  valvular  di.sease 
of  the  heart :  and  if  these  conditions  are  absent  there  is  good  reason  for  suspicion 
that  the  effusion  has  resulted  from  a  tubercular  inflammation  of  the  jieritoneum. 
The  circumscribed  form  of  tubercular  ascites  might  be  simulateil  by  a  small 
ovarian  cyst,  pregnancy,  pyosalpinx  or  hydrosalpinx,  pyonephrosis  or  hydro- 
nephrosis,*^ cyst  of  the  pancreas,  a  distended  bladder,  an  enlarged  gall-bladder, 
and  pelvic  abscess.  All  of  these  conditions  must  be  kept  in  view  in  making  a 
differential  diagnosis.  An  exploratory  incision  may  become  necessary  before 
rendering  a  jiositive  opinion. 

Treatment. — Abdominal  section  with  drainage  has  proved  most  useful  in 
arresting  the  disease  if  the  dropsy  is  circumscribed.  After  evacuation  of  the 
fluid  the  parts  .should  be  well  dried  and  dusted  lightly  with  iodoform.  The 
abdominal  cavity  must  be  drained  with  a  Keith's  large  glass  tube  loosely  packed 
with  iodoform  gauze  :  the  capillary  action  of  the  gauze  transfers  the  fluid,  which 


DISEASES  Axn   ixJi'inEs  OF  nil':  ahdomex.        779 

is  secreted  eonstaiitly,  into  tlie  livgroseopic  antiseptic  dressinj;.  'Die  drain  is 
allowed  to  remain  as  long  as  fluid  escapes,  wliich  is  often  the  case  for  several 
weeks  and  sometimes  for  months.  If  reaccnmiilation  of  fluid  takes  place, 
the  same  j)rocedure  can  be  repeated  after  an  interval  of  two  weeks.  In  ope- 
rating for  cireimiscrilx'd  tubercular  ascites  it  is  verv  important  to  exercise 
great  care  in  o]>ening  the  abdominal  cavity,  as  a  looj)  of  adherent  intestine 
may  be  found  at  tlie  ])oint  where  the  incision  is  made.  1'he  peritoneum  must 
be  recognized  and  carefully  divided,  in  order  to  avoid  wounding  of  the  bowel 
should  such  a  condition  be  met  with.  If  any  caseous  foci  are  found,  they 
should  be  removed  with  a  sharp  spoon,  or  they  can  be  destroyed  or  reiulered 
harndess  by  ignipuncture  and  thorougli  iodoformization.  A  tubercular  sal- 
pingitis calls  for  removal  of  the  affected  appendage. 

J\n'ace}it(i<i!<  (iMominin,  or  tapping  the  abdomen,  is  re(|uired  in  certain 
cases  of  ascites,  tubercular  or  otherwise.  It  is  performed  by  introducing  a 
trocar  and  canula  through  the  abdominal  wall,  in  the  middle  line,  between 
the  umbilicus  and  the  pubes.  The  patient  should  be  propped  up,  the  blad- 
der emptied,  and  the  line  of  dulness  determined  by  percussion  on  the  front 
of  the  abdomen.  The  trocar  must  be  introduced  below  the  level  of  dulness. 
The  puncture  is  dressed  with  aseptic  gauze.  During  the  withdrawal  of  the 
fluid  the  patient's  pulse  should  be  carefully  observed,  and  the  process  stopped 
if  any  sign  of  cardiac  weakness  becomes  manifest.  An  abdominal  binder 
adds  to  the  patient's  comfort  after  the  fluid  has  been  withdrawn. 

DISEASES  OF  THE   OMENTUM. 

The  omentum  being  only  a  duplicature  of  peritoneum,  between  the  layers 
of  which  more  or  less  fat  is  found,  and  being  in  contact  with  the  parietal  and 
visceral  peritoneum,  it  is  not  surprising  that  this  structure  almost  without 
exception  participates  in  all  the  acute  and  chronic  inflammatory  affections  of 
the  peritoneum.  It  is  a  well-known  pathological  fact  that  in  injuries  and  cir- 
cumscribed inflammatory  lesions  of  nearly  all  the  abdominal  organs  the  omentum 
becomes  adherent  to  the  affected  region,  and  in  this  manner  furnishes  a  valu- 
able protection  for  the  peritoneal  cavity  against  extravasation  through  small 
intestinal  wounds  and  perforations. 

Cysts. — Cysts  of  the  omentum  of  non-parasitic  origin  and  non-malignant 
in  character  are  exceedingly  rare."  They  can  be  readily  removed  by  enuclea- 
tion or  extirpation.  In  the  latter  case  it  is  necessary  to  guard  against  hemor- 
rhage by  tying  in  small  sections  the  part  of  the  omentum  which  has  to  be  cut 
through  with  fine  silk  ligatures  before  the  division  is  made.  Solitary  echino- 
coccus  cysts  are  extremely  rare.  Disseminated  echinococcus  cysts  from  rup- 
ture of  a  mother-cyst  in  the  liver  or  its  vicinity  are  occasionally  met  Avith, 
but  their  removal  by  operative  procedure  is  usually  impracticable.  An  iso- 
lated echinococcus  cyst  of  the  omentum  is  to  be  treated  in  the  same  manner 
as  when  the  cyst  is  located  in  the  liver ;  that  is,  by  an  operation  in  two  stages. 

Malignant  Tumors. — Primary  carcinoma  of  the  omentum  does  not  occur, 
as  the  essential  matrix  for  carcinoma,  epithelial  cells,  is  not  found  in  the  omen- 
tum. A  primary  malignant  tumor  which  springs  from  the  omentum  is  always 
a  sarcoma.  When  the  tumor  has  attained  considerable  size  it  is  easily  recog- 
nized, as  it  is  located  immediately  underneath  the  abdominal  wall,  and  adhe- 
sions to  surrounding  surfaces  do  not  take  place  at  an  early  stage  of  the  disease, 
and  consequently  the  tumor  remains  movable  for  a  long  time.  If  the  tumor 
has  attained  a  large  size  and  involves  the  omentum  over  its  whole  extent,  it  is 
flattened  out  and  feels  under  the  abdominal  wall  very  much  like  the  back  of  a 


780  AN  AMERICAN    TF.NT-llOOK    OF   Sl'HGERY. 

large  turtle.  Not  long  ago  one  operator  reinoveil  .such  a  tumor  that  weighed 
forty  pounds.  Sanguineous  tumors  of  the  omentum  have  been  described  by 
Reamy,  Doran,  Thornton,  and  Gardner,  but  these  are  only  a  vascular  variety 
of  sarcoma.  If  primary  malignant  disease  of  the  omentum  could  be  recognized 
before  the  disease  had  extended  to  adjacent  organs,  a  i-adical  ojteration  for  its 
removal  could  be  done  with  a  fair  prospect  of  a  pernument  cure.  In  such  cases 
it  would  be  necessary  to  divide  the  omentum  some  distance  from  the  tumor 
between  ligatures,  or  between  ligatures  and  clamp  forceps  on  the  tumor  side. 

CYSTS  AND  TUMORS  OF  THE  MESENTERY. 

Cysts. — Cysts  between  the  peritoneal  layers  of  the  mesentery  containing 
serum  or  a  sanguineous  fluid  have  been  successfully  removed  by  operative 
treatment.  Chylous  cysts,  resulting  from  the  obstruction  of  a  chyle-duct  and 
the  retention  of  secretion  behind  the  seat  of  obstruction,  sometimes  attain  the 
size  of  an  adult's  head.  Carson  of  St.  Louis  cured  such  a  case  by  abdominal 
section  and  drainage.  Extirpation  of  a  cyst  of  the  mesentery  should  not  be 
attempted,  as  it  is  attended  by  troublesome  hemorrhage,  and  the  obliteration  of 
a  number  of  mesenteric  vessels  might  be  followed  by  gangrene  of  the  intestine. 
These  cysts  can  be  dealt  with  successfully  by  incision  and  drainage.  It  is 
preferable  to  make  the  operation  in  two  stages.  The  incision  in  the  abdominal 
wall  is  made  over  the  most  prominent  portion  of  the  swelling,  and  the  cyst-wall 
is  stitched  to  the  incised  parietal  peritoneum  and  the  wound  packed  with  iodo- 
form gauze.  In  about  five  days  the  dressing  is  removed,  and  the  cyst  incised 
and  drained.  It  is  important  that  strict  antiseptic  precautions  should  be 
observed,  not  only  before  and  during  the  operation,  but  until  the  cyst  is  oblit- 
erated, in  order  to  prevent  suppuration  in  the  interior  of  the  cyst,  an  event 
which  Avould  indefinitely  postpone  recovery  or  even  endanger  life. 

TUxMORS. — The  only  tumor  of  the  mesentery  which  deserves  mention  is 
lipoma.  Lipoma  of  the  mesentery  has  been  subjected  to  operative  treatment 
by  Ellis,  Homans,  Terillon,  and  others.  The  I'emoval  of  such  tumors  when 
they  are  of  large  size,  as  in  the  two  cases  reported  by  Ilomans,  is  an  exceed- 
ingly difficult  and  dangerous  operation,  and  unless  they  give  rise  to  serious 
symptoms  it  is  best  to  be  content  with  the  exploratory  laparotomy  should  the 
relations  of  the  parts  indicate  great  difficulties  in  eff'ecting  enucleation. 

PART   v.— DISEASES  AND    INJURIES  OF  THE   LIVER,    GALL-BLADDKR, 
SPLEEN,    AND   PANCREAS. 

SECTION   I.— THE   LIVEK. 

Hydatid  Cysts  of  tin-;  LtVRH. — Hydatids  are  found  in  connection  with 
the  liver  more  frequently  than  with  any  other  organ.  The  cysts  vary  greatly 
in  size,  and  are  usually  single,  but  may  be  multiple  (Fig.  311*).  They  are 
found  in  every  part  of  the  liver — in  the  center,  at  the  upper  border,  where 
they  may  project  into  the  thorax,  and  on  the  lower  surface,  where  they  escape 
from  under  the  free  border  of  the  liver  and  may  even  fill  the  greater  part  of 
the  abdomen,  and  be  mistaken  for  cysts  of  the  ovary. 

Symptoms. — A  tumor  is  present  in  the  right  hyj)ochon(lriac  or  ejiigas- 
tric  region  ;  it  is  painless  and  does  not  interfere  with  the  general  health.  A 
hydatid  fremitus  has  been  noted  by  some,  but  this  sign  is  uncertain.  If  the 
tumor  is  behind  the  liver,  it  may  push  it  forward  and  increase  the  area  of 
liver  dulness.  When  enlargement  is  great,  symptoms  such  as  oedema  of  the 
lower  extremities  may  arise  from  pressure  on  the  inferior  cava.      The  tumor 


DISEASES  AND    INJURIES    OF   THE  ABDOMEN.  781 


in  some  cases  is  liable  to  enlarge  very  rapidly,  and  to  become  inflamed  and 
sui.i)urato,  or  rupture  mav  take  i)laee  into  the  abdominal  cavity.  It  is  often 
a  most  diflicult  affection  to  diagnosticate  from  cancer  or  other  tumor  ot  tfie 
liver,  and  when  suppurating  it  is  not  readily  distinguished  from  abscess  ot 
the  liver.     The  pus  of  a  hydatid  tumor  has  a  peculiar  odor,      ihe  diagnosis 

Vui.  ;51D. 


Fig.  320. 


Hydatids  enclosed  in  a  common  cyst  (Gross). 


Echinococci  (Gross). 


may  often  be  cleared  up  by  the  aspirator.  Should  the  fluid  evacuated  con- 
tain booklets  and  scolices  (Fig.  320),  all  doubt  as  to  the  character  of  the 
tumor  is  at  an  end.  Konig  condemns  preliminary  aspiration,  considering  it 
dano-erous.  He  prefers  to  open  the  abdomen  at  once  in  doubtful  cases  and 
examine  the  tumor.  Should  the  case  not  prove  to  be  one  of  hydatids,  the 
operator  >vill  be  in  a  position  immediately  to  remove  the  tumor  if  prac- 
ticable. ,      .,      .        11-  •  J_■^.^ 

Treatment. — Although  the  existence  of  hydatids  in  the  liver  is  compatible 
with  a  fairly  comfortable  existence,  and  most  medical  authorities  advise  non- 
interference when  there  are  no  distressing  symptoms,  still  the  success  of  opera- 
tive treatment  has  been  so  great  that  it  is  advisable  when  hydatids  have  been 
diagnosticated  to  proceed  at  once  to  operation.  Simple  aspiration  has  been 
successful  in  many  cases,  but  more  recent  authorities  state  that  by  this  method 
of  treatment  the  mother  cyst  has  not  been  removed,  and  that  relapses  fre- 
quently occur  after  apparent  cure.  When  suppuration  has  set  in,  some  sur- 
geons yet  advocate  the  employment  of  a  large  trocar  and  canula  and  the  fre- 
quent washing  out  of  the  cyst  with  iodine,  Condy's  fluid,  carbolic  acid,  or  other 
antiseptic ;  but  operative  measures  have  proved  so  safe  that  most  modern  sur- 
geons do  not  hesitate  to  recommend  them.  The  operation  may  be  performed 
in  either  one  or  two  stages :  i    i  •          i 

Operation  in  One  Stage. — Lindemann  was  the  first  to  recommend  this  mode 
of  operating,  and  Landau  and  Konig  both  practise  it  in  preference  to  Volk- 
mann's  operation  in  two  stages.  Tait  also  advocates  performing  the  operation 
in  one  stage.  All  antiseptic  precautions  having  been  taken,  as  in  other  opera- 
tions on  the  abdomen,  an  incision  is  made  over  the  most  prominent  part  of  the 
tumor  down  to  the  peritoneum.  This  is  then  carefully  opened  and  the  edges 
packed  round  with  sponges.  The  tumor  is  incised,  the  contents  are  evacuated, 
and  the  edges  of  the  cyst  sewed  to  the  abdominal  wound,  the  sponges  being 
withdrawn  as  the  stitches  are  introduced.  Silk  or  catgut  may  be  used.  A 
large  drainage-tube  should  be  introduced  into  the  cavity  and  the  wound  dressed 
antlseptically.  In  cases  where  the  cyst  is  covered  by  a  considerable  thickness 
of  liver,  an'aspirating  needle  should  first  be  introduced  to  make  sure  of  the 
character  of  the  contents,  the  liver  incised,  and  the  finger  thrust  through  the 


Ts-j  .i.v  AMKRK'AX  'n:xT-ii<)()h'  or  sf/:(;/:/n: 

opening  to  prevent  hemorrhage,  which  can  usually  he  controlled  hy  sponge 
pressure.  The  eilges  of  the  opening  in  the  liver  should  next  he  stitched  to 
the  ahdoniinal  wound,  and  a  large  drain  introduced  into  the  cyst  and  a  dress- 
ing applied.  The  stitches  in  the  liver  usually  hold  well.  Tait,  in  a  case  where 
he  accidentally  opened  a  large  sinus,  arrested  the  hemorrhage  easily  hy  pass- 
ing a  thread  down  on  one  side  of  the  sinus  and  up  on  the  other  and  tying  it. 
Landau  before  incising  the  liver  recommends  the  passing  of  deep  sutures  par- 
allel to  the  a.xis  of  the  wound  at  each  angle.  These  sutures  should  be  of  strong 
silk,  and  should  include  the  abdominal  wall  as  well  as  the  cyst-wall. 

Operation  in  Two  iStai/rs. — This  operation,  which  was  first  recommended 
by  Volkmann,  is  easily  performed.  An  incision  is  made  along  the  lower  mar- 
gin of  the  ribs  over  the  cyst  down  to  the  peritoneum:  all  bleeding  having  been 
arrested,  the  peritoneum  is  incised  the  whole  length  of  the  wound,  and  then  the 
wound  is  dressed  with  iodoform  gauze  or  other  antiseptic  dressing.  Adhesions 
between  the  parietal  peritoneum  and  that  covering  the  tumor  are  usually  pretty 
firm  in  five  or  six  days,  when  the  tumor  may  be  incised,  the  contents  evacu- 
ated, the  cavity  washed  out  with  antiseptic  solution,  and  a  drainage-tube  intro- 
duced. This  operation  has  been  most  successful,  and  is,  perhaps,  safer  than 
the  operation  performed  in  a  single  stage.  Some  cases  of  hydatids  of  the  upper 
surface  of  the  liver  have  been  successfully  attacked  through  the  thorax  by 
resecting  the  ribs.  All  other  methods  of  treating  hydatids  of  the  liver,  such 
as  acupuncture,  electrolysis,  caustics,  parasiticide  injections,  have  been  super- 
seded by  the  more  scientific  operative  procedures  above  described.  After  ope- 
ration for  hydatid  tumor  of  the  liver  a  biliary  fistula  sometimes  results. 

Simple  Cysts,  and  also  dermoid  cysts,  are  occasionally  found  in  the  liver. 
These  should  be  treated  in  exactly  the  same  Avay  as  hydatid  cysts. 

Tumors. — Carcinoma,  sarcoma,  gumma,  lymphoma,  adenoma,  and  erectile 
tumors  are  seen  in  the  liver,  but  usually  they  are  not  amenable  to  surgical 
treatment.  Cases  of  excision  of  cancerous  and  gummatous  nodules  have  been 
reported,  and  also  of  tumors  formed  by  hydatid  cysts.  Excision  of  cancerous 
nodules  would  usually  be  of  little  avail,  as,  when  the  liver  is  affected  with  car- 
cinoma, it  is,  as  a  rule,  secondary  and  the  organ  is  studded  with  nodules.  Car- 
cinomatous tumors  of  the  liver  have,  however,  been  successfully  removed  by  \'on 
Eiselsberg  and  others,  and  Hochenberg,  in  a  case  of  carcinoma  of  the  gall- 
bladder, removed  the  diseased  and  the  neighboring  portion  of  the  liver.  Simple 
tumors  of  the  liver  have  not  infreiiuently  been  successfully  removed  of  late, 
cases  being  reported  by  Liicke,  Von  Bergmann,  and  Keen.  The  latter,  in  a 
paper,  gives  a  table  of  50  cases  of  liver  resection,  42  of  which  occurred  in 
females  ;  of  the  59  cases.  48  recovered.  The  tumor  may  be  removed  by  repeated 
small  touches  of  the  cautery — all  large  vessels  bein<]j  tie<l.  In  tliis  wav  hemor- 
rhage  is  ])revented.  In  6  of  the  cases  above  mentioned  the  stump  was  sutured 
to  the  abdominal  wound ;  in  the  others  it  was  returned  into  the  abdominal  cavity. 

Abscess  of  the  Liver. — This  affection  may  follow  contusions,  wounds,  etc. 
It  is  much  more  common  in  tropical  than  in  temperate  climates,  and  is  associated 
fre<iuently  with  dysentery.  Acute  hepatitis  may  terminate  in  abscess.  It  may 
follow  operation  on  the  rectum,  being  due  to  septic  phlebitis.  It  has  followed  con- 
finement, with  jihlebitisof  the  uterine  veins.  It  is  an  occasional  result  of  pyemia. 
Hydatid  cysts,  by  taking  on  suj)purative  infiammation,  may  result  in  abscess, 
and  abscesses  have  been  excited  by  the  invasion  of  lumbrici.  The  predisposing 
causes  are  exposure,  drinking,  irregular  habits,  and  residence  in  tropical  climates. 

Symptoms. — The  patient  usually  has  had  freipient  attacks  of  illness,  has 
an  unhealthy  look,  a  rapid  pulse,  elevation  of  temperature,  vomiting,  a  furred 
tongue,  and  an  anxious  countenance.      He  may  occasionally  have  a  rigor,  or 


DISEASES    AM)    IX.Ii'lilES    OE    THE    A  li  DOM  EN.  7.S3 

merely  shivering  fits.  There  is  :i  <lull.  aching  pain  felt  in  the  liver  and  some- 
timo/in  the  ri.'ht  shoulder,  and  tenderness  over  the  liver  ;  sometimes  fluctuation 
mav  he  made  T)ut.  When  the  ahscess  has  attained  any  size  there  are  fulness 
and  hulcrincr  in  the  right  hvpochon.lrium.  Jaundice  is  rare.  Should  the  ahscess 
be  on  the  upper  surfiice  of  the  liver,  it  may  push  up  the  diaphragm  and  cause 
shortness  of  breath  :  occasionally  it  may  inflame  the  diaphragm  and  adjacent 
pleura   and  iiive  rise  to  severe  pain.  n         ■   a         ^       a 

Diagnosis. It  is  sometimes  difficult  to  diagnosticate  trom  inflamed  ana 

distended  gall-bladder,  hydatids,  cancer,  malaria,  pneumonia,  etc.  The  intro- 
duction of  an  aspirating  needle  will  frciiuently  clear  up  the  case.  These 
abscesses  may  burst  into  the  pleura,  lung,  or  pericardium,  may  point  exter- 
nally or  may^pen  into  the  intestine  or  the  general  cavity  of  the  peritoneum, 
the  connection  of  liver-abscess  with  the  amceba  coU  has  been  carefully 
worked  out  by  Kartulis.  Councilman,  and  Lafleur,  and  they  have  proved  be- 
yond a  doubt"  that  amreke  are  the  cause  of  the  large  single  liver-abscess.  In  a 
'person  suspected  of  liver-abscess,  whether  or  not  there  be  enlargement  of  the 
liver,  exploratory  asjjiration  is  indicated  ii'  ama-hce  coli  be  found  in  the  stools. 
Aspiration  is  best  performed  bv  introducing  the  needle  in  the  mid-axillary  line 
between  the  seventh  and  eighth  ribs  :  too  small  a  needle  should  not  be  used. 
When  a  liver-abscess  bursts  into  the  pleura  it  may  be  mistaken  for  em- 
pyema. The  character  of  the  pus  is,  however,  distinctive,  for  it  is  of  a 
brown-red  color  and  contains  amoehce.  Again,  the  pus  may  perforate  the  lung 
and  be  coughed  up:  here  the  same  reddish  color  and  the  presence  of  the  amoeba 
coli  would  enable  the  surgeon  to  distinguish  the  aff"ection  from  simple  empyema. 
The  prognosis  of  liver  abscess  is  usually  grave.  Septic  cases  are  almost 
universally  fatal,  surgical  treatment  being  of  no  avail. 

Treatment.— In  tropical  abscess  surgical  treatment  is  not  infrequently  fol- 
lowed by  success.  In  some  cases  the  abscess  has  been  cured  by  aspiration,  but 
if  the  abscess  has  been  definitely  located  it  should  be  treated  like  an  abscess 
anywhere  else,  viz.  by  incision  and  drainage.  The  incision  should  be  made 
along  the  edge  of  the  ribs,  near  the  subcostal  angle,  and  when  the  liver  is 
reached  it  sh'ould  be  stitched  to  the  abdominal  wound,  incised,  the  abscess 
evacuated,  washed  out  if  fetid,  and  drained :  in  fact,  treated  much  in  the  same 
way  as  a  hydatid  cyst.  Some  have  advised  operation  in  two  stages,  but  in  one 
stage  with  aseptic' precautions  the  operation  has  been  eminently  successful. 
Abscesses  which  form  on  the  upper  surface  of  the  liver  frequently  discharge 
through  the  lung.  They  have  been  successfully  attacked  through  the  lower 
part  of  the  thorax  by  excising  one  or  two  ribs,  incising  the  diaphragm,  and 
draining.  It  is  advisable  to  sew  the  parietal  and  phrenic  pleura  together  before 
incising  the  liver  through  the  diaphragm. 

Rupture  of  the  Liver. — An  injury  sufficient  to  cause  rupture  of  the 
liver  usually  causes  equally  serious  eff"ects  in  other  organs,  so  that  surgical 
interference'  ordinarily  is  of  no  avail.  Still,  if  not  immediately  fatal,  the 
abdomen  should  be  opened  and  the  wound  brought  together.  Wounds  of  the 
liver  substance  heal  rapidly,  and  hemorrhage  is  generally  at  once  arrested  by 
approximating  the  torn  edges.  In  one  case  reported  by  H.  E.  A^  alton  there 
was  rupture  o^  both  liver  and  kidney.  The  liver  rupture  was  so  far  back  that 
it  could  not  be  sutured,  so  was  packed  with  iodoform  gauze.  The  patient  made 
a  rapid  recovery,  going  out  of  hospital  well  in  five  weeks. 

Wounds  of  the  Liver.— These  may  occur  accidentally  during  an  opera- 
tion or  be  produced  bv  stabs,  bullets,  etc'  Many  cases  of  recovery  after  punc- 
tured and  incised  wounds  of  the  liver  are  reported  by  Otis  in  the  Medical  and 
Surgical  History  of  the  War  of  the  Rebellion.     Cases  of  recovery  are  reported 


784 


A.\    AMi:incAX    TEXT- HOOK    OF   SVlidKRY. 


after  a  bullet  Imd  ]»;isso(l  conijiletcly  tlir«»u<^li  the  liver.  Should  tlic  case  be 
complicated  by  Avoiind  of  the  stoiiiach,  spleen,  kidney,  or  <:reat  vessels,  it  is 
very  unfavorable.  In  cases  of  incised  or  gunshot  -wounds  of  the  liver  the 
proper  course  is  to  open  the  abdomen  and  suture  the  wounds.  In  suturing 
the  liver  it  is  important  to  place  the  sutures  at  some  distance  from  the  edge 
of  the  wound.  No  doubt  in  the  future  a  quicker  resort  to  laparotomy  in 
wounds  of  the  viscera  will  save  many  lives,  and  surgeons  will  no  longer  be 
willing  to  stand  by  and  see  the  patient  die  without  attempting  some  form  of 
surgical  relief. 

Resection  of  Portions  of  the  Liver. — Portions  of  the  liver  have  been 
of  late  successfully  excised  both  by  the  knife,  by  the  thermo-cautery,  and  by 
the  elastic  ligature  applied  externally  after  suturing  the  liver  to  the  margins 
of  the  abdominal  incision.  Langenbuch  records  a  case  in  which  he  successfully 
removed  the  greater  part  of  the  left  lobe  in  a  woman  aged  thirty.  The  lobe 
had  been  extensively  deformed  by  tight  lacing,  and  caused  serious  inconveni- 
ence. There  was  considerable  hemorrhage,  but  the  vessels  were  secured  and 
the  woman  made  a  good  recovery.  Portions  of  the  liver,  the  seat  of  hydatid 
cysts,  have  also  been  successfully  removed  by  the  thermo-cautery  and  elastic 
ligature.  Nodules  of  cancer  and  gummata  have  been  excised,  but  with  no 
great  permanent  benefit  to  the  patient,  the  operations  having  usually  been 
based   on   mistaken   diagnoses.      Portions   of  the  liver    have   extruded  from 

the    abdominal    wound,    and 
Fig.  321.  have  been  removed  success- 

fully. Free  hemorrhage 
sometimes  occurs  in  ope- 
rating on  the  liver,  which  is 
usually  rapidly  arrested  by 
tamponing  with  iodoform 
gauze  and  securing  the 
bleeding  vessels. 

Floating  Liver. — In 
this  rare  malady  the  liver 
forms  an  abdominal  promi- 
nence which  can  be  moved 
about,  which  is  apt  to  trans- 
mit aortic  pulsations,  and 
which  changes  its  situation 
as  the  patient  shifts  her  atti- 
tude. This  condition  usually 
arises  from  a  lax  abdominal 
wall  following  repeated  preg- 
nancies. Fig.  321  exhibits 
a  typical  case  verified  by  a 
post-mortem. 

The  only  treatment  that 
is  needed  in  some  cases  is 
the  use  of  an  abdominal  belt. 
If  this  should  fail  to  relieve 
the  symptoms,  an  oi)eration 
may  be  undertaken,  with  the 
view  of  suturing  the  liver 
Treves  and  others  have  reported  successful  cases 


Floating  Liver  (original). 


in  its  proper  position, 
of  hepatopexy. 


DISEASES  AND   INJURIES    OF    THE   ABDOMEN.  7S5 

GALL-f^TONES   AND    DISTENTION   OF   THE    GaLL-IJLADDER. Gall-StoneS,  or 

biliary  calculi,  occur  more  f'recjuently  in  wonion  than  in  men.  They  are  rare  in 
infiincy  and  childhood.  Tifi;ht  lacing,  by  obstructing  the  flow  of  bile,  and 
hence  leading  to  its  inspissation,  is  one  of  the  causes  of  gall-stones.  High 
living  and  want  of  exercise  also  favor  their  formation.  They  occur  of  all 
sizes,  from  that  of  a  grain  of  sand  to  that  of  a  hen's  egg.  Gall-stones  are 
most  fre({uently  multiple,  and  arc  then  faceted  by  reciprocal  pressure — a  valu- 
able point  in  diagnosis  when  a  stone  has  been  passed  and  found  in  the  stools — 
but  when  of  large  size  they  are  usually  single  or  double.  When  small  they 
occur  in  large  numbers,  several  thousands  having  been  found  in  one  person 
(Otto).  When  small  and  numerous  the  patient  frequently  passes  them,  and 
they  may  be  found  in  the  stools.  The  passage  of  gall-stones  from  the  gall- 
bladder to  the  duodenum  is  attended  by  vomiting  and  intense  pain,  which  is 
relieved  only  by  full  doses  of  morphine,  administered  preferably  hypoder- 
matically.  After  an  attack  of  biliary  colic,  jaundice,  to  a  greater  or  less 
extent,  is  observed.  If  the  urine  be  examined,  bile-pigment  Avill  often  be  dis- 
covered in  it,  even  if  there  be  no  jaundice. 

The  conditions  which  call  for  surgical  interference  may  be  caused  by  the 
arrest  of  the  gall-stone  in  its  passage  to  the  intestine,  either  in  the  cystic  or  in 
the  common  duct.  When  arrested  in  the  common  duct  there  is  obstruction  to 
the  outflow  of  bile  and  consequent  jaundice,  and  the  gall-bladder  becomes 
enlarged,  and  may  be  felt  as  a  rounded,  pear-shaped  tumor  under  the  edge 
of  the  right  lobe  of  the  liver.  The  contents  are  not  usually  bile,  but  may 
be  mucous,  muco-purulent,  or  purulent  fluid,  Avhen  the  cystic  duct  is 
occluded.  A  greatly  distended  gall-bladder  has  been  mistaken  for  ascites,  and 
has  been  tapped  for  ovarian  tumor,  hydatids,  etc.  The  bile-duct  may  become 
obstructed  also  by  the  pressure  of  tumors  involving  neighboring  organs,  as  the 
stomach,  pancreas,  or  liver,  or  it  may  become  occluded  by  the  spread  of  cancer- 
ous diseases  commencing  in  the  contiguous  organs.  Gall-stones  are  not  infre- 
quently the  accompaniment  of  cancer  of  the  liver,  as  obstruction  to  the  flow  of 
bile  favors  their  formation.  Obstruction  of  the  common  duct  is  always  accom- 
panied by  jaundice,  but  the  cystic  duct  may  be  occluded  and  give  rise  to  grave 
symptoms  without  there  being  any  trace  of  jaundice  or  any  history  of  biliary 
colic.  Not  a  few  cases  of  enlarged  gall-bladder  thickened  and  altered  bv  in- 
flammation  are  difficult  of  diagnosis,  owing  to  the  downward  displacement  of 
the  liver  from  tight  lacing  or  other  causes.  Such  tumors  have  been  mistaken 
for  diseased  or  floating  kidney,  malignant  disease  of  the  bowel,  etc.  On  the 
other  hand,  cancerous  nodules  in  the  liver  have  been  mistaken  for  diseased 
gall-bladder  and  the  abdomen  opened.  In  many  cases  there  is  no  distention 
of  the  gall-bladder,  but,  on  the  contrary,  it  is  small  and  surrounded  by  thick 
adhesions  produced  by  the  presence  of  the  calculi. 

Rupture  of  the  Gall-bladder. — Several  cases  of  this  accident  have 
been  successfully  treated  by  incision  and  drainage  (Lane)  or  by  aspiration  (I. 
Bell).  In  these  cases  large  quantities  of  bile  escaped  into  the  abdominal  cav- 
ity.    Peritonitis  does  not  necessarily  folloAv,  as  the  bile  is  usually  aseptic. 

Suppuration  of  the  gall-bladder  not  infrequently  occurs,  and  this  adds  much 
to  the  seriousness  of  the  case.  The  obstruction  in  these  cases  is  nearly  always 
situated  in  the  cystic  duct.  In  some  cases  the  gall-stones  may  ulcerate  through 
the  gall-bladder  into  the  stomach,  duodenum,  or  colon,  and  in  this  way  large 
stones  have  escaped  from  the  gall-bladder  and  afterward  have  produced  ob- 
struction of  the  bowels.  For  the  relief  of  the  conditions  of  the  gall-bladder 
above  described  two  operations  have  been  devised,  viz.  cholecystotoniy  and  cho- 
lecystectomy. 

50 


786  AN   AMNincAS    TKXr-JiOOK    OF  SUlKiFAiY. 

Cholecystotomy  is  porfonnt'd  lor  tlie  relief  of  distention  of  the  gall- 
bladder from  obstruction  of  the  cystic  or  common  duct  and  for  the  re- 
moval of  calculi.  This  operation  has  been  very  successful.  It  is  essen- 
tially of  American  origin,  iiaving  been  first  done  by  liobbs  of  Indiana})oli8 
in  181)7,  and  its  establishment  and  practical  perfection  being  due  to  Marion 
Sims  in  1878.  Tait  in  54  cases  had  -VJ  j)erlecl  recoveries.  In  170  cases 
of  ojierations  in  gall-bladder  bile-ducts  perfoi-med  by  Mr.  Mayo  Kobson 
10  patients  died,  in  1>8  patients  operated  on  without  jaundice  all  recov- 
ered ;  the  deaths  occurred  among  the  remaining  77  cases  with  jaundice. 
Of  115  cholecystectomies,  5  died;  of  6  choledochotomies,  1  died.  Murphy 
of  Chicago  collected  201  cases  of  cholecystectomies,  with  a  death-rate 
of  19  per  cent.  The  operation  is  performed  by  making  an  incision  over 
the  tumor,  if  it  l)e  present;  if  not,  a  vertical  incision  in  the  right  semi- 
lunar line.  If  more  room  be  needed,  an  incision  at  right  angles  to  the 
first  may  be  made  Avith  advantage.  Then  the  distended  gall-bladder,  if 
very  much  distended,  is  aspirated.  It  then  should  be  carefully  packed 
around  with  aseptic  j)ads  before  it  is  opened  and  the  stones  removed. 
The  cut  edges  of  the  gall-bladder  are  now  stitched  to  the  deeper  parts 
of  the  wound  (not  to  the  skin),  a  drain  introduced,  and  the  skin-incision 
closed  as  far  as  possible.  If  the  gall-bladder  is  stitched  to  the  skin,  an 
incurable  fistula  often  results.  Bile  flows  freely  from  the  tube  for  some  time, 
but  after  its  removal  the  fistula  usually  closes  in  from  two  to  four  weeks. 
Occasionally  it  remains  open  and  there  is  a  permanent  biliary  fistula.  In 
such  cases  the  common  duct  is  probably  occluded  by  gall-stones.  There 
is  often  great  difficulty  in  removing  stones  impacted  in  the  ducts.  A  long- 
handled  scoop,  something  like  a  uterine  curette,  will  be  found  useful  for  remov- 
ing stones  from  the  gall-bladder  and  cystic  duct.  Some  surgeons  have  succeeded 
in  piercing  the  stone  with  a  needle,  thus  breaking  it  up  and  pushing  the  frag- 
ments into  the  duodenum  ;  others  (Tait)  break  up  the  stone  by  using  padded 
forceps  from  outside  the  duct ;  others  again  have  oi)ened  the  duct,  removed 
the  stone,  and  afterward  sutured  the  duct  successfully.  In  cases  where  the 
stone  is  lodged  near  the  duodennl  opening  of  the  duct,  McBurney  has  suc- 
cessfully removed  it  by  incising  the  duodenum,  slitting  up  the  duct,  and  thus 
reaching  the  stone.  Abbe  has  performed  a  somewhat  similar  operation  for 
obstruction  of  the  common  duct,  but  in  his  case  the  obstruction  was  due  to  a 
cancerous  nodule.  In  perfi)rming  the  operation  of  cholecystotomy.  Sir 
t'j)encer  Wells,  after  evacuating  the  distended  gall-bladder  and  removing  the 
•  stones,  stitches  it  up  ;igain  by  continuous  suture  and  returns  it.  In  these 
cases  the  gall-bladder  is  first  carefully  packed  around  with  carbolizcd  sj)onges, 
aspirated,  and  then  drawn  out  of  the  wound  before  being  incised.  By 
this  means  the  necessary  manipulations  are  carried  on  without  any  danger  of 
the  contents  of  the  gall-bladder  getting  into  the  peritoneal  cavity.  In  many 
eases  the  operation  of  cholecystotomy,  or  incision  of  the  gall-bladder,  is  an 
easy  one,  but  the  operation  may  present  unusual  difficultii-s  when  the  gall- 
bladder is  small  and  shrunken  and  cannot  be  brought  to  the  abdominal  wound. 
In  such  a  condition  it  may  be  sutured  and  returned  into  the  abdomen,  as 
recommended  by  Kuster,  or  a  drain  packed  around  with  iodoform  gauze  may 
be  inserted. 

Van  Hook  recommends  air-distention  in  operations  upon  the  bile-tracts, 
as  the  operator  may  thus  readily  identify  these  structures,  locate  obstructions 
if  present,  or  determine  that  they  are  absent.  It  also  serves  to  test  the 
accuracy  of  sutures  of  the  duct  walls.  He  has  devised  a  s])ecial  ai)i)aratus 
for  infiating  the  ducts;  but  some  other  form  of  pump  can  easily  be  devised. 


DISEASES   AND    INJURIES    OF    THE   ABDOMEN  787 

Tlic  first  step  is  tlio  iutroductiou  of  a  suitable  canula  into  the  gall-bladder, 
which  is  held  firmly  by  a  purse-string  suture  in  the  latter.  No  danger  is  to 
be  apprehended  from  the  use  of  this  measure. 

Cholecvstotomv  is  tlie  proper  operation  in  cases  where  the  common  duct  is 
blocked,  ami  also  in  eases  where  gall-stones  exist  in  the  gall-bladder,  giving  rise 
to  repeated  attacks  of  biliary  colic.  ,,,,,,  .     .  .1 

Cholecystectomy,  or  excision  of  the  gall-bladder,  was  hrst  practised 
bv  Lan-eubuch  of  Berlin  in  1880.  His  method  is  as  follows:  An  incision  is 
made  iifthe  right  hypochondrium,  parallel  to  the  lower  border  of  the  liver 
an.l  is  ioiued  by  a  second  incision  running  along  the  outer  border  of  the  right 
rectus  "imiscle.  The  abdomen  having  been  opened,  the  transverse  colon  and 
small  intestine  are  pushed  aside  by  a  large  sponge;  the  liver  is  then  ele- 
vated, so  as  to  bring  the  lesser  omentum  into  prominence,  ^^^e  gall- 
bladder is  easily  separated  from  the  liver  by  a  few  strokes  of  the  knile, 
and  the  cystic  duct  freed  and  ligatured  in  two  places  with  silk.  Atter 
removal  of  the  gall-bladder  the  wound  in  the  abdomen  is  closed  and  the 
operation  is  completed.  ,  •      1 

Cholecystectomy  is  also  advocated  in  cases  where  there  is  degeneration 
of  the  .ndl-bladder  and  there  is  no  chance  of  restoring  its  function,  or  where 
the  cralf-bladder  is  small,  contracted,  or  perhaps  suppurating  so  that  it  can- 
not be  fixed  to  the  abdominal  incision.  Excision  of  the  gall-bladder  is  also 
indicated  in  cases  of  gangrene,  phlegmon,  or  cancer.  If  the  common  duct 
is  not  patent,  this  operation  is  contraindicated. 

Cholecyst-enterostomy,  or  the  formation  of  a  communication  between  the 
intestines  and  the  gall-bladder,  has  been  successfully  performed.  ihis  ope- 
ration endeavors  to  avoid  the  formation  of  a  biliary  fistula;  but,  ot  course, 
the  danger  to  the  patient  is  much  greater,   and  the  opening   is   liable  to 

contract.  ,  ^  i   1  r  i.r 

This  operation  has  of  late  been  frequently  performed  by  means  ot  the 
smallest-sized  Murphy's  button.     It  is  a  rapid,  easy,  and  comparatively  sate 
method   of  forming  a   communication  between   the   gall-bladder   and   small 
intestine.     In  cases  in  which,  after  the  operation  of  cholecystotomy,  the 
fistula  persists  and   discharges  large   quantities  of  bile,   it  may  be  taken 
for   ^ranted  that  the  common  duct  is  occluded  and   cholecyst-enterostomy 
shoutd    be    undertaken,    the    opening    in    the   gall-bladder   closed   by   Lem- 
bert's    sutures,    and    then    the    gall-bladder    should    be    returned    into    the 
abdominal  cavity  and  the  abdominal  wound  closed.     It  would  be  well  to 
keep  in  a  drain  for  a  few  days,  in  case  any  leak  should  occur  in  the  gall- 
bladder. ^  ,.  „  .  .  ,, 
Gall-stones  in  the   Common  Bile-duct— According  to  Courv-oisier,  gall- 
stones are  in  the  common  duct  in  about  4  per  cent,  of  all  cases  of  cholelithi- 
asis     In  67  per  cent,  of  the  cases  the  stone  is  found  in  the  duodena   end  ot 
the  common  duct,  according  to  Mayo  Robson.    Jaundice  with  distended  gall- 
bladder not  due  to  gall-stones  is  presumptive  evidence  of  malignant  disease. 
Jaundice  without  distended  gall-bladder  favors  the  diagnosis  of  cholelithiasis. 
Courvoisier  found   that  in  35  operations  performed  for  obstruction   m  the 
common  duct,  in  18  the  obstruction  was  due  to  causes  unconnected  with  ga   - 
stones— e^.  g.,  cancer,  tumor,  stricture— and  in  all  these  18  cases  the  gall- 
bladder was  dilated.                                                                                     ^^    i        e 
If  there  is  no  enlargement  of  the  gall-bladder  with  frequent  attacks  ot 
pain,  each  attack  accompanied  by  an  increase  in  the  jaundice,  which  is  never 
wholly  absent;  if  there  are  loss  of  weight  and  feverishness  during  the  attack, 
and  pain  in  the  epigastric  region,  then  we  may  conclude  we  have  a  stone  in 


788  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

the  common  duct.  A'arious  methods  of  getting  rid  of  the  stone  have  been 
mentioned  above ;  but  the  best  method  by  far,  when  possible,  is  the  operation 
of  choledochotomy,  or  removal  of  the  stone  by  incising  the  duct.  After  se)ia- 
rating  ndhcsions  and  making  an  assistant  retract  the  parts  well,  the  duct  will  be 
made  out  along  the  free  border  of  the  lesser  omentum.  A  finger  introduced 
into  the  foramen  of  Winslow  should  j)ush  the  duct  and  contained  stone  into 
prominence ;  then  an  incision  is  made  over  the  prominence  and  the  stone 
removed.  A  probe  should  now  be  introduced  to  see  if  there  are  any  more 
stones.  The  incision  should  be  closed  by  a  double  row  of  sutures,  the  outer 
layer  a  continuous  Lendjert  of  fine  silk.  A  drainage-tube,  packed  around 
with  gauze,  should  be  left  in  the  abdomen.  The  gauze  should  reach  the  in- 
cision in  the  duct.  The  mortality  in  the  operation  of  choledochotomy  is 
about  25  per  cent.,  and  the  difficulties  are  great.  In  some  cases  stones  have 
been  removed  from  the  hepatic  duct  with  success. 

SECTION    II.— THE   PANCREAS, 

Notwithstanding  the  fact  that  the  pancreas  is  the  most  inaccessible  of  all 
the  abdominal  organs,  it  has  been  a  number  of  times  successfully  subjected  to 
operative  measures. 

Cysts. — This  affection  has  been  fully  described  by  Senn,  who  comes  to 
the  conclusion  that  all  cysts  are  retention  cysts,  and  are  due  to  cylindrical  con- 
traction or  obliteration  of  the  common  duct  or  its  branches,  or  to  impacted  cal- 
culi. Cysts  are  more  frequently  met  with  in  men  than  in  women,  and  often 
follow  injury.  The  cyst  usually  grows  rapidly  and  is  situated  above  the 
umbilicus.  Gastro-intestinal  disturbances,  such  as  vomiting  and  diarrhea,  are 
common  symptoms.  The  skin  has  an  unhealthy,  muddy  look,  and  the  pain  is 
sometimes  considerable. 

The  tumor  itself  is  generally  well  defined  and  has  an  elastic  feel,  as  if  very 
tense.  If  aspirated,  the  fluid  has  a  brownish  color,  is  alkaline  in  reaction,  digests 
fat,  and  turns  starch  into  sugar.  The  skin  about  the  sinus  which  is  left  after 
operation  is  often  raw  and  sore.  A  considerable  number  of  cases  are  now  scat- 
tered through  medical  literature,  and  not  a  few  have  been  diagnosticated  before 
operation. 

Pancreatic  Cysts. — (Jf  12  cases  of  extirpation  of  the  cyst,  5  died  ;  of 
31  cases  treated  by  incision  and  drainage  of  the  sac,  2  died;  but  10  of  those 
who  recovered  had  more  or  less  permanent  fistulse.  Simple  tapping  has 
proved  fatal  in  2  cases.  The  cyst  has  been  mistaken  for  hydatids,  ovarian 
cyst,  tumor  of  the  kidney,  etc. 

Treatment. — An  incision  is  made  over  the  tumor  down  to  the  cyst,  which 
is  then  aspirated,  pulled  gently  out  of  the  wound,  and  incised.  After  evacu- 
ating the  contents  the  cyst  should  be  stitched  to  the  parietal  wound  and  the 
cavity  drained.     A  fistula  may  persist  for  some  time. 

Abscess  of  the  pancreas  is  sometimes  seen,  and  usually  ends  fatally,  nearly 
all  the  reported  cases  having  been  found  only  post-mortem.  Should  a  diagno- 
sis be  arrived  at,  the  proper  procedure  would  be  to  incise  and  drain. 

Wounds  of  the  pancreas  have  been  recorded  from  time  to  time.  Rupture 
of  the  pancreas  has  been  seen  from  severe  contusions.  Many  cases  of  gunshot 
wound  of  the  organ  are  reported,  also  stab  wounds  from  a  knife  or  other  instru- 
ment. In  such  cases  portions  of  the  pancreas  have  protruded  from  the  wound 
and  have  been  cut  off,  with  subsequent  recovery  of  the  patient.  Dargan 
reports  a  case  where  the  pancreas  was  successfully  replaced  in  the  abdominal 
cavity.     In  cases  of  severe  abdominal  wounds  where  the  pancreas  is  injured  the 


DISEASES  AND    INJURIES    OF    THE  ABDOMEN.  789 

lesion  ^Y()uld  be  diseovered  in  performing  abdominal  section  for  the  treatment 
of  wounds  of  other  organs.  It  would  be  quite  justifiable  to  excise  portions  of 
bruised  or  injured  pancreas.  .         ,    •     • 

Cancer  of  the  pancreas  is  so  insidious  that  when  diagnosticated  it  is 
usually  too  for  advanced  for  operation. 

Portions  of  the  pancreas  have  been  removed  during  operation  on  neighbor- 
mcr  orf^ans  for  carcinomatous  tumors  or  other  diseases,  without  bad  results. 

SECTION   III.— THE  SPLEEN. 

Cysts  of  the  Spleen.— These  may  be  simple,  dermoid,  or  hydatid,  and 
are  very  difficult  to  diagnosticate  positively  without  opening  the  abdomeii. 
Hydatids  may  be  recognized  by  the  fremitus  or  by  an  examination  of  the 
aspirated  fluid.  Usually  these  cysts  should  be  treated  like  those  of  the  liver, 
viz.  by  abdominal  incision  over  the  tumor,  fixing  the  cyst-wall  to  the  abdom- 
inal wound,  incising,  evacuating,  and  then  draining. 

Carcinomatous  and  Sarcomatous  Tumors  of  the  spleen  do  not  otter 

any  hope  of  being  treated  surgically  with  success.  .     .   ,     .  , 

Abscesses  may  follow  injury  or  be  the  result  of  septic  infection,  and 

should  be  incised  and  drained  with  strict  aseptic  precautions.     They  are  not 

usually  recognized  until  they  approach  the  surface  and  fluctuate  freely. 

Rupture  produced  by  "kicks,  blows,  or  other  injuries  is  usually  fatal. 
When  accompanied  by  an  external  wound  the  spleen  may  protrude,  and  the 
sur^reon  may  find  it  necessary  to  remove  it  wholly  or  partially. 

"Stab  or  Gunshot  Wounds.— If  the  patient  be  seen  m  time,  it  will  be 
proper  to  perform  abdominal  section  and  endeavor  to  arrest  the  hemorrhage  by 
tamponing  with  iodoform  gauze,  by  ligature  of  vessels,  or  even  by  excision  ot 
the  spleen  if  the  injury  be  great.  ^         ,  x.       e 

Splenectomy,  or  excision  of  the  spleen,  has  been  performed  a  number  ot 
times.  Vulpius  has  collected  117  cases  of  splenectomy  with  a  death-rate  of 
50  per  cent. ;  if,  however,  from  these  cases  those  suff"ering  from  leucocy- 
themia,  lardaceous  spleen,  spleno-megaly,  in  which  the  operation  should  not 
be  done,  be  deducted  (32),  the  mortality  in  the  remaining  cases  (85)  is  re- 
duced to  33  per  cent.  The  indications  for  the  operation  are  tumors  and 
cysts,  wounds,  and  movable  or  dislocated  spleen.  In  leukemia  the  operation 
has  been  invariably  fatal  from  hemorrhage,  which  is  the  great  danger  of 
splenectomy.  Hypertrophied  spleens  have  been  successfully  removed,  but 
for  the  most  part  these  cases  are  not  suitable  for  operation. 

Operation. — An  incision  is  made  in  the  left  semilunar  line,  the  perito- 
neum freely  opened,  and  the  hand  introduced  to  explore  the  tumor.  All  adhe- 
sions are  separated,  and  ligated  if  necessary,  and  the  spleen  delivered  through 
the  wound,  the  lower  extremity,  first.  Great  care  should  be  taken  not  to  twist 
or  drag  on  the  pedicle.  The  vessels  entering  the  hilum  should  be  clamped, 
the  spleen  removed,  and  tLen  each  vessel  ligated  separately  some  distance  from 
its  extremity.  Some  advise  cutting  the  pedicle  away  piecemeal  between 
pressure  artery  forceps  and  then  securing  the  vessels.  The  after-treatment  is 
the  same  as  after  ovariotomy. 

PART  VI.-DISEASES  AND  INJUEIES  OF  THE  RECTUM. 

Surgical  Anatomy. — The  rectum  in  the  male  is  in  relation  in  front 
with  the  trigone  of  the  bladder  and  the  seminal  vesicles,  and  in  the  female 
with  the  vagina  and  uterus.     The  lower  three  or  four  inches  are  uncovered 


790  A.\    AMhJi'JCAA    Ti:XT-ll()Uh'    OF   .SI  /,'(; J./n'. 

bv  peritoncnin.  It  is  freely  supplied  l»y  blood-vessels,  eliieHy  iVom  the  supe- 
rior heinorrhoidiil  braueh  of  the  inferior  mesenteric  artery.  This  artery  passes 
down  in  the  niesorectuiu.  and  divides  into  two  branches,  each  of  which  forms  a 
loop  on  the  side  of  tiie  bowel,  about  five  inches  above  the  anus.  From  these 
loops  a  number  of  vessels  are  given  oft"  which  pierce  the  muscular  coat  and  run 
down  immediately  beneath  the  mucous  membrane  to  the  anus.  There  is  a  branch 
in  each  column  of  the  rectum.  These  arteries  anastomose  freely  with  one  another, 
and  are  connected  by  lateral  branches,  but  they  do  not  anastomose  with  the 
middle  and  inferior  hemorrhoidal  arteries,  which  supply  the  skin  about  the 
anus.  From  a  knowledge  of  the  development  of  the  rectum  it  will  be  easily 
understood  that  the  lower  end  descends  a  considerable  distance  to  meet  the 
involution  of  the  skin  at  the  anus,  and  in  descending  carries  with  it  its  own 
vessels,  the  superior  hemorrhoidal.  The  veins  have  much  the  same  anatomical 
arrangement  as  the  arteries. 

Iseliio-reetal  Fossa. — On  each  side  of  the  rectum  is  a  fossa  called  the 
iscbio-rectal.  It  is  two  or  three  inches  in  depth,  pyramidal  in  shape,  ami  filled 
with  fat.  There  are  very  few  blood-vessels  in  this  fossa,  and  it  is  the  common 
seat  of  fistulse  and  ischio-rectal  abscess. 

Congenital  Malformations. — These  are  not  infrequent,  and  are  very 
various.  In  early  foetal  life  the  bowel  and  urogenital  sinus  end  in  a  common 
cloacal  opening  ;  later,  separation  between  the  bhulder  and  urethra  and  the 
rectum  takes  place,  and  there  are  two  distinct  orifices.  But  occasionally  this 
separation  does  not  occur,  and  the  lower  end  of  the  rectum  opens  into 
the  bladder  (Fig.  322),  or,  more  commonly,  if  the  child  be  a  male,  into 
the  membranous  portion  of  the  urethra ;  or  into  the  vagina  if  the  child  be 
a  female. 

Imperforate  Anus  and  Imperforate  Rectum, — The  lower  one  and  a 

Fig.  322.  Fig.  32o. 


Rectum  opening  into  Bladfler:  a,  penis;  ft,  bladder;  A,  Depression  for  aniil  jmce  of  n-ctum;  R  B, 

c,  rectum  opening  into  bladder  (Owen).  bladder ;  M,  Meckel's  diverticulum  ;  CE,  future 

cesophagus;  I',  pharynx  ;  T,  urachus  lOwen). 

half  to  two  inches  of  the  rectum  are  not  formed  from  the  hypobla.st.  as  is  the 
rest  of  the  alimentary  canal  (with  the  exception  of  the  mouth),  but  by  an 
involution  of  the  epiblast  or  skin  which  meets  the  end  of  the  alimentary  canal 
formed  by  the  hypoblast  (Fig.  823).  Occasionally  this  involution  does  not 
occur,  and  there  is  no  union  with  the  lower  end  of  the  alimentary  canal.  This 
is  called  imperforate  anus.  Again,  a  simple  cul-de-sac  may  exist  at  the  anus, 
and  the  bowel  may  terminate  at  some  distance  above,  and  either  end  by  a  blind 
extremity  or  open  into  the  membranous  urethra  or  the  vagina.     In  such  a  case 


DTSEASKS   AND    INJURIES    OF    THE   ABDOMEN. 


791 


the  involution  ot"  the  skin  oecurred  nornuilly,  but  the  rectum  above  was  not 
sufficiently  (levelo])e(l  to  meet  it,  and  the  result  is  a  deformity  called  imper- 
fonitc  rectum  (Fig-  324).  Im- 
perforate anus  and  imperforate  Fio.  324. 
rectum  may  exist  together.  The  ^^.. 
term  imperforate  anus  is  often 
applied  to  either  condition.  In 
some  cases  the  involuted  por- 
tion of  skin  meets  the  end  of 
the  large  intestine,  but  a  sep- 
tum remains  between  them  still 
unabsorbed,  and  occludes  the 
bowel.  This  may  be  easily  di- 
vided, and  the  child  will  then 
have  a  free  exit  for  feces.  Some- 
times the  anal  opening,  though 
present,  is  so  small  as  to  admit 
only  a  fine  probe,  and  the  sur- 
geon is  compelled  to  nick  the 
edges  with  a  narroAV-bladed  knife 
and  then  dilate  with  his  finger. 

Diagnosis. — The  fact  that 
the  child  has  had  no  motion  of 
the  bowels  is  usually  noticed  at 
an  early  period  by  the  nurse : 
even  if  there  should  be  a  well- 
formed  anus,  an  intelligent  nurse 
will  inform  the  doctor  that  there 
has  been  no  passage  through  the 
bowels,  and  an  examination  will 
soon  reveal  the  condition.  Should  the  bowel  communicate  with  the  vagina 
or  the  urethra,  the  passage  of  meconium  from  these  orifices  will  soon  be 
detected. 

Treatment. — In  cases  where  there  is  imperforate  anus  the  bowel  usually 
lies  close  to  the  skin,  and  a  simple  incision  into  the  bulging  anal  region  will 
reach  the  lower  end  of  the  rectum  distended  by  meconium.  The  edges  of  the 
bowel  should  be  fixed  to  the  external  opening,  and  the  mother  should  be 
instructed  to  pass  her  little  finger  daily  into  this  opening,  so  as  to  prevent 
contraction. 

In  some  cases,  ow  ing  to  deficiency  of  the  rectum,  no  fulness  can  be  felt, 
and  the  bowel  cannot  be  reached  through  an  anal  incision,  even  though  a  deep 
exploration  be  made.  In  such  patients  the  abdomen  should  be  opened  in  the 
left  groin,  as  in  inguinal  colostomy,  and  the  end  of  the  bowel  searched  for. 
Sometimes  the  sigmoid  flexure  is  absent,  and  other  portions  of  the  large  bowel 
must  be  secured  and  brouo;ht  to  the  abdominal  wound.  Some  surgeons,  when 
the  bowel  cannot  be  reached  thi'oun;h  the  anal  region,  advocate  leaving  the  case 
alone,  saying  that  a  child  is  better  dead  than  with  a  false  anus  in  the  groin, 
but  the  fact  remains  that  individuals  have  grown  to  full  maturity  in  comfort 
with  such  openings,  and  have  even  married  and  lived  to  an  advanced  age. 

Operation  is  especially  necessary  when  the  bowel  ends  in  the  urethra  or 
vagina,  for  here  the  bowel  usually  terminates  in  a  narrow  canal  and  cannot 
be  reached  from  the  perineum.  These  cases,  if  left  alone,  do  not  die  in  three 
or  four  days,  as  do  the  others  described  above,  but  live  on  very  uncomfortably, 


Imperforate  Rectum  (Holmes). 


792  AN   AMERICAN    TEXT- BOOK    OF   SURGERY. 

j)assing  feces  through  tlie  urethra  ami  vagina.  In  such  cases  inguinal  colos- 
touiv  is  a  very  necessary  operation,  and  one  which  gives  great  relief  to  the 
little  patient. 

Mode  of  Examining  the  Anus  and  the  Rectum. — In  all  cases  of  ordinary 
external  examination  the  patient  should  lie  on  the  side  or  hend  over  the  back 
of  a  chair ;  of  course,  previous  to  the  inspection  the  lower  bowel  should  have 
been  washed  out  with  an  enema.  In  some  cases  where  the  anus  is  deeply  sit- 
uated, placing  the  patient  in  the  position  assumed  when  at  stool  will  cause  some 
]>r«)lapse  of  the  mucous  membrane,  and  thus  hemorrhoids,  polypi,  and  fissures 
can  easily  l>e  diagnosticated.  For  ordinary  purposes  of  examination,  the 
fin^rer  well  covered  w ith  vaseline  is  the  most  valuable  instrument ;  it  should 
be  slowly  and  cautiously  insertetl,  and  any  tumors,  indurations,  or  internal 
o])e!iings  of  fistulse  should  be  felt  for.  Malignant  and  other  ulcerations 
of  the  lower  three  or  four  inches  can  be  made  out,  especially  if  the  patient 
strains  whilst  in  the  squatting  position.      Strictures  can  also  be  felt.      For  a 

Fig.  .325. 


Kelly's  Urethral  Specula. 

liigher  and  more  thorough  examination  other  means  are  required,  such  as 
soft,  flexible  bougies  and  specula.  In  any  case  of  doubt  the  ])atient  should  be 
placed  under  other,  the  sphincter  should  be  forcibly  dilated,  and  then  a  com- 
plete and  thorough  examination  made.  For  purposes  of  high  exploration 
Kelly  of  Baltimore  has  devised  a  series  of  cylindrical  specula  of  various 
lengths  (Fig.  325).  The  examination  is  made  with  reflected  light,  the  patient 
being  in  the  knee-chest  po.«ition.  Anesthesia  is  not  always  necessary.  "The 
patient  kneels  on  an  ordinary  kitchen  table,  with  the  elbows  spread  out  at 
the  sides  so  as  to  bring  the  chest  as  close  to  the  table  as  possible,  while  the 
thighs  are  perpendicular  to  it,  supporting  the  pelvis  as  high  as  possible  "  (see 
Fig.  326).  A  number  of  specula  of  different  sizes  and  lengths  are  used,  the 
one  for  diagnosis  of  the  sigmoid  flexure  being  as  much  as  14  inches  long  and 
1^  of  an  inch  in  diameter.  Each  speculum  is  provided  with  a  blunt  obturator 
with  a  stout  handle ;  before  introduction  the  speculum  is  well  coated  with 
vaseline.  "  The  buttocks  are  drawn  apart  and  the  blunt  end  of  the  obturator 
is  laid  on  the  anus,  which  is  also  coated  with  vaseline.     The  direction  of  the 


DISEASES  AND    INJURIES    OF    THE  ABDOMEN. 


793 


instrument  should  be  Hrst  downward  and  forward,  and,  wlicn  tlic  splnnctcr  is 
well  passed,  up  under  the  sacral  promontory.  The  moment  the  speculum 
clears  the  sphincter  ani  and  the  obturator  is  withdrawn  air  rushes  in  audibly 
and  distends  the  bowel."  Kelly  has  introduced  the  longest  instrument  as 
much  as  12  inches,  and  has  diagnosticated  stricture  ^  inches  up;  owing 
to  the  distention  of  the  rectum  with  air  the  mucosa  is  plainly  seen  and  the 
valves  recognizable.  By  moving  the  instrument  about  m  various  directions 
the  condition  of  the  different  parts  can  be  easily  made  out  •  il  feces  interfere 
with  the  view,  they  can  be  removed  with  a  special  scoop,  l^or  inspection  of 
the  lower  end  of  the  rectum  a  short  (4  cm.),  stout  speculum  is  used  (sphincter- 
oscope)  After  introduction  and  removal  of  the  obturator  by  slowly  withdraw- 
ing and  pushing  back  a  little  the  whole  sphincter  area  is  brought  into  view. 

Fin.  326. 


Examination  of  the  Rectum  by  Reflected  Liglit  (Kelly) 


Hemorrhoids,  or  Piles.— These  may  be  defined  as  tumors  which  are 
composed  chiefly  of  varicose  or  dilated  veins  of  the  lower  end  of  the  rectum, 
surrounded  by  infiltrated  connective  tissue.    Fig.  327  shows  the  rectal  veins. 

Causes.— The  chief  predisposing  causes  of  piles  are  man's  erect  position 
and  the  absence  of  valves  in  the  hemorrhoidal  veins.  Heredity  also  influences 
their  formation,  as  it  does  that  of  varicose  veins  elsewhere.  Pregnancy  and 
anything  which  obstructs  the  portal  circulation  predispose  to  piles,  as  do  also 
sedentarv  habits,  over-eating,  over-drinking  of  alcoholic  liquors,  the  excessive 
use  of  purgatives,  and,  lastly,  constipation,  which  is  nearly  always  the  exciting 
cause  of  an  attack.  Piles  are  almost  as  common  in  women  as  m  men,  and  are 
oftenest  seen  in  middle  life.  They  rarely  occur  before  puberty,  though  cases 
occurring  in  infants  and  young  children  are  reported.  Piles  are  usually 
divided  Into  external  or  blind  piles,  and  internal  or  bleeding  piles. 


794 


^l.V  AMERICAN  TEXT-BOOK  OF  SlUCEIiY. 


External  Piles. — The  external  are  subdivided  into  venous  and  ciitaneons. 

renous  Piles. — These  are  due  to  a  varicose  condition  of  the  external 
hemorrhoidal  veins.  They  appear  about  the  margin  of  the  anus  as  bliiisli, 
soft,  round  tumors  which,  by  pressure,  can  be  easily  emptied  of  the  contained 
blood.  When  thrombosed  and  intliuned  they  are  filled  with  blood-clot  iind 
become  hard,  tense,  and  extremely  painful,  causing  often  much  constitutional 
disturbance.  There  is  a  great  deal  of  tenesmus  and  a  feeling  as  if  a  foreign 
body  were  in  the  rectum.     Defecation  causes  severe  suffering. 

Cutaneous  Piles. — These  are  often  a  sequence  of  the  venous  pile,  frequent 
inflammations  producing  hyperplasia  of  the  connective  tissue  around  the 
dilated  veins,  and  thus  small  tags  or  tumors  are  formed,  which,  in  some  cases. 


VH}f 


VIIM 


VHE- 


Eectal  veins  seen  from  without ;  Amp,  rectal  pouch  or  ampulla;  P,  skin  at  margin  i>i  anus  reflected; 
SE,  external  sphincter  ;  VHE,  external  or  inferior  hemorrhoidal  vein ;  VUI,  internal  or  superior 
hemorrhoidal  vein;  VHM,  middle  hemorrhoidal  vein  (Dnret). 

are  pedunculated.  In  other  cases,  however,  the  cutaneous  pile  consists  of  a 
hypertrophied  fold  of  skin  about  the  anus,  which  Avhen  inflamed  becomes 
(Edematous,  infiltrated,  and  acutely  painful. 

External  piles  when  quiescent  give  but  little  trouble,  but  when  inflamed 
they  are  excessively  sensitive  and  cause  much  malaise  in  the  most  robust. 
Suppuration  occasionally  supervenes,  but  usually  the  inflammation  subsides  in 
a  few  days,  and  the  pile  remains  as  a  somewhat  larger  tag  of  skin.  Associated 
vrith  external  piles  is  not  infrequently  seen  a  fissure  or  eczema  of  the  anus. 
External  piles  rarely  if  ever  bleed. 

Treatment. — Palliative  treatment  is  unsatisfactory,  yet  when  patients 
refuse  operative  treatment  it  must  be  undertaken.     It  is  most  important  to 


DISEASES   AM)    lyjl'lilES    OF    THE   AJiDOMFN.  795 

overcome  the  constipation  which  usually  coexists,  and  this  may  he  done  by 
the  administration  of  confection  of  senna  and  sulphur,  the  compound  liquorice 
powder,  cascara,  or  other  laxative.  Usually,  to  relieve  pain  an  application  of 
equal  parts  of  the  extracts  of  belladonna  and  opium,  or  belladonna  and  ;^lyce- 
rin,  may  be  made  to  the  part,  and  then  a  hot  fomentation  applied.  If  the  in- 
flammation is  very  severe,  leeches  often  do  good. 

Operative  Treatment. — For  the  venous  pile  immediate  relief  may  be 
obtained  by  incising  the  tumor  and  turning  out  the  contained  clot,  and  then 
dusting  the  parts  with  iodoform.  Before  making  the  incision  the  part  should 
be  painted  over  with  an  8  or  10  per  cent,  solution  of  cocaine.  A  very  small 
bit  of  cotton  should  be  placed  betAveen  the  lips  of  the  Avound  if  the  pile  be 
of  any  size.  The  patient  should  be  kept  in  bed  for  a  day  after  the  incision, 
lest  there  be  subsequent  hemorrhage.  For  the  cutaneous  pile  there  is  no  rem- 
edy so  efficacious  as  excision,  even  when  the  pile  is  inflamed  and  oedematous ; 
there  is  no  bleeding  Avhich  is  not  easily  controlled  by  pressure  ;  some  advise 
excision  by  dissection  and  afterward  sewing  up  the  skin.  If  the  ulcer  left 
does  not  granulate  rapidly,  it  may  be  stimulated  by  balsam  of  Peru  or  the 
local  application  of  sulphate  of  copper.  The  bowels  should  be  confined  for  a 
day  or  tAvo  and  the  patient  kept  in  bed.  The  wound  should  be  dusted  with 
iodoform.  In  cutting  away  cutaneous  piles  care  should  be  taken  not  to  cut 
into  the  anus,  for  stricture  may  follow  too  free  excision. 

Internal  or  Bleeding  Piles  are  situated  Avithin  the  sphincter,  and  are 
much  moi'e  serious  and  troublesome  than  the  external.  They  are  conveniently 
divided  into  venous,  columnar,  and  ncevoid  (Ball).  ^\iQ  internal  ve7i02is  pile 
resembles  the  external  one,  except  that  it  is  covered  with  mucous  membrane 
instead  of  skin,  and  tends  to  bleed  easily,  especially  during  defecation.  This 
form  is  often  seen  in  people  with  cirrhotic  livers,  in  spirit-drinkers,  and  in 
women  who  have  borne  many  children. 

The  Columnar  Pile  is  commoner  than  the  venous,  and  "  consists  essentially 
of  hypertrophy  of  folds  of  mucous  membrane  surrounding  the  anal  opening, 
the  so-called  pillars  of  Glisson.  They  have  a  red,  almost  vermilion  color, 
elongated  form,  and  contain  within  them  one  of  the  descending  parallel  branches 
of  the  superior  hemorrhoidal  artery"  (Hamilton).  In  these  piles  the  arteries 
can  be  frequently  felt  pulsating. 

The  Ncevoid  Piles,  or  capillary  hemorrhoids,  are  small,  bright-red  tumors 
having  a  spongy,  granular  look,  situated  high  up  in  the  rectum.  They  are 
rarely  larger  than  a  ten-cent  piece,  and  bleed  very  easily ;  in  fact,  the  loss  of 
blood  is  continuous  and  is  a  serious  drain  on  the  system.  They  are  composed 
of  hypertrophied  connective  tissue,  plentifully  supplied  with  both  arteries  and 
veins,  Avhich  become  thrombosed  when  the  pile  is  inflamed.  In  fact,  the  blood- 
vessels are  so  numerous  that  they  look  like  ncevoid  groAvths. 

Symptoms. — Of  course  the  symptom  Avhich  most  attracts  the  attention 
of  the  patient  is  the  frequent  and  sometimes  constant  bleeding,  Avhicli  is  much 
increased  by  defecation.  Hence  the  name  bleeding  piles.  At  first  the  patient 
loses  blood  at  stool  only ;  then  for  some  time  before  and  after.  Later  the 
bleeding  may  occur  at  any  time,  exhausting  the  patient,  and  sometimes  pro- 
ducing extreme  anemia.  During  defecation  there  is  usually  considerable  pain, 
or  rather  discomfort,  and  the  piles  have  a  tendency  to  protrude,  dragging  with 
them  the  boAvel  and  causing  prolapse.  -Occasionally  the  pile  tumors  remain 
protruded  so  long  that  they  become  strangulated,  being  caught  by  the  sphinc- 
ter, or  they  may  inflame  and  become  so  congested  that  their  great  size  prevents 
their  return.  The  pain  in  these  cases  is  excessively  great.  If  left  to  them- 
selves, they  sometimes  become  gangrenous  and  slough  off.  thus  producing  a  nat- 


796  AN   AMi:i!l(\{N    TKXT-JiOOK    OF  SURGERY. 

unil  cure  of  the  disease,  though  often  not  a  complete  one.  In  such  cases,  if  the 
consent  of  the  patient  can  be  obtained,  it  is  better  at  once  to  proceed  to  the 
radical  cure  by  operation.  The  irritation  of  inflamed  internal  piles  not  unfre- 
(juently  produces  urinary  disturbance  and  even  retention.  In  women  these 
piles  are  often  the  accompaniment  of  womb  disease.  If  there  be  excessive 
pain  during  and  after  defecation,  an  examination  will  probably  reveal  a  fissure 
of  the  anus.     Small  i)olypi  also  are  sometimes  seen  in  cases  of  hemorrhoids. 

Treatment  of  Internal  Piles. — Palliative  treatment  in  the  milder  forms 
of  piles  is  sometimes  successful,  but  in  the  severer  forms,  especially  where  there 
is  much  bleeding,  nothing  but  a  radical  operation  will  afford  permanent  relief. 
The  patient  slujuld  above  all  things  avoid  constipation.  His  bowels  should  be 
kept  regular  by  laxatives,  such  as  the  compound  licjuorice  powder,  confection 
of  senna  and  sulphur,  a  pill  of  aloes  (gr.  1|),  belladonna  (gr.  \)^  nux  vomica 
(gr.  1^),  aided  by  an  enema  or  some  mineral  water  in  the  morning.  Next,  the 
patient  should  wash  and  grease  the  protruded  piles  after  defecation,  and  then 
carefully  return  them  by  gentle  pressure.  Regular  exercise  sliould  be  taken, 
and  over-eating  should  be  avoided ;  alcoholic  liquors  should  be  given  up.  The 
piles  may  occasionally  be  anointed  with  some  astringent  ointment,  such  as  the 
unguentum  gallae  comp. 

Operative  Treatment. — The  two  chief  methods  of  radically  curing  piles  are 
by  the  ligature  and  by  the  clamp  and  cautery. 

Before  any  operation  for  the  radical  cure  of  piles  the  patient  should  be  pre- 
pared by  the  administration  of  a  brisk  purgative  the  evening  previous  to  the  ope- 
ration, and  immediately  before  the  operation  the  rectum  should  be  well  washed 
out  with  two  or  three  large  soap-and-water  enemata.  After  an  anesthetic  has 
been  administered  the  sphincter  should  be  stretched  by  the  introduction  of  both 
thumbs,  and  the  tension  should  be  kept  up  until  the  muscle  is  felt  to  give  way. 
By  this  means  the  rectum  can  be  easily  explored  and  the  whole  diseased  area 
brought  into  view ;  in  addition,  there  is  much  less  pain  after  operation.  This 
procedure  also  enables  the  surgeon  immediately  to  recognize  the  occurrence  of 
hemorrhage  after  operation,  for  all  the  blood  flows  externally  instead  of  being 
confined  by  the  spasmodically  contracted  sphincter,  as  it  would  be  if  the 
muscle  were  not  stretched.  The  patient  should  be  placed  during  operation  in 
the  lithotomy  position,  the  knees  being  kept  apart  by  Clover's  crutch  or  other 
means ;  or  on  the  side  with  the  thigh  drawn  up. 

Ligature. — Each  pile  should  be  seized  with  a  small  volsellum  forceps, 
drawn  down,  and  separated  from  the  submucous  and  muscular  tissue  from 
below  with  scissors.  As  the  vessels  enter  the  pile  from  above,  there  is  no 
danger  in  separating  the  lower  end  of  the  pile.  The  pedicle  should  now  be 
tied  tightly  with  a  strong  silk  ligature  :  that  there  may  be  no  danger  of  the  knot 
slipping,  three  half  hitches  should  be  employed  instead  of  the  usual  two.  The 
ligature  should  be  cut  off  short,  and  also  the  pile  beyond  the  ligature,  enough 
being  left  to  prevent  the  knot  from  slipping.  It  is  better  to  tie  the  piles  from 
below  up.  In  the  columnar  pile  it  may  be  necessary  to  transfix  the  base  with 
a  curved  needle  on  a  needle-holder  armed  with  a  double  thread,  and  then  the 
muco-cutaneous  border  around  the  base  of  the  pile  should  be  incised,  the  pile 
tied  in  two  halves,  and  the  superfluous  portion  cut  off. 

Clamp  and  Cautery. — The  patient  having  been  prepared  as  descri])ed 
above,  each  pile  is  seized  in  a  volsellum,  brought  down,  and  clamped  tightly 
with  one  of  the  numerous  clamps,  such  as  Smith's,  Lee's,  Yolkmann's,  etc. 
Smith's  clamp  without  the  ivory  plates  is  as  good  as  any.  The  pile  should 
now  be  cut  off  about  an  eighth  of  an  inch  in  front  of  the  clamp,  and  the  cut 
surface  slowly  cauterized  several  times  with  a  Paquelin  cautery  heated  to  a 


DISEASES   AM)    IXJURIES    OE    THE   ABDOMEN.  797 

dull-red  heat.  The  clamp  should  then  bo  relaxed  slightly,  and  if  there  is  any 
bleedincr  the  pile  should  again  be  cauterized.  The  old-fashioned  cautery, 
althou.rh  more  troublesome,  is  quite  as  good  as,  if  not  better  than,  Paquelin  s. 
Some  dispense  Avith  the  cutting  of  the  pile  by  scissors,  preferring  to  trim  it  off 
with  the  cautery.  After  both  the  above-described  operations  the  parts  should 
be  washed  thoroughly  with  an  antiseptic  solution,  then  dusted  with  iodoform 
and  a  morphia  siTppository  introduced.  Absorbent  cotton  should  be  placed 
over  the  perineum  and  kept  in  place  with  a  T  bandage. 

After-treatment— Miex  pile  operations  it  is  necessary  to  confine  the  bowels 
for  a  few  days,  and  this  may  most  easily  be  done  by  giving  a  gram  of  opium 
two  or  three*^  times  a  day.  Bv  this  means  also  the  pam  is  controlled.  Un  the 
third  mornin^^  the  patient  should  have  a  dose  of  castor  oil,  and  after  that  a 
daily  movement  of  the  bowels.  There  is  often  difficulty  in  urination  after 
operations  for  piles.  This  may  be  overcome  by  applying  hot  fomentations 
over  the  lower  part  of  the  abdomen  and  by  encouraging  the  patient  to  make 
a  i^reat  effort  to  urinate.  If  retention  does  occur,  a  catheter  may  have  to  be 
used  for  a  few  days.  Operation  for  piles  by  ligature  or  cautery  is  very  sate, 
the  mortality  being  very  slight  indeed.  i     •     i   r-      .-u 

Other  operations  than  those  above  mentioned  have  been  devised  tor  the 
cure  of  piles.  Excision  of  the  piles  has  been  extensively  practised  by  Mr. 
Whitehead  of  Leeds,  England. 

Wldtehead's  Operation.— l^he  whole  circumference  of  the  mucous  mem- 
brane of  the  bowel  is  divided  at  the  muco-cutaneous  junction ;  the  mucous 
membrane  bearincr  the  hemorrhoidal  tumors  is  dissected  from  the  muscular  coat 
and  brought  do^^  below  the  margins  of  the  anus.  The  mucous  membrane 
above  the^iles  is  then  divided  transversely  and  attached  by  sutures  to  the  tree 
maro-in  of  the  skin  below.  In  this  way  the  whole  hemorrhoidal  area  is  got  rid 
of  ^The  objections  to  the  operation  are  that  it  is  tedious,  bloody,  and  apt^to 
cause  stricture  if  one  does  not  get  union  by  first  intention ;  m  fact,  it  has  few 
advantages  over  the  ligature  or  the  clamp  and  cautery.  • .  /i     im 

Treatment  by  ignipuncture,  crushing,  the  injection  of  carbolic  acid  (1 :  lU), 
all  have  their  advocates,  but  none  of  these  methods  has  given  as  satisfactory 
results  as  the  two  first  described,  viz.  ligature  and  the  clamp  and  cautery. 

Prolapsus— This  is  a  descent  or  a  protrusion  of  the  mucous  membrane 
of  the  bowel  only  (prolapsus  ani).  or  of  the  whole  thickness  of  the  bowel, 
throucrh  the  Sinus\proIapsus  recti)  (Fig.  328).  When  the  whole  bowel  pro- 
trude? the  tumor  may  reach  the  length  of  five  or  six  inches.  It  is  a  rare 
affection  in  adults,  but  is  comparatively  common  m  children,  and  it  is  usually 
seen  in  those  of  slight  resisting  power  and  of  relaxed  fiber.  Anything 
which  causes  straining  at  stool  will  produce  it,  such  as  constipation,  phimo- 
sis, stone  in  the  bladder,  polypi,  irritation  from  worms,  etc.  in  elderly 
people  it  frequently  accompanies  hemorrhoids,  enlarged  prostate,  etc 

Treatment—In  children  the  cause  should  be  removed  if  possible,  and 
the  general  condition  improved  by  iron,  tonics,  and  cod-liver  oil,  which  will 
help  to  keep  the  bowels  regular.  The  stools  should  be  passed  with  the 
child  Ivincr  on  its  side,  and  when  the  bowels  protrude  they  should  be^ gently 
pushed  bJck  and  kept  in  place  with  a  bandage.  Broad  strips  of  adhe- 
sive plaster,  applied  so  as  to  keep  the  buttocks  together,  are  usef^il  m  young 
children.  In  sime  cases  touching  the  protruded  bowel  m  several  longitudinal 
strips  with  a  solid  stick  of  nitrate  of  silver  or  with  nitric  acid  is  beneficial 
In  adults  palliative  treatment  is  not  so  successful,  and  operation  is  frequently 
demanded  Many  operations  have  been  devised  for  the  relief  of  prolapse  of 
the  rectum.      Some  still  believe  the  cautery  is  the  best  method  of  treatment. 


71>8 


j.v  AMi:i!i(A.\   ri:xr-i'>()()K  of  sri.'ai.m' 


Crijips  says  four  linos  of  (.-iiutery  a  (juarterof  an  inch  wide  sliouM  bi"  (|iiic'kly 
drawn  in  the  h)ng  axis  of  the  bowel  at  eijual  distances;   then  the  bowel  is 


Fu;.  328. 


Prolapsus  Ilt'cti  (oriifiiial). 


returned  and  a  tube  introduced  some  five  or  six  inches.  This  is  packed  around 
with  cotton  wool  and  iodoform.  The  bowels  should  be  confined  by  opium  for 
ten  days,  and  for  at  least  six  weeks  the  patient  should  pass  his  motions  lying 
on  his  side.  In  using  the  cautery  the  old-fashioned  cautery-iron  is  better  than 
Paquelin's,  as  it  does  not  cool  so  quickly.  In  the  most  inveterate  cases  a 
V-shaped  piece  has,  with  good  result,  been  excised  from  the  sphincter  and  the 
edges  of  the  wound  brought  tog-ether.  Roberts  advocates  the  excision  of 
V-shaped  portions  of  the  sphincter  and  the  entire  posterior  wall  of  the  rectum, 
having  a  common  base  at  the  back  of  the  anal  opening.  Treves  excises  the 
protruded  mucous  membrane  and  attaches  the  cut  mucous  mem])rane  to  the 
skin.  The  sphincter  is  not  divided.  The  removal  of  several  of  the  vertical 
folds  ])y  clamp  and  cautery  is  an  operation  which  is  often  successful  When 
the  patient  refuses  operation  he  should  be  directed  to  inject  5vij-viij  of  warm 
water  into  the  bowel  before  going  to  the  closet,  and  after  the  motion  has  passed 
an  ounce  of  cold  water  should  be  introduced  and  allowed  to  remain. 

To  reduce  a  prolapsus  the  patient  should  be  placed  on  his  side;  the  tumor 
should  be  well  oiled,  and  then  pressed  back  gently  Avith  a  soft  towel,  or,  if  this 
fail,  the  finger  may  be  covered  with  lint  and  introduced  into  the  bowel,  gently 
pressing  up  the  tumor ;  the  finger  can  then  be  withdrawn  and  the  lint  left 
behind.  Occasionally  the  tumor,  if  allowed  to  remain  out  for  any  time,  becomes 
strangulated  and  gangrenous,  and  finally  sloughs  off,  the  affection  thus  under- 
going a  spontaneous  cure. 

Sphincterismus,  or  spasm  of  the  sphincter,  is  nearly  always  avssociated  with 
ulcer  or  fissure  of  the  rectum  or  an  inflammation  of  some  neighboring  organ,  as 
the  prostate,  bladder,  etc.  In  some  very  rare  cases  there  is  no  discoverable 
lesion.  It  is  attended  by  considerable  pain,  and  is  liable  to  occur  in  women 
who  are  hysterical.  If  due  to  fissure  or  ulcer  this  must  be  first  treated. 
Sometimes  in  hysterical  cases  a  suppository  of  belladonna  (gr.  j  of  extract) 


DISILiSI'JS   AX  J)    IXJllilES    OF    THE   ABDOMEN.  71)5) 

and  the  luhiiinistration  of  eneinatii  Avill  leuiovo  tho  spasm,  bvit  should  these 
means  fail,  forcible  dilatation  of  the  sphincter  with  the  surgeon's  fingers,  under 
ether,  will  surely  cure. 

Pruritus,  or  painful  itching  of  the  anus,  is  a  most  troublesome  affection, 
and  due  to  many  causes,  such  as  thread-worms  (oxyuris  vermicularis),  pediculi, 
scabies,  eczema,  small  external  piles,  etc.  In  some  cases  it  is  a  pure  neurosis, 
and  there  is  no  local  inflammation  to  be  made  out,  the  skin  about  the  anus 
having  a  dead-white,  parchment-like  look.  These  cases  are  the  most  difficult 
to  treat. 

The  irritation  usually  is  worse  at  night  after  the  patient  gets  warm  in  bed, 
and  then  the  itching  is  intolerable.  Nervous  patients  who  give  way  to 
scratching  often  produce  an  eczema  or  excoriate  the  whole  anus  and  its  neigh- 
borhood. Many  patients  who  suffer  from  this  troublesome  affection  are  of  a 
gouty  diathesis. 

Treatment. — If  due  to  thread-worms  or  eczema,  these  should  be  treated. 
The  eczema  may  be  moist  or  dry.  If  moist,  soothing  applications,  such  as 
liquor  plumbi  (1 :  40),  linimentum  calcis,  etc.,  should  be  employed,  but  if  dry, 
then  some  preparation  of  tar,  such  as  liquor  carbonis  detergens,  oil  of  cade, 
etc.  It  is  a  very  important  thing  to  keep  the  buttocks  apart,  and  this  may  be 
done  by  a  pledget  of  marine  lint  (fine  oakum),  the  tar  with  which  it  is  impreg- 
nated acting  remarkably  well  as  a  local  application.  To  get  rid  of  the  thread- 
worms, cold  water  may  be  injected  into  the  rectum,  or  salt  and  water,  or  infusion 
of  quassia,  but  it  must  be  remembered  that  these  parasites  live  chiefly  in  the 
caecum,  and  that  removing  them  from  the  rectum  is  a  temporary  measure,  as 
they  will  soon  reappear.     Purgatives  often  prove  useful. 

The  neurotic  cases  are  usually  elderly  persons  and  the  most  difficult  to  treat. 
First,  the  patient  should  avoid  scratching  and  should  keep  the  bowels  regular ; 
should  abstain  from  alcoholic  liquors  and  smoking,  especially  cigar-smoking; 
should  live  plainly  and  on  a  non-gouty  diet.  Marine  lint  locally  applied  is 
useful,  and  in  some  cases  a  mercurial  ointment,  as  the  dilute  citrine,  oleate  of 
mercury,  etc.  Bathing  in  very  hot  or  cold  water  or  in  solutions  of  cocaine 
sometimes  relieves.  Painting  the  part  with  iodine  or  nitrate  of  silver  may  be 
tried.  In  some  cases,  however,  nothing  seems  to  benefit.  The  actual  cautery 
has  been  used  and  the  sphincter  has  been  stretched  with  good  result,  but  it  is 
very  common  to  find  that  what  will  relieve  one  patient  will  have  no  influence 
on  another. 

Foreign  Bodies. — These  are  not  infrequently  introduced  into  the  rectum 
to  arrest  a  diarrhea  or  from  perverted  sexual  impulse  or  by  the  insane.  A 
great  variety  of  these  foreign  bodies  have  been  removed  from  the  rectum — 
jam-pots,  stones,  pieces  of  wood,  soap,  nails,  bottles,  etc.  Sometimes  foreign 
bodies,  such  as  fish-bones,  chicken-bones,  etc.,  that  have  successfully  passed 
through  the  rest  of  the  alimentary  canal  become  arrested  in  the  rectum. 
These  may  form  the  nucleus  of  concretions.  It  may  severely  tax  the  inge- 
nuity of  the  surgeon  to  extract  such  foreign  bodies.  If  the  body  be  small, 
it  may  be  removed  with  forceps  or  thumb  and  finger;  if  larger,  the  patient 
should  be  placed  under  ether,  and,  after  thoroughly  dilating  the  sphincter, 
the  body  should  be  extracted. 

Wounds. — These  are  sometimes  produced  by  the  rough  use  of  an  enema 
syringe  or  the  careless  introduction  of  a  bougie,  and  cases  are  recorded  where 
perforation  of  the  bowel  and  entrance  into  the  peritoneal  cavity  have  occurred 
and  death  from  peritonitis  has  followed.  Wounds  caused  by  falling  on  sharp  in- 
struments may  perforate  the  rectum  and  bladder.  Punctured  wounds  are  much 
more  likelv  to  lead  to  septic  complications  than  free  incised  wounds  where  thei-e 


«UU  A^y   AMKIIIVAN    TKXT-JKJOK    OF  SllidKltY. 

is  "00(1  tlraiua«a'.  Tlie  rectuin  may  be  iiijiiicil  (Imiiii:  parturition  and  the  recto- 
vaginal septum  completely  torn  through.  Gunsiiot  wounds  of  the  rectum  and 
bladder  may  occur  and  yet  the  patient  recover,  but  if  the  peritoneum  be  per- 
forated the  chance  of  recovery  is  not  so  great.  In  gunshot  wounds  pieces  of 
bone  may  be  lodged  in  the  rectum.  Wounds  of  the  rectum  nuiy  occur  during 
an  operation  for  stone,  and  if  discovered  should  be  sutured  innnediately. 

In  the  treatment  of  wounds  of  the  rectum  free  draituuje  should  be 
obtained,  even  if  the  wound  has  to  be  made  larger.  This,  with  frequent 
irrii^ation  with  antiseptic  solutions  and  antiseptic  dressings  retained  by  a 
T-bandage,  ought  to  be  sufficient.  (For  the  treatment  of  puerperal  lacerations 
see  the  chapter  on  the  Female  Genito-urinary  Organs.) 

IiM FACTION  OF  Fkchs. — This  most  frequently  occurs  in  elderly  people  of 
sedentary  habits  who  have  been  the  victims  of  habitual  constipation.  In  them 
the  rectum  above  the  sphincter  is  dilated  into  a  pouch  in  which  feces  collect 
and  become  a  hard,  solid  mass  which  the  bowel  is  unable  to  expel.  The 
patient,  of  course,  complains  of  constipation,  distention,  pain,  etc.,  and  the 
presence  of  the  mass  of  feces  produces  sufficient  irritation  to  cause  a  spurious 
or  catarrhal  diarrhea.  In  some  cases  acute  obstruction  supervenes,  with  vomit- 
ing and  symptoms  of  collapse.  On  attempting  to  administer  an  enema  it  is 
found  that  but  a  small  quantity  of  fluid  can  be  injected,  and  the  introduction 
of  the  finger  reveals  the  bowel  packed  with  feces.  The  fecal  mass  should  be 
removed  with  the  handle  of  a  large  spoon  or  a  lithotomy  forceps,  aided  by 
copious  injections  of  hot  water  and  soapsuds.  Many  of  these  cases  when 
not  examined  have  been  treated  as  cases  of  diarrhea,  with  the  result  of  aggra- 
vating the  condition  of  the  patient. 

Fissure,  or  Anal  Ulcer. — This  is  a  most  painful  and  troublesome  affec- 
tion, which  must  not  be  confounded  with  the  larger  ulcerations  occurring  in 
the  bowel.  It  commences  first  as  a  mere  excoriation  or  crack  of  the  mucous 
membrane,  produced  by  the  passage  of  a  large,  hard  motion.  This  exposes 
some  of  the  nerve-filaments  of  the  anus,  and  every  motion  increases  the  pain 
and  irritation  until  an  ulcer  is  formed  which  will  not  heal.  Fissure  is  always 
accompanied  by  severe  spasm  of  the  sphincter. 

The  symptoms  are  severe  pain  during  and  after  defecation,  with  the  dis- 
charge of  a  small  amount  of  blood.  The  patient  dreads  a  motion  of  the  bowels 
and  postpones  the  act  as  long  as  possible,  with  the  result  of  very  much  increas- 
ing the  pain,  which  is  out  of  all  proportion  to  the  amount  of  disease.  Fissure 
is  more  common  in  women  than  in  men,  and  women  frequently  refer  the  pain 
to  the  vagina  and  womb,  and  have  much  unnecessary  special  treatment  before 
the  cause  of  the  trouble  is  discovered.  On  examination  the  fissure  is  found  on 
the  posterior  border  of  the  anus,  marked  by  a  red  oedematous  fold  of  mucous 
membrane  which  looks  like  an  external  pile,  and  which  is  very  tender  on  pres- 
sure. On  separating  these  folds  about  the  anus  a  fissure  is  seen  leading  to  a 
rather  broad  elliptical  ulcer,  which  is  often  not  so  large  as  the  nail  of  the 
little  finger. 

Treatment. — If  the  case  is  a  recent  one,  it  may  possibly  be  cured  with- 
out operation.  The  bowels  should  be  opened  daily  with  a  mild  laxative,  and 
afterward  the  parts  should  be  well  washed  with  soap  and  water,  and  some  mer- 
curial ointment  applied,  such  as  the  ung.  hydrarg.  amnion,  chlor.  or  dilute 
citrine  ointment,*  etc.     The  ointment  should  be  spread  on  a  piece  of  lint  and 

'  Mr.  AUingham  recommends  the  following  ointment: 

Ilydntrfr.  ohlor.  mit.,  gr.  iv  ; 

Piilv.  o|'ii, 

Ext.  belladonna;,  ad  gr.  ij  ; 

Ung.  simpl.,  Sj* 


I)isi:ases  and  injuries  of  the  abdomen.       801 

carefully  inti-odiicod  into  the  amis,  'roucliing  the  ulcer  with  a  sharp-pointed 
stick  of  nitrate  of  silver  or  the  actual  cautery  is  excellent  practice,  but  is  so 
painful  that  the  previous  application  of  cocaine  is  necessary.  In  the  event 
of  the  milder  measures  not  being  successful,  the  surgeon  can  promise  a  speedy 
cure.  Placing  the  patient  under  ether,  the  ulcer  is  exposed  by  means  of  a 
speculum  and  is  incised  in  its  whole  length,  the  incision  reaching  well  into  the 
sphincter  and  partially  dividing  it.  Many  surgeons  strongly  recommend  dila- 
tation of  the  sphincter  under  ether  as  a  curative  measure,  a  procedure  which  is 
now  undertaken  before  performing  most  operations  on  the  rectum.  The  after- 
treatment  should  be  rest  in  bed,  Avith  opium  to  confine  the  bowels,  followed  by 
a  dose  of  castor  oil  on  the  third  day,  and  daily  evacuation  thereafter. 

Rectal  Abscess. — There  are  various  kinds  of  abscess  found  about  the 
rectum.  The  commonest  are  the  ischio-rectal  and  the  marginal.  We  may 
also  have  an  intramural  abscess  of  the  rectum  or  a  perirectal  abscess ;  these 
two  latter  give  rise  to  but  few  symptoms  except  fulness  and  weight,  and  are 
usually  first  discovered  by  the  exit  of  pus  through  the  anus. 

Ischio-rectal  Abscess  may  be  acute  or  chronic.  The  acute  variety  is 
attended  by  very  severe  pain  and  often  considerable  constitutional  disturbance- 
It  is  more  common  in  middle  life  in  people  who  are  run  down  in  health  ;  it 
may  follow  severe  illness.  It  is  felt  on  one  side  or  other  of  the  anus  as  a 
prominent,  hard,  brawny  mass,  having  as  it  softens  a  red  surface.  If  not 
opened  it  may  burst  externally  or  into  the  rectum. 

Chronic  Ischio-rectal  Abscess. — This  occurs  in  the  broken-down  and  debili- 
tated and  in  people  of  a  phthisical  diathesis.  It  commences  insidiously,  with- 
out much  if  any  pain,  and  the  pus  gradually  collects  and  presents  externally 
or  bursts  into  the  bowel.  It  sometimes  follows  kicks  and  blows,  or  it  may 
be  due  to  a  tubercular  or  carcinomatous  focus  in  the  rectum  which  ulcerates 
into  the  ischio-rectal  fossa. 

Treatment  of  Ischio-rectal  Abscess. — Early  and  free  incision  in  the 
acute  form  is  the  proper  treatment.  The  surgeon  should  operate  as  soon  as  the 
hardness  can  be  felt,  and  not  Avait  for  fluctuation,  which  rarely  appears.  The 
patient  should  be  etherized  and  an  incision  made  deeply  into  the  fossa.  The 
finger  or  a  sharp  spoon  should  be  introduced  and  all  the  loculi  should  be  broken 
down.  If  the  pus  has  burrowed  in  any  direction,  it  should  be  followed  by  free 
incision.  After  thoroughly  washing  out  the  cavity  with  sublimate  or  other 
solution,  it  should  be  stuffed  Avith  iodoform  gauze.  Some  recommend  dusting 
the  cavity  with  iodoform  and  introducing  a  large  drain.  Early  and  free  incis- 
ion will  prevent  in  most  cases  the  formation  of  a  fistula.  The  treatment  of  the 
chronic  variety  is  similar  to  that  of  the  acute,  free  incision  and  drainage. 

The  3Iarginal  Abscesses  usually  originate  from  a  suppurating  pile  or  an 
inflammation  of  one  of  the  anal  mucous  follicles,  due  possibly  to  some  foreign 
body,  as  a  fish-bone,  etc.  These  abscesses  are  often  attended  with  great  pain 
and  frequently  end  in  fistula.  Treatment  by  early  and  free  incision  under 
ether  spray  or  chloride-of-ethyl  spray  or  cocaine  is  ahvays  satisfactory. 

Fistula. — This  is  a  sinus  going  up  the  side  of  the  rectum,  and  having 
usually  tAvo  openings,  one  in  the  boAvel  and  one  in  the  skin,  and  is  the  result 
of  ischio-rectal  abscess.  When  a  fistula  folloAVS  an  anal  abscess,  it  is  not  a 
very  serious  matter,  the  extent  of  the  suppurating  tract  being  small  and  sub- 
cutaneous, and  the  internal  opening  superficial  to  the  sphincter  and  at  the 
ver2;e  of  the  anus.  The  more  severe  forms  of  fistula  are  altogether  outside 
the  sphincter,  the  internal  opening  being  half  an  inch  to  an  inch  and  a  half 
from  the  edge  of  the  anus — that  is,  either  between  the  external  and  internal 
sphincter  or  above  the  internal — and  the  external  opening  may  be  anywhere 

51 


802  AN  AMERICAN    TEXT-IiOOK    OF  SURGERY. 

in  the  neighboihood  of  the  :iii:il  ri'^fion  ;  usually  it  is  in  the  ischio-rcctal 
fossa.  There  may  be  several  external  openings,  and,  in  fact,  the  fistulous 
tract  may  burrow  in  all  directions ;  occasionally  a  fistulous  opening  is  seen  on 
each  side  of  the  gut.  The  more  severe  forms  of  fistula  with  sinuses  proceed- 
ing from  them  in  all  directions  are  not  infreciuently  connected  with  stricture 
of  the  gut.  In  some  cases  the  fistula  is  very  tortuous  and  will  not  readily 
admit  a  probe. 

The  usual  division  of  rectal  fistuhxi  is  into  Complete  and  Incoinvlete.  The 
incomplete  are  again  subdivided  into  Blind  External  and  Blind  Internal. 

Complete  Fistula. — This  is  the  most  common  form.  It  has  both  an 
external  and  an  internal  opening.  The  external  o])ening  is  usually  situated 
within  an  inch  of  the  anal  verge,  and  is  small ;  it  is  distinguished  by  a  little 
projecting  mass  of  granulation,  and  continually  discharges  a  thin,  purulent 
fluid.  The  internal  opening  is  generally  within  an  inch  of  the  margin  of  the 
anus,  most  frequently  immediately  above  the  sphincter,  and  from  this  opening 
a  sinus  may  extend  for  some  distance  up  the  bowel.  The  escape  of  fluid  feces 
and  flatus  through  a  complete  fistula  is  common,  and  the  patient  is  subject  to 
repeated  inflammatory  attacks  due  to  the  fistula  being  blocked  up  with  portions 
of  feces.  This  may  lead  to  suppuration  and  the  formation  of  new  external  o))en- 
ings.  The  internal  opening  may  be  on  the  opposite  side  from  the  external,  and 
the  sinus  may  almost  encircle  the  bowel  ("  horseshoe  fistula  ").  A  single  inter- 
nal opening  may  communicate  with  several  external  ones. 

Incomplete  Flstul.e  may  be  of  two  kinds,  internal  and  external.  When 
a  sinus  leads  up  to  the  bowel  from  an  external  opening  in  the  skin,  but  there 
is  no  opening  into  the  bowel,  it  is  called  a  blind  external  fistula.  When  there 
is  only  an  internal  opening,  but  no  opening  in  the  skin,  it  is  called  a  blind 
internal  fistula.  This  is  much  more  difiicult  to  diagnosticate  than  the  blind 
external.  A  blind  internal  fistula  may  be  suspected  when  the  patient  gives 
all  the  usual  symptoms  of  fissure  and  yet  no  fissure  can  be  found  (Kelsey). 
From  time  to  time  there  will  be  swelling  about  the  anus,  which,  after  a  dis- 
charge of  pus  from  the  bowel,  will  disapj)ear.  It  is  only  by  placing  the  ])atient 
under  ether,  stretching  the  sphincter,  and  carefully  examining  the  lower  three 
inches  of  the  bowel  with  a  speculum  that  the  aff"ection  can  be  satisfactorily 
detected.  If  the  sinus  is  of  any  size,  it  will  betray  it.self  by  induration,  and 
in  this  region  the  internal  orifice  should  be  searched  for. 

The  diagnosis  of  an  ordinary  complete  fistula  is  easy,  for  the  patient  is 
usually  already  under  the  care  of  the  surgeon  for  ischio-rectal  abscess,  or  con- 
sults him  for  some  of  the  secondary  attacks  of  suppuration  which  are  so  com- 
mon in   the  severe  forms  of  fistula. 

Symptoms. — Where  a  fistula  is  Avell  established,  it  may  give  rise  to  but 
little  trouble,  but  usually  there  are  some  tenesmus,  a  little  blood  in  the  stools, 
the  passage  of  flatus  and  pus  through  the  external  opening,  and  the  incon- 
venience and  discomfort  of  stained  linen.  With  fistula  is  often  associated  a 
condition  of  hypochondriasis.  To  examine  a  patient  with  fistula  he  should  be 
placed  on  the  side  on  which  the  disease  is  supposed  to  be,  the  buttocks  brought 
well  over  the  edge  of  the  examining  table  or  couch  ;  a  probe  should  now  be 
gently  introduced  into  the  external  opening,  and  without  force  pressed  onward 
till  it  reaches  the  internal  opening ;  now  the  finger  should  be  introduced  and 
the  probe  felt  in  the  bowel.  Should  one  attempt  to  ))ass  a  probe  with  the  finger 
in  the  bowel,  the  contraction  of  the  sphincter  would  much  distort  the  sinus 
and  make  the  passage  of  the  probe  difiicult.  Should  the  sinus  be  tortuous  or 
the  probe  not  pass  easily,  the  finger  may  be  introduced  to  feel  for  the  internal 
opening  and  the  indurated  track  leading  to  it. 


DISEASES  AXI>    INJURIES    OF    THE   ABDOMEN.  «03 

TrPatment-'Hie  evening  before  operation  the  patient's  bowels  should 

found,  01   t\^^\^^^^y^^3^^f;|,';fi,tula,  instead  of  being  cut  through  at  once  with 

no  unnecessary  sacrifice  ot  iieaitny  tissue. 

^""t:i,Lt:h:  ™:i;°fi£.f  crUas  .e^  Cssected  out  and  excsed^  the 

only  a  Lgle  straight  cut  should  be  made  through  the  sphmc  e.^     ^  -  a'-aJ^ 

"""ho  treatment  by  elastic  ligature  as  a  rule  should  be  advised  on^y  in  these 
cases  or  .here  the  patient  .ill  -t  subm>.  to  //-'^-^f ^  -^^.^X  L  tissue 
cutting  operat,on  .s  much  -P-j™- ,. -,  '°f;|,  rsho,ufbe  of  solid  India  rub- 
wtra'bouTr tenth    '^'^1^ in^diameter.  and  after  having  passed. 

^S- r  d^bSs:t:^:^^^^^^^-= — 

'"'phthis::?"ar;fi;tula  inanoare  not  ™f-<."»»'V-^reCr';:^Ti: 

operafon  m  these  ?f^'  '  "^  '^Xre      The  operation  should  be  followed  by  a 
rrouinrpfnt  o'SV  ^Xlus  track.     Unless  the  lung  trouble  is  very 


804  .l.V   AJfKRICAN    TEXr-BOOK    OF   SUlid i:i!  Y. 

result  of  abscess.  Wouinl  of  the  gut  during  the  ojieration  of  hiteral  lithotomy 
has  produced  this  form  of  fistula.  The  affection  can  be  easily  recognized  by 
the  fact  that  urine  is  continually  dribbling  through  the  anus,  causing  excori- 
ation and  giving  rise  to  an  off'ensive  urinous  odor.  When  the  o)»ening  between 
the  rectum  and  bladder  is  of  some  size,  as  occurs  in  cancerous  fistula?,  feres 
and  flatus  may  be  discharged  through  the  urethra  ;  in  such  cases  the  opening 
of  coinmunication  is  usually  high  up. 

Treatment. — In  cancerous  fistulae  curative  treatment  is  impossible :  all 
that  can  be  done  is  to  keep  the  parts  clean,  and  if  the  amount  of  feces 
escaping  into  the  bladder  be  large,  relief  may  be  obtained  by  the  performance 
of  colotomy.  In  fistula  from  other  causes,  if  small,  the  application  of  the 
thermo-cautery  may  prove  successful,  but  in  fistube  of  larger  size  the  edges 
should  be  freely  pared  and  brought  together  with  silkworm  gut  or  horse- 
hair sutures,  the  urine  being  drained  away  by  a  soft-rubber  catheter  intro- 
duced into  the  bladder.  In  recto-urethral  fistulce  an  old  method  of  treatment 
Avhich  is  often  successful  is  to  introduce  a  grooved  staff"  into  the  bladder  and 
cut  on  this  through  the  sphincter  ani,  commencing  the  incision  at  the  fistula. 
In  this  way  the  rectal  is  converted  into  a  perineal  fistula.  During  the  heal- 
ing process  the  bladder  should  be  drained  by  a  soft-rubber  catheter. 

Recto-vaginal  Fistula  and  its  treatment  are  described  elsewhere. 

Syphilitic  Ulceration. — This  usually  occurs  near  the  anus  during  the 
first  year  after  the  contraction  of  the  initial  lesion.  The  severer  forms  of 
ulceration  are  met  with  in  the  later  stages  of  the  disease,  and  are  due  to  the 
breaking  down  of  gummata.  This  form  is  most  intractable.  There  is  also  a 
form  of  ulceration  about  the  anus  in  inherited  syphilis  which  appears  three 
or  four  months  after  birth. 

Tubercular  Ulceration  may  occur  as  a  primary  lesion  or  be  secondary 
to  disease  in  other  parts.  It  is  often  very  extensive,  oval  in  shape,  with  ragged, 
undermined  edges.  The  long  axis  of  the  ulcer  is  parallel  to  that  of  the  bowel. 
It  not  infrequently  leads  to  the  formation  of  a  fistula.  Ulceration  is  occasion- 
ally seen  in  connection  with  hemorrhoidal  tumors.  Multiple  follicular  ulceration 
is  sometimes  seen,  and  in  old  people  with  chronic  venous  congestion  about  the 
lower  end  of  the  bowel  a  varicose  nicer  may  form.  Cancerous  ulceration  of 
the  bowel  has  already  been  fully  described.  Ulceration  following  true  epi- 
demic dysentery  is  seen  in  countries  Avhere  this  disease  occurs. 

Symptoms. — Ulceration  of  the  rectum  has  been  frequently  mistaken  for 
dysentery,  and  not  without  reason,  for  pain,  diarrhea,  and  discharge  of  bloody 
mucus  are  the  constant  accompaniments  of  ulceration  of  the  rectum.  There  is 
a  constant  desire  to  go  to  stool,  and  when  the  desire  is  satisfied  only  a  little 
bloody  mucus  is  the  result.  Ulceration  about  the  anus  is  much  more  painful 
than  ulceration  higher  up.  There  may  be  extensive  ulceration  high  up  without 
the  patient's  suffering  any  great  degree  of  pain.  The  diagnosis  is  to  be  made 
by  digital  examination  and  by  the  use  of  some  form  of  speculum.  Kelly's 
method  of  examination  is.  in  many  cases,  of  invaluable  assistance. 

Treatment  of  Ulceration  of  the  Rectum. — This  is  not  very  .satis- 
factory. The  earlier  forms  of  f<_i/i>Jiih'fi('  nicer  about  the  anus  usually  yield  to 
anti-syphilitic  treatment  and  the  application  of  some  form  of  mercurial  oint- 
ment. The  severer  forms,  which  are  more  common  in  women,  are  difljcult  to 
treat.  They  lead  to  a  form  of  inveterate  stricture,  and  the  only  relief  to  l;e 
obtained  is  either  by  excision  or  colostomy. 

Patients  the  subjects  of  tubercnlar  ulceration  should  be  treated  constitution- 
ally with  cod-liver  oil  and  nourishing  diet.  The  parts  about  the  ulcer  should 
be  kept  clean  by  washing  out  the  bowel  morning  and  evening  with  warm  water. 


DISEASES   A.XJ)    INJURIES    OF    THE   ABDOMEN.  805 

Occasional  injections  of  starch  f.lj)  and  tincture  of  opium  (iTlxx)  give  much 
relief.  When  the  ulceration  is  situated  low  down  and  there  is  much  spasm  of 
the  sphincter,  the  ulcer  should  be  incised. 

TUMORS  OF  THE  RECTUM. 

Polypus. — This  affection  is  not  very  rare  in  children.  It  frequently  gives 
rise  to  hemorrhage,  for  in  children  the  polypi  are  more  vascular  than  in  adults. 
Polypi  are  more  often  seen  in  patients  under  ten  years  of  age.  and  may  cause 
intussusception,  prolapsus,  and  hemorrhage.  Frequent  hemorrhages  from  the 
bowel  in  children  are  nearly  always  due  to  a  vascular  polypus.  These  polypi 
are  from  the  size  of  a  pea  to  that  of  a  cherry,  and  are  often  attached  by  long 
stalks  to  the  bowel.  If  high  up,  the  polypus  is  difficult  to  find,  but  when  low 
down  the  small  red  growth  may  protrude  from  the  anus.  If  it  cannot  be  seen, 
an  enema  will  bring  down  the  bowel  and  the  polypus  with  it.  It  may  be  felt 
by  the  finger  in  the  bowel.      Removal  is  the  only  treatment. 

Villous  Growths. — These  are  comparatively  rare,  and,  though  innocent 
at  first,  may  develop  malignant  characters  later  on.  The  tumor  is  sessile  or 
has  a  short,  broad  pedicle  growing  into  the  bowel ;  it  is  lobulated,  and  the  sur- 
face has  a  soft,  velvety  feel.  When  situated  low  down  it  may  give  rise  to 
straining  and  prolapse,  and  also  to  hemorrhage.  There  is  no  induration  about 
the  base,  as  in  cancer,  and  it  is  freely  movable.  On  microscopical  examination 
it  has  all  the  characteristics  of  an  adenoid  polypus.  Complete  removal  is  the 
only  treatment.     Recurrence  is  not  uncommon. 

Condylomata  are  met  with  about  the  anus,  and  are  usually  due  to  syphilis. 
(See  Syphilis.) 

Warty  growths  are  sometimes  seen,  and  call  for  excision.  They  may  be 
of  large  size. 

Sarcoma  of  the  rectum  is  very  seldom  seen. 

Caxcer. — The  form  met  with  in  the  rectum  is  nearly  always  cylindrical 
epithelioma,  and  it  commences  in  the  epithelium  of  the  follicles  of  Lieberkiihn. 
Colloid  cancer,  as  well  as  scirrhus,  may  affect  the  rectum,  but  both  are  very 
rare.      Colloid  cancer  is  often  a  later  stage  of  epithelioma. 

There  are  two  forms  of  the  epithelial  cancer.  The  first  commences  in  the 
mucous  membrane,  ulcerating  and  soon  destroying  it,  and  afterward  invading 
the  submucous  tissue.  It  extends  more  commonly  laterally,  often  completely 
surrounding  the  bowel  by  a  ring  of  cancerous  ulceration  and  having  an  indu- 
rated base.  This  ulcer  bleeds  easily  and  increases  by  extending  upward.  In 
the  later  stages  a  fungating  mass  may  project  into  the  bowel. 

The  second  variety  is  first  seen  as  a  nodule  beneath  the  mucous  membrane, 
projecting  into  the  bowel,  and  may  attain  considerable  size  without  ulcerating 
through  the  mucous  membrane.  It  increases  equally  in  all  directions,  and 
exists  in  its  earlier  stages  more  as  a  cancerous  tumor  than  as  a  cancerous 
ulceration  of  the  bowel.  Later,  when  the  mucous  membrane  ulcerates,  it 
grows  rapidly,  presenting  a  huge  fungating  mass  in  the  cavity  of  the  bowel. 

There  are  also  various  degrees  of  hardness  in  these  cancers.  In  some,  the 
fibrous  stroma  being  more  abundant,  the  cancer  grows  and  ulcerates  slowly, 
and  bleeds  less  readily  when  touched.  The  softer  varieties  grow  more  rapidly, 
quickly  infiltrate  surrounding  structures,  and  soon  involve  the  lymphatic  glands. 
Thev  break  down  readily  under  the  finger  and  bleed  freely.  In  these  forms  the 
glandular  elements  are  more  abundant,  alveoli  being  numerous.  The  softer 
varieties  are  not  so  favorable  for  operation  as  the  slowly-growing,  firmer  cancers. 
When  cancer  affects  the  anus  it  is  always  of  the  squamous  form  of  epithelioma. 

Symptoms. — Rectal  cancer  is  a  disease  of  middle  life,  usually  occurring 


806  ^.V   AMERICAN    TEXT-HOOK    OF  SL'JidEltY. 

in  persons  over  forty.  It  often  comes  on  very  insidiously,  and  is  not  discovered 
until  the  surgeon  makes  an  examination.  The  symptoms  may  be  first  consti- 
pation, pain,  and  bearing  down,  •with,  at  times,  discharge  of  mucus  and  blood. 
Blood  alwavs  appears  sooner  or  later,  and  diarrhea  occurs  from  time  to  time. 
The  pain  occasioned  by  the  feces  passing  over  the  ulcerated  surface  is  very 
severe,  and  the  patient  dreads  a  movement  of  the  bowels.  On  examining  the 
rectum  with  the  finger,  at  from  three  to  five  inches  from  the  anus  a  hardened, 
ulcerated  mass  will  be  met  with,  which  has  so  contracted  the  bowel  that  the 
finger  can  be  passed  through  it  with  difficulty  or  not  at  all.  The  edges  of  the 
stricture  feel  ragged  and  irregular.  When  the  cancer  is  high  up  it  ma}'  be 
difficult  to  reach  unless  the  patient  bears  down  strongly  or  is  examined  in  the 
standing  position.  In  the  late  stages  of  the  disease  the  patient  suffers  from 
marked  cachexia,  the  cancer  having  by  this  time  invaded  the  neighboring 
organs.  Death  occurs  from  extension  of  the  disease,  exhaustion,  rupture  into 
the  peritoneal  cavity,  etc.  The  stricture  caused  by  the  malignant  disease  fre- 
quently leads  to  fistulje.  which  may  open  into  the  vagina,  into  the  bladder,  or 
on  the  external  surface,  forming  a  sort  of  artificial  anus. 

The  diagnosis  of  cancer  rests  between  that  of  other  tumors  outside  the 
bowel  and  that  of  non-malignant  stricture.  In  non-malignant  stricture  the  dis- 
ease is  apt  to  extend  to  the  anus,  whereas  in  cancerous  stricture  there  is  usually 
healthy  mucous  membrane  between  the  disease  and  the  anus.  Xon-malignant 
stricture  has  a  smoother  feel  and  is  devoid  of  nodules,  but  often  the  diagnosis 
is  very  difficult,  and  can  be  determined  only  by  microscopic  examination. 
The  diagnosis  between  malignant  and  non-malignant  stricture  is  described  in 
the  section  on  Stricture  of  the  Rectum  (pp.  800.  810).  Tubercular  ulceration 
of  the  rectum,  enlarged  prostate  and  tumors  of  the  prostate,  and  villous 
tumors  have  been  mistaken  for  cancer. 

Tubercular  Ulceration  of  the  Rectum  much  resembles  epithelioma, 
and  a  microscopic  examination  is  often  necessary  to  clear  up  the  case.  But 
the  history  of  the  individual  and  the  fact  that  tuberculosis  may  exist  else- 
where are  often  conclusive. 

In  Enlarged  Prostate  and  Tumors  of  the  Prostate  one  always  finds 
the  tumor  on  the  anterior  wall  of  the  bowel  and  covered  with  healthy  rectal 
mucous  membrane.  The  tumor  itself  is  firm  and  smooth  if  the  case  be  one 
of  simple  hypertrophy  of  the  prostate. 

Villous  Tumor. — This  is  a  rare  form  of  growth,  which  is  soft  and  is 
not  accompanied  by  the  deep  infiltration  of  cancer.  Villous  tumor  is  always 
covered  by  a  viscid  mucus,  and,  although  it  bleeds,  does  not  do  so  readily. 
The  discharge  may  be  blood-stained  in  villous  tumor — in  cancer  the  dis- 
charge is  always  bloody.  Villous  tumor  may  exist  for  years  without  affect- 
ing the  general  health;  frequently,  however,  it  ends  by  becoming  malignant. 

Abscess  or  Acute  Inflammation  has  been  mistaken  for  cancer,  but  the 
history  of  the  case  and  time  will  easily  clear  up  the  diagnosis. 

Treatment. — Proctectomy,  or  Excision. — In  all  cases  where  there  is 
a  possibility  of  entire  removal  of  the  growth  its  excision  should  be  under- 
taken. Should  the  growth  be  freely  movable  and  should  there  be  no  great 
involvement  of  the  glands,  while  at  the  same  time  the  general  condition 
of  the  patient  remains  good,  the  case  is  one  in  which  extirpation  by  the  peri- 
neal or  sacral  method  should  be  attempted.  It  was  formerly  advised  that  no 
excision  should  be  attempted  unless,  under  anesthesia,  the  finger  could  reach 
above  the  growth,  but  recently  many  successful  cases  of  excision  have  been 
reported  where  the  growth  was  high  up,  as  much  as  twelve  inches  of  the  lower 
bowel  being  removed.     In  these  cases  Kraske's  operation  or  some  modifica- 


DISEASES   AND    INJURIES    OF    THE   AEDOMEN. 


807 


tion  of  it  is  usually  adcptcd.  When  tl.c  sij^.noia  il.xuvc  .s  mvolvoa,  the  gro^Uh 
may  be  reached  from  aboye.  The  most  fayorable  cases  tor  operation  are  those 
r  vhich  the  disease  occurs  in  the  posterior  Avail.  When  the  anter.or  v^xll  .8 
iuyolye.1  the  bhulder  an.l  prostate  in  the  male  and  the  yagma  m  the  female 
are  sure  to  be  implicated  early,  rendering  operation  difficult  and  often  inef- 
fectual If  the  patient's  geneVal  condition  is  feeble  and  cachexia  is  present, 
exci  ion  is  contriindicated!  The  imn.ediate  results  are  fayorable  only  from 
10  to  15  per  cent,  succumbing  from  the  operation.  Of  course  in  selected  cases 
the  mortality  should  not  be  so  high  as  this.  .       ^v,    •   ,  . 

Z-mfA'l-The  patient  is  prepared  for  the  operation  by  haying  the  intes- 
tines thorou-^hly  emptied,  and  immediately  before  operation  the  rectum  should 
bedashed  out  with  warm  water  and  boric  acid  by  means  of  a  tube  carried 
wel7up1he  bowel.     He  shouhl  then  be  placed  in  the  lithotomy  position,  with 
The  buttocks  ra  seel.     The  bladder  should  be  emptied  before  operation,  and 
f  the  rectu  B  has  to  be  dissected  out,  a  sound  should  be  placed  in  the  bladder 
for  a  Juide.     If  the  cancerous  nodule  be  small,  movable,  and  on  tbe  poste- 
rior wSl    it  may  be  excised  by  an  elliptical  transverse  incision,  and  the  cut 
ed^esof  the  mucous  membrane  should  then  be  brought  together  with  sutures  or 
?fe  wound  packed  with  iodoform  gauze.     When  the  disease  is  more  extensive 
an  incisfon  should  be  made  from  the  anus  to  the  coccyx  in  the  median  Ime  ;  then 
the  o^^n^art  of  the  rectum  should  be  separated  from  the  tissues  m  front  of  he 
sphin  ter  by  two  crescentic  cuts,  which  go  into  the  ischio-rectal  foss^,  and  dis- 
sS  up  quickly  beyond  the  growth  posteriorly,  and  more  carefully  m  front, 
wh  "e    he\ttachment  is  closer^nd  the  structures  more  important.     B  eeding 
Thould  be  stopped  by  forceps,  or  the  cut  parts  should  be    ightly  packed  w  th 
spon.es     When  the  tectum  has  been  separated  to  a  point  well  above  the  gro..^h 
k  is  cut  off  and  any  enlarged  lymphatic  glands  are  removed      The  upper  end 
of  the  c.ut  should  then  be  brought  down  as  closely  as  possible  to  the  lower  end 
and  sutm-ed.     The  external  woSnd  should  be  well  irrigated  with  sublimate  solu- 
tion  and  a  drainage-tube  packed  around  with  strips  of  iodoform  gauze  intro- 
duc;crabove  the  sStured  g^t.     The  wound  and  bowel  should  be  ^^^^^-^^J^^^ 
crated  twice  a  day.     Some  surgeons  suture  the  external  wound,  but  this  method 
I?      nt^few  a  vantages,  secre^tions  being  retained  and  the  pam  and  discomfor 
Tthe  patient  being  much  greater.     Packing  the  wound  -^  ^do  -m  g^^^^^^^ 
a  simple  procedure  and  gives  good  results.     Immediately  after  the  operation 
the  Wis  should  be  ke'pt  confined  by  opium   but  later  laxatives  should  be 
given.     After  the  second  week  bougies  should  be  passed  daily. 
^     Kraske^s  Operation.-Y or  cancer  high  up  m  the  rectum  Kraske  of  Frei- 
burf  has  devised  a  very  radical  operation.     The  patient  is  placed  on  his  left 
sMet  and  In  incision  is  'made  from'the  second  piece  of  the  sacrum   in    he  mid- 
dle line   to  the  anus.     The  soft  parts  are  then  dissected  off  on  the  lett  side  to 
the  edg;  of  the  sacrum;  then  thi  coccyx  is  excised  and  the  attachment  of  the 
sacro-sdatic  ligaments  divided  close  to  the  sacrum      In  this  way  the  rectum  is 
exposed;  but  still  better  access  is  obtained  by  chiselling  away  a  part  of  the 
leffsideof  the  sacrum,  commencing  opposite  the  third  lelt  sacral  foramen  and 
avoidincr  the  nerves  passing  through  the  foramina  (line  BA  in  J^ig.  6^\i).     i^y 
this  operation  the  upper  part  of  the  rectum  can   be  fully  exposed  and  ex^ 
led  Sout  iniurin  ^he  lower  end.      Should  the  peritoneum  be  injured  m 
frrefn^the  recul^  it  should  be  immediately  sutured    and,  as  a  rule,  no  ill 
S?  will  follow.     Some  surgeons  deliberately  open  the  peritoneum  and  t^rn- 
T^on  it  with  iodoform  gauze  or  after  operation  leave  a  dram  m  it.      Utliers 
have  removed  even  larger  portions  of  the  sacrum  transversely,  thus  mvadmg 
the  spTnal  canal  and  without  any  ill  results.     These  various  operations  are 


808 


AX   AMERICAN    TEXT-HOOK    OF  SURGERY. 


shown  in  Fig.  321*. 


Fig.  329. 


Different  levels  of  Resection  of  the  Sacrum  :  KG,  Kocher's 
line  :  BA,  Kraske's  ;  BU,  Hochenegg's ;  BD,  Baidenheuer's  ; 
RS,  Rose's  (Maas). 


It  i.s  well  bct'ore  exci.sing  the  diseased  jxjrtion  of  howel 

to  slit  the  posterior  wall  of  the 
rectum  down  to  the  sphincter, 
and  then  to  make  tlie  trans- 
verse cut  behjw  an<l  above 
the  cancer.  The  advantage 
of  completely  suturing  the  cut 
edges  of  the  rectum  is  doubt- 
I'ld.  The  sutures  do  not  hold, 
and  feces  are  apt  to  escape  be- 
tween them.  Kraske  now  pro- 
vides an  artificial  anus  at  the 
line  of  suture,  whilst  Schede, 
after  making  a  complete  suture 
of  the  bowel,  performs  inguinal 
colostomy.  The  sacral  wound 
should  be  left  open  and  stuffed 
with  iodoform  gauze.  The 
after-treatment  is  the  same  as 
after  other  forms  of  excision. 
Rydygiers  Operation. — 
The  soft  parts  are  incised  on  the  left  side,  beginning  at  the  posterior  superior 
spine  of  the  ilium  and  extending  downward  to  the  tip  of  the  coccyx  ;  from 
here  the  incision  proceeds  in  the  median  line  to  the  anus.  After  division  of 
the  sacro-sciatic  ligaments  the  soft  parts  are  separated  from  the  anterior  sur- 
face of  the  sacrum.  A  transverse  incision  is  now  made  below  the  third  sacral 
foramina  and  the  bone  divided  along  this  line  with  a  chisel.  The  flap  of  soft 
parts  and  bone  is  then  reflected  to  the  right  side,  the  rectum  exposed,  and  the 
diseased  structures  excised,  the  cut  ends  of  the  bowel  sutured  after  excision  ; 
the  flap  of  soft  tissues  and  bone  is  replaced,  the  flap  being  retained  in  place 
by  silk  or  other  sutures  through  the  soft  parts.  Levy  has  devised  a  new 
operation  for  exposing  the  rectum.  He  makes  a  transverse  incision  through 
the  soft  parts  and  bone,  half  an  inch  above  the  cornua  of  the  coccyx,  four 
and  a  half  inches  long,  and  from  the  ends  of  this  incision  vertical  ones  down 
through  the  gluteus  maximus  on  each  side.  lie  then  frees  the  connective  tis- 
sue on  the  anterior  wall  of  the  sacrum,  and  the  bone  and  skin  flap  is  turned 
down  and  the  rectum  exposed  ;  after  resecting  and  suturing  the  })()wel  the  flap 
is  replaced  and  the  bone  and  skin  sutured  in  position.  In  many  cases  excision 
of  the  cancerous  portion  is  much  facilitated  by  a  simple  removal  of  the  coc- 
cyx in  connection  with  the  posterior  incision.  In  cases  unsuitable  for  excision, 
and  where  the  stricture  has  considerably  reduced  the  lumen  of  the  bowel  and 
obstruction  occurs,  inguinal  colostomy  should  be  performed.  This  frequently 
gives  great  relief  to  the  i)atient  and  prolongs  his  life.  Ullmann  in  these 
cases  recommends  the  formation  of  an  anastomosis  of  the  bowel  above  the 
disease  and  the  lower  end  of  the  rectum  by  means  of  Kraske's  incision.  In 
women  the  vaginal  route  has  been  adopted  in  a  few  cases  with  advantage. 

When  there  is  but  little  obstruction,  or  where  operation  is  refused,  the 
patient's  life  may  be  made  more  bearable  by  a  strict  attention  to  diet.  A 
purely  milk  diet,  with  some  form  of  meat  juice,  is  often  very  satisfactory. 
Cod-liver  oil  and  milk  laxatives  give  much  relief,  as  does  a  daily  enema  of 
warm  water.  It  should  be  injected  high  up  and  beyond  the  disease  by  means 
of  a  rubber  catheter  attached  to  the  syringe,  and  afterward  a  small  starch 
injection  with  20  to  30  drops  of  laudanum  should  be  administered.      The  parts 


DISEASES  AXI>    J y JURIES    OF    THE  ABDOMEN.  809 

should  be  kept  very  clean,  and,  if  the  patient  has  much  pain  and  is  restless  at 
night,  opium  should  be  given. 

STRICTURE  OF  THE   RECTUM. 

Stricture  of  the  rectum  may  be  either  simple  or  malignant.  The  latter 
has  already  been  considered  under  Tumors.  The  simple  stricture  is  fibrous, 
and  is  fre(|uently  the  result  of  one  of  the  forms  of  ulceration  described  above, 
or  is  due  to  some  form  of  chronic  inflammation  (as  dysenteric),  which  leads  to 
the  deposition  and  subsequent  contraction  of  fibrous  tissue  normally  arranged 
circularly  in  the  bowel.  Pelvic  cellulitis  may  lead  to  stricture  of  the  bowel, 
as  ma}'  also  the  various  operations  performed  for  prolapsus,  piles,  fistula,  etc, 
A  stricture  is  occasionally  found  in  young  women  which  appears  to  be  due  to 
partial  persistence  of  the  septum  between  the  anus  and  the  rectum  :  it  grad- 
ually grows  narrower  from  irritation  and  recurring  ulceration  until  it  attracts 
attention  and  requires  relief.  The  fibrous  stricture  is  divided  into  the  annular 
and  tubular.  Stricture  involving  less  than  an  inch  of  the  bowel  is  called  annu- 
lar. The  strictures  involvino;  a  larfrer  extent  of  bowel  are  named  tubular. 
Fibrous  stricture  of  the  rectum  is  found  from  four  to  six  inches  from  the  anus 
or  immediately  above  that  opening.  Syphilitic  stricture  is  usually  found  imme- 
diately above  the  anus,  and  is  most  frequently  seen  in  young  women  under 
thirty.  All  forms  of  simple  stricture  ai'e  more  common  in  Avomen  than  in  men. 
When  the  stricture  has  lasted  some  time  the  bowel  above  becomes  dilated  and 
often  ulcerated. 

Symptoms. — If  due  to  ulceration,  it  will  be  preceded  by  symptoms  of 
that  affection,  but  surcreons  rarelv  see  stricture  of  the  rectum  in  an  early  sta^e, 
being  first  called  in  when  symptoms  of  obstruction  present  themselves.  The 
patient  has  frequent  attacks  of  diarrhea,  followed  by  constipation.  He  will 
often  have  difficulty  in  defecation,  straining  at  stool  and  passing  scybala  or 
motions  reduced  in  size.  Flat,  ribbon-shaped  motions  are  usually  but  not 
always  due  to  stricture,  as  they  may  be  produced  by  an  irritable  sphincter. 
After  having  passed  a  motion  the  patient  will  feel  as  if  the  bowel  has  not  been 
emptied,  and  when  diarrhea  exists  it  will  compel  him  to  go  to  stool  very  fre- 
quently, passing  each  time  only  a  little  flatus  and  mucoid  discharge,  with  a  few 
small  scybalous  masses.  Later  on,  bloody  mucus  may  be  discharged  and  the 
diarrhea  is  almost  continuous.  The  patient  spends  most  of  his  time  trying  to 
relieve  his  bowels.  Abscesses  may  now  form  in  the  neighborhood  of  the  stric- 
ture and  result  in  fistula.  Recto-vaginal  fistula  is  a  not  uncommon  sequence  of 
stricture.  The  parts  about  the  anus  become  excoriated  and  raw,  and  the  pa- 
tient's condition  is  pitiable  :  his  general  health  fails,  he  becomes  hectic,  has  albu- 
men in  his  urine,  and  death  ensues,  produced  either  by  complete  obstruction  or 
by  peritonitis.  This  is  the  course  of  a  severe  form  of  stricture.  Many  cases  of 
annular  stricture  do  not  produce  such  severe  symptoms  and  do  not  go  on  to  a 
fatal  termination.  Should  the  stricture  be  within  three  or  four  inches  of  the 
anus,  the  diagnosis  is  easily  made  by  the  finger,  but  in  strictures  high  up  the 
diagnosis  is  often  very  difficult ;  the  patient  has  diarrhea,  alternating  with 
obstinate  constipation.  The  detection  of  such  strictures  by  the  passage  of  a 
bougie  is  uncertain,  and  may  be  dangerous  because  of  the  risk  of  perforating 
the  bowel.  Bryant  of  London  describes  a  condition  of  "  balloonincr  of  the 
rectum."  which  exists  when  the  stricture  is  high  up.  The  finger  in  passing 
the  sphincter  will  enter  a  cavity  the  walls  of  which  are  "ballooned"  or 
expanded.  The  surgeon  will  be  able  to  move  his  finger  freely,  and  the  walls 
of  the  rectum  can  be  felt  only  when  searched  for.     The  high  strictures  may, 


810  AX  AMERICA  X    TEXT-BOOK    OE  SlEdEEY. 

of  fourso,  bo  diagiiostieatod  b_v  tlio  passage  of  the  band  into  the  rectum,  as 
recouiniended  by  Simon  :  it  shoiibl  be  passed  cautiously  after  dilating  the 
sphincter,  and  a  small  hand  is  necessary  for  this  j>rocedure.  The  most  def- 
inite information  will  be  obtained  bv  the  use  of  one  of  the  specula  devised 
by  Kelly. 

The  diagnosis  bet^vt'on  malignant  and  simple  stricture  is  not  always  easy. 
The  fact  that  the  stricture  has  existed  some  time  and  is  in  a  patient  under 
middle  age  will  often  determine  the  diagnosis.  The  peculiar  sensation  of 
malignant  stricture  conveyed  to  the  finger  is  almost  unmistakable :  masses  of 
new  growth  can  be  felt,  and  there  is  ulceration  at  some  one  point  where  the 
growth  is  more  pronounced.  The  sacral  lymphatic  glands  are  involved  in  the 
later  stages  of  rectal  cancer. 

Treatment. — If  the  stricture  be  of  moderate  extent  and  Avithin  reach,  the 
patient  may  be  made  comparatively  comfortable  by  proper  diet  and  the  use  of 
laxatives  and  enemata.  Rectal  bougies  should  also  be  passed  daily  and  be 
gradually  increased  in  size.  The  bougie  should  be  retained  five  minutes  to  an 
hour — as  long,  indeed,  as  the  pain  is  not  severe.  It  is  well  at  the  conmiencement 
to  confine  the  patient  to  bed.  After  the  stricture  has  been  fully  dilated  the 
patient  should  pass  a  bougie  himself  at  least  once  a  week. 

If  this  treatment  fails,  the  stricture  must  be  divided.  An  annular  stricture, 
if  low  down,  should  be  divided  posteriorly  and  bougies  passed  as  before.  In 
the  severer  cases  proctotomy,  as  described  below,  with  division  of  the  external 
parts,  is  by  far  the  best  procedure.  This,  however,  cannot  be  practised  when 
the  stricture  is  high  up  or  of  great  extent ;  here  w^e  must  perform  colotomy  to 
save  the  patient's  life.  In  these  cases  it  is  a  most  satisfactory  operation. 
French  surgeons  have  recently  advocated  and  practised  with  success  the  extir- 
pation of  these  severe  forms  of  stricture  (especially  those  which  are  syphilitic) 
by  means  of  Kraske's  operation.  The  results,  according  to  reported  cases  by 
Qu^nn  and  Richelot,  are  excellent. 

Proctotomy  (Linear). — This  is  chiefly  performed  for  stricture  of  the  rec- 
tum, and  should  be  performed  only  when  dilatation  has  failed.  The  contents 
of  the  bowels  having  been  thoroughly  evacuated,  the  patient  is  placed  in  the 
lithotomy  position,  the  finger  introduced  through  the  stricture,  and  a  sharp- 
pointed  knife  inserted  in  front  of  the  tip  of  the  coccyx  and  pushed  through 
the  tissues  until  the  finger  is  reached;  a  blunt-pointed  bistoury  now  replaces 
the  first  knife,  and  all  tlie  tissues  between  the  anus  and  tip  of  the  coccyx  are 
cut  through.  Some  perform  this  incision  with  a  Paquelin  cautery  or  dcraseur, 
but  a  knife  is  the  best  and  speediest.  The  wound  should  be  packed  with  iodo- 
form gauze,  and  the  whole  supported  by  a  T  bandage.  The  after-treatment  is 
the  same  as  after  excision  of  the  rectum.  This  operation  in  simple  stricture  is 
often  curative,  and  as  the  wound  heals  power  of  retaining  feces  will  gradually 
return. 

PAET  VII.— HERNIA. 

By  Hernia  is  meant  the  protrusion  of  any  viscus  from  its  natural  cavity 
through  normal  or  artificial  openings  in  the  surrounding  structures.  Thus 
we  have  hernia  testis,  hernia  of  the  lung,  etc.  But  by  the  term  hernia  used 
alone  we  mean  the  ]>rotrusion  of  a  portion  of  the  abdominal  contents 
through  the  parietes,  and  this  is  known  by  the  popular  term  "rupture." 
The  commonest  forms  of  rupture  protrude  through  one  of  the  natural  openings 
or  weak  spots  in  the  abdominal  parietes,  as.  for  instance,  the  inguinal  and 
femoral  canals.  Hernia  may  occur  at  the  umbilicus  or  even  at  the  obturator 
foramen.     The  contents  of  a  hernia  are  bowel  and  omentum,  separately  or 


J)  IS/:  ASKS   AX  J)    lyJCL'IKS    OF    THE    A  J:  POM  EX. 


811 


Fig.  330. 


together.  An  omental  lu-rnia  i.^  called  an  epiplocele,  and  ii  hernia  of  the 
inte.>*tine  an  enterocele;  a  combination  of  the  two  is  called  an  entero- 
epiplocele.  The  bowel  involved  in  a  hernia  i.s  usually  the  lower  {jortion  of 
tht'  small  intestine,  but  the  large  intestine  is  also  found,  even  the  whole  caecum  ; 
also  the  bladder  ((■//stocch'^),  stomach  [</astrocele),  ovaries,  gall-bladder,  etc. 

Anatomy. — Covering  the  bowel  or  omentum  we  have  the  sac ;  this  con- 
sists of  the  protruded  portion  of  peritoneum,  which  has  been  pushed  gradually 
through  one  of  the  canals  (inguinal  or  femoral),  or  of  the  process  of  perito- 
neum, which  has  been  carried  down  by  the  testicle  in  its  descent,  and  the  con- 
nection of  which  with  the  peritoneum  of  the  abdomen  still  continues,  not  hav- 
ing been  obliterated,  as  it  usually  is,  before  birth.  The  former  is  called  an 
acquired  hernial  sac ;  the  latter  is  called  a  congenital  hernial  sac  (Birket),  and 
is  found  only  in  inguinal  hernia.  After  the  hernia  escapes  from  the  canal 
through  which  it  passes  it  enlarges  greatly,  and  is  covered,  of  course,  still  by 
its  sac.  This  portion  of  the  sac  is  called  the  body,  the  portion  which  lies  in 
the  canal  is  called  the  neck,  and  the  opening  in  the  abdominal  cavity  is  called 
the  mouth.  The  sac,  taken  as  a  whole,  has  somewhat  the  shape  of  a  Flor- 
ence flask  (Fig.  330).  In  a  hernia  of  long  standing  the  sac  becomes  very 
much  thickened  and  often  adherent  to 
the  surrounding  structures,  so  that  even 
should  the  contents  of  the  sac  be  wholly 
reduced  the  sac  still  remains,  and  is  ever 
ready  to  receive  its  contents  agam  on  the 
slightest  provocation.  The  sac  of  a  re- 
cent hernia  is  thin  and  transparent,  as  it 
is  peritoneum,  and  is  easily  reduced  with 
its  contents,  no  adhesions  as  yet  binding 
it  to  the  surrounding  structures.  The 
neck  of  the  sac  is  thrown  into  pleats  and 
folds,  owing  to  the  constriction  produced 
by  the  narrow  hernial  opening.  The  parts 
covering  the  hernia  outside  the  sac  vary 
according  to  the  situation  of  the  hernia  ; 
they  usually  consist  of  various  fascijie, 
tendons  of  muscles,  and  even  portions  of 
muscles  themselves,  and.  lastly,  super- 
ficial fascia  and  skin. 

Etiology. — Hernia  is  more  common  in 
males  than  in  females,  and  may  occur  at 
any  period  of  life.  The  majority  of  cases,  however,  occur  before  middle  age,  and 
the  largest  number,  according  to  Kingdon,  during  the  first  ten  years  of  life, 
owing  to  the  non-closure  of  the  process  of  peritoneum  which  is  carried  down 
by  the  testicle.  Frequently  the  hernia  is  congenital.  Hernia  is  most  fre- 
quently strangulated  between  the  ages  of  forty  and  fifty. 

Hereditary  predisposition  to  hernia  exists  without  doubt  in  many.  Mr. 
Kingdon  estimates  that  in  about  34  per  cent,  there  is  an  hereditary  tendency 
to  hernia,  many  of  these  patients  being  born  with  it. 

Occupation  predisposes,  people  who  have  laborious  occupation  being  most 
liable  to  the  acquired  form  ;  some  assert,  however,  that  it  is  more  commonly 
seen  in  these  individuals  only  because  there  are  more  of  them.  It  is  said  that 
persons  with  abnormally  long  mesenteries  are,  on  that  account,  predisposed  to 
hernia.     After  abdominal  section  the  patient  is  very  liable  to  have  rupture  at 

*  This  term  is  also  applied  to  the  bladder  protruding  or  tending  to  protrude  at  the  vulva. 


Hernial  sac.  with  contained  bowel :  X,  neck  of 
sac  ;  S,  sac  ;  B,  bowel  (original) 


812  AN   AMERICAN    TEXT-BOOK    OF  SURGERY. 

the  site  of  the  wound,  and  stout  women  who  have  borne  many  ehihlren  are 
especially  subject  to  rupture.  Certain  diseases,  as  bronchitis,  whoojjing-cough, 
stricture,  and  constipation,  predispose  to  rupture  by  causing  violent  and  pro- 
longed use  of  the  ab(h)minal  muscles.  These  aflections  occurring  in  old  people 
with  relaxed  tissues  not  infre((uently  start  a  rupture. 

Seat  of  IIkiinia. — This  will  be  more  fully  discussed  in  treating  of  the 
various  kinds  of  hernia.  The  most  common  seats  of  hernia  are  the  inguinal, 
the  femoral,  and  the  umbilical  regions,  though  occasionally  protrusion  occurs 
through  the  diaphragm,  obturator  foramen,  ischiatic  notch,  vagina,  etc. 
Out  of  every  100  cases  of  hernia,  84  are  inguinal,  10  femoral,  and  5 
umbilical.  According  to  Berger  of  Paris,  in  every  5  cases  of  inguinal 
hernia  4  are  of  the  double  variety.  In  10,000  cases  3.31  per  cent, 
had  suffered  some  time  or  other  from  complications,  as,  for  instance, 
strangulation,  etc. 

DrA(JN0Sis. — Hernia  is  first  noticed  at  one  of  the  rings  (inguinal,  femoral, 
umbilical)  as  a  fulness  or  swelling,  which  is  especially  evident  on  standing. 
Coughing,  lifting  heavy  weights,  etc.  make  the  swelling  more  tense  and  elastic. 
This  swelling,  which  is  smooth  and  uniform,  will  disai)pear  on  lying  down,  and 
after  long  rest  in  bed  may  not  immediately  reappear  on  standing.  The  sur- 
geon can  usually,  in  recent  hernia  especially,  easily  reduce  the  swelling  by 
manipulation  with  the  fingers  (taxis).  The  bowel,  as  it  is  returned,  often  gives 
a  gurgling  sound  and  slips  in  quickly.  On  placing  the  finger  in  the  ring 
through  which  the  bowel  has  been  pushed,  and  keeping  it  there  when  the 
patient  stands  up,  there  is  no  return  of  the  hernia.  As  soon  as  the  finger  is 
removed,  however,  the  tumor  reappears.  On  making  the  patient  cough  the 
tumor  becomes  tense,  and  there  is  a  decided  impulse  which  does  not  occur  in 
other  tumors.  Should  the  contents  of  the  swelling  be  bowel,  there  will  be  a 
tympanitic  note  on  percussion,  but  if  the  contents  be  omentum,  the  tumor  will 
have  a  doughy  feel,  a  dull  note  on  percussion,  and  Avill  lie  reduced  with  much 
greater  difficulty.  Hernial  tumors  which  contain  both  boMcl  and  (mientum 
may  be  tympanitic  at  some  points,  dull  at  others,  and  Avhen  reduced  give  out 
a  gurgling  noise.  Persons  with  hernia  are  conscious  of  a  weakness  at  the  seat 
of  rupture,  especially  during  exertion.  There  may  also  be  uneasiness  and 
griping  pain,  which  are  attributed  to  constipation  or  other  cause. 

Prognosis. — Provided  the  hernia  can  be  kept  reduced  by  a  truss  placed 
over  the  aperture  of  exit,  the  prognosi-s  is  favorable.  The  patient,  however, 
always  runs  the  risk  of  strangulation  of  the  hernia  should  the  truss  get  dis- 
placed during  severe  exertion  or  if  it  should  fail  through  some  defect  to  keep 
the  hernia  entirely  reduced. 

The  prognosis  is  not  so  favorable  in  a  very  large  hernia,  for  it  is  difficult 
to  get  a  truss  that  will  keep  it  in  place,  owing  to  the  large  size  of  the  hernial 
ring  ;  nor  in  irreducible  hernise,  as  they  tend  to  increase  in  size.  In  very 
small  hernine  the  danger  of  strangulation  by  the  entrance  of  an  additional 
knuckle  of  gut  into  the  sac  renders  the  prognosis  unfavorable. 

In  irreducible  omental  herniae,  where  there  is  an  occasional  descent  of  small 
intestine,  the  prognosis  is  still  less  fixvorable,  owing  to  the  danger  of  the  bowel 
suddenly  becoming  strangulated  at  the  orifice  of  tJie  sac. 

Palliative  Treatment. — Every  individual,  young  or  old,  who  is  the  sub- 
ject of  a  hernia  which  is  reducible  should  wear* a  properly-fitting  truss.  A 
truss  is  an  instrument  composed  of  a  pad  which  fits  over  the  site  of  the  her- 
nia, and  a  belt  which  surrounds  the  pelvis  or  body  and  keeps  the  pad  in  place ; 
the  belt  is  often  made  to  act  as  a  spring.  A  properly-fitting  truss  should 
keep  in  the  hernia  on  all  occasions  without  causing  pain  or  discomfort.     In 


DISH  ASKS   Ay  I)    lyJlRIKS    OF    THE   ABDOMEN.  813 

young  infants  a  skein  of  Berlin  wool  may  be  made  to  Jo  service  for  a  truss  by 
doubling;  and  passin<:;  it  around  the  abdomen,  j)lacing  the  loop  directly  over 
the  outer  abdominal  ring,  and  then  passing  the  free  ends  of  the  skein  through 
the  loop,  thus  making  a  knot  opposite  the  site  of  the  hernia:  the  ends  which 
are  passed  through  are  then  carried  down  the  upper  part  of  the  thigh  between  it 
and  the  scrotum,  brought  round  the  external  side  of  the  thigh  near  the  top  of 
the  great  trochanter,  and  there  tied  or  fixed  with  a  safety-pin  to  the  band  of 
worsted  already  round  the  pelvis.  The  advantage  of  this  truss  is  that  it  can 
be  easily  washed  and  easily  applied. 

A  truss  should  be  worn  all  day,  and  should  be  j)ut  on  in  the  morning  before 
rising  and  taken  off  at  night  after  going  to  bed.  It  should  never  be  removed 
except  when  the  patient  is  lying  down.  Some  individuals  in  whom  the  hernia 
tends  to  come  down  even  when  in  the  recumbent  position  require  to  Avear  a 
truss  night  and  day.  The  night  truss  need  not  be  so  strong  as  the  day  truss. 
The  wearing  of  a  truss  in  the  very  young  often  results  in  cure  by  closure  of 
the  neck  of  the  sac,  but  even  in  these  cases  it  is  unwise  to  leave  oflF  wearing  a 
light  truss,  for  it  not  unfrequently  happens  that  on  any  sudden  exertion  the 
bowel  Avill  descend  in  the  old  channel,  become  strangulated,  and  thus  endansrer 
the  patient's  life,  especially  should  he  happen  to  be  beyond  the  reach  of  skilled 
surgical  assistance.  Trusses  are  very  difficult  to  adjust  to  the  very  fat,  and 
some  forms  of  hernia  are  from  their  situation,  etc.  extremely  troublesome  to 
fit  with  a  truss — e.  g.  umbilical  hernia.  The  pressure  of  the  pad  should  always 
be  in  the  direction  of  the  hernial  canal,  and  should  cover  the  aperture  through 
which  the  hernia  protrudes.  The  pad  should  not  be  too  convex,  for  this  shaped 
pad  has  the  effect  of  distending  the  aperture  and  so  increasing  the  size  of  the 
rupture.  The  pad  should  be  flat,  and  the  shape  should  be  suited  to  the  form  of 
hernia  for  which  it  is  used.  Pads  are  made  of  various  substances — vulcanite, 
wood,  india-rubber,  etc. ;  water-bags  and  sand-bags  have  been  used,  and  all 
have  their  advocates.  The  variety  of  trusses  is  innumerable.  In  some  the 
spring  is  formed  by  the  belt  which  encircles  the  pelvis,  and  in  others  is  situ- 
ated in  the  pad  itself.  Some  pads  are  fixed  solidly  to  the  encircling  belt,  and 
others  are  attached  by  a  ball-and-socket  joint.  The  truss  best  suited  to  the 
patient  is  one  which  keeps  in  place  in  all  the  various  movements  of  the  body, 
and  does  not  permit  of  the  descent  of  the  hernia  whilst  coughing,  jumping, 
or  straining.  One  of  the  best  tests  is  to  make  the  patient  stoop  forward, 
with  his  knees  apart  and  his  hands  resting  on  his  knees,  and  then  direct  him 
to  cough.  If  the  truss  stands  this  test,  it  is  one  which  is  suitable  to  the 
patient.  For  the  majority  of  cases  it  will  be  found  that  the  circular  spring 
truss  is  the  best. 

To  Measure  for  a  Truss. — The  size  of  the  aperture,  the  kind  of  hernia, 
and  whether  it  is  single  or  double,  should  be  noted.  The  circumference  of  the 
pelvis  one  inch  below  the  crest  of  the  ilium,  the  girth  of  the  body  opposite  the 
hernial  aperture,  and  the  distance  of  the  hernial  ring  from  the  iliac  spine  should 
all  be  accurately  measured.  Instructions  should  also  be  given  the  instrument- 
maker  as  to  the  direction  in  Avhich  the  pressure  should  be  made,  forward,  back- 
Avard,  or  inward. 

Radical  Cure. — The  radical  cure  of  hernia  has  for  years  exercised  the 
ingenuity  and  talents  of  surgeons.  Many  operations  have  been  devised,  and 
have  for  a  time  been  popular,  and  then  have  been  forgotten  or  have  fallen  into 
disuse.  The  operation  devised  by  Wiitzer  is  never  practised  noAv,  and  Wood's 
elaborate  operation  is  so  difficult  and  complicated  that  no  other  surgeon  has  been 
able  to  get  such  good  results  as  the  originator.  These  operations  since  the  intro- 
duction of  aseptic  surgery  have  been  entirely  superseded  by  that  of  open  incision. 


814  .l.V   AMERICAN    TEXT-BOOK    OF  SUUdERY. 

There  have  been  other  methods  which  have  met  with  a  measure  of  success — viz. 
those  which  aim  at  the  obliteration  of  the  canal  by  the  introduction  into  it  of 
some  irritant  and  astrin>:ent,  such  as  the  fluid  extract  of  oak-bark,  alcohol, 
iodine,  etc.  ;  but  here,  again,  the  result  is  often  unsatisfactory,  and  tlie  method 
is  suitable  for  the  cure  of  only  the  smaller  varieties  of  hernia. 

It  is  as  well  to  state  that,  before  recommending  a  so-called  radical  operation 
for  the  cure  of  hernia,  the  surgeon  should  consider  the  position  of  the  patient. 
If  he  is  a  man  past  middle  age  or  has  a  hernia  that  is  not  very  large  and  is 
easily  retained  in  place  by  a  properly-fitting  truss,  no  operation  should  be 
recommemled.  Macready  says  that  under  twelve  months  of  age  08  per  cent, 
of  congenital  ruptures  are  cured  by  truss  ;  from  one  year  to  five  years,  1<>  per 
cent. :  and  after  that  no  cures  occur.  Up  to  fifteen  years  of  age  only  5  per 
cent,  of  acifuired  herni;«  are  cured  by  a  truss.  It  is  also,  in  most  ca.ses,  unwise 
to  attempt  a  radical  cure  of  hernia  by  operation  in  very  young  infants.  But 
if  the  hernia  is  .strangulated  or  very  large  or  irreducible,  or  such  that  a  truss 
will  not  keej)  it  in  place,  or.  perhaps,  if  the  patient  is  desirous  of  entering 
some  public  .service  for  which  a  strict  physical  examination  is  demanded,  or 
desires  to  be  rid  of  the  .serious  annoyance  of  a  truss,  it  is  justifiable  to  recom- 
mend an  operation  for  the  radical  cure  of  the  hernia.  In  deciding  this  ques- 
tion it  must  also  be  remembered  that  a  hernia  which  in  youth  is  easily  retained 
and  gives  little  trouble  may  become  a  very  serious  source  of  annoyance  and 
danger  in  later  life. 

The  principles  of  the  modern  operations  for  the  radical  cure  of  hernia  are 
much  the  same  in  all — viz.  to  di.ssect  out  the  sac  and  excise  it  and  to  en- 
deavor to  close  the  hernial  canal  by  sutures.  There  are  many  diff'erent  opera- 
tions for  effecting  this  purpose,  and  it  would  be  impossible  in  a  work  of  this 
kind  to  describe  them  all.  The  operation  practised  by  Czerny,  Banks.  An- 
nandale,  and  others  is  very  simple  and  one  which  gives  good  results.  It  is 
mo^t  important  in  order  to  secure  a  permanent  and  satisfactory  result  after 
the  radical  operation  that  three  conditions  be  fulfilled:  (1)  Complete  extir- 
pation of  the  sac;  (2)  closure  of  the  canal;  and  (3)  imme<liate  union  of 
the  Avound.  This  latter  is  by  far  the  most  important.  The  most  com- 
mon form  of  hernia  is  the  infiuinaL  and  it  is  for  this  variety  that  the 
operation  for  a  radical  cure  is  mo.st  frequently  performed,  and  for  which 
it  is  most  suitable,  though  it  is  also  done  in  cases  of  umbilical  and  femoral 
herniie. 

Inguinal  Hernia. — An  incision  is  made  over  the  tumor  and  the  parts 
carefully  divided  until  the  sac  is  reached.  This,  if  old,  is  known  by  its  white 
appearance.  The  sac  should  then  be  dissected  out  carefully,  and  cautiously 
separated  from  the  spermatic  cord.  The  bowel  shoubl  be  reduced  before  the 
sac  is  opened  ;  but  if  it  contains  omentum  which  is  adherent,  the  sac  should 
be  opene«l  and  the  omentum  tied  and  cut  off.  The  sac  should  now  be  pulled 
down  and  a  ligature  of  silk  or  catgut,  preferably  the  former,  applied  to  the 
neck  as  high  up  as  possible,  and  the  sac  removed.  Xext  the  canal  is  closed 
by  sewing  the  pillars  of  the  ring  together,  or,  better  still,  if  the  hernia  be 
inguinal,  suturinij  the  conjoined  tendon  of  the  internal  oblique  and  transver- 
sal is  to  Poupart's  ligament  by  means  of  three  or  four  sutures  of  kangaroo 
tendon.  The  external  wound  is  closed  by  several  intorrujjted  sutures  and  a 
drain  place<l  at  the  lower  end.  It  should  be  dressed  like  any  other  wound, 
the  object,  of  course,  being  to  get  union  by  first  intention. 

Macewen's  Operation. — Macewen  of  Glasgow  preserves  the  sac  and  re- 
turns it  within  the  abdomen,  where  it  is  retained  in  a  j»uckered-up  condition 
by  ligatures  (Fig.  331),  and  acts  as  a  pad  placed  against  the  abdominal  aspect 


I  >  IS  EASES    AND    INJURIES    OF    THE   ABDOMEN. 


815 


by  suturing  the 
Fig.  332. 


of  the  intonial   ring  (Fig.  •J'52).      He  also  closes 
conjoined  tendon  to  I'oujjart's  ligament  (Fig. 
333). 

Ball  of  Dublin,  after  dissecting  out  tlie 
sac,  reeonuuends  torsion  or  twisting  before 
suturing  and  cutting  off  the  sac. 

Barker  of  Lonilon  dissects  out  only  tlic 
neck  of  the  sac,  ligatures  it,  and  cuts  it  off 
half  an  inch  below  the  ligature,  but  does  not 
dissect  out  the  lower  scrotal  portion.  The 
neck  of  the  sac  is  fixed  to  the  abdominal  wall 
by  the  ligatures  that  close  the  internal  ring; 
the  canal  is  closed  by  several  sutures,  the 
wound  dressed  with  dry  dressing,  and  no 
drainage  used  (Fig.   334). 

Hahted  of  Baltimore  divides  the  mus- 
cles of  the  abdominal  wall  nearly  as  far  as 
the  level  of  the  anterior  superior  spine ;  the  walls  of  the  sac  are  sutured 
by  (quilted  sutures  at  as  high  a  level  as  possible,  and  then  the  lower  por- 
tion cut  away.  The  spermatic  cord  is  now  lifted  and  the  divided  muscles, 
including  the  aponeurosis  of  the  external  oblique,  are  stitched  with  very  deep 
quilted  sutures  in  layers.      The  veins  of  the  cord,  excepting  one,  are  then 

excised  and  the  cord  is  placed  directly 
Fig.  333.  under  the  skin.      The  skin  wound  is 


Fig.  302.— Macewen's  Operation;  the  sac 
transfixed  and  drawn  into  folds. 

Fig.  303.— The  sac  as  a  pad  covering  the 
abdominal  aspect  of  the  internal  ring 
in  Macewen's  operation  (Tillmanns). 


Fig.  334. 


Macewen's  Operation :  the  threads  ready 
for  tying  (original). 


Barker's  Operation  for  the  Radical  Cure  of  Hernia :  aa, 
skin  incision  ;  b,  spermatic  cord  ;  c,  r,  hernial  sac  ;  d, 
suture  for  the  sac ;  e,  sutures  for  drawing  the  walls 
of  the  canal  together.  All  the  sutures  are  represented 
in  situ,  ready  to  be  drawn  close  and  knotted  (original). 


then  closed  with  buried  skin  sutures.  The  dressing  consists  of  a  small  pad 
of  sterilized  gauze,  held  in  place  by  a  bandage  which  has  been  soaked  in 
alcohol,  and  the  whole  covered  with  celluloidin. 

BassiHis  Operation  (Fig.  335). — Bassini  of  Padua  has  devised  the  fol- 
lowing operation,  which  is  now'  largely  adopted  by  surgeons :  The  aponeurosis 


SIG 


,i.v  AMKRK'Ay  Ti:x'r-r,o<)K  of  surgery. 


Fio.  335. 


A-c,  Bassini's  Operation  for  the  Cure  of 
Inguinal  Hernia  (Esmarch  and  Kow- 
alzig). 


of  the  external  obli(iue  and  the  pillars  of  the  ring  are  first  exposed,  and  then 
the  canal  is  slit  up,  the  aponeurosis  of  the  external  oblique  being  dissected 

from  the  tissues  below  so  as  to  form  two 
flaps.  The  cord  is  now  drawn  out  and  sepa- 
rated from  the  neck  of  the  sac,  the  sac  dis- 
sected out,  opened,  and  its  contents  reduced. 
The  neck  of  the  sac  is  then  ligatured  after 
twisting,  and  the  sac  cut  oft"  below  the  liga- 
ture. The  cord  is  held  up  and  kept  in  the 
upper  angle  of  the  wound,  whilst  the  border 
of  the  rectus  and  edges  of  the  internal  ob- 
liffue,  the  transversalis.  and  transversalis 
fascia  are  united  by  a  continuous  suture  to 
Poupart's  ligament  underneath  the  held-up 
cord,  thus  forming  the  posterior  wall  of  a 
new  canal.  The  divided  aponeurosis  of  the 
external  obli(jue  is  now  sutured  over  the 
cord,  thus  forming  the  anterior  wall  of  the 
new  spermatic  canal.  The  wound  in  the 
skin  is  closed  in  the  usual  way,  a  drainage- 
tube  being  used  only  in  cases  of  very  large 
hernijfi. 

BuJJ  and  Coley  of  New  York  report  250 
cases  of  operations  on  children  under  four- 
teen years  by  this  method,  with  three  deaths  and  four  relapses :  since  those 
statistics  have  been  published  Coley  has  operated  on  230  consecutive  cases 
in  children  without  a  death. 

Kochers  Operation. — Instead  of  slitting  up  the  aponeurosis  of  the  exter- 
nal oblique,  a  buttonhole  opening  is  made  through  the  aponeurosis  over  the 
internal  ring.  A  pair  of  artery  forceps  is  then  passed  through  the  slit  and 
brought  out  at  the  external  ring,  and  the  sac,  which  has  previously  been 
isolated,  is  seized  by  the  forceps,  drawn  out  through  the  slit,  and  drawn 
down  so  as  to  lie  over  the  aponeurosis.  Here  four  or  five  sutures  are  passed 
through  "  the  obliijue  fibres  of  the  aponeurosis,  external  obli(iue  muscles  and 
underlving  muscle  fibres  of  the  internal  oblique  and  transversalis,  through 
the  sac  itself  and  the  ligament  of  Poupavt  beneath  it.  These  sutures  bring 
together  the  pillars  of  the  external  ring  to  which  the  lower  end  of  the  sac  is 
fastened." 

Many  other  operations  have  been  devised,  but  these  are  the  chief.  After 
every  operation  for  the  radical  cure  of  hernia  it  is  well  to  keep  the  patient  in 
bed,  so  that  the  wound  should  be  perfectly  and  soundly  healed  before  it  is  sub- 
ject to  any  great  tension.  The  wearing  for  a  time  of  a  light  truss  is  advisable, 
but  a  truss  that  compresses  the  parts  strongly  should  be  avoided,  as  it  tends  to 
reproduce  the  previous  condition  by  promoting  the  absorption  of  the  cicatricial 
tissue.  With  strict  antisepic  precautions  the  immediate  results  of  the  operation 
have  been  good,  especially  in  small  hernia  in  young  adults.  Still,  the  operation 
is  not  without  risk,  especially  in  stout,  old  people  with  large  hernise  and  who 
are  perhaps  the  subjects  of  chronic  bronchitis.  As  to  the  curative  results  of 
this  operation,  many  operators  report  wonderfully  successful  series  of  cures 
after  six  months,  a  year,  and  even  two  to  three  years,  by  some  special  form 
of  operation,  but  recent  investigations  by  impartial  observers  of  the  average 
number  of  permanent  cures  of  hernia  by  direct  method  of  incision  give  the 
proportion  of  permanent  cures  as  about  60  per  cent.      Cas^s  may  relapse  after 


DISEASES  AND   INJURIES    OF   THE   ABDOMEN.  817 

even  five  years  of  ;i|iiiareiit  cure.  Most  of  our  stati-tic-s  are  based  on  insuf- 
ficient (lata,  series  of  cases  having  been  reported  within  six  months  to  a  year 
after  the  operation. 

In  femoral  hernia  the  operation  may  consist  simply  in  dissecting  out  and 
removing  the  sac,  no  attempt  being  made  to  close  the  ring.  Gushing  of  Bos- 
ton after  returning  the  gut  fastens  the  sac  as  a  pad  in  the  femoral  ring,  doubling 
it  on  itself,  as  in  INIacewen's  operation,  and  sewing  it  -by  ligatures  which  at  the 
same  time  pass  through  Poupart's  ligament  and  the  pubic  portion  of  the  fascia 
lata,  thus  closing  the  ring.  The  saphenous  opening  is  also  closed  by  slipping 
the  pubic  fascia  under  the  iliac  fascia  and  suturing  them  together.  Salzer 
removes  the  sac  and  then  closes  the  external  orifice  by  a  flap  formed  by  the 
fascia  covering  the  pectineus  muscle.  Watson  Cheyne  closes  the  crural  canal 
with  a  flap  taken  from  the  pectineus  muscle  itself. 

Bassints  Metliod. — The  patient  is  placed  on  the  back,  with  the  pelvis 
raised,  so  as  to  bring  the  hernial  tumor  prominently  forward.  An  incision 
should  now  be  made  directly  over  the  tumor  and  parallel  with  Poupart's  liga- 
ment. After  cutting  through  the  superficial  structures  and  ligating  all 
bleeding  vessels,  the  sac  is  exposed,  isolated,  and  opened.  Any  adhesions 
of  bowel  or  omentum  are  broken  down  and  the  bowel  returned :  then  the 
neck  of  the  sac  is  lighted,  the  sac  cut  ofi",  and  the  stump  returned  into  the 
abdomen.  AVith  a  curved  needle  threaded  with  strong,  moderately  large 
silk  the  posterior  and  under  portion  of  Poupart's  ligament  is  sewed  to  the 
pectineal  aponeurosis  (pubic  portion  of  fascia  lata)  close  to  its  origin  from 
the  pectineal  line,  with  three  sutures.  The  first  suture  perforates  the  ligament 
immediately  external  to  the  pubic  spine;  the  second  is  placed  half  a  centi- 
meter outside  of  this,  and  farther  out  still  is  placed  a  third.  These  sutures 
are  left  untied  until  the  next  are  in  position.  Three  or  four  sutures  now  are 
passed  through  the  falciform  border  of  the  fascia  lata  and  the  corresponding 
part  of  the  pectineal  fascia,  and  over  the  internal  saphenous  vein.  All  the 
sutures  are  now  tied ;  the  upper  ones  draw  Poupart's  ligament  backward  to 
the  pectineal  line,  and  thus  close  the  mouth  of  the  crural  canal ;  the  other 
sutures  close  the  saphenous  opening.  The  skin  is  next  sutured  and  no 
drainage  is  used. 

Bassini  had  operated  (when  his  paper  was  written)  on  54  cases,  and 
forty-one  of  them  he  had  kept  under  observation  for  from  two  to  nine  years, 
and  so  far  had  observed  no  relapses. 

In  umbilical  hernia  the  edges  of  the  hernial  opening  may  be  pared  and 
Iwought  together,  and  the  sac  itself  used  as  a  plug  to  stop  the  opening. 

Radical  Cure  in  Congenital  Hernia. — In  congenital  inguinal  hernia  the 
sac,  being  continuous  with  the  tunica  vaginalis,  cannot  be  dissected  out  and 
removed  in  its  entirety.  It  should  first  be  separated  from  the  surrounding 
structures  in  the  inguinal  canal,  and  then  divided  transversely  without  injuring 
the  cord.  The  lower  part  is  left  behind  and  forms  the  tunica  vaginalis ;  the 
upper  part  should  be  freed  from  the  cord  by  splitting  it  up  behind  and  the 
cord  carefully  separated.  The  sac  itself  should  now  be  pulled  down  and  liga- 
tured high  up,  and  cut  ofi"  as  in  other  forms  of  hernia. 

C^ECAL  Hernia. — Hernia  of  the  cnecum  alone  is  seldom  or  never  seen, 
for  in  nearly  every  case  in  addition  to  the  caecum  we  find  the  vermiform 
appendix,  a  portion  of  the  ileum,  and  a  portion  of  the  ascending  colon. 
According  to  the  most  recent  observations,  a  ceecocele  with  an  incomplete  sac 
is  rare.  The  sac  is  usually  complete,  and  the  caecum  and  other  portions  of 
the  intestines  accompanying  it  are  free  within  the  lumen  of  the  sac,  and  the 
walls  of  the  sac  are  not  reflected  around  any  part  of  the  intestine  (Lock- 

52 


818  AN    AMl'.incAX    TEXT-IIOOK    <)l'   SC /,'(.■  K/n'. 

wood).  CV)ii<^enital  ciococele  is  the  most  coiuuion  variety,  and  is  usually  eauscd 
by  the  descent  of  the  testicle,  which  pulls  down  the  ciecum,  apjtendix,  and 
])ortions  of  the  ileum  with  it.  This  is  due  to  the  existence  of  a  fold  of  peri- 
toneum (plica  vascularis)  reaching  from  the  globus  major  of  the  testicle  to  the 
ci«cum,  appendix,  ileum,  and  mesentery,  and  which  contains  the  sj)ermatic  ves- 
sels and  gubcrnaculum  testis.  In  accpiired  ciecoccle  thoc  has  usually  been 
an  antecedent  hernia  of  the  small  intestines,  but  in  some  cases  where  the 
cfecum  with  the  ascending  colon  float  freely  in  the  abdomen,  owing  to  the 
large  and  small  bowel  liaving  a  common  mesentery,  hernia  of  the  caecum  may 
occur  in  the  same  way  as  does  hernia  of  the  small  intestines. 

SkjmoU)  Hkrxia  is  very  much  like  c:ocal  hernia,  and  in  the  same  way 
may  be  divided  into  congenital  and  ac([uired,  with  an  incomj)lete  or  complete 
sac.  The  sigmoid  Uexure,  like  the  c;ecum,  has  connected  with  it  the  fold  of 
peritonenm  (plica  vascularis),  which  contains  the  spermatic  vessels,  and  in 
fetal  life  connects  the  testicle  with  the  sigmoid  flexure.  During  the 
4lescent  of  the  testicle  the  sigmoid  flexure  may  be  carried  down  with  it,  but 
on  the  other  hand  nniy  be  the  cause  of  keeping  the  testicle  from  descending. 

Irreducible  Hernia. — A  hernia  is  said  to  be  irreducible  when  the  pro- 
truded bowel  cannot  be  returned  into  the  abdominal  cavity,  and  this  without 
any  symptoms  of  strangulation  or  obstruction.  Irreducible  herniaj  are  usually 
of  long  standing  and  large  size.  This  condition  is  often  caused  by  careless- 
ness in  the  patient  and  neglect  to  keep  in  a  reducible  hernia  with  a  truss. 
There  is  always  a  large  amount  of  omentum  in  the  sac,  and  this  it  is  which 
cannot  be  returned,  the  gut  often  sli])ping  in  without  difliculty.  The  reason 
why  the  hernia  cannot  be  reduced  is  that  adhesions  have  formed  between  the 
omentum  and  sac  and  also  between  the  omentum  and  the  bowel  itself.  As 
time  goes  on,  the  neck  of  the  sac  thickens  and  becomes  narrower,  while  the 
mass  of  omentum  becomes  larger.  The  hernia  sometimes  reaches  an  enormous 
size,  preventing  the  patient  from  following  any  occupation.  Even  if  it  be 
small,  it  gives  rise  to  much  discomfort,  and  the  ])atient  is  always  in  danger  of 
strangulation  of  the  rupture. 

Treatment. — The  reduction  of  an  irreducible  hernia  can  be  satisfactorily 
accomplished  by  performing  the  operation  for  radical  cure.  The  sac  should 
be  opened,  the  excess  of  omentum  tied  off  with  catgut  or  silk,  and  the  bowel 
returned  ;  then  a  radical  cure  should  be  performed.  Should  the  individual  be 
old  and  fat,  the  operation,  even  when  performed  with  the  strictest  aseptic  pre- 
cautions, is  not  without  danger.  In  very  large  hernije  in  stout  people  it  is 
well  to  prepare  them  by  keeping  them  in  bed  for  a  couple  of  weeks  or  more, 
feeding  them  on  a  diet  which  will  not  make  ftit,  such  as  lean  meat  and  vege- 
tables, and  giving  them  no  fats,  sugar,  starch,  or  alcohol.  By  this  means  the 
patient's  size  is  reduced,  and  the  bowel,  which  has  perhaps  not  entered  the 
abdomen  for  years,  may  sometimes  be  reduced  without  much  difficulty.  In 
some  of  these  cases,  where  the  ring  is  of  large  size,  the  radical  cure  may  be 
made  much  more  certain  by  the  removal  of  the  testicle  and  the  cord  of  the 
affected  side.  Some  surgeons  advise  attempting  reduction  without  operation 
by  keeping  the  patient  in  bed,  with  hips  raised,  ice  to  the  scrotum,  and  on  low 
diet.  Taxis  should  be  employed  daily,  and  occasional  saline  purgatives  should 
be  given.  By  this  means  the  fat  is  absorbed  and  reduction  has  been  accom- 
plisheil  after  a  few  weeks.  "Where  operation  is  refused  or  is  inadvisaltle  owing 
to  age,  etc.,  this  method  may  be  tried.  Trusses  with  a  large  concave  pad 
have  been  devised  for  the  support  of  this  form  of  hernia. 

Incarcerated  Hernia. — By  this  term  is  indicated  an  irreducible  hernia 
in  old  people,  which  becomes  obs^tructed  with  gases,  feces,  or  undigested  food, 


I)Isi:asi:s  am)  lwhiuks  of  the  AnnoMiiy.        «19 

and  lioiico  the  ])ass:i(ro  tliroiiirh  the  Ixnvels  is  ])l(icki'tl.  It  is  most  common  in 
umliilical  licniia.  Tlieiv  may  be  eructation  of  ^as  and  slitrlit  vomiting,  with 
constipation,  but  there  is  no  tenderness  or  tension  of  the  hernial  tumor  and 
all  the  symptoms  are  subacute.  Impulse  on  coughing  is  well  marked.  It  is 
necessary  in  these  cases  to  give  large  enemata  of  sweet  oil  with  a  little  turpen- 
tine. Taxis  may  be  tried,  and  in  this  way  the  gases  and  feces  may  be  made  to 
move  on.  Tiie  local  application  of  ice  or  of  hot  fomentations  aids  in  relieving 
this  condition.  A  full  dose  of  castor  oil  may  be  given  after  the  above  means 
have  been  tried. 

Inflamed  Hernia. — This  is  generally  the  result  of  violence  or  may  be 
produced  by  pressure  of  a  badly-fitting  truss.  The  part  is  hot,  red,  painful, 
and  tender,  but  there  is  not  much  tension  ;  there  may  be  increase  in  the  size 
of  the  tumor.  Pyrexia  is  always  present,  and  there  are  all  the  symptoms  of 
a  local  peritonitis.  There  may  be  vomiting  and  constipation,  but  no  great 
constitutional  depression,  as  in  strangulated  hernia,  and  there  is  still  impulse 
on  coughing.  Irreducible  hernia  are  the  most  liable  to  become  inflamed, 
especially  irreducible  femoral  epiplocele. 

Treatment. — Rest  in  bed,  with  the  local  application  of  an  ice-bag,  relaxa- 
tion of  the  parts  by  position,  and  if  there  is  much  pain  opium  should  be  given. 
Should  the  condition  go  on  to  suppuration,  an  incision  should  be  made  and  the 
pus  in  the  sac  evacuated.  The  effects  of  the  inflammation  are  seen  in  the  sub- 
sequent firm  adhesions  of  the  gut  or  omentum  to  the  sac. 

Strangulated  Hernia. — A  rupture  is  said  to  be  strangulated  when  it  is 
so  tightly  constricted  at  its  neck  that  it  cannot  be  returned  into  the  abdomi- 
nal cavity  and  its  circulation  is  interfered  with  ;  thus  there  is  not  only  obstruc- 
tion to  the  passage  of  feces,  but  also  an  arrest  of  circulation  in  the  protruded 
portion  of  bowel  Avhich,  if  not  relieved,  results  in  gangrene  and  death.  It 
occurs  more  often  in  old  than  in  recent  hernias,  and  more  often  in  conjrenital 
than  in  acquired. 

Mechanism  of  Strangulation. — It  is  usually  due  to  the  descent  of  an 
additional  fresh  knuckle  of  bowel  into  an  old  hernial  sac,  or,  in  a  case  in 
which  there  has  been  no  prior  hernia,  to  a  sudden  descent  of  a  knuckle  of 
bowel  during  some  violent  exertion  through  some  of  the  natural  apertures  of 
the  abdomen.  This  sudden  forcing  of  the  bowel  through  a  narrow  aperture 
causes  constriction,  which,  if  it  continues,  is  followed  by  strangulation.  It 
does  not  always  occur  during  violent  effort,  but  may  be  produced  by  increased 
peristaltic  action  of  the  bowels  in  a  patient  who  has  been  suffering  from  diar- 
rhea, constipation,  or  what  is  commonly  called  '"bowel  complaint."  At  first 
there  is  merely  constriction  at  the  hernial  ring :  this  leads  to  congestion  of  the 
part  and  arrest  of  return  of  venous  blood,  which  results  in  engorgement  and 
swelling  of  the  protruded  portion  of  gut.  This  swelling  increases  the  con- 
striction, strangulation  ensues,  and,  if  it  is  very  severe,  death  of  the  part 
rapidly  follows.  In  some  cases  where  the  strangulation  is  not  so  extreme 
the .  circulation  is  not  entirely  arrested ;  the  progress  of  the  disease  is  not 
so  rapid,  and  ulceration  of  the  constricted  portion  may  be  the  result.  This 
is  followed  by  perforation,  escape  of  feces  into  the  peritoneum,  and  general 
peritonitis. 

The  seat  of  stricture  may  be  at  the  hernial  orifice  or  in  the  neck  of 
the  sac  itself  It  is  most  fre([uently  outside  the  neck  of  the  sac  at  one  of  the 
hernial  rings.  When  it  occurs  at  the  neck  of  the  sac,  it  is  due  to  thickening 
at  that  point  and  the  fusing  together  of  the  various  pleats  and  folds  into 
which  a  large  sac  is  thrown  where  it  passes  through  a  small  opening.  The 
seat  of  stricture  may  be   in  the  sac   itself,  produced   by  bands  of  adhesions 


b-20  A.\   AMERICAN    TEXT-BOOK    OF   SLUUEUY. 

which  stretch  across  it.  Cases  are  on  record  where  the  straiif^ulation  has  been 
proihiced  by  the  twistin<^  of  a  h)oj)  of  tlie  protruded  bowel  in  tlie  sac. 

Local  Changes  the  Result  of  Strangulation. — First.  congeHtion 
occurs  in  the  protruded  j)arts,  j)r(jduc-ed  by  the  arrest  of  circuhition  through 
the  veins,  but  not  the  arteries ;  then  engorgement  and  swelling  occur,  and  the 
bowel  has  first  a  dark-red,  then  a  ])urplish,  appearance.  At  the  same  time 
there  is  effusion  of  serum  into  the  sac,  and  now  the  circulation  is  completely 
obstructed  and  the  bowel  becomes  almost  black,  and  soon  becomes  gangrenous. 
When  the  obstruction  to  the  circulation  is  not  complete  and  has  laiited  some 
time,  the  effects  of  inflammation  are  seen  :  the  bowel  becomes  dark  in  color,  loses 
its  glistening  appearance,  is  covered  with  flakes  of  lymph,  and  becomes  soft 
and  less  elastic,  and  the  serous  coat  is  covered  with  ashy-gray  spots.  Omen- 
tum, when  strangulated,  has  first  a  dark -purplish,  and  afterward  a  yellowish- 
gray,  color.  In  a  hernia  that  has  been  strangulated  for  some  time  there  are 
always  evidences  of  inflammation.  As  the  gangrene  advances,  gas  is  generated 
and  the  parts  crackle,  the  gut  ruptures,  and  fecal  matter  is  extravasated.  The 
fluid  in  the  sac,  which  was  at  first  clear,  becomes  reddish,  turbid,  and  finally 
off'ensive.  It  is  sometimes  very  difficult  to  tell  positively  whether  the  gut  is  so 
damaged  as  to  be  beyond  recovery.  It  may  be  very  dark  colored  and  yet  be 
sufficiently  alive.  The  best  test  is  the  condition  of  the  peritoneal  coat,  which 
peels  off"  easily  when  it  has  lost  its  vitality.  If  the  bowel  is  flaccid  and  in- 
elastic, then,  without  doubt,  gangrene  has  set  in.  The  bowel  may  be  ulcerated 
at  the  line  of  stricture  and  perfectly  healthy  elsewhere.  Perforation  may  result 
and  feces  escape  into  the  abdominal  cavity,  leading  to  general  peritonitis  and 
death.  Suppuration  of  the  sac  may  occur  as  the  result  of  strangulation,  but 
this  is  rare.  Gangrene  of  the  intestine  is  more  frequent  in  femoral  than  in 
inguinal  hernia,  but  ulceration  of  the  line  of  stricture  is  more  common  in 
strangulated  inguinal  hernia. 

Symptoms. — In  cases  in  which  there  is  sudden  and  complete  constipation 
with  perisistent  vomiting  a  strangulated  hernia  should  always  be  suspected,  and 
the  various  apertun's  through  which  a  hernia  might  ])rotrude  should  always 
be  examined.  If  at  the  site  of  a  hernia  is  found  a  tumor  which  is  tense,  hard, 
and  painful  and  irrreducible,  there  will  not  be  much  difficulty  in  making  a 
diagnosis. 

The  symptoms  of  strangulated  intestine  are  always  the  same,  whether  the 
strangulation  occurs  in  the  abdomen  or  outside  of  it — viz.  faintness,  collapse, 
severe  abdominal  pain,  chiefly  referred  to  the  umbilical  region,  complete  con- 
stipation, so  that  flatus  ceases  to  pass,  then  vomiting,  at  first  of  food,  then  of 
bile-stained  fluid,  and  finally  of  fluid  with  a  fecal  odor.  The  tongue  is  dry  and 
brown  and  the  pulse  rapid.  In  strangulated  hernia  there  are  ivi  addition,  at 
first,  pain  at  the  seat  of  rupture,  a  greater  degree  of  tension,  the  tumor  having 
increased  in  size,  dulness  on  percussion  over  the  hernia,  and  absence  of  impulse 
on  coughing,  with  the  fact  that  the  tumor  is  irreducible. 

If  unrelieved,  the  abdomen  becomes  much  distended,  retching  is  more  fre- 
quent and  thirst  intense,  hiccough  sets  in,  the  urine  is  much  diminishea  in 
quantity,  and  the  patient  gradually  sinks  from  exhaustion  in  eight  or  nine 
days,  though  in  very  acute  cases  he  may  die  in  forty-eight  hours.  The  bowel 
by  this  time  has  become  gangrenous  or  there  is  general  peritonitis.  With  the 
onset  of  gangrene  there  is  often  a  cessation  of  the  more  urgent  symptoms,  as 
vomiting  and  pain.  The  severe  collapse,  pain,  and  vomiting  which  set  in  early 
in  a  case  of  strangulation  are  due  to  the  profound  impression  produced  on  the 
abdominal  sympathetic  plexuses  by  the  pinching  of  the  gut.  This  also 
accounts  for  the  diminished  excretion  of  urine. 


J)/.s/:asI'Js  a XI)  i\.iii!ii':s  or  rni:  MinoMrx.        821 

Often  the  symptoms  are  not  so  severe  as  described  above,  especially  in 
femoral  hernia,  where  the  patient  may  be  unaware  for  some  time  that  strangu- 
lation exists  or  even  that  he  has  a  hernia.  In  recent  hernise  the  symptoms  are 
much  more  acute  than  in  old  herniiie,  and  they  are  not  so  urgent  when  omen- 
tum is  protruded  witli  the  bowel  or  when  the  tumor  has  for  some  time  been 
irreducible.  In  cases  of  obturator  or  sciatic  hernia  it  may  be  impossible  to 
discover  the  tumor  even  by  the  most  careful  examination.  A  small  knuckle 
of  bowel  may  become  strangulated  behind  a  piece  of  omentum  and  be  out  of 
the  reach  of  the  surgeon :  there  is  no  impulse  on  coughing,  not  much  tender- 
ness, and  the  tumor  may  feel  soft  and  lax.  A  knuckle  of  gut  may  become 
strangulated  inside  the  sac  of  a  large  hernia,  and  yet  the  hernia  as  a  whole 
may  give  no  evidence  of  strangidation.  Again,  a  hernial  tumor  may  have 
all  the  symptoms  and  appearances  of  strangulation,  and  yet  not  be  the  seat 
of  the  obstruction.  All  these  possibilities  of  error  emphasize  the  need  of  ex- 
ploratory operations,  either  herniotomy  or  abdominal  section,  in  any  case  in 
which  life  is  seriously  endangered  and  the  exact  cause  obscure. 

Richter's  Hernia  (P.arti.al  Exterocelk). — This  was  formerly  de- 
scribed as  the  constriction  of  a  pre-existent  diverticulum  in  a  hernial  orifice, 
but  the  name  is  now  applied  to  that  form  of  hernia  where  only  a  part  of  the 
circumference  of  the  bowel  is  constricted  by  the  margin  of  a  hernial  opening. 
This  artificial  diverticulum  looks  like  a  nipple,  and  protrudes  from  the  con- 
vex surface  of  a  loop  of  bowel.  On  relieving  the  strangulation  the  nipple, 
as  a  rule,  disappears,  leaving  a  deeply  indented  ring  of  a  dark-blue  color  in 
strong  contrast  to  the  rest  of  the  bowel.  It  occurs  most  frequently  at  the 
femoral  ring,  only  a  few  cases  having  been  seen  elsewhere.  The  symptoms 
are  not  so  severe,  on  the  whole,  as  when  the  whole  circumference  of  the 
bowel  is  involved.  The  vomiting  is  not  so  persistent,  and  feces  and  flatus 
may  continue  to  pass.  The  tumor  itself  is  often  so  small  as  to  be  overlooked, 
and  if  the  patient  is  stout  even  the  most  careful  examination  will  fail  to  make 
it  out. 

The  proper  treatment  of  Richter's  hernia  is  either  herniotomy  or,  if 
there  be  every  symptom  of  hernia  and  no  tumor  present,  an  abdominal 
section. 

Littre's  Hernia. — This  term  is  applied  to  a  hernia  which  contains  a 
Meckel's  diverticulum.  It  is  vei'v  rare,  and  when  strangulation  takes  place 
the  symptoms  closely  resemble  those  met  with  in  partial  enterocele. 

Strangulated  Omental  Hernia. — When  omentum  alone  is  strangulated, 
as  sometimes  occurs,  the  symptoms  are  similar  to  those  of  strangulation  of  the 
bowel,  but  not  so  severe ;  the  pain  is  less,  vomiting  not  so  persistent,  and  con- 
stipation not  so  complete.  In  fact,  the  symptoms  are  those  of  Littre's  hernia, 
and  some  suroreons  assert  that  in  all  cases  of  so-called  strangulated  omental 
hernia  there  is  an  error  in  diacrnosis.  and  that  a  small  stranfjulated  knuckle  of 
gut  behind  the  omentum  has  been  overlooked. 

Diagnosis  of  Strangulated  Hernia. — Usually  the  diagnosis  of  stran- 
gulated hernia  presents  but  little  difiiculty.  It  may,  however,  be  confounded 
with  incarcerated  or  inflamed  irreducible  hernia. 

In  incarcerated  hernia  there  is  impulse  on  coughing  and  absence  of  tender- 
ness ;  vomiting,  when  present,  is  not  severe.  Constipation  exists  in  both,  but  in 
this  form  yields  to  treatment.  In  inflamed  hernia  the  local  inflammation  is  very 
marked,  and  elevation  of  temperature  always  exists ;  constipation  is  not  com- 
plete, flatus  and  fluid  feces  readily  passing,  and  there  is  no  vomiting.  When 
hernia  is  double,  it  sometimes  requires  a  careful  examination  to  determine 
which  one  is  strangulated.     Various  tumors,  glandular  and  others,  have  been 


822  .l.V   AMElilVAX    TKXT-Ji(J(Jh'    OF   SL'IH; Kin'. 

mistaken  for  strangulated  lieniia  and  operated  on.  The  loeal  evidence  of 
tumor  Avould  serve  to  diagnosticate  strangulated  hernia  from  iiitestinal 
obstruct  t'loi. 

Prognosis. — If  unrelieved  by  reduction  or  operation,  the  prognosis  is  bad. 
In  very  acute  cases  the  patient  will  die  in  forty-eight  hours  if  the  hernia  is  not 
reduced.  Some  cases  which  have  been  "  left  to  nature  "  have  lived  a  fortnight, 
and  in  others  the  bowel  has  become  gangrenous  and  the  sac  and  skin  have 
sloughed,  thus  exposing  the  opening  in  the  bowel.  Recovery  with  an  artificial 
anus  may  result. 

Treatment. — JS^o  deJay  is  permissible,  for  unless  the  strangulation  be 
relieved  the  patient  will  surely  die.  There  are  only  two  methods  of  treatment 
— first,  td.vis  :  second,  lierniotomy. 

Taxis. — This  is  the  reduction  of  the  bowel  into  the  abdomen  by  means  of 
manipulation  with  the  fingers.  When  seen  very  early  the  hernia  may  be 
returned  without  the  administration  of  an  anesthetic ;  indeed,  the  patient  him- 
self frequently  returns  the  hernia  by  assuming  the  recumbent  position  and 
pressing  in  the  protruded  bowel.  If  the  patient  is  seen  later  and  there  is  con- 
siderable tension  of  the  part,  an  anesthetic  should  be  administered  before  taxis 
is  attempted.  It  is  remarkable  how  simple  the  reduction  of  many  herniae 
becomes  under  ether  or  chloroform.  A  rupture  that  would  not  previously  yield 
to  taxis  often  goes  in  under  anesthesia  with  the  slightest  amount  of  manipu- 
lation. 

Method  of  Performing  Taxis. — When  fully  under  the  influence  of  the 
anesthetic,  the  patient  is  placed  on  his  back  with  the  pelvis  raised,  and  the  thigh 
of  the  affected  side  flexed  and  rotated  inward  if  the  hernia  be  femoral  or  inguinal. 
Indeed,  it  is  important  that  everything  should  be  done  to  relax  the  parts  about 
the  hernial  ring.  The  neck  of  the  sac  is  then  seized  with  the  thumb  and  fin- 
gers of  one  hand,  and  thus  fixed,  while  with  the  other  hand  the  surgeon  endeav- 
ors to  return  the  strangulated  gut  by  gentle  pressure  in  the  proper  direction. 
In  femoral  hernia  this  is  at  first  downward,  to  bring  the  gut  opposite  the 
saphenous  opening,  then  backward,  and  then  upward.  In  inguinal  hernia  it 
is  usually  slightly  upward  and  outward.  The  part  which  protruded  last,  pre- 
sumably at  the  neck  of  the  sac,  is  that  first  to  be  returned.  The  bowel  should 
be  coaxed  rather  than  forced  in.  A  kneading  and  squeezing  movement  or 
gently  pulling  the  tumor  from  side  to  side  or  downward  often  proves  .success- 
ful, the  gut  returning  Avith  a  sudden  gurgle  or  rush,  a  sensation  which  is  quite 
peculiar  to  hernia.  Too  prolonged  or  violent  manipulation  is  strongly  to  be 
condemned,  and  may  do  an  infinite  amount  of  injury.  If  by  moderate  and 
gentle  taxis  for  from  five  to  ten  minutes  the  surgeon  fails  to  overcome  the 
strangulation,  he  should  waste  no  further  time,  but  proceed  at  once  to  the  per- 
foriiumce  of  hcrniotornif. 

When  Taxis  is  Contraindicated. — Taxis  should  not  be  employed  when 
it  is  suspected  that  the  gut  is  already  gangrenous,  in  cases  where  the  hernial 
tumor  is  inflamed  by  previous  manipulation,  Avhere  stercoraceous  vomiting  has 
set  in,  or  in  many  of  the  later  stages  of  strangulation.  If  the  strangulation 
occurs  in  an  old  irreducible  hernia,  herniotomy  should  be  at  once  performed. 
The  older  methods  of  treatment  by  opium,  ice-bag,  or  hot  bath  should  be  tried 
in  those  cases  only  where  the  symptoms  are  not  urgent  or  the  patient  refuses 
operation. 

Strangulation  after  Reduction. — It  occasionally  happens  that  after  the 
reduction  of  a  hernial  tumor  symptoms  of  strangulation  persist,  and  when  such 
an  occurrence  takes  place  it  is  due  to  one  of  the  following  conditions :  (1)  the 
return  of  injured  or  gangrenous  bowel ;  (2)  paralysis  of  the  bowels,  existing 


DISEASES   Ayj>    jyJLJ:iES    OF    THE   ABDOMEN.  823 

as  the  result  of  freneral  ]»eritonitis;  (3)  tlie  presence  of  a  second  strangulated 
hernia  ;  and  (4)  the  reduction  of  the  hernial  tumor  en  ma»se  or  en  bloc. 

The  trt'atnient  of  all  these  conditions  is  the  same — viz.  abdominal  section 
and  the  immediate  examination  of  the  condition  of  affairs.  If  the  bowel  is 
jraiiirrenous,  an  artificial  anus  should  be  established,  or,  if  the  patient's  condi- 
tion warrants  it,  a  resection  and  lateral  anastomosis  of  the  affected  bowel  should 
be  performed.  In  the  other  cases  the  surgeon  should  be  guided  by  the  condi- 
tions found  on  opening  the  abdomen. 

If  the  sac  and  its  contents  are  returned,  still  strangulated,  into  the  abdom- 
inal cavity,  the  condition  is  known  as  reduction  en  masse.  The  tumor  disap- 
pears without  any  gurgling  sound,  and  the  constitutional  symptoms  are  still 
unrelieved.  Immediate  incision  should  be  practised,  either  in  the  median  line 
or  over  the  site  of  the  hernia.  This  accident  occurs  most  frequently  in  the 
inguinal  variety  of  hernia. 

In  certain  rare  cases  the  sac  is  ruptured  and  the  gut  makes  its  escape  into 
the  subserous  connective  tissue,  the  protruded  bowel  still  remaining  strangu- 
lated. Treatment  by  herniotomy  should  be  performed  for  the  relief  of  the  latter 
two  conditions. 

Remote  Consequences  following  Reduction  of  a  Strangulated  Hernia. — 
Intestinal  obstruction  may  ensue  some  time  after  a  reduction  of  hernia :  (1) 
owing  to  the  formation  of  bands  of  adhesion ;  (2)  from  a  displaced  hernial 
sac :  (3)  from  cicatricial  stenosis,  due  to  some  sloughing  of  part  of  the 
injured  bowel. 

In  all  these  cases  exploratory  laparotomy  is  called  for.  and  in  the  last- 
mentioned  resection  of  the  stenosed  portion   of  the  bowel. 

After-treatment. — After  a  strangulated  hernia  has  been  reduced  the 
vomiting  ceases  and  the  patient  feels  greatly  relieved.  He  should  be  kept  in 
bed  for  some  days,  and  fed  on  nutritious  fluid  diet  until  the  bowels  act  sponta- 
neously. It  is  well  to  fix  a  pad  over  the  hernial  ring  by  means  of  a  properly- 
applied  bandage,  to  prevent  the  return  of  the  hernia. 

Herniotomy. — Should  taxis  fail  or  the  case  be  one  where  the  conditions 
are  adverse  to  taxis,  the  surgeon  must  at  once  proceed  to  perform  herniot- 
omy. Having  shaved  the  parts  and  carefully  cleansed  them  antiseptically, 
an  incision  about  two  inches  long  should  be  made  over  the  tumor  and  the 
various  structures  carefully  divided  down  to  the  sac.  It  is  often  very  difficult 
to  recognize  the  sac,  it  varies  so  much  in  character,  sometimes  bein^r  thick  and 
fibrous,  and  at  other  times  thin  and  translucent.  It  is  often  hard  to  distin- 
guish it  from  bowel  or  omentum.  Most  commonly,  in  recently  strangulated 
cases  which  have  been  previously  reducible,  it  looks  like  a  cyst,  fluctuating 
and  having  a  bluish  color.  When  reached  it  should  be  pinched  up  between  two 
artery  forceps  and  divided ;  immediately  there  is  an  escape  of  fluid  often  hav- 
ing a  fecal  odor,  and  the  bowel  is  seen  lying  within  the  sac.  The  constriction, 
which  is  usually  at  the  hernial  ring,  should  now  be  relieved  by  cutting.  To 
effect  this  the  finger  is  introduced  up  to  the  constricting  point,  a  blunt-pointed 
bistoury  pushed  along  it.  and  the  constriction  divided  cautiously  in  the  proper 
direction  suitable  to  each  form  of  hernia.  The  bowel  should  then  be  exam- 
ined :  if  healthy  and  full  of  vitality,  as  evidenced  by  its  elasticity  and  capacity 
to  transmit  its  contents  (the  strangulation  having  been  relieved),  it  may  be  at 
once  returned  into  the  abdomen  with  the  omentum.  If  the  protruded  omen- 
tum be  large  in  amount  or  adherent,  it  is  better  to  tie  it  with  silk  or  catgut  in 
sections  and  then  remove  it.  Any  adhesions  that  exist  should  be  freed  and, 
if  vascular,  cut  between  two  ligatures.  The  sac  should  then  be  treated  as  in 
operations  for  the  radical  cure  of  hernia,  and  the  neck  of  the  sac  ligatured  as 


824  AN   AMKinCAN    TEXT-llOOK    OF   srUdERY. 

hiirh  up  as  possible.  If  the  sac  be  small,  it  should  be  dissected  out  and  cut 
off  lialf  an  inch  below  the  ligature  at  its  neck  ;  but  if  it  be  large,  it  may  be 
left,  after  cutting  it  througli  or  excising  a  small  part  of  the  upper  portion. 
The  canal  is  closed,  as  in  the  radical  cure  of  hernia.  If  the  hernia  is  actjuired, 
as  is  most  commonly  the  case,  the  conjoined  tendon  should  be  sutured  to  Pou- 
part's  ligament  with  three  or  four  stout  silk  sutures.  The  external  wound  is 
closed  in  the  usual  way  with  silkworm-gut  or  silk  sutures,  and  the  ordinary 
antiseptic  dressings  applied,  maintained  in  place  by  a  firmly-applied  spica 
bandage. 

The  patient  should  have  no  iluiil  or  food  of  any  kind  for  twenty-four  hours : 
there  is,  hoAvever,  no  objection  to  the  administration  of  a  small  dose  of  mor- 
phia hypodermatically  if  there  be  much  pain.  The  bowels  may  be  allowed  to 
act  of  their  own  accord,  and  if,  at  the  end  of  a  Aveek,  they  are  still  constipated, 
they  may  be  relieved  by  enemata,  castor  oil,  and  salines.  If  there  be  much 
distention  previous  to  this,  salines  often  prove  beneficial. 

Abdominal  Section  to  Reduce  Strangulated  Hernia. — Tait  has 
recently  proposed  to  treat  strangulated  hernia  by  abdominal  section  and 
reduction  of  the  hernia  by  traction  from  within  the  belly,  aided  by  pressure 
from  without,  instead  of  the  usual  method  of  external  herniotomy.  In  excep- 
tional cases  this  may  be  commended ;  as,  for  instance,  in  a  case  of  evident 
acute  intestinal  obstruction  from  a  femoral  hernia  so  small  as  not  to  produce 
any  perceptible  tumor  externally,  or  in  a  pre-peritoneal  hernia ;  but  it  will 
hardly   replace  herniotomy  as  a  routine  practice. 

Gangrenous  Intestine  and  its  Treatment. — When  on  opening  the  sac 
the  intestine  is  found  to  be  gangrenous,  what  should  be  done?  There  are  seve- 
ral methods  advocated :  (1)  To  resect  the  gangrenous  gut,  suture  the  cut  ends, 
and  return  the  bowel  into  the  abdomen.  (See  Enterotomy.)  (2)  To  fasten  it 
outside  the  abdomen  and  open  it  at  once.  The  patient  recovers  with  an  arti- 
ficial anus  or  a  fecal  fistula,  Avhich  can  be  treated  at  a  later  period  when  he  has 
regained  his  strength.  (3)  If  only  a  small  portion  of  the  bowel  be  gangrenous, 
to  return  it  within  the  abdominal  cavity,  anchor  it  Avith  a  suture  just  inside  the 
ring,  and  introduce  a  large  drain  through  the  ring  in  close  proximity  to  the 
bowel.  (1)  Resection  of  the  gut,  owing  to  the  Aveak  condition  of  the  patient, 
may  not  ahvays  be  advisable.  In  such  cases  the  use  of  Murphy's  button,  or 
some  other  means  of  rapidly  uniting  the  ends  of  the  divided  bowel,  is  recom- 
mended. The  second  method  is  perhaps  the  safest  for  the  general  prac- 
titioner Avho  has  ha-d  no  practice  in  resecting  intestine.  His  patient  Avill  have 
a  better  chance  of  recovery,  and  later  operative  procedures  for  closing  the  fecal 
fistula  can  be  undertaken.  A  method  advocated  lately  by  llelferich  of 
GreifsAvald  is  Avorthy  of  mention — viz.  to  make  an  immediate  alxlominal  sec- 
tion and  establish  intestinal  anastomosis  betAveen  the  part  of  the  intestine 
above  the  gangrenous  gut  and  the  part  beloAv  it.  The  gangrenous  gut  is 
alloAved  to  remain  outside  the  hernial  opening.  By  this  means  peristalsis  is 
obtained  from  the  first,  and  later  the  gangrenous  gut  may  be  resected  Avith- 
out  danger,  the  anastomosis  favoring  the  early  closure  of  the  fecal  fistula. 

Seqnehe  to  Herniotomy. — (1)  Tiie  Avound  may  not  unite  by  first  intention, 
and  if  the  sac  has  been  very  adherent  the  disturbance  of  the  cellular  tissue 
mav  cause  some  sloughing.  In  such  cases  the  Avound  should  be  reopened  and 
stuffed  with  iodoform  gauze. 

(2)  Diffuse  general  peritonitis  may  set  in  ;  this  is  known  by  the  persistence 
of  the  vomiting,  the  continuance  of  the  pain,  distention,  and  tenderness  of  the 
abdomen,  Avith  elevation  of  temperature.  This  may  be  due  to  leakage  from  a 
j>erforation,  to  a  gangrenous  condition  of  the  boAvel,  or  to  the  introduction  of 


DISEASES  AND    INJURIES    OF    THE   ABDOMEN 


825 


septic  matter  from  will.out  at  tlie  time  of  operation,  as  in  any  other  alxlominal 
section.     Immediate  laparotomy  should  be  done. 

(3)  The  reduced  j^it,  ^vhicli  has  been  returned  as  suspicious,  may  become 
gancrrenous  and  obstruction  of  the  bowel  still  continue.  If  this  condition  be 
su^lKH'ted.  the  abdomen  should  be  opened  and  the  <rancrrenous  bowel  sought 
for,  and  either  resected  or  incised,  and  kept  outside  the  abdomen  with  the 
object  of  forming  an  artificial  anus. 

'  (4)  The  bowel  may  not  be  gangrenous,  yet  be  so  injured  that  it  may  not  be 
able  to  resume  its  proper  functions,  and  the  patient  may  die  in  consequence  if 
not  relieved  bv  a  laparotomy. 

(5)  The  bowel  may  be  temporarily  paralyzed  by  local  inflammation  so  as 
not  to  be  able  immediately  to  resume  its  functions,  though  alter  some  days  it 
may  recover  completely  its  normal  condition.  In  such  cases  there  is  obstinate 
constipation,  without  vomiting  or  other  signs  of  peritonitis. 

(G)  Cases  of  acute  mania  have  followed  the  operation  tor  strangulatea 
hernia,  some  of  which  have  proved  fatal  (Shepherd). 

SPECIAL  HERNIiE-INGUINAL  HERNIA. 

This  is  the  commonest  form  of  rupture.  More  than  two-thirds  of  the  cases 
4ipplying  to  the  London  Truss  Society  for  trusses  suffered  f'-^m  inguinal  hernia. 
Accordmcr  to  Bercrer,  as  the  result  of  the  examination  of  10,000  cases  ot 
hernia,  9G  per  cent,  of  the  males  had  inguinal  hernia,  and  44.6  per  cent. 

of  the  females.  ,  .  ,   .      .       ,    ^     ^    ^^  .^    ■ 

By  inguinal  hernia  is  meant  a  rupture  which  is  situated  wholly  or  partly  in 
the  inguinal  canal  or  in  the  inguinal  canal  and  scrotum. 

Ino-uinal  hernia  may  be  oblique,  or  external,  and  db'ect,  or  internal. 
An  Oblique  Inguinal  Hernia  is  one  which  passes  through  the  spermatic 
canal,  having  the  same  course  as  the  spermatic  cord— viz.  through  the  internal 
rin..  aloncr  the  inguinal  canal,  and  through  the  external  abdominal  ring  to  the 
scrStum.  ''in  its  course  it  passes  to  the  outer  side  of  the  epigastric  artery,  and 
hence  is  also  called  external  mguinal  hernia.  Oblique  inguinal  hernia  consists 
of  two  forms,  congenital  and  acquired. 

Direct  or  Internal  Inguinal  Hernia  passes  directly  through  the  abdom- 
inal walls  to  the  external  abdominal  ring,  and  thence  to  the  scrotum.  It  pushes 
in  front  of  it  or  passes  through  the  conjoined  tendon,  and  is  i7iternal  to  the  epi- 
gastric artery,  passing  through  a  triangle  bounded  internally  by  the  rectus 
abdominis,  externally  by  the  epigastric  artery,  and  below  by  Poupart  s  liga- 
ment (HesselhacK s  triangle).  . 

Congenital  Inguinal  Hernia.— The  tubular  process  of  peritoneum  which 
accompanies  the  testicle  in  its  descent  to  the  scrotum  becomes  obliterated  at  its 
upper  part  durino-  the  later  months  of  foetal  life.  The  lower  part  remains, 
envelops  the  testicle,  and  is  called  the  tunica  vaginalis.  The  previous  connec- 
tion of  the  tube  with  the  peritoneum  is  marked  by  a  dimple  at  the  internal 
rino-  Occasionally  this  obliteration  does  not  take  place,  and  the  tube  remains 
con'tinuous  with  the  abdominal  peritoneal  cavity,  so  that  a  hernia  may  suddenly 
descend  in  this  tube  to  the  scrotum.  The  hernia  is  in  the  tunica  vaginalis, 
which  forms  its  sac.  This  is  the  form  of  hernia  which  is  named  congenital 
(Ficr    .3.36)      It  is  said  to  occur  most  fref|uently  on  the  right  side. 

Iviethod  of  Obliteration  of  tlie  Tubular  Process.— There  are  two 
points  at  which  the  obliteration  takes  place— viz.  at  the  internal  ring  and  a 
little  above  the  epididvmis  (Fig.  337).  The  obliteration  begins  first  at  the 
higher  point   and  takes  place  later  at  the  lower  point,  thus  leaving  a  serous 


826 


.l^V  AMERICAN    TEXT-BOOK    OF  SURGERY. 


tultc  bftwt'on  them. 


Fi(i.  33ti. 


Tbis  tubt'  .sodu  .shrinks  into  ;i  Hla-ous  curd;  but  on  the 
other  hand  the  process  of  obliteration  ujay  not  go 
on,  and  while  the  two  ends  are  closed  the  tube  re- 
mains patent,  and  in  it  a  hydrocele  of  the  cord  may 
subseipieiitlv   form. 

Infantile  or  Encysted  Hernia.  — In  certain 
cases  the  tubular  process  of  peritoneum  closes  only 
at  the  upper  end,  thus  leaving  only  a  thin  layer  of 
membrane  between  the  peritoneal  cavity  and  the 
tunica  vaginalis.  "When  a  hernia  occurs,  as  it  some- 
times does,  even  in  adult  life,  suddenly,  the  hernial 
sac  is  pushed  into  the  tunica  vaginalis,  carrying  the 
septum  before  it.  and  hence  in  front  of  the  gut  there 
will  be  three  layers  of  peritoneum  (Fig.  338).  Oc- 
casionally the  septum  is  ruptured,  and  the  gut  may, 
as  in  true  congenital  hernia,  descend  into  the  sac  of  the  tunica  vaginalis. 


Congenital  Hernial  Sac 
(original). 


Fig.  337. 


Fig.  338. 


Fig.  339. 


Infantile  Hernial  Sac, 
first  stage  (original). 


Infantile  Hernial  Sac,  sec- 
ond stage  (original). 


Funicular  Hernial  Sac 

(original). 


Hernia  into  tlie  Funicular  Process. — When  the  tubular  prolongation 
of  peritoneum  closes  at  the  loiver  point  only,  there  is  a  funicular  process  of 
peritoneum  which  passes  through  the  internal  ring,  down  the  canal,  and  into  the 
scrotum.  The  gut  gets  into  this  process,  and.  as  in  congenital  hernia.  pas.ses 
down  into  the  scrotum,  but  the  testicle  remains  quite  distinct  from  the  rupture 
(Fig.SlOj. 

Congenital  hernia,  as  its  name  implies,  appears  at  birth  or  soon  after,  devel- 
oping suddenly  ;  at  once  descending  into  the  scrotum,  it  envelops  the  testicle. 
This  form  of  hernia  is  much  more  liable  to  strangulation  than  the  acquired^ 
and  is  very  difficult  to  reduce  when  strangulated,  because  the  neck  of  the  sac 
remains  long  and  narrow  (Fig.  309). 

Congenital  inguinal  hernia  is  almost  the  only  form  of  hernia  seen  in  female 
children.  The  bowel  protrudes  into  the  canal  of  Xuck,  a  process  of  perito- 
neum which  descends  along  the  round  ligament  in  the  female  foetus. 

Acquired  Inguinal  Hernia  (Plate  XIX,  Fig.  1). — This  fonn  is  rarely 
or  never  seen  before  jjuberty,  and  is  more  common  in  men  than  in  women.  It 
may  be  either  oblique  or  direct. 

The  oblique  form  descends  along  the  inguinal  canal  to  the  outer  side  of  the 
epigastric  artery,  and  is  the  most  common  variety  of  hernia.  Its  coverings 
from  within  out  are  the  peritoneum,  infundibuliform  process  of  the  transver- 
salis  fascia,  cremaster  muscle,  intercolumnar  fascia,  superficial  fascia,  and  skin. 
As  it  emerges  from  the  external  rinir  and  enters  the  scrotum  it  becomes  much. 


HERNIA. 


Plate  XIX. 


1.  Femoral  hernia.    2.  Inguinal  (scrotal)  hernia. 


J) IS i: ASKS  AM)  lyjrniKs  of  the  abdomen.        827 

larger,  and  in  some  cases  is  of  enoniioiis  size  (Plate  XX,  Fig.  1).  In  the 
female  it  enters  the  laliium  majus  (Plate  XX,  Fig.  2). 

In  old  eases  of  ae(|uired  ()bli([iie  hernia  the  rings  l)ecome  much  enlarged 
and  are  approximated,  so  that  the  internal  ring  lies  directly  behind  the  exter- 
nal. This,  of  course,  has  the  effect  of  shortening  tlie  neck.  Whilst  an  oblique 
hernia  is  in  the  inguinal  canal  it  is  called  a  bubonocele.  It  always  forms 
sloAvly,  and  in  this  is  very  different  from  the  congenital  form.  It  is  always  in 
front  of  the  s])ermatic  cord,  and  when  it  reaches  the  scrotum  the  testicle  is 
always  below  and  distinct  from  the  hernia. 

In  acquired  direct  inguittal  hernia  the  hernial  sac  protrudes  directly  through 
the  external  ring  to  the  scrotum.  It  either  passes  through  the  conjoined  tendon 
or  to  the  outer  side  of  it,  and  there  is  no  long  neck,  as  is  the  case  in  the  oblique 
variety.  When  reduced,  tlie  fino;er  can  be  puslied  directly  throujih  the  exter- 
nal  ring  nito  the  abdominal  cavity,  whereas  in  the  oblique  form  the  finger  passes 
along  the  inguinal  canal  to  the  internal  ring  and  then  into  the  abdominal 
cavity.  In  old  hernige,  however,  as  mentioned  above,  where  the  rings  are 
large  and  opposite  each  other,  the  contrast  is  not  so  marked,  and  in  fact  a 
diagnosis  cannot  always  be  made. 

Direct  hernire  are  never  congenital. 

Diagnosis  between  Congenital  and  Acquired  Inguinal  Hernia. — 
Congenital  hernia  occurs  suddenly  at  birth  or  soon  after,  passes  at  once  to  the 
scrotum,  and  envelops  the  testicle,  rendering  its  recognition  difficult.  Acquired 
hernia  comes  on  slowly  in  adult  life,  and  has  the  testicle  below  and  quite  dis- 
tinct from  the  hernial  sac. 

Diagnosis  of  Inguinal  Hernia  from  Other  Tumors. — Usually  a 
hernia  is  recognized  by  the  history  of  the  case,  the  impulse  on  coughing, 
the  tympanitic  note  on  percussion,  and  its  reducibility.  The  intestine  always 
returns  with  a  gurgle.  The  swelling  occupies  the  inguinal  canal,  and  its  upper 
limit  cannot  be  reached.  The  testicle  in  the  acquired  variety  is  situated  at  the 
bottom  of  the  sac,  and  the  spermatic  cord  is  obscured.  There  is  always  an 
impulse  on  coughing,  even  in  an  irreducible  hernia.  When  the  sac  contains 
omentum  it  is  dull  on  percussion,  has  a  doughy,  knotty  feeling,  and  returns 
without  a  gurgle. 

Hydrocele. — History  of  a  tumor,  beginning  below  and  extending  upward ; 
is  dull  on  percussion,  pyriform  in  shape,  gives  no  impulse  on  coughing;  is 
translucent ;  the  testicle  is  behind  and  at  the  middle. 

Hematocele  comes  on  suddenly  after  injury  ;  is  dull  on  percussion,  gives  no 
impulse  on  coughing ;  is  opaque,  with  a  doughy  feel. 

Congenital  Hydrocele. — Is  translucent,  dull  on  percussion,  gives  an  im- 
pulse on  coughing ;  the  testicle  is  behind  the  tumor ;  the  tumor  disappears 
when  the  patient  lies  down,  and  returns  slowly  on  standing,  and  fills  from 
the  bottom,  whereas  in  hernia  the  tumor  is  opacjue  and  reappears  quickly  on 
standing.     When  hernia  and  hydrocele  coexist  the  diagnosis  is  not  so  easy. 

Hydrocele  of  the  Cord. — This  appears  as  a  tense,  fluctating  swelling  in  the 
inguinal  canal,  having  distinct  limits  above.  On  pulling  the  cord  it  moves 
with  it.     (See  Diseases  of  the  Spermatic  Cord.) 

Varicocele. — Is  dull  on  ])ercussion,  but  may  have  an  impulse  on  coughing; 
feels  like  a  bag  of  worms.  It  can  be  reduced  by  pressure,  but  returns  even  if 
pressure  be  made  on  the  ring  sufficient  to  retain  any  hernia. 

Undescended  Testicle. — In  every  case  of  inguinal  swelling  the  surgeon 
should  examine  the  scrotum  to  see  if  it  contains  two  testicles,  and  then  he 
cannot  mistake  an  undescended  testicle  for  a  hernia,  as  has  been  frequently 
done. 


828  AN  AMERICA X    TEXT- BOOK    OF  SURGERY. 

Treatment. — The  treatment  by  trusses  has  already  been  described.  In 
some  eases  of  congenital  hernia  a  cure  is  not  infrequently  effected  in  a  year  or 
two  by  a  properly-fitting  truss,  but  in  the  acijuired  variety  it  is  very  rarely  safe 
to  leave  off  the  truss. 

Taxis. — In  reducing  an  inguinal  hernia  the  pressure  in  the  o])li(|ue  variety 
should  be  in  the  direction  of  the  canal,  -whereas  in  the  direct  variety  and  in 
old  oblique  herniae  the  pressure  should  be  directly  backward.  Before  employ- 
ing taxis  the  thigh  should  be  adducted  and  flexed. 

Herniotomy. — In  performing  herniotomy  for  strangulated  inguinal  her- 
nia the  only  vessel  in  danger  of  being  wounded  is  the  deep  epigastric,  and  to 
avoid  tliis  the  incision  of  the  constriction  should  be  directly  upward.  In 
oblique  hernia  the  constriction  is  usually  at  the  internal  ring,  and  in  direct 
hernia  the  conjoined  tendon  is  the  cause  of  the  strangulation. 

The  treatment  of  the  various  forms  of  irreducible,  inflamed,  obstructed, 
and  inguinal  hernine  must  be  based  on  the  principles  already  laid  down  when 
treating  of  hernia  generally.  The  radical  cure  of  inguinal  hernia  has  been 
sufficiently  described. 

FEMORAL  HERNIA   (PLATE  XIX,   FIG  2). 

Femoral  or  crural  hernia  occurs  when  the  bowel  escapes  from  the  abdom- 
inal cavity  under  Poupart's  ligament,  passes  through  the  femoral  ring,  and 
enters  the  femoral  or  crural  canal. 

The  femoral  canal  commences  at  the  femoral  ring  and  ends  at  the 
saphenous  opening  in  the  fascia  lata.  It  is  about  half  an  inch  long,  and 
wider  at  its  termination  than  at  its  commencement.  The  peritoneal  sac  in 
femoral  hernia  is  always  acquired,  never  congenital.  The  hernia  first  of  all 
passes  through  the  femoral  ring,  pushing  in  front  of  it  peritoneum  and  the 
septum  crurale  (Cloquet's  fascia);  then  it  descends  along  the  femoral  canal, 
lying  on  the  pectineus  muscle  and  covered  by  the  sheath  of  the  vessels  and 
fascia  lata  ;  finally,  it  reaches  the  lower  border  of  the  saphenous  opening, 
passing  outward  under  the  falciform  border,  and  pushes  in  front  of  it  the  crib- 
riform fascia.  When  it  escapes  from  tliis  opening  it  passes  upward  beneath  the 
loose  superficial  fascia  and  over  Poupart's  ligament,  and  becomes  very  much 
larger.  So  its  direction  from  within  outward  is  first  downward,  then  forward, 
and  then  upward.  A  fully-developed  femoral  hernia  has  somewhat  the  shape 
of  a  retort.  From  without  inward  the  coverings  of  a  femoral  hernia  are  :  skin, 
superficial  fascia,  cribriform  fascia,  sheath  of  the  vessels,  septum  crurale,  and 
peritoneum.  The  neck  of  the  hernia  is  always  situated  at  the  femoral  ring, 
which  is  bounded  externally  by  the  femoral  vein,  internally  by  Giinl>eniat's 
ligament,  above  by  Poupart's  ligament,  and  below  by  the  pubes  covered  by  the 
pectineus  muscle.  "When  strangulated  the  stricture  is  usually  at  the  femoral 
ring,  the  sharp  edge  of  Gimbernat's  ligament  being  the  constricting  point. 

To  the  outer  side  of  the  neck  of  the  sac  we  have  the  epigastric  artery,  and 
above  the  spermatic  cord.  In  about  one  in  three  and  a  half  cases  the  obtura- 
tor artery  arises  from  the  epigastric  and  passes  down  to  the  obturator  foramen. 
In  10  per  cent,  of  such  cases  it  ])asses  to  the  inner  side  of  the  femoral  ring, 
and  would  be  in  danger  of  being  wounded  when  the  edge  of  Gimbernat's 
ligament  is  cut  to  relieve  a  strangulation. 

About  Q.Q  per  cent,  of  all  cases  of  hernia  are  femoral  in  males.  Femoral 
hernia  is  much  more  common  in  females  (37.1  per  cent.)  than  in  males.  It 
rarely  occurs  before  adult  life.  It  is  much  more  liable  to  become  strangulated 
than  inguinal,  it  being  not  uncommon  to  find  a  femoral  hernia  strangulated 


HERNIiE. 


Plate  XX. 


DISEASES  AND    INJURIES    OF    THE   ABDOMEN.  829 

at  the  time  of  its  first  descent.  The  lieinia  is  rarely  of  large  size,  and  its 
contents  consist  usually  of  a  portion  of  the  ileum.  Omentum  is  never  found 
in  large  (juantities,  but  is  fre({uently  irreducible. 

Diagnosis. — It  is  not  always  easy  to  distinguish  femoral  from  inguinal 
hernia  in  stout  females  when  it  has  mounted  above  Poujjart's  ligament. 
Femoral  hernia  can  always  be  pushed  to  the  outside  of  the  spine  of  the  pubes, 
Avhilst  inguinal  hernia  always  lies  to  the  inner  side.  In  stout  people  the  spine 
can  always  be  felt  by  abducting  the  thigh,  and  thus  bringing  into  prominence 
the  adductor  longus  tendon,  which  arises  immediately  below  the  pubic  spine. 
To  assist  in  the  diagnosis  the  line  of  Poupart's  ligament  should  always  be 
marked  by  a  string,  and  not  by  the  eye. 

Femoral  hernia  as  usually  seen  is  a  small,  tense,  round  tumor  situated  in  the 
groin,  inside  the  vessels  and  outside  the  pubic  spine.  In  some  rare  cases  it 
has  been  seen  outside  the  vessels. 

Diagnosis  from  Other  Tumors. — Psoas  Abscess. — This  is  very  apt  to 
simulate  hernia,  as  it  has  an  impulse  on  coughing  and  partially  or  wholly  dis- 
appears on  the  patient's  lying  down,  though  without  the  gurgle  of  a  hernia.  It 
is  always  situated  to  the  outside  of  the  vessels,  and  is  accompanied,  usually,  by 
some  angular  deformity  of  the  spine. 

Fatty  Tumor  has  a  lobulated  feeling,  no  impulse  on  coughing,  is  dull  on 
percussion,  and  irreducible. 

Varix  of  the  Saphena  Vein  may  simulate  hernia,  but  on  reducing  it  and 
asking  the  patient  to  stand  whilst  the  finger  presses  on  the  ring,  it  will  always 
return,  while  a  femoral  hernia  will  not. 

Enlarged  Lymphatic  Grlands,  when  inflamed,  have  sometimes  been  mis- 
taken for  strangulated  femoral  hernia  and  operation  has  been  performed.  In 
some  cases  the  crural  branch  of  the  genito-crural  nerve  has  been  found 
stretched  tightly  over  an  enlarged  and  inflamed  gland,  giving  rise  to  such 
reflex  symptoms  as  vomiting  and  constipation.  A  strangulated  hernia  and  an 
enlarged,  inflamed  gland  may  coexist.  In  some  cases  the  diagnosis  cannot  be 
made  without  incision. 

Cysts  in  the  Femoral  Canal  are  very  diflScult  to  diagnosticate  ;  they  are 
always  irreducible  and  have  no  impulse  on  coughing. 

Treatment  of  Femoral  Hernia. — When  reducible,  a  properly-fitting 
truss  should  be  worn.  A  truss  will  never  cure  a  femoral  hernia,  and  in  some 
cases  cannot  be  made  to  keep  in  the  hernia. 

When  strangulated,  taxis  should  first  be  employed,  the  thigh  of  that  side 
being  flexed,  adducted,  and  rotated  inward.  In  this  way  the  margin  of  the 
saphenous  opening  is  relaxed.  If  the  hernial  tumor  has  reached  above  Pou- 
part's ligament,  it  should  be  lifted  and  drawn  downw'ard  before  pressure  is 
employed.  Not  the  slightest  violence  should  be  used,  and  if  taxis  fail,  resort 
should  be  immediately  had  to  herniotomy. 

Herniotomy. — The  parts  having  been  shaved  and  rendered  aseptic,  an 
incision  should  be  made  over  the  inner  side  of  the  tumor  in  the  direction  of 
its  long  axis,  and  the  tissues  cautiously  divided  until  the  sac  is  reached.  It  is 
often  very  difficult  in  femoral  hernia  to  distinguish  the  sac,  owing  to  its  altered 
appearance  from  the  pressure  of  a  truss  or  from  the  accumulation  of  fluid  out- 
side the  sac.  In  most  cases  there  is  no  fluid  in  the  sac,  and  the  sac  is  often 
opened  before  the  surgeon  is  aw^are  of  the  fact.  It  may  be  recognized  by  its 
smooth  lining  and  the  presence  of  bowel.  The  sac  having  been  opened,  the 
seat  of  stricture,  which  is  usually  the  sharp  edge  of  Gimbernat's  ligament,  is 
sought.  The  finger  is  introduced  into  the  sac,  the  pulp  facing  inward,  until 
the  edge  of  the  ligament  is  felt ;  a  hernia  knife  or  a  blunt-pointed  bistoury  is 


s:M)  a\  amhl'K'ax  text-book  of  srnoERY. 

passed  along  the  finger  with  its  edge  down  and  gently  insinuated  heneath  the 
ligament,  and  then  the  edge,  turned  inward,  nicks  a  few  of  the  constricting 
fibers  until  the  stricture  is  relieved.  Tlie  stricture  having  been  relieved,  the 
bowel  is  examined,  and  if  normal  is  reduced  with  omentum.  If  the  omentum 
is  adherent,  it  should  be  tied  and  removed.  If  the  condition  of  the  patient 
is  good,  the  sac  should  next  be  dissected  out  and  its  neck  ligatured  as  high 
up  as  possible.  It  is  then  cut  off  a  little  below  the  point  of  ligature.  In  some 
cases  it  is  wise  to  fix  the  neck  of  the  sac  at  the  femoral  ring  by  ligatures. 
The  wound  should  be  closed  with  silkworm-gut  sutures  and  a  small  drain 
introduced  at  its  lower  angle.  The  dressings  should  be  carefully  applied,  so 
that  they  will  not  be  soiled  by  contact  with  urine  or  feces. 

The  results  of  this  operation  are  usually  remarkably  good.  A  radical  cure 
does  not  always  take  place,  but  the  life  of  the  patient  is  saved  and  recovery  is 
generally  rapid.  In  case  an  abnormal  obturator  artery  is  wounded,  it  would 
be  well  to  enlarge  the  incision  upward  and  look  for  the  bleeding  point.  The 
artery  when  cut  completely  through  usually  retracts  to  such  an  extent  that  it 
is  most  difficult  to  secure.  In  some  cases  a  needle  has  been  successfully  ])laced 
beneath  it  and  the  hemorrhage  arrested.  Wounding  of  the  obturator  is  an 
accident  which  will  rarely  happen  if  the  knife  is  dull  and  the  incision  is  not 
too  free.     (For  the  radical  cure  of  feiuoral  hernia  see  p.  817.) 

UMBILICAL    HERNIA. 

This  form  of  hernia  occurs  in  5.46  per  cent,  of  all  cases  in  males,  and 
27.34  in  females.  It  is  congenital  in  nearly  all  cases  in  males  and  in  the 
majority  in  females  (Berger). 

There  are  three  forms  of  this  hernia — viz.  (1)  congenital;  (2)  infantile; 
and  (3)  adult. 

(1)  Congenital  Umbilical  Hernia  occurs  most  frequently  in  female 
children,  and  is  due  to  an  arrest  of  development  whereby  the  abdominal  walls 
do  not  properly  close.  It  is  sometimes  of  large  size,  and  contains  not  only  the 
intestines,  but  various  organs,  as  the  spleen,  liver,  etc.  In  some  monsters  all 
the  abdominal  contents  are  contained  in  the  hernia.  This  form  of  hernia  may 
be  small,  and  is  seen  as  a  tumor  at  the  root  of  the  umbilical  cord.  The  sac 
protrudes  into  the  cord,  and  cases  are  on  record  where  the  bowel  has  been  in- 
cluded in  the  ligature  applied  to  the  cord  at  birth.  In  some  cases  where  oidy 
a  small  diverticulum  of  gut  is  included  recovery  may  proceed  uninterruptedly, 
but  in  others  a  fecal  fistula  may  result.  If  a  large  amount  of  intestine  is  in- 
cluded, a  fatal  issue  is  inevitable 

As  a  rule,  the  coverings  of  the  hernia  are  so  thin  that  the  contents  of  the 
sac  can  easily  be  seen. 

Treatment. — 'V\\e  hernia  should  be  returned  and  kept  in  place  by  strips 
of  plaster  encircling  the  abdomen,  so  as  to  bring  the  recti  muscles  close  together; 
over  this  a  tight  binder  should  be  applied.  A  flat  cork  pad  the  size  of  a  silver 
dollar  under  the  strapping  is  sometimes  advised.  Occasionally  um))ilical  hernia 
has  ])een  operated  on  successfully. 

Infantile  Umbilical  Hernia. — This  form  is  very  common,  and  comes  on 
after  separation  of  the  umbilical  cord,  and  is  caused  by  the  stretching  or  yield- 
ing of  the  cicatrix  at  the  umbilicus.  It  never  reaches  a  large  size,  and  tends 
to  undergo  a  spontaneous  cure. 

Treatment. — The  hernia  can  be  easily  reduced,  and  kept  so  by  the  appli- 
cation of  adhesive  or  porous  plaster.  Plaster  is  objectionable,  however,  because 
of  its  tendency  to  produce  troublesome  oczema  on  an  infant's  skin.  A  truss 
may  be  applied.     Infantile  umbilical  hernia  never  becomes  strangulated. 


DISEASES   AND    /XJ CRIES    OF    THE   ABDOMEN.  831 

Adult  Umbilical  Hernia. — This  form  of  hernia  very  rarely  commences 
in  infancy :  it  is  almost  always  acquired  rather  late  in  life.  It  is  seen  most 
commonly  in  stout  women  who  have  borne  many  children  :  also  in  men  with 
pendulous  bellies.  It  sometimes  reaches  a  lar<re  size,  but  usually  is  not 
larger  than  the  closed  fist.  The  contents  are  commonly  the  transverse  colon 
and  omentum.  The  stomach  has  been  found  in  hernia?  of  very  large  size,  and 
even  the  gravid  uterus.  Umbilical  hernia  is  very  liable  to  become  obstructed 
or  inflamed,  but  is  rarely  strangulated.     It  is  often  irreducible. 

Treatment. — When  reducible,  it  should  be  kept  in  place  by  a  belt  sur- 
rounding the  abdomen.  "When  irreducible,  a  cup-shaped  pad  kept  in  position 
by  a  belt  or  bandage  should  be  applied.  Trusses  or  belts  are  very  difficult  to 
fit  so  as  properly  to  retain  this  form  of  hernia,  and  the  stouter  the  individual 
the  more  difficult  it  is  to  apply  a  suitable  truss. 

Should  the  hernia  become  strangulated,  taxis  should  first  be  employed,  and 
it  often  succeeds ;  but  should  it  fail,  herniotomy  should  be  performed  without 
delav,  as  crancrrene  sets  in  verv  rapidlv.  It  is  well  to  remember  that  the  skin 
and  the  sac  in  this  region  are  very  thin,  and  the  operator  may  open  the  sac 
before  he  is  aware  of  it.  The  contents  also  are  commonly  adherent.  The 
patient  is  frequently  old  and  feeble,  and  perhaps  suffers  from  a  chronic  bronchitis. 
Altogether,  the  subjects  of  strangulated  umbilical  hernia  are  not  usually  in  a 
very  favorable  condition  to  bear  well  a  severe  operation. 

After  reaching  the  sac,  it  should  be  carefully  opened  and  the  hernial  ring 
divided  at  its  lower  border,  and  if  necessary  at  one  or  two  other  points.  The 
gut  should  be  examined,  and  if  in  good  condition  returned  ;  the  adherent  omen- 
tum separated,  ligated,  removed,  and  the  stump  also  returned.  The  sac  should 
now  be  dissected  out,  the  neck  drawn  down  a  little,  and  either  sutured  with  a 
continuous  suture  and  amputated  half  an  inch  below,  or  ligatured  with  stout 
silk  and  removed,  as  in  other  forms  of  hernia.  The  pillars  of  the  ring  should 
be  freshened  a  little  and  sutured  with  strong  silk.  The  wound  should  then  be 
closed  and  a  drainage-tube  inserted.  If  the  gut  be  gangrenous,  an  artificial 
anus  should  be  established. 

In  cases  of  strangulated  umbilical  hernia  where  the  assistance  is  poor  and 
the  condition  of  the  patient  is  unfavorable,  no  time  should  be  wasted  in  sepa- 
rating large  intestine  from  its  adhesions  or  in  ligaturing  omentum  ;  the  recently 
descended  intestine  which  has  become  strangulated  should  be  returned  as 
quickly  as  possible,  and  the  operation  completed  without  delay. 

The  radical  cure  of  umbilical  hernia  may  be  undertaken  and  fairly  good 
results  as  to  permanent  cure  may  be  obtained ;  that  is,  if  the  hernia  be  not 
too  large.  In  performing  the  operation  the  neck  of  the  sac  should  be  well 
separated  from  the  surrounding  structures,  the  bowel  returned  into  the  abdo- 
men, and  the  sac  tied  off.  The  pillars  of  the  ring  should  then  be  brought 
together  with  silkworm  gut  or  strong  silk  sutures ;  the  external  wound 
closed  with  horsehair  or  silkworm  gut  and  the  dressings  applied.  In  many 
cases,  owing  to  the  protruded  omentum  having  an  attachment  to  the  sac,  it  is 
necessary  to  open  the  sac  and  tie  off  the  protruded  omentum  in  sections.  The 
sac  is  afterward  lioratured  and  cut  off.  Some  surgeons  recommend  that  the 
hernial  ring  should  be  dissected  out  (omphalectomy)  and  the  new  ring  brought 
together  with  deep  sutures  of  catgut  and  silkworm  gut.  By  this  more  radical 
operation  it  is  held  that  cure  is  much  more  likely  to  be  permanent. 

Ventral  Hernia. — This  term  is  applied  to  any  hernia  coming  through 
the  abdominal  walls  in  regions  not  the  usual  sites  of  hernise.  It  is  frequently 
seen  in  the  scar  following  operations  for  ovarian  tumors,  appendicitis,  etc.  It 
may  also  follow  injury  or  abscess  in  the  abdominal  walls.     Ventral  hernia  is 


«;52  AN  AMERICAN    TEXT-liOOK    OF  SURGERY. 

usually  large,  and  rarely  or  never  becomes  strangulated,  owing  to  the  size  of 
the  opening.      Most  of  the  cases  are  found  in  the  linea  allm. 

Treatment. — The  application  of  a  suitable  abdominal  belt  or  truss  ia 
generally  all  that  is  required,  but  in  some  cases,  where  the  protrusion  causes 
great  discomfort  and  inconvenience,  and  the  general  condition  of  the  patient 
is  good,  reoj)ening  the  wound  and  suturing  afresh  may  be  advised.  In  cases 
not  due  to  operation  the  sac  has  been  dissected  out,  ligatured,  and  removed 
with  success. 

Lumbar  Hernia. — This  variety  is  very  rare.  The  rupture  occurs  through 
a  triangle  bounded  by  the  external  oblique,  latissimus  dorsi,  and  crest  of  the 
ilium  (Petit's  triangle).  Lesshaft  states  that  the  triangle  is  constant  only  in 
women,  and  is  not  seen  in  young  children.  Before  reaching  this  triangle  the 
sac  passes  through  the  lumbar  fvscia  near  the  outer  border  of  the  (juadratus 
lumborum  muscle.  It  may  follow  wounds,  contusions,  strains,  or  abscesses.  In 
(il<l  people  it  may  come  on  without  any  apparent  cause.  It  is  easily  reduced, 
antl  never  attains  a  large  size.  Cases  are  on  record  where  it  has  become 
strangulated.  This  form  of  hernia  has  been  mistaken  and  incised  for  tumor, 
abscess,  hematoma,  etc.  Males  and  females  are  e((ually  liable  to  lumbar  her- 
nia. A  well-made  abdominal  belt  is  usually  sufficient  to  retain  it  properly  in 
position. 

Perineal  Hernia. — This  form  descends  in  front  of  the  rectum,  and  is  most 
often  seen  in  females.  The  protrusion  escapes  between  the  fibers  of  the  leva- 
tor ani  muscle.  It  may  be  due  to  traumatism,  and  in  males  to  constipation. 
Ebner  thinks  that  perineal  hernise  are  congenital.  The  prominence  may  appear 
in  males  in  the  perineum  near  the  anus  or  scrotum,  and  in  females  may 
descend  into  the  labium  majus  (pudendal  hernia).  When  this  hernia  appears 
in  the  vagina  or  labium,  it  may  be  mistaken  for  mucous  cyst,  but  it  is  always 
reducible.     In  females  it  may  contain  the  bladder. 

IscHiATic  Hernia. — This  is  a  protrusion  of  gut  through  the  great  sacro- 
sciatic  foramen,  most  commonly  above,  but  sometimes  below,  the  pyriformis 
muscle.  It  has  over  it  the  gluteus  maximus  muscle,  but  may  escape  beneath 
its  lower  border.  When  small  and  strangulated  it  may  be  overlooked,  owing 
to  its  great  depth.     It  is  one  of  the  rarest  forms  of  hernia. 

Obturator  Hernia. — This  also  is  rarely  seen,  and  still  more  rarely 
recognized  before  death.  The  gut  protrudes  through  the  obturator  foramen, 
usually  at  its  upper  part,  where  the  canal  is  situated.  It  pushes  before  it  the 
obturator  fascia,  and  perhaps  a  j)ortion  of  the  obturator  externus  muscle,  and 
is  covered  by  the  pectineus  muscle.  It  is  internal  to  the  femoral  vessels. 
The  neck  of  the  sac  is  deeply  situated  in  the  obturator  canal,  and  may  have 
the  obturator  artery  to  its  outer  or  inner  side.  It  is  rarely  recognized  unless 
strangulated,  and  even  then  it  is  often  overlooked.  There  is  a  prominence  to 
the  inner  side  of  the  vessels  in  the  region  of  the  pectineus  muscle.  When 
strangulated,  in  addition  to  the  usual  signs  of  strangulated  hernia,  there  is  a 
tender,  hard  swelling  at  the  upper  and  inner  part  of  the  thigh,  and  severe  pain 
down  the  inner  side  of  the  thigh  as  far  as  the  knee  in  the  course  of  distribution 
of  the  obturator  nerve.  It  is  most  common  in  females,  rarely  occurs  before 
fifty,  and  may  be  mistaken  for  femoral  "hernia. 

Treatment. — Taxis  is  not  usually  successful,  bur  should  be  tried  with  the 
thigh  tlexed.  adducted,  and  rotated  outward.  Herniotomy  should  be  performed 
if  the  seat  of  the  strangulation  be  recognized.  The  stricture  is  always  at  the 
neck  of  the  sac,  and  should  be  relieved  by  cutting  down^^^ird.  The  saphena 
vein  may  give  trouble.  In  some  cases  the  hernia  might  be  easily  reduced  by 
performing  median  abdominal  section,  thus  relieving  rapidly  and  safely  the 


DItiEASES   AND   INJURIES    OF    THE   ABDOMEN.  833 

strarifijnlated  gut  by  traction  from  above.  This  lu'riiia  has  sometimes  been 
recoii;nizo<l  by  vaginnl  examination. 

Diaphragmatic  Hehxia. — There  are  two  forms  of  this  hernia,  congenital 
and  traumatic. 

Tlie  confieuitaJ  form  is  due  to  the  defective  devehjpment  of  the  diaphragm, 
whereby  it  is  ini])erfectly  closed,  and  thus  some  of  the  abdoiuinal  contents  are 
protruded  into  the  tlioracic  cavity.  The  stomach  is  the  viscus  most  often  dis- 
jdaced,  next  tlie  coh)n,  and  then  the  small  intestines.  The  spleen  and  liver 
have  also  been  found  in  the  thoracic  cavity.  The  deficiency  nearly  always 
occurs  on  the  left  side. 

The  traumatic  form  is  due  to  rupture  of  the  diaphragm  by  violence  or  to 
stab  Avounds.  It  occurs  most  commonly  on  the  left  side,  and  the  stomach  is 
the  organ  most  frequently  displaced.  It  is  rarely  recognized  before  death. 
Of  250  cases  collected  by  Leichtenstern,  only  5  were  diagnosticated.  After 
severe  crushing  injury  Bryant  of  London  refers  to  excessive  thirst  as  a  promi- 
nent symptom. 

Hernia  into  the  Foramen  of  Winslow  occasionally  occurs,  and  gives 
rise  to  symptoms  of  intestinal  obstruction.  It  can  be  recognized  only  by 
abdominal  section  or  after  death. 

Properitoneal  Hernia  is  a  form  of  hernia  which  occupies  an  abnormal 
position  within  the  abdominal  or  pelvic  wall  and  in  front  of  the  peritoneum. 
It  may  lie  between  the  parietal  peritoneum  and  the  muscles,  between  the  planes 
of  the  abdominal  muscles,  or  outside  of  them  and  just  beneath  the  skin  and 
superficial  fascia.  The  first  of  these  varieties  is  the  true  properitoneal 
hernia. 

As  a  rule,  these  cases  are  originally  inguinal  hernife :  they  are  usually  con- 
genital, and  are  apt  to  be  associated  with  an  undescended  and  more  or  less 
atrophied  testicle.  After  they  have  for  a  time  occupied  the  inguinal  canal  the 
resistance  to  their  descent  offered  by  the  testicle  forces  them  out  during  a  mus- 
cular effort  on  the  part  of  the  patient  into  the  connective  tissue  between  the 
peritoneum  and  the  muscles  or  into  one  or  other  of  the  spaces  above  men- 
tioned. 

The  cause  of  this  peculiarity  in  the  congenital  form,  according  to  Trende- 
lenburg, is  the  persistence  of  a  cavity  which  must  exist  at  a  certain  stage  in 
the  descent  of  the  testes — an  instance  of  arrested  development.  In  acquired 
cases,  according  to  Kronlein,  the  cause  is  mechanical,  the  pressure  of  a  badly- 
fitting  truss  or  repeated  attempts  at  taxis  forcing  the  internal  away  from  the 
external  ring,  and  dilating  the  sac  or  canal  into  a  pouch  between  the  layers 
of  the  parietes. 

Properitoneal  herniae  are  found  just  above  Poupart's  ligament  and  are  par- 
allel with  it,  extending  upward  and  outward  as  far  as  the  anterior  spine.  Some- 
times the}^  are  large  and  overlap  Poupart's  ligament,  extending  doAvnward  to  the 
upper  portion  of  the  thigh.  There  is  apt  to  be  thinning  of  the  abdominal  wall 
at  the  seat  of  sw'elling. 

In  case  of  strangulation  taxis  may  be  apparently  successful,  and  yet  the 
abdominal  pain  Avill  become  more  intense  and  the  symptoms  will  not  disappear. 
The  tumor  will  not  go  back  with  the  characteristic  gurgle,  and  the  symptoms 
will  continue  unabated,  or  even  aggravated,  by  attempts  at  reduction.  If  the 
scrotal  tumor  or  that  occupying  the  canal  disappears,  the  swelling  above  Pou- 
part's ligament  will  become  more  tense  and  increase  in  size.  Upon  operation 
the  loops  of  gut  lying  in  the  scrotum  cannot  be  reduced  as  usual,  or  if  reduced 
persistently  descend  again  or  lie  fixed  in  close  proximity  to  the  internal  abdom- 
inal ring. 

53 


834  AN   AMERICAN   TEXT-BOOK   OF  SURGERY. 

The  treatment  should  consist  in  a  free  incision,  such  as  wouhl  ])e  proper 
in  a  stran^iuhited  inguinal  licM-nia,  followed  by  dilatation  with  the  finger  or  by 
division  of  the  ring  through  which  the  hernia  ])rotrudes ;  or  Trendelenburg's 
method  may  be  adoj)ted  and  an  incision  made  tinough  the  linea  alba,  and  repo- 
sition of  the  bowel  effected  by  traction  from  within. 

Rktro-I'KRITOxXEAL  Hernia  (Mem-nti'n'c  Hernia  of  Cooper). — This  rare 
form  of  hernia  is  caused  by  the  lodgment  of  small  intestine  in  the  fossa  duo- 
deno-jejunalis.'  The  intestine  pushes  its  way  onward,  forcing  the  fold  of 
peritoneum  forming  the  fossa  before  it.  In  time  there  is  quite  a  large  sac 
filled  with  bowel  behind  the  posterior  layer  of  peritoneum.  In  one  case  Sir 
Astley  Cooper  found  the  whole  of  the  small  intestines,  with  the  exception  of 
the  duodenum,  hidden  from  view,  occupying  a  large  sac  in  the  middle  of  the 
abdomen  and  surrounded  by  large  intestine.  As  a  rule,  these  cases  are  only 
diagnosticated  post-mortem.  On  opening  the  abdomen  and  entering  the  peri- 
toneal cavity,  a  second  sac  containing  the  small  intestine  is  found.  This  sac 
is  clear  and  free  from  blood-vessels,  being  composed  of  mesentery  which  haa 
been  pushed  forward  by  the  herniated  bowel. 

The  symptoms  in  extreme  cases  have  been  severe  pain,  vomiting,  weak- 
ness, and  cullupse. 

Treatment. — By  opening  the  abdomen  the  condition  could  be  easily 
recognized,  and  the  intestine  might  be  pulled  out  of  the  enlarged  fossa  duo- 
deno-jejunalis.     No  successful  cases  of  treatment  have  been  reported. 

1  This  fossa  is  seen  if  the  transverse  colon  be  thrown  upward  and  the  small  intestine  drawn 
to  the  right.  It  is  formed  l\v  a  fold  of  serous  membrane  passing  from  the  parietal  peritoneum 
to  the  left  of  the  terminal  part  of  the  duodenum  (Treves). 


SURGERY   OF    THE    GENITO- URINARY    TRACT. 


835 


CHAPTER   VII. 


Fig.  340. 


SURGERY  OF  THE  GENITO-URINARY  TRACT. 

PART   I.— DISEASEvS  OF  THE  KIDNEYS  AND  URETERS. 

Surgical   Anatomy. — The  kidneys  are  seated  in  tlio  lumbar  and  liypo- 
chondriac  regions.    Their  lower  levels  are  sonieAvhat  above  the  umbilicus.    The 

right  kidney  is  three-quarters  of 
an  inch  lower  than  the  left.  Their 
upper  borders  are  about  on  the 
level  of  the  interval  between  the 
eleventh  and  twelfth  dorsal  spines. 
The  lower  edge  of  the  left  kidney 
is  about  two  inches  above  the 
crest  of  the  ilium ;  of  the  right 
kidney,  one  and  a  quarter  inches. 
The  hilum  is  on  the  level  of  the 
first  lumbar  spine,  and  is  two 
inches  from  the  middle  line  (Fig. 
340). 

The  kidneys  are  only  par- 
tially covered  with  peritoneum. 
Portions  of  the  anterior  surface 
are  in  relation  Avith  the  back  of 
the  ascending  and  descending 
colon,  some  cellular  tissue  inter- 
vening, and  with  the  duodenum 
and  pancreas.  The  posterior  sur- 
face is  uncovered.  The  external 
border  is  sometimes  partially  cov- 
ered with  peritoneum.  The  kid- 
neys are  usually  surrounded  with 
a  large  quantity  of  fatty  tissue 
poorly  supplied  with  blood-ves- 
sels. The  ureters  are  about  14^ 
to  16  inches  in  length  and  of  the 
caliber  of  an  ordinary  goose-quill,  narrowing  where  they  pass  through  the 
bladder-walls.  Their  walls  are  compar- 
atively thick  and  muscular,  but  are  sus- 
ceptible of  great  dilatation  without  rupture 
when  the  dilating  force  is  gradual.  They 
are  entirely  retro-peritoneal  (Fig.  341). 

Anomalies. — The  kidneys  may  oc- 
cupy a  position  in  the  pelvis  in  front  of  the 
spine,  or  the  one  on  the  left  side  may  rest 
above  the  spleen.  They  may  be  altered 
in  shape  and  size  by  arrest  of  develop- 
ment, or  one  kidney  may  be  entirely 
absent,  in  which  case  the  remaining 
organ  is  apt  to  be  of  unusual  size. 
Occasionally  they  are  united  at  their 
extremities'^ (usually  the  upper)  and  form  the  "horseshoe"  kidney. 


Diagram  of  the  Relations  of  Kidney  to  Viscera,  Spine,  and 
Surface  Points  (original). 


Fig.  341. 


Kidneys,  Ureters,  Ascending  and  Descendtag 
Colon  from  behind  (original). 


836  AN  AMElilCAN    TKXT-BOOK    OF  .SURGERY. 

Floatiiifi  Kldnei/. — Eitlur  kidney,  especially  the  ri^flit,  may  lie  uiiiiat- 
urally  inoval)le  and  constitute  the  "  Hoating  kidney.  "  'I'he  kidneys  are  held 
in  phiee  normally  by  the  connections  of  the  peritoneum  ^\■ith  the  j»erine|diric 
fat.  If  the  latter  is  absorbed  during  acute  disease  or  from  long-continued 
ill  health,  the  organ  can  move  more  freely,  and  by  its  weight  elongates  the 
peritoneal  folds,  which  in  other  cases  are  abnormally  long  and  lax.  The 
kidney  may  also  be  dislocated  by  traumatism,  and  become  a  floating  kidney. 

Movable  kidneys  are  most  common  in  poorly-nourished  fenuiles  who  have 
borne  children,  the  scarcity  of  the  fat  and  tlie  relaxation  of  the  abdomiiuil 
walls  following  pregnancy  acting  as  predisposing  causes. 

Symptoms. — The  symptoms  may  vary  from  a  slight  uneasiness  referred 
to  the  lumbar  or  the  hypochondriac  or  sometimes  the  umbilical  region,  to  agon- 
izing pain,  which  when  paroxysmal  has  been  supposed  to  be  due  to  a  strangu- 
lation by  twisting  of  the  renal  nerves  and  vessels.  The  length  of  the  latter 
limits  the  degree  of  mol)ility  of  the  kidney,  which  can  only  describe  the  seg- 
ment of  a  circle  of  which  the  vessels  are  the  radius. 

Physical  examination  may  show  undue  lumbar  resonance  (a  fallacious  and 
uncertain  symptom),  or  may  reveal  a  movable  tumor  in  the  hypochondrium  or 
in  the  umbilical  or  even  the  iliac  region.  The  depression  of  the  hilum,  and 
sometimes  the  pulsation  of  the  renal  artery,  may  be  recognized,  and  if  the 
tumor  on  manipulation  plainly  recedes  toward  the  loin  and  is  of  the  size  and 
consistence  of  the  kidney,  the  diagnosis  becomes  reasonably  certain.  Malig- 
nant omental  growths,  solid  tumors  of  the  ovai'ies,  growths  of  the  abdominal 
wall,  beginning  enlargement  of  the  spleen,  and  distention  of  the  gall-bladder 
may  usually  be  easily  excluded. 

Treatment. — When  the  symptoms  are  moderate  in  degree,  the  use  of  a 
compress  attached  to  a  broad,  neatly-fitting  elastic  bandage  will  often  suffice 
for  their  relief.  When  of  greater  severity,  the  operation  of  nephrorrhapliy 
should  be  considered,  but  only  after  the  treatment  by  belt  and  compress  has 
failed,  and  after  thorough  attention  has  been  paid  to  the  general  health  and 
condition   of  the  patient. 

Nephrorrhaphy  or  Nephropexy. — The  operation  is  as  follows:  Place 
the  patient  in  the  })rone  ])osition,  with  a  cylindrical  ])ad  beneath  the  abdomen, 
the  ilio-costal  space  on  the  side  of  operation  being  turned  upward  and  made 
prominent.  Define  carefully  the  position  of  the  twelfth  ril),  so  that  accidental 
opening  of  the  pleura  may  be  avoided;  make  an  incision  parallel  to  it  and  about 
half  an  inch  below  it,  and  four  inches  in  length,  beginning  two  and  a  half 
inches  from  the  spines  of  the  vertebniB  (Fig.  342,  A).  Divide  the  latissimus 
dorsi,  the  external  oblique,  the  internal  oblique,  the  transversalis,  and  the  lum- 
bar fascia;  separate  the  perinejiliric  fiit,  which  will  bulge  into  the  wound,  with 
the  fingers,  or  Avith  two  pairs  of  dissecting  forceps,  and  thus  ex])0se  the  cap- 
sule of  the  kidney.  Up  to  this  point  the  operations  of  nephrorrhaphy,  neph- 
rotomy, ne])hro-lithotomy,  and  nephrectomy  are  identical.  In  the  case  of 
nephrorrhaphy  the  surgeon  next  proceeds  to  pass  by  means  of  curved  needles 
four  to  six  sutures  of  medium-sized  plaited  or  twisted  silk  through  the  capsule, 
including  a  portion  of  kidney  tissue,  and  then  through  the  adjacent  lumbar 
fascia  and  muscles,  knotting  them  and  cutting  them  off  short.  If  there  lias 
been  but  little  disturbance  of  the  fat,  the  wound  may  be  closed  without  drain- 
age ;  otherwise  it  is  well  to  leave  in  a  rubber  drainage-tube  for  a  day  or  two. 

The  ultimate  results  of  this  operation  have  been  favorable  in  most  of  the 
reported  cases.  There  is  no  means  of  estimating,  however,  the  unsuccessful 
cases  not  reported.  Performed  with  proper  antiseptic  precautions,  the  mortality 
should  be  very  trifling. 


SVL'(li:in-    OF    THE    GIJXITO- URINARY    TRACT. 


837 


Nephralgia. — The  urine,  as  a  consecjuence  of  overwork,  of  error.s  in  diet, 
of  the  rheumatic  or  jj;onty  diathesis,  etc.,  may  become  a  positive  irritant  and 
give  rise  to  various  forms  of  nej)hritis,  more  appropriately  considered  in  text- 
books on  medicine.  If  it  is  persistently  acid,  it  may  give  rise  to  nephralgia, 
a  deep-seated  unilateral  lumbar  pain,  of  a  dull  aching  character,  with  exacerba- 
tions of  sharper  pain  extending  along  the  course  of  the  ureters  toward  the 
groin  or  into  the  testicle.  The  best  time  to  test  the  urine  in  making  the  diag- 
nosis of  this  condition  is  about  two  hours  after  a  meal,  preferably  breakfast, 
when  it  is  normally  mildly  alkaline.  This  pain  may  be  diagnosticated  from 
that  accom])anying  the  more  serious  conditions  of  renal  calculus,  pyelitis,  dis- 
ease of  the  bladder  or  prostate,  etc.  by  the  absence  of  the  symptoms  character- 

FiQ.  342. 


|lf*"^y  #^^>^''//'^^ 


Anatomy  of  Renal  Region  to  illustrate  Operations  on  the  Kidneys  (after  Esmarch  and  Kowalzig):  A, 
usual  incision  midway  betweeia  twelfth  rib  and  crest  of  the  ileum  for  operation  on  the  kidney ;  B, 
Kouig's  incision;  J/c,  trapezius  ;  J/W,  latissimus  dorsi ;  8p,  erector  spina- ;  Q^,  quadratus  lumborum; 
oe,  obliquus  externus :  oi,  obliquus  internus  ;  Tr,  transversalis  abdominis ;  Fid,  lumbar  fascia ; 
C,  descending  colon  ;  R,  kidney ;  xi,  xii,  ribs. 

istic  of  those  ailments  and  by  the  relief  afforded  by  attention  to  the  general 
health,  to  the  diet,  and  to  the  hygiene  of  the  sexual  organs.  Alkalies,  such  as 
potassium  citrate  or  potassium  acetate,  Vichy,  or,  if  there  is  constipation,  Fried- 
richshail  water,  regular  baths  followed  by  friction,  great  moderation  in  the  use 
of  meats,  sweets,  and  alcohol,  are  clearly  indicated. 

The  very  similar  pain  due  to  myalgia  of  the  lumbar  muscles  is  generally 
rheumatic  or  gouty,  and  may  be  cured  by  the  use  of  belladonna  in  ointment 
or  liniment,  and  by  the  administration  of  the  salicylates. 

Phosphatic  Urixe,  in  which  the  opposite  condition  of  over-alkalinity 
prevails,  is  found  most  commonly  in  nervous,  overworked  persons  of  sedentary 
habits  and  feeble  digestion.  It  is  associated  with  general  lassitude,  occipital 
headache,  and  depression  of  spirits.  In  young  males  it  is  a  constant  source 
of  sexual  hypochondriasis,  the  patient  referring  his  symptoms  to  early  mastur- 
bation or  to  sexual  excess,  and  often  mistaking  the  milky  deposit  of  phosphates 
for  seminal  losses.  Dilute  mineral  acids,  strychnia,  a  regulated  diet,  and  rest 
or  chanare  of  scene  will  effect  a  cure. 


838  AX  AMElilCAN   TEXT-BOOK   OF  SURGERY. 

UXALURIA  is  often  an  unsuspected  cause  of  a  variety  of  genito-urinary 
symptoms.  It  may  be  found  in  young  persons,  overfed,  of  indolent  habits, 
with  ungratified  sexual  desires,  or  may  follow  sexual  excesses,  especially  in 
gouty  or  rheumatic  ])ersons.  In  the  latter  case  it  is  fre(juently  the  cause  of 
persistent  and  distressing  sexual  feebleness  or  even  of  entire  imjiotence.  It  is 
always  well  in  patients  with  the  vague  genital  symptoms,  ill-defined  lumbar  or 
hvpogastric  pains,  mental  depression,  etc.  so  constantly  found  in  sexual  hypo- 
chondriacs to  examine  the  urine  for  the  octahedral  or  dumb-bell  crystals  of 
calcium  oxalate,  with  which  will  often  be  found  an  excess  of  uric-acid  crys- 
tals, and  of  amorphous  phosphates  or  urates. 

Here,  again,  the  mineral  acids  in  infusions  of  vegetable  tonics,  and  a  rigidly 
restricted  diet,  with  an  occasional  course  of  sodium  phosphate  (20  grains  four 
times  daily)  in  some  alkaline  diluent,  such  as  Vichy  or  Lithia  water,  will 
cause  a  rapid  disappearance  of  all  the  annoying  symptoms.  Change  of  air 
and  scene  will  often  effect  a  cure  when  drugs  alone  have  failed. 

Gravel. — When  the  crystalline  substances  naturally  held  in  solution  in 
the  urine  are  deposited  in  the  uriniferous  tubules  or  elsewhere,  the  condition 
known  as  gravel  exists.  It  is  due  to  too  great  concentration  of  the  urine, 
caused  by  lack  of  exercise,  high  living,  excess  of  meats  and  sugars  in  the  food 
and  of  malt  or  sweet  effervescing  liquors  in  the  drink.  It  is  due  also  to  the 
gouty  diathesis,  to  excessive  sweating,  and  much  more  frequently  than  is  sup- 
posed to  an  insufficiency  of  water  in  the  daily  diet,  a  common  but  often  unsus- 
pected cause  of  many  chronic  kidney  diseases.  The  deposit  may  be  uric  acid, 
urates,  or  calcium  oxalate,  the  relative  frequency  corresponding  to  the  order 
of  mention.  The  symptoms  of  gravel  are  those  of  hyperacidity  of  the  urine, 
with  marked  vesical  and  urethral  symptoms  superadded,  increased  frequency  of 
micturition  and  ardor  urinre  being  especially  noticeable.  The  treatment  is  the 
same   as   that  for  nephralgia  or  oxaluria. 

Renal  Calculus. — If  the  crystalline  particles  or  the  amorphous  powder 
deposited  become  glued  together  by  colloid  material  derived  from  mucus  or 
blood-clot,  they  form  a  nucleus  on  which  further  depositions  of  salines  from  the 
urine  occur,  and  constitute  a  calculus,  which  may  soon  attain  a  size  that  pre- 
vents its  passage  through  the  ureter.  It  may,  and  most  frequently  does,  con- 
sist of  uric  acid ;  next  in  frequency  is  calcium  oxalate,  and  much  more  rarely 
the  stone  is  composed  of  calcium  carbonate  or  of  the  mixed  jihosphates.  Cal- 
culi may  form  in  the  tubules  or  in  one  of  the  calyces,  and  may  vary  in  num- 
ber from  one  to  hundreds. 

When  the  stone  finds  its  way  into  the  ureter  it  may  exceptionally  escape 
almost  unnoticed,  but  as  a  rule  its  entrance  into  and  pa.ssage  through  that  duct 
give  rise  to  a  group  of  symptoms  known  as  nephritic  colic,  which  are  as 
follows :  A  person  who  has  been  entirely  comfortable  and  in  ])erfect  health  is 
seized  instantaneously  with  a  violent  pain,  felt  first  in  the  luml)ar  or  hypo- 
chondriac region,  but  at  once  extending  down  the  line  of  the  ureter  toward  the 
scrotum  and  the  end  of  the  penis.  The  testicle  is  strongly  drawn  upward  by 
spasm  of  the  cremaster.  The  pain  follows  the  branches  of  the  lumbar  plexus 
into  the  groin,  thigh,  and  hypogastrium.  The  patient  is  apt  to  prefer  a  sitting 
position,  stooping  over  so  as  to  relax  the  ilio-psoas  and  lumbar  muscles — those 
in  closest  relation  to  the  ureter.  Vesical  irritation  and  tenesmus  are  fre(iucnt. 
Faintness,  cold  sweating,  and  even  collapse  are  not  uncommon  accompaniments 
of  such  an  attack.  It  may  cease  as  suddenly  as  it  began,  but  the  relief  is  not 
permanent  until  the  stone  has  either  receded  into  the  pelvis  of  the  kidney  or 
more  luckily  has  passed  onward  into  the  bladder.  In  the  latter  case  no  further 
attacks  may  follow.     If  the  former  event  has  occurred,  the  next  paroxysm 


SURGERY   OF   THE   GENITO-URINARY   TRACT,  839 

and  atropia  in  small  doses,  wann   Datiis,  and  uiuici 

other  kidney   be  aiseasta;  uiui  i,,!.,^  tk^no  of  the  Ion,  ffivmj?  rise  to 

ulceration,  the  stone  escapes  ™/» '^^«  ^'i"^;  ,'  H,  n  cS>n  ca^  le  esublished 
a  l.nnbar  or  pdv.c  aWs.  "  *'  ™f  "fean  now  be  done  by  an  expert  in 
:;':'',.::^o/r:.-";S itfthS  »c.  the  urete.  operation  ,s  elcar.y 

cated^'ra  Lti^ctly  localized  ar..  of  tenderness  .n^t^^^^^^^^^ 

'thTs  method  was  employed  have  recent^  ''^'HZl^t,  curved  incision  on 

If  the  calculus  .8  m  the  upper  P«' ''"Vf  *^,  ""  ,ffth  rib,  then  directed 

a  line  beginning  just  below  ami  parallel  to    he  '^f  j;'j,,j  j^^  external 

Sacted  if  thVSf  though  a^tgin^al  incis.on  which  opens  neither  the 
bladder  nor  the  peritoneum.  '  incision 

on  ir::ryt\tit:r;rr:irvaT^^^^^^^^^^     ^vith^i.  cocey. 
-Ai:errr:^r::LTir?^^^^^^^ 

/.       ^    •   ^  fi.o  ,irPtPr   it  will  <^  ve  rise  to  some  or  all  ot  the  toliowing  symp 
from  entering  the  uietei,  it  will  ^ive  ^■cc^.,,^,.,   cases-    lumbar  pains  and 


840  AN  AMKIiK'AX    TKXT-liOOK    OF  SUJiGERY. 

hematuria  is  tlie  most  valuable.    There  is  often  a  history  of  personal  or  family 
predisposition  to  oxaluria  or  to  litheraia. 

Direct  exploration  with  a  needle  will  sometimes  reveal  the  existence  of 
stone,  and  if  done  with  care  is  not  a  dangerous  procedure.  Rarely  in  emaci- 
ated ])ersons  and  in  cases  of  excessively  large  stone  it  may  be  recognized  by 
direct  l)inianual  palpation. 

Diagnosis. — Early  tubercular  jryelitis  will  be  associated  with  an  excess 
of  j)us,  a  slighter  hematuria,  a  strumous  rather  than  a  lithemic  history,  bacilli 
in  the  urine,  etc.  Spinal  caries  may  be  associated  with  a  degree  of  renal  irri- 
tation that  is  misleading,  especially  where  the  abscess  is  close  to  or  presses  upon 
the  kidneys.  Usually  the  deformity  or  tenderness  of  the  spine  will  suffice  to 
differentiate  the  condition.  Nepliralgia^  lithiasis,  oxaluria,  hi/dronephrosis, 
and  pf/onepJirosis  should  be  carefully  eliminated. 

Nephro-lithotomy, — Operation  should  be  decided  upon  when  the  diag- 
nosis is  reasonably  certain,  the  patient  is  disabled  by  pain  or  exhaustion,  pre- 
vious treatment  has  failed,  and  there  is  no  reason  to  fear  grave  organic  disease 
of  the  other  kidney.  A  moderate  amount  of  albumin,  with  casts,  is  to  be 
expected,  and  in  the  face  of  distinct  symptoms  of  stone  should  not  deter  the 
surgeon,  as  the  results  without  operation  are  so  unpromising.  The  preparatory 
treatment  should  consist  in  the  free  use  of  diluents,  restricted  diet,  the  admin- 
istration of  a  laxative  and  of  an  enema,  and  rest  in  bed  for  some  days. 

The  position  of  the  patient  and  the  incisions  until  the  kidney  is  exposed  are 
the  same  as  in  the  operation  of  nephrorrhaphy.  (See  page  836.)  If  more  room  is 
needed,  the  edge  of  the  quadratus  may  be  incised.  Firm  counter-pressure 
should  be  made  on  the  anterior  surface  of  the  abdomen  by  an  assistant  while 
the  lower  ribs  are  elevated  by  another.  The  diff'ercnt  surfaces  of  the  kidney 
should  then  be  examined  by  the  finger  of  the  surgeon  and  compressed  between 
the  finger  and  thumb,  and  if  no  stone  is  disclosed  an  exploring  needle  or  long 
acupressure  pin  may  be  inserted  in  several  directions.  Howse  has  compared 
the  sensation  given  to  the  finger  by  a  stone  imbedded  in  the  kidney  to  the  out- 
line of  the  last  joint  of  a  finger;  Morris,  to  the  uncut  end  of  a  pencil.  It 
varies,  of  course,  with  the  size  and  shape  of  the  stone  and  its  distance  from  the 
surface.  Instances  have  been  recorded  of  large  stones  so  situated  that  they 
could  not  be  felt  even  Avhen  the  kidney  was  removed  and  was  lying  on  a  table, 
and  were  disclosed  only  when  it  was  laid  open.  If  the  above  means  fail,  there- 
fore, in  a  case  with  well-marked  symptoms,  a  linear  incision  may  be  made  large 
enough  to  admit  the  end  of  a  finger,  the  pressure  of  which  usually  stops  the 
hemorrhage,  which  is  apt  to  be  free  at  first.  For  the  purpose  of  obtaining  a 
better  opportunity  of  examining  the  kidney  in  operations  involving  this 
organ  than  has  hitherto  been  possible,  Edebohls  has  devised  an  inflatable 
cylindrical  rubber  bag.  The  patient  should  be  in  the  prone  position  and  the 
bag  inflated  and  placed  under  the  abdomen  transversely.  After  the  usual 
incision  has  been  made  and  the  kidney  exposed  and  thoroughly  separated 
from  its  fatty  capsule  and  any  adhesions  that  may  exist,  the  )»atient  is  to  be 
grasped  by  the  feet  and  drawn  toward  the  foot  of  the  table.  The  cylindrical 
pad  is  thus  brought  under  the  costal  margin,  and  the  kidney,  in  most 
cases,  can  be  entirely  extruded  through  the  wound.  If  a  stone  is  found,  it 
may  be  shelled  out  with  the  finger-nail,  or  if  very  large  and  branched,  with 
light  adhesions,  it  may  be  broken  by  forceps  and  the  fragments  removed  with 
the  finger  and  curette.  The  cavity  should  be  syringed  forcibly  with  antiseptic 
lotions,  sponged  with  fine  small  sponges,  and  packed  with  iodoform  gauze  around 
a  drainage-tube.  The  operation  may  be  a  very  difficult  one,  OAving  to  the  thick- 
ening and  adhesion  of  all  the  perinephric  tissues,  to  hardening  of  the  kidney 


SURGERY   OF   THE   GENITO-URINARY   TRACT.  841 

itself,  to  the  small  size  of  the  stone,  or  to  its  situation  near  the  anterior  surface 
of  the  kidney.      Death  may  result  from  hemorrhai^e,  septicemia,  or  uremia. 

In  some  cases  anuria  (suppression  of  urine)  follows  this  operation.  The 
freijuent  existence  of  stone  in  both  kidneys  then  justifies  the  immediate 
exploration  of  the  other  kidney. 

Nephrectomy. — Before  deciding  upon  this  operation  the  presence  of 
the  second  kidney  sliould  be  ascertained,  for  very  rarely  there  is  but  one — a 
"horse-shoe"  kidney — the  removal  of  which  would  be  necessarily  fatal. 
This  may  be  done  either  by  an  independent  lumbar  incision  on  the  opposite 
side,  which  is  immediately  closed  when  the  presence  of  this  kidney  is  ascer- 
tained ;  or  the  hand  may  be  introduced  through  the  original  abdominal  in- 
cision and  the  presence  of  the  other  kidney  be  proved  by  pal{):ition. 
During  an  operation  begun  for  the  removal  of  a  stone  it  may  be  thought 
advisable  to  take  away  the  kidney  itself,  on  account  of  its  disorganiza- 
tion, the  existence  of  multiple  abscesses,  or  the  impossibility  of  taking 
away  all  fragments  of  the  stone.  As  a  rule,  hoAvever,  a  free  nephrotomy  with 
thorough  drainage  gives  tlie  patient  the  best  chance  for  recovery  from  the 
immediate  danger  of  the  condition  and  operation.  This  will  leave  the  patient 
with  a  urinary  fistula,  which,  if  it  does  not  close  spontaneously  in  two  or  tliree 
months,  may  necessitate  a  secondary  nephrectomy.  Eemoval  of  the  kidney 
may  also  be  indicated  in  tubercular  or  calculous  pyo-nephrosis,  or  even  hydro- 
nephrosis, nephrotomy  and  free  drainage  having  first  been  tried. 

Nephrectomy  for  malignant  disease  in  both  adults  and  children  has  been 
thus  far  a  very  fatal  and  a  very  unsuccessful  operation.  The  best  results  have 
been  obtained  in  nephrectomies  for  sarcoma  in  adults,  but  even  in  these  the 
mortality  has  been  very  large.  The  kidneys  may  also  require  removal  for 
wounds,  ruptures,  tears  of  the  ureter,  and  occasionally  for  movable  kidney, 
after  failure  of  nephrorrhaphy. 

Catheterization  of  the  ureters  is  performed  in  the  female  with  moderate 
ease,  and  is  possible,  but  far  more  difficult,  in  the  male.  It  may  enable  the 
surgeo-n  to  advise  or  reject  nephrectomy  in  a  given  case  by  demonstrating  the 
presence  or  absence  of  a  functionally  active  and  sound  kidney  on  the  opposite 
side. 

The  lumbar  operation  is  performed  through  the  same  incisions  as  those 
already  described  (p.  836),  special  care  being  taken  to  secure  sufficient  room. 
Incision  of  the  quadratus  and  a  vertical  slit  downward,  making  the  orig- 
inal cut  irregularly  T-shaped,  will  often  be  required.  Konig's  method  (Fig. 
342,  B)  may  be  needed  in  cases  of  exceptionally  large  or  very  adherent 
kidneys.  The  soft  parts  are  divided  vertically  along  the  border  of  the  erector 
spinse  ;  the  incision  is  then  continued  anteriorly  in  the  direction  of  the  umbili- 
cus, ending  at  the  outer  border  of  the  rectus  ;  the  muscles  are  divided  down 
to  the  peritoneum,  which  should  be  pushed  forw^ard.  Or  the  kidney  may  be 
reached  by  direct  incision  along  the  outer  edge  of  the  rectus,  or  through  the 
linea  alba^  both  methods,  as  a  rule,  opening  the  peritoneal  cavity ;  sometimes 
the  peritoneum  can  be  stripped  oflF  the  abdominal  wall  and  the  kidney  be 
removed  without  opening  the  abdomen.  The  lumbar  incisions  are  to  be  pre- 
ferred, except  in  cases  of  neoplasms  of  large  size.  When  the  kidney  is  reached 
it  should  be  enucleated  from  its  capsule,  or,  if  the  latter  is  adherent,  should  be 
separated  with  it  from  the  perinephric  fat  and  surrounding  tissues.  The  ureter 
should  be  tied  separately  and  the  stump  curetted  and  disinfected.  The  vessels 
should  be  tied  by  one  stout  silk  ligature,  or,  better,  in  two  bundles,  by  passing 
a  pedicle  needle  carrying  a  double  ligature  between  them,  tying  the  two  halves 
separately,  and  then  "  tying  back  "  around  the  whole  mass. 


842  AN  AMERICAN   TEXT-BOOK    OF  SURGERY. 

The  pedicle  should  then  be  cut  through  uith  scissors  at  least  a  half-inch 
from  the  ligature.  Further  hemorrhage  may  be  arrested,  if  serious,  by  hemo- 
static forceps  left  in  situ,  or,  if  moderate,  by  plugging  with  iodoform  gauze 
around  a  drainage-tube. 

INFLAMMATORY  AND  SUPPURATIVE  AFFECTIONS  OF  THE   KIDNEYS. 

Interstitial  Nephritis  as  a  surgical  affection  is  due  either  to  some 
inflammation  or  ulceration  of  the  urinary  tract  below  the  kidney  or  to  some 
reflex  irritation,  such  as  that  from  catheterism,  acting  upon  a  kidney  which 
has  already  long  been  subjected  to  pressure  caused  by  anterior  obstruction, 
such  as  urethral  stricture  or  prostatic  hypertroj)hy.  A  rigor  may  usher  in 
the  attack  if  it  is  acute  and  follows  instrumentation,  or  the  symptoms  may  be 
very  insidious  in  the  subacute  variety  due  to  associated  chronic  obstruction  or 
irritation.  In  either  case  there  are  likely  to  be  moderate  fever,  thirst,  ano- 
rexia, dry  tongue,  and  gradual  exhaustion.  In  the  absence  of  inflammation 
of  the  bladder,  prostate,  or  urethra  the  urine  contains  merely  a  trace  of  albu- 
min. Hyaline  casts  are  present,  but  may  be  scanty.  As  a  rule,  this  condition 
runs  into  suppuration  of  the  kidney,  or,  if  it  has  arisen  acutely  from  catheter- 
ism with  a  septic  instrument,  is  associated  with  a  suppurative  pyelitis  or  iryelo- 
nepltritis.  These  conditions  have  the  same  causes  as  the  non-suppurative  affec- 
tion, with  the  additional  factor  of  infection  by  the  pyogenic  bacteria. 

A  patient  who  has  had  chronic  inflammation  or  atony  of  the  bladder,  or 
prostatic  disease  with  residual  urine,  or  an  old  tight  stricture  with  occasional 
retention,  or  who  has  recently  had  an  operation  upon  the  urethra  or  the  blad- 
der, or  who  has  a  renal  calculus,  or  tubercle  or  carcinoma  of  some  portion  of 
the  urinary  tract,  may  suddenly  develop  a  high  temperature,  drowsiness,  a  dry, 
furred  tongue,  a  sallow  color,  and  rapid  loss  of  flesh ;  or  such  a  case  may  run  a 
more  chronic  course,  with  pain  in  the  back,  frequent  micturition,  evening  rig- 
ors, quotidian  or  tertian,  and  a  variable  quantity  of  pus  in  the  urine.  Often 
the  lumbar  pain  and  the  fever  are  in  inverse  proportion  to  the  percentage  of 
pus  while  it  accumulates  in  the  dilated  and  often  sacculated  kidney  ;  tension 
and  pain  are  great,  septic  absorption  and  fever  are  marked.  The  discharge 
of  the  pus  is  followed  by  a  subsidence  or  temporary  disappearance  of  these 
phenomena. 

Pyo-nephrosis. — If  a  considerable  accumulation  takes  place,  the  kidney 
becomes  converted  into  a  mere  sac  or  bag  containing  pus,  and  forming  a 
tumor  most  prominent  in  the  ilio-costal  space  posteriorly,  moderately  tender 
to  the  touch,  diminishing  sometimes  in  size  coincidently  with  an  increase  of 
pus  in  the  urine,  obscurely  fluctuating,  and  dull  on  percussion  ;  on  the  right 
side  its  dulness  may  be  separated  from  that  of  the  liver  by  a  line  of  resonance 
over  the  colon,  but  this  is  not  constant,  as  the  kidney  and  liver  may  have 
become  adherent  at  various  points. 

This  condition  of  pyo-nephrosis  is  most  apt  to  occur  when,  in  addition  to 
the  usual  causes  of  pyelo-nephritis,  the^'e  is  some  anterior  obstruction,  as  stric- 
ture or  enlarged  prostate,  or  still  more  constantly  if  the  obstruction  is  in  the 
ureter,  as  from  contraction  of  its  vesical  orifice,  or  from  an  impacted  stone. 

In  women,  as  has  been  demonstrated  by  Kelly,  it  is  possible  to  catheter- 
ize  separately  the  two  ureters,  and  in  this  manner  determine  from  which  kid- 
ney the  pus  or  blood  may  come.  Harris  of  Chicago  has  devised  an  instru- 
ment which,  by  means  of  a  blunt  blade  inserted  in  the  rectum  in  men  and  in 
the  vagina  in  women,  will  raise  the  posterior  floor  of  the  bladder  into  a  ridge 
in  the  middle  line,  thus  forming  two  lateral  pouches  into  which  the  two 
ureters  deliver  the  urine  of  the  two  kidneys  separately,  and  from   which  the 


SURGERY   OF    THE    G EN ITO- URINARY   TRACT.  843 

urino  of  each  kidiiev  can  be  drawn  tlirouf^'Ii  separate  tubes.  This  instru- 
ment has  been  successfully  used  by  a  number  of  surgeons,  and  bids  fair  to 
be  of  some  use  in  differentiating  tlie  condition  of  the  two  knlneys. 

llYDiiu-NEPiiKusis  when  not  congenital  is  due  to  similar  conditions. 
Althouc^h  the  cause  of  hydro-nei)hvosis  is  always  mechanical  and  obstruc- 
tive, itis  congenital  in  a  large  proportion— nearly  one-third— of  the  cases,  and 
is  tiien  due  to  various  pathological  conditions  of  the  ureter,  such  as  twists  or 
kinks  or  stenosis,  or  to  its  compression  from  some  abnormality  of  surrounding 
structures,  or  to  obstruction  at  its  point  of  emergence  from  the  kidney  or  at 
that  of  its  entrance  into  the  bladder. 

Among  the  causes  which  exert  their  influence  later  in  hie,  malignant  dis- 
ease of  the  pelvic  viscera  is  one  of  the  most  common.  Then,  of  course,  the 
hydro-nephrosis  is  merely  a  symptom  altogether  secondary  in  importance  to  the 
uiiderlyinc^  disease,  but  it  may  serve  as  an  important  aid  to  diagnosis  in  doubt- 
ful cases  m  the  rather  exceptional  instances  where  it  forms  a  distinct  lumbar 
swellincr.  Impaction  of  a  calculus  in  the  ureter,  which  has  been  found  m  40 
per  cent  of  acute  cases,  is  of  much  more  practical  significance,  and  may  require 
operative  interference  by  the  method  already  described.  An  accumulation  ot 
urine  in  the  kidney. from  obstruction  in  floating  kidney  may  also  be  the  cause 
of  ac((uired  hydro-nephrosis,  which  is  then  intermittent. 

It  should  not  be  forgotten  that  frc(iuent  micturition  is  in  itself  a  compe- 
tent cause  for  the  production  of  hydro-nephrosis,  acting  through  the  oft- 
repeated  interference  with  the  escape  of  the  urine  from  the  vesical  ends  of  tbe 
ureters.  Hydro-nephrosis  may  aftect  either  kidney,  and  in  about  15  per  cent, 
of  the  reported  cases  both  kidneys  have  been  involved. 

Symptoms.— While  the  case  is  a  simple  one  of  hydro-nephrosis— z.  e., 
before  infection  with  pyogenic  microbes  has  occurred,  there  may  be  almost  no 
evidence  of  disease  of  the  kidney  until  a  distinct  swelling  is  apparent  m  the 
loin,  or,  more  rarely,  in  the  abdomen.  In  children  frequency  of  urination  may 
be  the  only  noticeable  symptom,  and  may  lead  to  an  ineffectual  search  for  ves- 
ical calculus  and  to  circumcision.  In  adults  it  is  even  more  difficult  of  early 
recognition,  on  account  of  the  greater  thickness  of  the  abdominal  walls. 

It  should  not  be  forgotten  that  the  frequency  with  which  hydro-nephrosis 
causes  a  visible  or  palpable  tumor  in  the  loin  or  abdomen  is  very  slight,  com- 
pared with  the  great  number  of  cases  found  at  autopsies.     In  advanced  cases 
the  concomitant  disturbance  of  the  renal  function  may  give  rise  to  thirst,  to 
nausea  or  vomiting,  to  persistent  headache,  to  dryness  and  sallowness  of  the 
skin ;  yet  these  are  symptoms  common  to  many  affections  of  the  kidneys.     If 
there  is  a  rapid  rate  of  growth,  lumbar  aches,  obscure  abdominal  pains,  and 
frequent  micturition  may  be  added  to  the  symptoms,  and  if  the  disease  is  bilat- 
eral there  may  be  intermittent  anuria  of  varying  degrees,  followed  by  uremia. 
Constipation  from  pressure  on  the  descending  colon  is  an  occasional  symptom. 
When  the  swelling  appears,  it  will  present  the  characteristics  which  distinguish 
growths  involving  the  kidneys ;  i.  e.  it  will  first  show  in  the  flank,  and  will 
have  the  colon  in  front  of  it,  and  often  the  small  intestine  also.     It  will,  in 
addition,  be  dull  on  percussion,  more  or  less  distinctly  fluctuating,  and  rounded 
or  irregularly  lobulated.     A  history  of  a  lumbar  tumor  varying  in  size  is 
almost  pathognomonic,  but  it  should  be  remembered  that  patients  with  other 
cystic  swellings,  and  even  with  solid  tumers,  will  often  innocently  make  very 
misleading  statements  as  to  changes  in  size  which  they  imagine  they  hare 
noticed.     If,   however,   the  variation  was   unmistakable,   and  especially  if  a 
diminution  in  size  was  associated  with  an  increased  outflow  of  urine,  the  diag- 
nosis may  be  made  with  much  positiveness.     The  symptoms  of  pyo-nephrosis, 


844  JiV   AMKRIVAN    TEXT-BOOK    OF  SLUUKUY. 

which  niav  at  any  tiiiu'  supervene  in  such  a  case,  will  he  easily  recofi;nized. 
The  development  of  ritjors,  fever,  .sweating,  and  increased  local  pain  and  ten- 
derness, together  with  the  appearance  of  pus  in  the  urine,  will  often  clear  up 
the  case  at  once.  If  these  syniptonis  are  wanting,  as  they  sometimes  are,  the 
diagnosis  may  be  impossible. 

Ilydro-nephrotic  tumors  have  been  mistaken  for  ovarian  growths  with  con- 
sideral)le  fre(iuency,  a  number  of  cases  having  been  submitted  to  laparotomy 
before  the  error  was  recognized.  If  an  accurate  history  is  obtainable,  the  direc- 
tion of  the  growth  of  the  swelling,  its  association  with  some  renal  symptom,  the 
relation  to  the  colon,  and  the  negative  results  of  vaginal  and  uterine  examina- 
tion will  usually  clear  up  all  doubts. 

It  might  be  thought  that  an  examination  of  a  small  portion  of  the  fluid 
withdrawn  by  means  of  an  aspirator  would  be  conclusive,  but  such  is  not  inva- 
riably the  case.  It  is  never  })ure  urine,  but  usually  contains  urea,  with  acid 
and  a  little  albumin.  Sometimes,  however,  these  ingredients  are  wanting,  and 
the  tapping  may  simply  furnish  a  thick,  ])urulent,  putrid  fluid,  which  could 
scarcely  be  distinguished  from  that  of  a  perinephric  abscess  (9-.  v.). 

Prognosis. — The  prognosis  varies  with  the  cause.  If  that  is  not  malig- 
nant or  in  itself  necessarily  fatal,  if  the  tumor  is  of  but  moderate  size  and  is 
stationary,  if  only  one  kidney  is  affected,  and  if  the  lower  urinary  organs  are 
not  the  seat  of  suppurative  disease,  there  is  but  little  risk  to  life.  If  both  kid- 
neys are  involved,  uremia  commonly  results. 

Treatment. — The  administration  of  drugs  is  of  no  avail.  Frictions  and 
manipulations  have  seemed  to  be  successful  in  a  few  cases,  all  of  them  young 
children,  but  obviously  little  dependence  can  be  placed  on  such  methods,  which 
might  even  be  dangerous  if  vigorously  employed.  Tapping  is  folloAved  by  cure 
in  a  certain  proportion  of  cases,  but  usually  has  to  be  repeated  a  number  of  times. 
It  is  better  to  use  a  small  needle  and  to  remove  the  fluid  by  aspiration.  If  the 
right  kidney  is  affected,  the  best  point  for  the  insertion  of  the  needle  is  halfway 
between  the  last  rib  and  the  crest  of  the  ilium,  and  about  two  and  a  quarter 
inches  posterior  to  the  anterior  superior  spine.  On  the  left  side  the  absence 
of  the  liver  makes  it  safe  to  go  a  little  higher,  and  a  spot  just  below  the  last 
intercostal  space  may  be  selected. 

A  simple  aspiration  may  effect  a  complete  cure,  either  by  the  relief  of  tension 
or  by  permitting  the  unfolding  of  a  twist  of  the  ureter.  If  repeated  tappings 
fail  to  bring  about  a  cure,  nephrotomy,  stitching  of  the  edges  of  the  cyst  to 
the  parietal  wound,  and  drainage  and  irrigation  should  next  be  employed. 
Nephrectomy  should  be  used  only  in  cases  in  which  a  permanent  fistula 
with  offensive  purulent  discharge  indicates  great  disorganization  of  the  renal 
tissue  and  threatens  the  development  of  sepsis.  If  ai  the  first  tapping  the  fluid 
is  found  to  be  distinctly  purulent,  nephrotomy  should  be  done  either  at  once 
or  as  soon  as  the  tumor  re-forms. 

Weir  has  suggested  that  in  cases  of  acute  septic  invasion  of  the  kidney  an 
exploratory  incision  on  one  or  both  sides  mijjht  relieve  the  acute  interstitial 
invasion,  and,  if  a  large  and  well-defined  focus  of  pus  were  found,  might  do 
still  more  good,  lie  did  a  nephrectomy  successfully  in  one  case  of  septic 
pyelo-nephritis,  but  the  frequency  with  which  both  kidneys  are  involved  in 
such  cases  makes  it  improbable  that  the  operation  would  often  result  favor- 
ably. 

Perinephritis. — Inflammation  in  the  loose  connective  and  fatty  tissues 
surrounding  the  kidney  is  of  very  fre(iuent  occurrence.  It  is  most  frequently 
found  in  adults,  and  is  not  uncommon  in  children. 

Etiology. — Perinephritis  may  be  simple  and  idiopathic,  or  may  be  the 


SURGERY   OF   THE    GENITO-URINARY    TRACT.  845 

result  of  an  aftectioM  of"  the  kidney  itself.  Occasionally  its  exciting  cause  is 
to  be  found  in  some  noiglil)oring  or  remote  organ  or  structure,  or  it  may  be 
due  to  traumatism. 

Symptoms. — When  it  is  not  the  result  of  infection,  it  has  but  little 
importance  from  a  surgical  point  of  view.  The  symptoms  are  vague,  the 
most  noticeable  being  localized  tenderness  and  pain,  relieved  somewhat  by 
flexion  of  the  thigh  upon  the  abdomen  ;  stiffness  of  tlie  spinal  column  ;  incli- 
nation of  the  trunk  toward  the  affected  side ;  inability  to  bi'ing  the  ham  to 
the  surface  on  which  the  patient  lies  su])ine,  or  at  least  inability  to  do  so  with- 
out much  pain.     There  is  also  fever,  sometimes  quite  marked. 

Diagnosis. — This  condition  is  often  mistaken  for  coxalgia  or  for  Pott's 
disease  in  the  early  stage.  Perinephritis  should  be  recognizable  by  the  locali- 
zation of  the  tenderness,  the  absence  of  the  characteristic  deformities  of  either 
the  spine  or  the  lower  extremity,  and  the  failure  to  elicit  pain  or  tenderness  by 
pressure  on  the  trochanter  or  by  crowding  together  the  vertebrae.  Occa.sion- 
ally  pain  in  the  knee  increases  the  resemblance  to  coxalgia. 

Treatment. — Rest  is  most  important.  Stimulating  liniments  applied 
with  deep  friction  may  be  useful ;  leeches  or  wet  cups  followed  by  hot  stupes 
have  been  employed  with  apparent  benefit.  Laxatives  are  indicated,  and 
small  doses  of  opiates  and  of  belladonna,  by  relieving  the  spasm  of  the  psoas, 
may  be  of  much  value.  The  case  may  terminate  in  resolution,  but  much  more 
commonly  runs  on  to  suppuration. 

Perinephric  Abscess. — The  infective  inflammation  in  these  cases  may 
extend  to  the  loin  from  any  portion  of  the  urinary  or  intestinal  tract  in  rela- 
tion by  contiguity  or  continuity  with  the  retro-peritoneal  connective  tissue. 
Thus  it  has  been  known  to  follow  lithotomy,  internal  urethrotomy,  castration, 
prostatic  abscess,  appendicitis,  etc.  It  may  result  from  perforation  of  the 
diaphragm  by  an  empyema.  In  many  cases  it  is  secondary  to  suppurative 
pyelitis,  usually  calculous  in  its  origin.  Actual,  or  at  least  demonstrable,  per- 
foration of  the  capsule  of  the  kidney  is  not  a  necessity  in  these  cases,  the 
inflammation  appearing  to  spread  by  contiguity,  although  doubtless  all  such 
cases  indicate  true  microbic  infection  of  the  area  secondarily  invaded. 

Symptoms. — The  indications  of  the  formation  of  pus  in  a  case  of  peri- 
nephritis are  similar  to  those  which  accompany  deep-seated  suppuration  any- 
where. Rigors,  sw^eats,  high  temperature,  etc.  are  apt  to  be  marked.  If  the 
abscess  is  consecutive  to  disease  of  the  kidney  and  the  result  of  the  escape  of 
urine  through  a  renal  fistula,  the  debilitated  condition  of  the  patient  and  the 
putrescible  and  highly  poisonous  character  of  the  extravasated  fluid  are  factors 
which  give  the  case  peculiar  gravity ;  an  intense  primary  septic  intoxication 
(sapremia)  immediately  resulting,  often  soon  followed  by  Avell-developed  septice- 
mia. In  other  instances  the  case  runs  a  slow  course,  the  constitutional  symp- 
toms being  vague  and  ill  defined.  In  these  cases  the  following  group  of  local 
symptoms  will  be  of  chief  diagnostic  importance  :  deep-seated,  paroxysmal 
lumbar  pain  extending  into  the  thigh  and  the  hypogastrium,  sometimes  into 
the  groin  and  scrotum ;  tenderness  on  direct,  and  especially  on  bimanual,  pres- 
sure upon  the  loin,  one  hand  being  in  front,  the  other  behind ;  increased  re- 
sistance and  fulness  in  the  lumbar  region,  followed  by  brawniness  of  the  skin 
and  later  by  oedema ;  lameness,  flexion  of  the  thigh  upon  the  abdomen,  incli- 
nation of  the  body  toward  the  affected  side,  are,  as  in  simple  perinephritis,  of 
great  value ;  oedema  of  the  lower  limb  on  the  same  side  is  of  frequent  occur- 
rence ;  the  formation  of  a  distinct  fluctuating  swelling,  vague  in  its  outlines, 
would  ordinarily  be  conclusive  as  to  the  character  of  the  case,  but  if  doubt 
remains  the  use  of  a  hollow  needle  will  resolve  it. 


846  AN  AMERICAN   TEXT-BOOK    OF  SURGERY. 

Diagnosis. — Nephralgia  and  renal  calculus  lack  the  inflaniinatory  and 
constitutional  symptoms  which  accompany  abscess ;  lumbago  could  be  recog- 
nized by  the  absence  of  fever,  of  flexion  of  the  thigh,  and  of  lateral  bending 
of  the  trunk  ;  hip  disease  and  vertebral  caries,  by  the  characteristic  deformities 
and  by  the  gait  of  the  patients ;  aj)pendicitis  and  periciecal  altsco.ss,  by  the  site 
of  original  pain  and  by  the  concomitant  intestinal  and  abdominal  symptoms; 
psoitis  and  psoas  abscess,  by  the  situation  of  the  pain,  which  is  apt  to  be 
anterior  to  a  line  draAvn  from  the  front  border  of  the  axilla  to  the  crest  of  the 
ilium,  while  in  perinephritis  and  perinephric  abscess  the  local  symptoms  are 
apt  to  be  posterior  to  such  a  line  (Morris). 

Prognosis. — The  proba])ility  of  entire  recovery  of  course  varies  greatly 
with  the  cause.  In  simple  cases  treated  by  early  incision  recovery  is  prompt 
and  complete.  In  cases  dependent  upon  suppuration  along  the  urinary  or 
intestinal  tract,  extending  to  the  retro-peritoneal  connective  tissue,  early  ope- 
ration is  likewise  followed  by  cure  in  the  great  majority  of  instances.  In 
cases  secondary  to  pyelo-nephritis,  renal  calculus,  etc.  fistula  often  follows,  and 
the  final  outcome  is  greatly  influenced  by  the  character  of  the  renal  disease. 

Treatment. — In  all  cases  operation  should  be  resorted  to  as  soon  as 
the  condition  is  recognized,  or  even  as  soon  as  there  are  distinct  localizing 
symptoms  showing  the  presence  of  an  acute  inflammation  with  no  tendency 
to  disappear  by  resolution.  An  incision  on  the  outer  edge  of  the  quadratus, 
in  the  costo-iliac  space,  vertical  or  oblique,  and  opening  up  the  post-renal  space, 
is  of  no  gravity  whatever.  Delay  may  mean  extensive  burrowing,  perfora- 
tion of  the  diaphragm  with  consecutive  empyema,  and  opening  of  the  abscess 
into  some  of  the  contiguous  viscera  or  into  the  peritoneal  cavity.  An  explora- 
tion by  means  of  a  hollow  needle  should  certainly  be  made,  therefore,  when- 
ever the  earlier  symptoms  of  perinephric  inflammation  are  followed  by  fulness, 
hardness,  and  tenderness,  and  especially  if  in  addition  there  are  heat  and  red- 
ness of  the  skin.  Failure  to  find  pus  in  this  manner  may  warrant  further 
delay,  but  a  persistence  of  the  same  symptoms  would  certainly  justify  a  free 
incision  long  before  fluctuation  could  be  felt  through  the  thick  abdominal 
parietes.  Six  pints  of  pus  were  found  and  evacuated  in  one  such  case,  although, 
owing  to  the  thickness  of  the  subcutaneous  fat,  no  fluctuation  could  be  made 
out. 

After  evacuation  of  the  pus  the  finger  should  explore  the  kidney,  and  if 
a  renal  fistula  is  found  it  should  also  be  probed.  If  there  are  grounds  for 
believing  the  disease  to  be  of  calculous  origin,  the  kidney  should  be  carefully 
palpated,  or  even  pierced  with  an  exploring  needle  or  probe,  in  the  endeavor 
to  locate  a  stone.  If  one  is  found,  nephro-lithotomy  may  be  proceeded  with 
at  once  if  the  condition  of  the  patient  warrants  it.  As  a  rule,  nephrectomy 
even  in  cases  of  real  disorganization  of  the  kidney  should  be  postponed,  as 
statistics  show  a  much  lower  mortality  after  secondary  operations  for  removal  of 
the  kidney  than  after  those  done  at  the  time  the  loin  is  opened  for  abscess  or 
to  permit  of  the  extraction  of  a  stone. 

The  cavity  should  be  thoroughly  and  forcibly  sponged  out,  so  as  to  remove 
all  shreds  of  necrosed  connective  tissue,  the  ddbris  of  the  abscess,  and  much 
of  the  infected  granulation-tissue.  If  it  is  limited  in  extent,  it  may  be  well 
to  curette  the  walls.  Free  irrigation  with  sublimate  solution,  the  insertion  of 
a  drainage-tube,  the  inner  end  of  which  may  be  carried  directly  into  the  open- 
ing in  the  kidney  if  there  be  one,  and  the  packing  of  the  wound  with  anti- 
septic gauze,  complete  the  operation.  Only  a  few  sutures  at  each  angle  of  the 
wound  are  allowable.  Nutritious  food,  tonics,  and  often  stimulants,  are  urgently 
needed  by  the  patient  during  convalescence. 


SURGERY   OF   THE   GENITO- URINARY   TRACT.  847 


Tuberculosis  of  the  Kidney  is  usually  associated  with  evidences  of 
tul.crcular  disease  elsewhere,  and  occurs  chiefly  in  hroken-down  persons,  often 
of  middle  aj^e  or  younger.  It  has  been  differentiated  into  "scrofulous  kid- 
ney" and  "miliary  tuberculosis  of  the  kidney,"  etc.,  but  there  is  no  important 
clinical  or  pathological  distinction  between  the  varieties,  which  differ  only  in 
the  extent  of  the  renal  involvement.  If  the  tuberculosis  assumes  the  miliary 
or  disseminated  form,  it  is  apt  to  affect  both  kidneys,  and  as  a  rule,  reveals  an 
intense  de^rree  of  constitutional  infection.  The  other  form  is  a  tubercular 
pyelo-ncphntis,  sometimes  local  and  primary,  oftener  secondary  to  other  vis- 
ceral tuberculosis,  and  more  especially  to  ulcerating  tubercular  disease  of  the 
bladder  or  prostate.  The  symptoms  are  those  of  pyelo-nephritis  plus  the  evi- 
dences of  general  tubercular  disease.  The  patient  often  has  a  strongly  marked 
family  history  of  tuberculosis.  i        i    x-^      ^i  of 

It  has  been  said  that  vesical  irritation  is  the  most  usual,  and  often  the  most 
prominent  and  distressing,  symptom.  Dickinson  asserts  that  m  a  case  contain- 
in<^  pus  from  the  kidneys  the  absence  of  bladder  symptoms  excludes  renal 
tuberculosis.  It  is  more  probable,  however,  that  the  frequent  micturition  anu 
vesical  tenesmus  depend  on  a  beginning  tubercular  deposit  about  lie  lower  end 
of  the  ureter  or  in  the  bladder  itself.  There  may  not  be  a  lumbar  tumor,  ihe 
prominence  of  the  vesical  symptoms  and  the  coexistence  of  tubercle  elsewhere 
are  most  to  be  depended  on  for  diagnosis. 

The  prognosis  is  unfavorable.  ^  . 

The  treatment  in  advanced  cases  should  be  palliative.  In  primary  cases 
which  have  gone  on  speedily  to  suppuration  and  to  the  production  of  pyo- 
nephrosis or  perinephric  abscess,  and  in  which  the  condition  of  the  kidney  is 
therefore  discovered  during  the  operation  for  these  conditions,  and  before  the 
general  health  is  much  affected,  operation  may  be  considered,  it  but  one  or 
two  caseous  foci  are  found  and  the  kidney  is  not  much  enlarged  or  nodulated, 
incision,  curetting,  and  drainage  may  suffice.  In  more  extensive  disease 
nephrectomy  offers  the  only  hope  of  cure.  .     -,      t    .i,    ^  »ooo 

Cysts  of  the  Kidney  may  be  congenital  or  acquired.  In  the  former  case 
they  are  sometimes  of  enormous  size,  and  may  even  interfere  with  delivery. 
These  are  thought  to  be  due  to  defective  development  of  the  tubules,  as  in 
such  cases  there  are  often  other  imperfections  arising  from  developmental  iail- 
nre  In  the  adult  they  are  often  found  in  large  numbers  scattered  through 
the  parenchyma  of  the  organ  or  sometimes  occupying  chiefly  the  cortex,  ihey 
cannot  be  diagnosticated  during  life,  as  they  produce  no  distinctive  symptoms 
and  often  no  symptoms  at  all.  ^^+:^^ 

More  rarely,  however,  simple  or  serous  cysts  form  and  constitute  a  notice- 
able tumor.  They  begin  in  the  cortical  portion  of  the  organ  aad  grow  toward 
the  surface,  the  rest  of  the  kidney  remaining  normal.  The  precise  origin  of 
these  cysts  is  uncertain.  They  grow  toward  the  loin  increase  slowly  and  at 
first  painlessly,  and  have  the  usual  characteristics  of  renal  tumors:  as  they 
enlarge  the  cyst-wall  thins,  and  a  tumor  which  at  first  may  have  been  mistaken 
for  a  solid  growth  becomes  evidently  fluctuating.  Hemorrhage  may  take  place 
into  the  cavity  of  the  cyst,  or  it  may  become  the  starting-point  of  a  malignant 

^^""Thrdiagnosis  is  difficult,  and  it  is  often  impossible  to  distinguish  such  a 
cyst  from  one  of  the  spleen,  liver,  pancreas,  omentum,  or  mesentery,  or  indeed 
from  any  other  intra-abdominal  growth.  .i,     •   ^    p        „^  ^;^h 

Prognosis.— If  unrelieved,  death  may  result  from  the  interference  with 
nutrition  caused  by  the  immense  size  of  the  growth  and  its  pressure  upon  other 


848  A.y   AMKIUCAX    TEXT-noOK    OF  SURGERY. 

parts,  or  may  be  caused  by  exhaustion  from  repeated  hemorrhages  into  the 
cyst-cavity. 

Treatment. — Frequent  tapping  -will  often  effect  a  cure.  If  it  fails  to  do 
so.  the  cyst  sliould  be  cut  down  upon  and  oj)ened  and  its  edges  attached  to  those 
of  the  j)arietal  wound.  Complete  collapse  and  cure  often  follow.  If  a  per- 
sistent fistula  is  left,  nephrectomy  will  offer  the  only  prospect  of  cure,  but 
the  fact  that  the  kidney  is  probably  healthy  and  functionally  active  must 
weigh  strongly  against  operation  if  there  be  the  least  reason'  to  doubt  the 
condition  of  the  opposite  kidney. 

Hydatid  Cysts  are  found  in  the  kidneys  more  frequently  than  in  anv  other 
organ  except  the  liver  and  the  lungs.  They  are  sometim&s  secondary  to 
hydatids  of  those  organs.  They  give  rise  to  the  same  general  symptoms  a's  do 
other  renal  cysts,  but,  owing  to  their  tendency  to  rupture  into  the  pelvis  of  the 
ureter  and  to  discharge  their  contents  by  that  route,  the  prognosis  is  more 
favorable.  In  52  out  of  53  cases  collected  by  Roberts  the  cysts  were  evacuated 
in  this  manner,  and  there  is  no  authentic  case  recorded  in  which  such  a  cyst 
emptie<l  itself  through  the  loin. 

The  diagnosis  can  be  made  with  certainty  only  when  the  vesicles  or 
booklets  are  recognized  in  the  urine,  or  after  removal  through  a  trocar.  Their 
passage  along  the  ureter  excites  the  usual  symptoms  of  renal  colic. 

The  treatment  should  consist  in  incision,  suture  of  the  edges  of  the  cvst 
to  the  parietal  wound,  and  drainage.  Daily  irrigation  and  dressing  will  be 
required  for  a  long  time.  Tapping  may  be  employed  previous  to  incision,  but 
is  usually  unsuccessful. 

Solid  Tumors  of  the  Kidney. — Most  of  these  are  malignant,  and  the 
majority  are  carcinomatous.  The  greater  number,  again,  are  secondary  to 
cancer  of  the  testicle  or  to  cancer  of  some  other  organ.  The  most  frequent 
form  of  renal  cancer  is  the  soft,  or  medullary,  which  is  oftenest  found  in 
young  children  or  in  persons  of  advanced  age. 

Hematuria  and  pain  in  the  loin,  succeeded  by  the  development  of  a  hard, 
nodulated  tumor  attaining  an  extremely  large  size  in  a  comparatively  short 
time,  and  occurring  before  the  age  of  five  or  after  that  of  sixty,  would  consti- 
tute a  group  of  symptoms  justifying  the  diagnosis  of  renal  cancer.  Occasion- 
ally the  passage  t^f  small  cancerous  masses  per  urethram  admits  of  a  positive 
microscopical  diagnosis.  If  this  were  made  very  early,  nephrectomy  would 
offer  some  chance  of  cure,  otherwise  the  treatment  must  be  palliative.  Butlin 
reports  2  cases  out  of  18  free  from  recurrence  at  the  end  of  three  years  after 
operation. 

Sarcoma  presents  the  same  clinical  symptoms.  It  occurs  chiefly  in  the 
young.     The  only  chance  of  cure  lies  in  the  early  extirpation  of  the  organ. 

INJURIES  OF  THE  KIDNEY. 

SuBPARiETAL  INJURIES. — Injuries  of  the  kidney  without  wound  of  the 
abdominal  parietes  may  result  from  direct  violence,  as  from  crushes  and  blows 
upon  the  loin  or  upon  the  ilio-costal  region  of  the  abdomen,  or  from  indirect 
violence,  as  in  falls  from  a  height,  accompanied  by  sudden  bending  of  the 
trunk  at  the  time  of  alighting.  They  are  by  far  the  most  fretiuent  of  all  forms 
of  injury  to  the  kidney.  The}"  may  be  very  severe  up  to  rupture  or  even 
actual  pulpefaction  of  the  organ,  or  may  consist  of  an  extremely  slight  con- 
tusion with  few  symptoms. 

Symptoms. — The  history  of  an  accident  or  traumatism  sufficient  to  have 
produced  the  injury,  lumbar  pain  and  tenderness  shooting  down  toward  the 


SURGERY   OF    THE    GENJTO-URINARY   TRACT.  849 

groin,  testicle,  or  tlii^ijli,  fV(M|ueiit  and  pninfiil  micturition,  and  hematuria,  are 
the  symptoms  most  commonly  present.  In  severe  cases  with  extensive  lacera- 
tions of  the  substance  of  the  kidney  there  are  superadded  the  constitutional 
symptoms  of  hemorrhage  and  shock,  and  sometimes  of  collapse.  As  to  the 
hematuria,  which  is  perhaps  the  most  distinctive  sign  of  injury  of  the  kidney, 
it  must  not  be  forgotten  that  it  may  be  marked  in  a  case  of  strain  or  simple 
contusion  in  which  there  has  been  a  sudden  congestion  in  some  portion  of  the 
urinary  tract,  or  may  be  absent  in  cases  of  laceration  of  the  kidney  in  which 
the  ureter  is  plugged  and  occluded  by  a  coagulum. 

Prognosis. — In  simple  contusions  the  prognosis  is  favorable,  and  even  in 
injuries  attended  Avith  a  certain  degree  of  laceration  there  is  a  larger  propor- 
tion of  recoveries  than  after  rupture  of  other  abdominal  viscera.  If  death 
occurs  speedily,  it  is  usually  due  to  hemorrhage  or  collapse;  later,  to  perito- 
nitis or  to  diffuse  suppuration  in  the  loin,  with  septicemia  or  pyemia,  or,  if  the 
opposite  kidney  happens  to  be  diseased,  to  uremia. 

Treatment. — The  patient  should  be  kept  absolutely  at  rest ;  the  diet 
limited  to  liquids;  gallic  acid  or  ergot  or  opium  and  lead  administered  if 
hematuria  is  extreme.  Strapping  the  affected  region  so  as  to  limit  the  move- 
ments, as  in  cases  of  fractured  rib,  will  often  give  great  relief  from  the  pain. 
Enemata  may  be  given  at  first  if  required.  Purgatives  should  be  avoided. 
Vomitino-,  by  encouraging  hemorrhage,  is  especially  dangerous.  If  persistent, 
the  patient  should  for  a  time  be  fed  entirely  by  enemata.  The  chief  difficulty 
often  consists  in  the  accumulation  of  blood-clots  in  the  bladder,  followed  by 
vesical  tenesmus  and  by  retention  of  urine.  If  the  blood-clots  are  small,  they 
will  probably  be  spontaneously  evacuated.  If  they  are  somewhat  larger, 
causing  retention  and  tenesmus,  a  large  catheter  with  two  good-sized  lateral 
openings  should  be  introduced  and  the  bladder  injected  wijth  some  non-irritating 
antiseptic  solution  with  moderate  force.  If  this  fails,  one  of  the  evacuating 
tubes  used  in  litholapaxy  may  be  inserted  and  connected  with  the  evacuator, 
and  fluid  thrown  into  and  drawn  out  from  the  bladder  by  that  means. 

Occasionally  all  these  methods  fail,  and  in  such  cases  a  median  urethrotomy 
is  indicated,  both  to  evacuate  clots  and  to  relieve  retention,  and  also  to  avoid 
decomposition  of  the  blood  and  urine  and  the  subsequent  pyelo-nephritis  from 
which  many  such  patients  have  died.  In  cases  of  profound  shock  with  or  with- 
out hematuria,  but  with  an  increasing  tumor  in  the  loin,  an  incision  should  be 
made  as  if  for  lumbar  nephrotomy  or  nephrectomy ;  the  kidney  should  be  thor- 
oughly examined,  and  if  torn  across  or  pulpefied  should  at  once  be  removed. 
Resection  of  a  portion  of  the  kidney  in  such  cases  has  been  proposed,  but 
seems  likely  to  be  attended  with  a  larger  mortality  than  nephrectomy. 

Penetrating  Wounds  of  the  Kidney. — A  wound  extending  through  the 
soft  parts  to  the  kidney  may  be  either  extra-  or  intra-peritoneal.  In  extra- 
peritoneal Avounds  of  the  kidney  the  posterior  surface  of  the  organ  is  involved, 
and  the  wound  extends  through  the  tissues  of  the  loin.  Exploration  with  an 
aseptic  finger  is  proper  and  Avill  often  establish  the  diagnosis.  The  appear- 
ance of  urine  in  the  wound  would  of  course  be  conclusive,  but  its  absence 
does  not  disprove  the  existence  of  a  renal  wound,  as  the  latter  may  involve 
only  the  cortex,  neither  the  pelvis  of  the  ureter  nor  a  renal  calyx  having 
been  opened.  Hematuria  may  be  due  to  coincident  contusion,  but  it  always 
points  strongly  to  involvement  of  the  kidney.  Perinephric  abscess  is  a  com- 
mon sequel. 

If  the  wound  is  on  the  anterior  surface  and  is  intra-perito?7eal,  the  symp- 
toms will  include  those  due  to  extravasation  of  blood  or  urine  into  the  peri- 
to^neal  cavity, 

54 


8.50 


.-l.V   AMi:iiirAy    TEXT- HOOK    <Jl'   SLRdKHV. 


Prognosis. — In  the  latter  class  of  cases  the  profrnosis  is  very  unfavor- 
able, hut  ill  extra-peritoneal  Avound?  of  the  kitlney.  uneoniplicated  hy  injury 
to  other  structures,  recovery  niav  he  expected  in  the  majority  of  cases. 

Treatment. — In  extra-peritoneal  wounds,  rest,  low  diet,  ergot,  and  small 
doses  of  opium,  and  thorough  antisepsis  in  and  around  the  wound,  are  clearly 
indicated.  Hemorrhage  may  be  arrested  by  packing,  accompanied,  if  neces- 
sary, hy  enlargement  of  the  wound,  so  as  to  prevent  urinary  infiltration. 
Drainage  should  be  secure<l  bv  the  introduction  of  a  larji-e  rubber  tube  down 
to  the  wounded  surface. 

In  iiitra-peritoneal  wounds  abdominal  section,  with  nephrectomy,  will  almost 
always  be  required. 

WOUNDS  OF  THE  UEETERS. 

There  are  very  few  recorded  instances  of  uncomplicated  wounds  of  the 
ureters.  In  the  historic  case  of  the  archbishop  of  Paris,  who  was  shot  in 
the  loin  during  the  revolution  of  1848,  and  who  died  in  eighteen  hours,  the 
ureter  was  divided  close  to  the  pelvis,  but  there  were  also  fracture  of  the  third 
lumbar  vertebra  and  division  of  the  cauda  equina. 

The  ureter  has  been  Avounded  during  the  removal  of  uterine,  ovarian,  and 
other  abdominal  tumors.  Occasionally  it  has  been  divided  purposely  on 
account  of  its  incorporation  Avith  a  malignant  groAvth  (Morris). 

A''an  Hook,  Avho  has  studied  the  surgery  of  the  ureter  extensively,  advises 
against  the  use  of  sutures  in  longitudinal  wounds  of  this 
Jig.  343.  duct.     For  cases  of  complete  division  of  the  ureter  he  has 

devised  the  folloAving  method  of  anastomosis  (Figs.  343, 
344).      If  the  division  of  the  ureter  is 
Fig.  344.  sufficient  to  exclude  the  chance  of  suc- 

cess by  suturing,  but  not  complete,  it 
should  be  made  so.  The  free  extremity 
of  the  distal  portion  is  then  ligated 
with  silk  or  catgut  one-fourth  to  one- 
half  inch  from  the  point  of  division. 
Then  make  Avith  fine,  sharp-pointed 
scissors  a  longitudinal  incision  in  the 
ureter,  beginning  one-quarter  of  an 
\\   /  /J^  \  I  j  h     ^1      X    /        inch  beloAv  the  ligature,  and  twice  as 

^F  Im^  a  I  \      \      Ai^      ^^^^c,   ^^   ^^^^    diameter  of   the    ureter. 

Next  make  an  incision  Avith  the  scis- 
sors, one-quarter  of  an  inch  in  length 
(  i   \  5^^vf     (  (r^    ^^^~Vn       ^"  *^^  ^''^^  ^^^  "^  ^^^®  proximal  por- 

)  \  \/j^'^M\    V  I      (y7^^'a\c    \    ^^^^'    ^^""^  ^^^y  small  cambric  needles, 

V  threaded  on  the  same  piece  of  catgut, 
are  passed  through  this  end  from  witliin 
outAvard.  one-eighth  of  an  inch  from 
the  free  end.  and  one-sixteenth  to  one- 
eighth  of  an  inch  apart.  The  needles 
are  then  carried  through  the  slit  in  the 
lower  portion  of  the  ureter  and  doAvn 
the  tube  for  half  an  inch.  Avhen  they 
are  pushed  througli  the  Avail  of  the 
duct  side  by  side ;  the  upper  portion 
of  the  ureter  is  draAvn  into  the  lower  by  traction  on  the  suture,  and  secured 
by  a  knot.      The  ureter  is  then  carefully  enveloped  Avith  peritoneum. 


Van  Hook's  Method  of  Uretero-ureteral  Ana.<!t(>- 
mosis:  Fig.  343  shows  the  ureter  rtividid.  and 
the  lower  end  tied  aijd  split  on  one  side,  ready 
to  ref-eive  the  upperend.  whieh  is  drawn  down 
into  it  bvtwo  traction  lii:atnres:  Fifr.  :M4shr>ws 
the  ureter  held  in  place  by  the  traction  liga- 
tures, which  have  been  tied.  The  five  untied 
sutures  unite  the  entering  ureter  to  the  cut 
edges  of  the  intussuscipient  ureter. 


SURGERY   or    THE    GENITO-URINARY   TRACT.  851 

Fowler  has  recently  reported  a  method  of  iinidaiitatioii  of  the  ureters 
into  the  rectum  in  exstrophy  of  the  bladder  (see  below),  by  which  the  abdo- 
men is  opened  in  the  median  line,  the  patient  being  in  the  Trendelenburg 
position  :  the  ureters  are  identified,  exposed,  and  cut  away  from  the  bladder 
wall,  and  then  placed  in  the  anterior  wall  of  the  rectum  through  a  valve-like 
opening.     He  has  had  a  good  result  in  one  case. 

Stricture  of  the  Ureter  is  of  very  rare  occurrence,  except  as  a  result 
of  compression  from  without  by  pelvic  or  abdominal  new  growths. 

Watson  of  Boston  has,  however,  reported  two  cases  of  stricture,  in  both 
of  which  a  ureter  was  nearly  or  quite  obliterated  by  a  dense  mass  of  connect- 
ive tissue.  In  one  case  there  was  a  doubtful  history  of  the  passage  of  a  renal 
calculus  years  previously.  The  condition  Avas  associated  with  pyo-nephrosis  in 
both  instances.     He  has  collected  four  other  cases  from  medical  literature. 

PART  II.— DISEASES  AND  INJURIES  OF  THE  BLADDER. 

Congenital  Deformities. — Occasionally,  but  rarely,  the  bladder  is  absent, 
and  in  that  event  the  ureters  may  open  directly  into  the  urethra,  rectum,  or 
va^dna,  or  upon  the  surface  of  the  body  in  the  middle  line.  The  condition 
is  usually  associated  -with  other  abnormalities,  such  as  undescended  testicles, 
imperforate  anus,  etc. 

Supernumerary  bladders  are  also  rare  forms  of  congenital  deformities, 
most  of  the  reported  cases  having  been  really  examples  of  multilocular  or  sac- 
culated bladder.  A  few^  authentic  instances  exist,  how^ever,  in  one  of  which 
there  were  said  to  be  five  separate  bladders. 

Cystocele,  or  hernia  of  the  bladder,  is  usually  secondary  to  obstructive  dis- 
ease. The  dilatation  of  the  organ,  the  thickening  and  weakening  of  its  coats, 
and  the  straining  during  the  frequent  efforts  to  evacuate  the  urine  constitute 
powerful  factors  in  bringing  about  a  protrusion  of  the  viscus.  This  is  also 
favored  by  weakness  or  relaxation  of  the  abdominal  walls,  as  from  ascites  or 
senility,  or  by  the  existence  of  a  broad  cicatrix  followdng  abdominal  section. 
The  bladder  in  these  cases  will  protrude  in  the  line  of  the  linea  alba,  but  in 
others  it  may  follow  the  track  of  the  cord  or  of  the  great  blood-vessels 
through  the  walls  of  the  abdomen,  and  appear  in  the  inguinal  or  femoral  or 
obturator  region.  In  the  female  prolapsus  frequently  takes  place  into  the 
vagina,  the  bladder  protruding  between  the  labia. 

Symptoms. — The  presence  of  a  rounded  fluctuating  tumor  in  any  of  the 
above  situations,  increasing  in  size  during  the  intervals  of  urination,  markedly 
reduced  in  size  by  catheterization  or  after  micturition,  and  lacking  the  charac- 
teristic signs  of  epiplocele  or  enterocele,  should  serve  to  establish  the  existence 
of  a  hernia  of  the  bladder.  In  case  of  doubt  a  grooved  needle  or  an  aspirator 
will  remove  all  difficulty.  It  should  not  be  forgotten  that  in  a  case  of  cysto- 
cele, especially  if  it  be  irreducible,  the  interference  with  the  evacuation  of  the 
urine  tends  to  favor  the  formation  of  calculi,  and  that  one  or  several  may 
exist  in  the  protruding  pouch  and  may  be  mistaken  for  nodules  of  malignant 
growths. 

Treatment. — When  the  tumor  is  reducible,  a  truss  should  be  worn  to 
retain  it  in  place.  When  it  is  irreducible,  a  support  or  truss  with  a  concave 
pad  may  be  used  to  prevent  its  increase.  Operative  treatment  has,  as  a  rule, 
been  unsatisfactoiy,  except  sometimes  in  vaginal  cystocele. 

Exstrophy  is  the  most  frequent  of  all  the  congenital  defects  of  the  bladder. 
It  occurs  in  males  in  from  80  to  90  per  cent,  of  all  cases.  It  results  from  an 
arrested  development  of  the  lateral  portions  of  the  uro-genital  cleft,  which  fail 
to  come  together  to  form  the  front  of  the  bladder  and  the  anterior  parietes  of 


852  ^^V  AMERICAJS^    TEXT-BOOK    OF  SURGERY. 

the  abdomen.  The  pubic  symphysis  is  absent.  The  posterior  wall  of  the 
bladder,  covered  with  mucous  membrane.  Imlges  forward  through  the  unnatural 
opening,  and  is  usually  covered  with  tenacious  vesical  mucus.  The  penis  is 
the  subject  of  complete  epispadias.  The  prostate  is  rudimentary.  There  is 
usually  complete  double  inguinal  hernia,  the  presence  of  which  in  the  two 
halves  of  the  scrotum,  already  separated  by  the  unnatural  interval  between  the 
pubic  bones,  causes  the  parts  to  resemble  the  labia  of  the  female.  If  the  scro- 
tum is  absent,  the  testes  are  found  in  the  inguinal  canal. 

A  similar  condition  in  tlie  female  causes  a  separation  of  the  labia  and 
nymph?e  and  converts  the  vagina  into  a  shallow  fissure,  but  the  disability  pro- 
duced is  not  so  great  as  in  the  male. 

Patients  with  exstrophy  are  usually  found  with  marked  cystitis  from  expo- 
sure of  the  mucous  membrane  to  the  air  and  from  its  friction  against  the  cloth- 
ing. The  urine  is  fetid  and  ammoniacal ;  the  skin  of  the  abdomen,  thighs, 
perineum,  and  buttocks  is  excoriated  or  eczematous.  The  general  nutrition  is 
often  affected,  and  the  child  is  apt  to  be  feeble  and  sickly. 

Treatment. — Appliances  intended  to  collect  the  urine  and  protect  the  ex- 
posed surface  of  the  bladder  have  thus  far  been  entire  failures.  Some  opera- 
tive procedure  is  necessary  as  a  preliminary.  Of  the  many  methods  which 
have  been  devised.  Wood's  operation,  which  consists  in  turning  down  a  flap 
from  the  abdomen  above  the  opening  (between  it  and  the  umbilicus)  and  cover- 
ing it  by  two  others  taken  from  the  inguinal  region,  is  perhaps  the  most  gene- 
rally applicable.  In  the  male,  Roux's  operation  as  modified  by  Maury  of  Phila- 
delphia is  often  most  useful,  and  sometimes  has  the  advantage  of  curing  at  the 
same  time  any  inguinal  hernia  which  may  coexist.  It  consists  in  turning  up  a 
large  convex  flap  from  the  scrotum,  the  groin,  and  the  perineum,  slipping  the 
penis  through  a  small  opening  near  the  base  of  the  flap,  and  sliding  the  edge 
of  the  latter  beneath  a  second  flap  raised  from  the  tissue  above  and  to  each 
side  of  the  opening.  The  flaps  are  held  in  place  by  the  "  tongue-and-groove 
suture." 

Successful  operations  for  exstrophy  greatly  diminish  the  annoyance  of  the 
condition,  concentrating  the  outflow  of  the  urine  at  a  single  point,  and  thus 
permitting  the  use  of  a  urinal  and  preserving  the  surrounding  skin-surfaces 
from  irritation.  Of  course  in  the  case  of  the  male  sexual  potency  is  never 
acquired,  the  penis  always  remaining  rudimentary. 

GENERAL  CONSIDERATIONS    IN  THE  DIAGNOSIS  OF    GENITO-URINARY  DISEASE. 

Pain. — The  pain  of  gen i to-urinary  disease  may  be  considered  in  relation 
to  the  region  in  which  it  is  felt  and  the  time  at  which  it  is  felt.  In  regard 
to  the  first  subdivision,  it  may  be  remarked  that  the  region  to  which  the  pain 
is  referred  should  not  be  considered  -as,  necessarily  the  seat  of  the  trouble.  A 
stone  in  the  bladder  causes  pain  which  is  felt  at  the  under  surface  of  the  penis 
a  short  distance  back  of  the  meatus  ;  disease  of  the  kidneys  constantly  gives 
rise  to  pain  which  is  felt  chiefly  in  the  groin,  down  the  thigh,  or  in  the  testi- 
cle ;  while  disease  of  the  testicle  in  its  turn  produces  pain  radiating  along  the 
inguinal  line.  In  the  majority  of  instances,  as  in  those  mentioned,  reflex  pain 
is  due  to  the  irritation  of  a  nerve-trank,  the  abnormal  sensation  being 
referred  to  the  point  of  termination  of  the  nerve :  pain,  however,  may,  of 
course,  be  felt  at  the  seat  of  trouble  itself,  as,  for  example,  in  urethritis, 
where  the  pain  is  felt  in  the  inflamed  urethra ;  in  retention  of  urine,  where  it 
is  referred  directly  to  the  bladder  and  hypogastric  region  ;  or  in  prostatitis, 
where  it  is  felt  in  the  rectum  and  perineum.  In  some  cases  of  the  last-men- 
tioned trouble  the   pain   is   duplex    in    character,   being  both   localized   and 


SURGERY   OF    THE    QENITO- URINARY   TRACT.  853 

referred,  a  patient  witli  a  tlireatencd  prostatic  abscess  having  rectal  pain  and 
urethral  ])ain  at  the  same  time,  the  latter  closely  resembling  that  produced  by 
vesical  calculus. 

The  second  subdivision  in  regard  to  pain  refers  to  the  time  at  -which  it  is 
felt.  Pain  during  micturition  may  be  due  to  cystitis,  prostatitis,  or  urethritis, 
or  to  the  passage  of  gravel,  or  to  a  small  calculus.  Pain  before  micturition, 
which  is  relieved  by  that  act,  may  be  due  to  cystitis  or  to  retention  of  urine. 
Pain  -which  is  increased  at  the  end  of  micturition  may  be  caused  by  vesical 
calculus  or  by  acute  prostatitis  ;  if  it  is  markedly  increased  during  defeca- 
tion, it  points  to  the  latter  trouble  ;  if  relieved  by  rest  and  much  increased  by 
movement,  it  indicates  the  former  condition. 

Frequency  of  Micturition. — Increased  frequency  of  micturition  is  a 
diagnostic  sign  Avhich  is  of  value  only  when  considered  carefully  in  its  relation 
to  other  symptoms.  Normal  micturition  depends  upon  the  healthfulness  of  a 
certain  nerve-tract,  which,  beginning  in  the  peripheral  extremities  of  the 
nerves  distributed  to  the  genito-urinary  apparatus,  extends  to  a  certain  por- 
tion of  the  lumbar  enlargement  of  the  spinal  cord,  and  thence  along  other 
nerves  to  the  muscles  of  the  bladder  and  urethra.  If  the  sensory  nerves  are 
unduly  irritated,  frequent  micturition  results.  This  is  seen  in  phimosis,  con- 
tracted meatus,  urethral  stricture,  urethritis,  cystitis,  prostatitis,  and  vesical  or 
renal  calculus.  If,  on  the  other  hand,  the  stimulus  to  these  sensory  nerves 
remains  normal,  but  the  spinal  center  becomes  irritable,  the  same  effect  is 
produced  as  in  cases  of  sexual  excess  or  spinal  concussion.  The  nerve-supply 
may  remain  normal,  and  yet  frequent  micturition  be  produced  either  by  an 
excessive  secretion  of  urine,  as  in  diabetes,  or  by  such  contraction  of  the  blad- 
der as  renders  it  disproportionately  small,  so  that  it  is  over-distended  by  even 
a  normal  amount  of  urine.  Or,  again,  micturition  may  be  too  frequent  from 
some  obstructive  cause,  such  as  hypertrophy  of  the  prostate,  or  when  from 
weakness  of  its  muscular  walls  the  bladder  fails  entirely  to  empty  itself,  always 
retaining  several  ounces  of  urine.  A  condition  which  seems  to  combine  the 
hypersecretion  of  urine  with  intolerance  of  the  bladder  is  that  known  as 
"nervousness,"  or  in  its  most  aggravated  form  as  hysteria. 

It  is  evident,  therefore,  that  we  know  but  little  which  is  of  value  so  long 
as  we  simply  know  that  the  patient  urinates  too  often.  Further  light,  however, 
may  be  thrown  upon  the  subject  by  a  question  as  to  whether  or  not  the  fre- 
quency is  increased  by  movement  or  by  rest.  If  the  former,  a  stone  in  the 
bladder  or  a  pedunculated  growth  of  the  bladder  may  account  for  it.  If  the 
latter,  it  may  result  from  retention  of  urine  due  to  atony  or  to  an  enlarged 
prostate.  The  patient  with  these  last-mentioned  troubles  will  find  that  he 
urinates  at  shorter  intervals  at  night  than  in  the  daytime. 

There  are  other  points  in  relation  to  this  act  which  will  help  in  arriving  at 
a  conclusion.  If  the  size  of  the  stream  is  diminished,  it  suggests  the  existence 
of  a  stricture,  a  contracted  meatus,  or  an  inflammatory  swelling  somewhere 
along  the  urethral  tract.  If  the  force  of  the  stream  is  diminished,  it  suggests 
obstruction,  as  from  stricture  or  prostatic  disease,  or  muscular  weakness,  as  in 
atony.  If  the  time  required  for  the  act  of  urination  is  increased,  it  likewise 
suggests  obstruction  or  weakness. 

Hematuria. — Bloody  urine  may  result  from  a  solution  of  continuity  at- 
tended Avith  hemorrhage  and  affecting  any  portion  of  the  genito-urinary  tract. 

When  the  blood  is  derived  from  the  kidneys,  there  will  usually  have  been 
a  history  of  renal  disease  and  coexisting  evidence  in  the  shape  of  albuminous 
urine,  granular  or  hyaline  casts,  oedema,  retinal  degeneration,  etc.  Or  there 
may  be  the  characteristic  symptoms  of  renal  calculi,  or  the  symptoms  of  wound 


854  AN  AMFAilCAN    TEXT- HOOK    OF  sriHlFHY. 

or  contusion  of  tlio  kidnev,  or  of  tumors,  or  tubercle  of  that  oriran  may  be 
present.  In  tlie  majority  of  cases  the  blood  wliicli  is  derived  from  the  kidneys 
is  found  when  the  urine  is  passed  to  be  uiiiloinily  distributed  throu^^li  it.  jrivin^ 
it  a  dark  smoky  hue,  but  in  cases  of  wounds  or  of  malignant  growths  of  the 
kidnev  it  is  passed  out  in  such  quantities  that  it  may  fill  the  bladder  with 
clots  (p.  841').      Long,  narrow  cylindrical  ureteral  clots  will  often  be  voided. 

Hemorrhage  from  the  ureters  is  almost  always  the  result  of  the  presence 
or  passage  of  a  calculus,  and  is  attended  with  all  the  symptoms  of  that  occur- 
rence, intense  pain  in  the  back  and  loins  extending  into  the  testicle  on  the 
affected  side,  retraction  of  the  testicle,  vomiting,  cold  sweat,  and  profound 
prostration. 

Hemorrhage  from  the  prostate,  if  non-traumatic,  is  usually  the  result  of 
tubercular  or  carcinomatous  ulceration,  and  is  attended  with  marked  enlarge- 
ment of  that  gland  and  with  the  usual  symptoms  of  obstruction  to  urination. 
Hemorrhage  from  the  urethra  is  rare,  except  as  a  result  of  instrumentation. 
In  botli  urethral  and  prostatic  hemorrhage  the  blood  is  discharged  in  clots, 
sometimes  tubular  or  cylindrical  in  shape,  which  precede  the  stream  of  urine. 

Hemorrhage  from  the  bladder  may  be  suspected  whenever  the  symptoms 
do  not  point  to  any  of  the  above  conditions,  and,  of  course,  may  be  recognized 
with  certainty  when  its  immediate  cause  can  be  discovered.  A  vesical  calculus 
or  tumor  (usually  a  papilloma),  a  tubercular  or  carcinomatous  ulceration,  may 
be  recognized  by  the  sound,  the  presence  of  fragments  of  the  neoplasm  in  the 
urine,  the  cystoscope,  etc. 

In  acute  cystitis  or  prostato-cystitis  the  symptoms  of  frequent  and  painful 
urination,  with  tenesmus,  will  point  to  the  cause.  Obstructive  disease  in  the 
form  of  hepatic  enlargement  or  abdominal  tumors  by  pressing  on  the  vena  cava 
may  give  rise  to  a  degree  of  congestion  in  the  vesical  plexus  which  results  in 
hemorrhage. 

Certain  drugs,  as  cantharides  and  turpentine,  in  full  doses  produce  the 
same  conditions.  Diseases  attended  by  profound  alteration  of  the  blood,  as 
purpura,  scurvy,  and  occasionally  some  of  the  exanthemata,  may  be  accom- 
panied by  vesical  hemorrhage.  The  invasion  of  the  coats  of  the  bladder  by 
the  Bilharzia  hcamatohia  is  a  possible  cause  of  hematuria  in  some  Eastern 
countries.  All  these  conditions  are  easily  recognized  by  their  concomitant 
symptoms. 

Treatment. — Of  course  when  the  cause  can  be  definitely  ascertained  it 
should  be  removed.  In  moderate  hemorrhage  without  great  distention  of  the 
bladder,  and  Avith  no  serious  interference  with  urination,  the  clots  may  safely 
be  left  to  the  processes  of  nature  if  the  bladder  is  a  non-infected  one.  They 
will  gradually  become  disorganized  and  will  pass  out  in  shreds  or  dissolved  in 
the  urine.  If,  however,  they  fill  up  the  entire  bladder  and  become  obstructive, 
or  if  such  bleeding  occurs  in  a  case  in  which  there  is  already  ammoniacal  and 
fetid  urine,  it  will  be  necessary  to  wash  them  out  and  to  irrigate  the  bladder 
with  antiseptic  and  hemostatic  solutions.  ,  A  full-sized  catheter  with  very 
large  eyes  should  be  used,  and  boric-acid  solutions  should  be  injected  and 
drawn  out  again  by  suction.  The  evacuating  tube  and  washing  bottle  used  in 
litholapaxy  will  be  found  very  serviceable  in  such  cases.  After  the  bladder 
is  free  from  clots,  nitrate-of-silver  solutions,  from  1  :  10,000  to  1  :  500,  may  be 
carefully  employed  with  great  advantage.  In  case  of  failure  with  the  catheter, 
a  cystotomy,  suprapubic  or  perineal,  is  indicated.  In  the  majority  of  cases 
the  former  is  preferable,  as  permitting  at  the  same  time  a  more  satisfiictory 
exploration  of  the  bladder,  and  possibly  the  removal  of  the  cause  of  the 
hemorrhage,  as  by  excising  a  tumor,  curetting  a  tubercular  ulcer,  etc. 


SURGERY    OF    THE    GENTTO- URINARY    TRACT. 


855 


RETENTION  OF  UKINi:. 
Tlie  l)la(l(ler  inav  fail  to  empty  itself  on  account  of  various  causes : 
(1)  OiKstnicthe  ntuscs  arc  found  in  urethral  stricture,  spasmodic  or  organic ; 
hvpertrophied  prostate  or  acute  prostatitis :  impacted  calculus ;  tumors  of  the 
urethra  and  bladder:  congenital  atresia  of  the  urethra  or  of  the  preputial 
orifice;  constriction  by  a  string  tied  around  the  penis;  pressure  by  the  gravid 
uterus  ;   or  fecal  impaction. 

(•2)  DctWtice  e.rj>uhirc  force  mav  result  from  paralysis;  from  disease  or  in- 
jury ;  from  atonv  ;  from  reflex  inhibition,  as  after  the  ligature  of  hemorrhoids ; 
from  shock  or  great  muscular  weakness  in  low  fevers,  etc. ;  or  from  the  toxic 
action  of  drugs,  as  belladonna,  opium,  or  canthandes. 

Symptorns.— In  either  event  the  symptoms  of  retention  are  easily  rec- 
ocrnized.  The  local  signs  are  the  gradual  formation  of  a  hypogastric  tumor 
ri'sinc'  into  the  abdomen  and  sometimes  extending  above  the  umbilicus.  The 
elonSition  of  the  vesical  fascia  caused  by  this  rise  of  the  viscus  is  accompanied 
by  a°  similar  elongation  of  the  urethra,  so  that,  as  in  prostatic  hypertrophy, 
ail  ordinary  catheter  may  not  be  long  enough  to  reach  the  bladder. 

The  tuinor  is  rounded  in  outline,  and  in  thin  persons  can  be  seen  through 
the  abdominal  walls.  .  It  is  most  prominent  when  the  patient  is  erect.  It  is 
dull  on  percussion  and  fluctuates;  the  flanks  are  resonant. 

Fi<T   345  shows  the  swelling  caused  by  a  distended  bladder.     Ihis  has  not 


Distended  Bladder  mistaken  for  an  Abdominal  Tumor  (original). 

seldom  been  mistaken  for  an  abdominal  tumor.     A  catheter  will  instantly 

clear  up  any  doubt.  .     ^         ..i 

The  subjective  symptoms  vary  with  the  cause.  In  acute  retention  the 
desire  to  micturate  is  extremely  urgent,  the  distress  an<l  anxiety  great ;  the 
patient  makes  constant  efforts  to  empty  the  bladder,  with  violent  straining, 
often  accompanied  by  escape  of  the  contents  of  the  lower  bowel,  it  the  reten- 
tion is  complete,  th^se  symptoms  continue  with  increasing  severity  until  the 
patient  passes  into  a  condition  of  toxemia,  with  rigors,  fever,  failure  of  circu- 
lation, dry  brown  toncrue.  delirium,  hiccough,  stupor,  and  finally  death  it 
the  retention  is  incomplete  and  the  distention  of  the  bladder  is  fairly  relieved 
by  the  escape  of  a  few  drops  of  urine  from  time  to  time,  these  symptoms  may 
be  slower  in  making  their  appearance,  and  the  case  will  run  a  more  chronic 
but  very  similar  course. 


856  AN  AMERICAN   TEXT- BOOK  OF  SURGERY. 

The  most  insidious  cases,  however,  are  those  in  which  eitlier  from  paralysis 
or  from  the  very  gradual  production  of  the  condition  it  is  not  attended  with 
auv  unusual  sensations,  the  patient  often  com])lainiiig  only  of  the  drilthling  of 
urine,  which  is  almost  constant,  and  which  results  iVoui  the  overliow  from  a 
hladder  already  distended  to  its  fullest  capacity  when  fresh  drops  of  urine  enter 
it  from  the  ureters.  This  dribbling — the  "incontinence  of  retention  " — is  too 
often  carelessly  or  ignorantly  regarded  as  evidence  that  the  bladder  is  empty- 
ing itself,  and  many  fatal  cases  have  resulted  from  this  mistake  on  the  j)art  of 
j)atient,  nurse,  or  physician.  The  condition  is  most  fre(iuent  in  cases  of  pros- 
tatic enlargement,  of  vesical  |)aralysis,  and  of  old  stricture.  The  secondary 
efl'ects  of  retention  of  urine  in  such  cases  are  those  of  obstructive  disease 
already  described.  (See  section  on  Diseases  of  the  Kidneys.)  If  long  contin- 
ued, it  results  in  disorganization  of  the  secreting  structure  of  the  kidneys  from 
the  backward  pressure.  If  acute  and  complete,  it  may  produce  fatal  suppi-es- 
sio7i  of  urine  from  tlie  same  cause. 

Treatment. — The  management  of  a  case  of  retention  of  urine  will  depend 
upon  the  cause  and  the  acuteness  and  urgency  of  the  symptoms.  When  cathe- 
terism  is  possible,  it  is  the  surgical  procedure  obviously  appropriate  to  the  great 
majority  of  cases.  In  urethral  or  vesical  spasm  occurring  during  acute  ure- 
thritis, or  in  the  retention  due  to  a  gonorrheal  prostatitis,  a  short  delay  may 
be  justifiable,  during  which  warm  baths,  opium,  enemata,  leeching  to  the  peri- 
neum, etc.  may  be  tried,  but  even  in  these  cases  the  catheter  should  be  resorted 
to  promptly  if  the  symptoms  are  at  all  urgent.  The  special  treatment  appli- 
cable to  the  other  conditions  before  mentioned  will  be  found  described  under 
their  respective  headings. 

In  some  cases,  however,  catheterism  is  found  to  be  impossible,  and  it  is 
evident  that  immediate  relief  should  be  given  the  patient.  Three  routes  for 
entering  the  bladder  have  been  described  and  employed :  (1)  suprapubic ; 
(2)  perineal ;  (3)  rectal. 

Of  these,  the  first  is  to  be  preferred  in  the  vast  majority  of  cases.  The  nee- 
dle of  an  aspirator,  or  a  small  trocar  and  canula,  should  be  inserted  in  the 
median  line  just  above  the  symphysis  and  the  urine  withdrawn.  The  usual 
antiseptic  precautions,  including  shaving  of  the  pubes,  should  be  taken :  the 
operation  requires  no  skill  in  its  performance  and  is  attended  with  reuuirkably 
little  danger.  The  small  puncture  should  be  closed  at  once  with  iodoform  and 
collodion. 

(2)  The  perineal  route  has  l)een  advocated  by  Ilowlett,  and  also  by  Harri- 
son, in  cases  of  enlargement  of  the  prostate  (q.  v.),  but  is  not  to  be  recom- 
mended simply  for  the  relief  of  retention. 

(3)  Rectal  puncture,  by  which  the  bladder  is  opened  by  a  large  curved  trocar 
and  behind  the  base  of  the  prostate,  has  been  employed  in  many  instances, 
but  is  even  less  desirable  than  the  perineal  route. 

INJURIES  OF  THE   BLADDER. 

The  bladder  may  be  wounded  directly,  as  in  stabs,  gunshot  wounds,  etc., 
through  the  hypogastrium,  the  vagina,  or  the  rectum,  or  even  from  the  pos- 
terior aspect  through  the  sacro-sciatic  foramen  ;  or  it  may  be  punctured  by 
one  of  the  pelvic  bones,  usually  the  pubic,  in  cases  of  fracture  of  the  pelvis ; 
or  it  may  be  involved  in  the  rent  occasioned  by  a  violent  disjunction  of  the 
symphysis  pubis. 

When  there  is  a  wound  communicating  with  the  surface  of  the  body 
through  the   abdominal  wall,  the   diagnosis  is  usually  easy.     The  escape  of 


SURGERY   OF    THE    GENITO-URINARY   TRACT.  857 

bloody  urine  in  some  cases,  or  in  others  the  diffital  exploration  of  the  wound, 
will  at  once  reveal  the  character  of  the  injury.  But  in  cases  arising  from 
fractures  or  in  those  in  which  the  bladder  is  ruptured,  the  recognition  of  the 
condition  may  be  much  more  difficult.  In  cases  where  a  violent  compressing 
force  is  applied  during  distention,  as  where  a  wheel  of  a  heavy  wagon  passes 
over  the  lower  part  of  the  abdomen,  the  healthy  bladder,  if  distended  at  the 
time,  may  be  ruptured.  An  atrophied  or  atonied  or  ulcerated  bladder  may 
give  way  under  a  much  more  insignificant  force,  such  as  involuntary  contrac- 
tion of  the  abdominal  muscles  during  vesical  tenesmus. 

In  the  former  class  of  cases  the  rent  in  the  bladder  is  usually  in  the  pos- 
terior wall,  running  downward  from  the  urachus  ;  in  the  latter  it  occurs  at  the 
region  of  greatest  weakness,  sometimes  involving  a  sacculus  or  diverticulum 
(Plate  XXI,  Fig.  1)  consisting  only  of  mucous  membrane  and  cellular  tissue 
and  protruding  between  the  muscular  ridges  of  an  hypertrophied  bladder, 
sometimes  passing  through  a  spot  which  has  been  thinned  by  the  pressure  of 
a  calculus  or  infiltrated  by  tubercular,  sj^philitic,  or  carcinomatous  deposits. 

Symptoms. — If  there  is  a  history  of  a  severe  fall  or  of  the  application 
of  a  comj)ressing  force  during  distention  of  the  bladder,  followed  by  collapse, 
with  inability  to  micturate,  wound  or  rupture  of  the  bladder  should  be  strongly 
suspected.  The  introduction  of  a  catheter  will  usually  be  followed  by  the 
escape  of  only  a  little  blood  or  bloody  urine.  If  a  known  quantity  of  a 
warm  boric-acid  solution  be  injected  Avith  moderate  force  into  the  bladder,  the 
gradual  rise  of  that  viscus  from  behind  the  pubes  into  the  abdominal  region, 
which  should  occur  when  it  contains  from  eight  to  ten  ounces  of  liquid,  does 
not  take  place,  and  on  permitting  the  escape  of  the  fluid  through  the  catheter  a 
diminished  quantity  will  be  found  to  have  returned.  Filtered  air  can  also  be  in- 
jected into  the  bladder  by  an  ordinary  Davidson  s^'ringe  over  the  outer  end  of 
which  cotton  has  been  tied.  If  the  bladder  be  intact,  it  will  become  distended 
as  a  suprapubic  tympanitic  tumor,  and  the  air  will  escape  through  the  cathe- 
ter ;  if  it  be  ruptured,  the  air  will  distend  the  general  peritoneal  cavity  and 
will  not  escape  through  the  catheter  to  any  extent.  If  the  rupture  is  extra- 
peritoneal, emphysema  of  the  cellular  tissue  will  be  produced. 

In  the  presence  of  this  group  of  symptoms  it  will  be  certain  that  there  is  a 
wound  or  rupture  of  the  bladder,  but  it  must  not  be  forgotten  that  a  minute 
perforation  or  puncture,  followed  by  leakage,  may  exist  and  be  of  grave 
importance,  while  none  of  the  above  phenomena  can  be  elicited,  and  that  occa- 
sionally, though  rarely,  the  opening  in  the  vesical  Avail  has  been  valvular  in 
character,  and  has  permitted  the  bladder  to  contain  a  considerable  quantity  of 
urine  under  pressure,  though  alloAving  it  to  trickle  through  when  the  organ 
has  collapsed. 

The  two  chief  varieties  of  wounds  or  ruptures  of  the  bladder  are :  (1)  the 
extra-peritoneal ;  (2)  the  intra-peritoneal.  , 

In  the  first  variety  the  urine  escapes  into  the  pre-vesical  connective  tissue 
or  into  the  vesico-rectal  or  vesico-uterine  space.  If  not  removed  by  operation, 
cellulitis  and  sloughing  follow,  involving  the  neighboring  parts  and  often 
extending  to  the  anterior  wall  of  the  abdomen  or  opening  the  rectum  or  vagina. 
The  patient  dies  from  septicemia. 

In  the  second  variety  (the  intra-peritoneal)  there  may  be  one  or  even  two 
days  during  which  no  special  symptoms  manifest  themselves.  The  more 
nearly  normal  the  condition  of  the  urine  the  longer  the  interval,  but  sooner  or 
later  general  peritonitis  occurs,  and  the  patient  dies  quickly  Avith  a  distended 
abdomen  and  symptoms  of  shock.  Intra-peritoneal  rupture  may  be  suspected 
in  the   interval  if  on   catheterization  the   instrument  seems  to  enter  a  large 


858  ,1-V   A.yfERICAX    TEXT-IK X )K    OF  SURGERY. 

cavity,  like  a  capacious  bladder,  and  can  be  moved  freelv.  and  yet  little  or 
no  urine  can  be  withdrawn. 

Treatment. — Whenever  there  is  good  <:round  for  suspecting  a  wound  or 
rupture  <>f  the  bladder,  operative  interference  is  imperative.  An  incision 
should  be  made  through  the  hypogastrium.  as  in  suprapul)ic  lithotomy,  the 
rectal  bag  having  first  been  introduced  and  distended,  cus  in  that  operation. 
The  peritoneum  should  be  gently  rolled  up,  with  the  pre-vesical  fat,  and 
the  parts  carefully  inspected.  If  a  rent  is  visible  or  if  an  extravasation 
of  blood  and  urine  leads  to  one,  it  may  be  sewn  up  and  the  surrounding 
region  irrigated  and  drained.  If  the  edges  are  much  lacerated  or  contused,  it 
would  be  better  to  put  a  large  drainage-tube  into  the  bladder.  If  the  urine 
has  found  its  way  into  the  scrotum  or  perineum,  free  incisions  must  be  made 
in  those  regions  to  give  it  exit.  If  the  rent  is  not  discovered  by  inspection 
and  palpation,  it  is  well  to  open  the  bladder  and  explore  its  inner  surface  with 
the  finger. 

If  an  intra-peritoneal  opening  is  found,  the  abdominal  incision  should  be 
extended  upward,  the  peritoneal  cavity  opened  and  the  wound  in  the  bladder 
closed  by  means  of  Lembert  sutures,  fine  silk  being  the  best  material  and 
the  stitches  being  inserted  through  only  the  muscular  and  peritoneal  coats,  and 
not  through  the  mucous  membrane.  They  should  be  about  one-eighth  of  an 
inch  apart.  They  may  be  tested  by  distending  the  bladder  before  the  abdomi- 
nal Avound  is  closed.  The  peritoneal  cavity  is  then  irrigated,  and  if  there  is 
any  peritonitis  a  drainage-tube  is  inserted,  ^^ome  modifications  are  advised 
by  different  surgeons,  but  on  the  whole  it  may  safely  be  said  that  prompt 
operative  interference,  suture  of  the  bladder,  antiseptic  irrigation,  and  drain- 
age have  greatly  lessened  the  mortality  after  injuries  of  the  bladder.  The 
adoption  of  Trendelenburg's  position  simplifies  these  procedures. 

The  results  of  laparotomy  for  intraperitoneal  rujnure  of  the  bladder, 
as  shown  in  the  cases  of  MacCormac,  Holmes.  Ilalstrom.  Grant,  Blum,  and 
others,  are  in  the  highest  degree  encouraging.  7  out  of  ItJ  cases  having  recovered, 
while  in  8  of  the  9  fatal  cases  the  average  time  between  the  operation  and  the 
injury  was  twenty-eight  hours,  and  in  the  ninth  case  the  vesical  sutures  were 
faulty.  In  Blum's  case  recovery  ensued,  though  the  operation  did  not  take 
place  until  forty  hours  after  the  rupture. 

ATONY  OF  THE    BLADDER. 

The  condition  known  as  atony  of  the  bladder  is  by  no  means  uncommon, 
and  may  even  be  said  to  exist  in  a  minor  degree  in  almost  all  persons  past 
middle  age.  Every  male  adult  who  will  carefully  observe  his  own  experience 
will  in  all  probability  find  that  he  is  unable  to  eject  as  forcible  a  stream  of 
urine  from  the  bladder  as  when  he  was  a  bov ;  and  the  slig-ht  enfeeblement 
increases  very  distinctly  when  middle  age  is  past.  This  form  of  atony  may 
be  said  to  be  physiological. 

There  is  another  variety,  which  is  a  true  muscular  paresis,  an  actual  loss  of 
tone,  as  the  name  implies,  in  the  muscular  walls  of  the  Idadder,  and  which  is 
dependent  upon  well-recognized  causes.  There  is  a  distinct  thinning  and 
■weakening  of  the  muscular  coat  of  the  bladder,  associated  sometimes  with  fatty 
degenei'ation  of  the  muscular  fibers,  sometimes  with  a  fibroid  change  resulting 
in  contracture  precisely  similar  to  that  which  occurs  in  disused  muscles  else- 
where. In  the  one  case  the  bladder  is  a  mere  flaccid  pouch  capable  of  disten- 
tion to  a  large  extent,  but  quite  incapable  of  completely  emptying  itself.  In 
the  other  it  will  hold  only  a  few  ounces  of  urine,  but  cannot  completely  evac- 
uate that  quantity. 


SURGERY  or  Till-:  (iKXiro-rinxAin'  thact.         859 

Bftwt'cn  these  two  exticines  and  a  foiulition  of  lioaltli  there  are  all 
degrees  of  atony.  A  common  cause  of  these  retrograde  changes  in  the  blad- 
der, apart  from  senility,  is  over-distention,  which  may  be  chronic  and  de- 
pendent upon  some  obstructive  condition,  such  as  enlarged  prostate,  vesical 
tumor  situated  near  the  neck  of  the  bladder,  tight  urethral  sti-icture,  etc.  ;  or 
it  may  have  resulted  from  true  paralysis  of  the  bladder,  which  is  very  apt 
in  neglected  cases  to  be  followed  by  secondary  atony  ;  or  it  may  have  been 
due  to  persistent  neglect  of  the  calls  of  nature  on  the  part  of  the  patient, 
whose  occupation  or  whose  pleasures  were  so  preoccupying  as  to  lead  him 
habitually  to  postpone  the  emptying  of  the  bladder  until  the  need  of  doing  so 
became  imperative.  Or  the  cause  may  liave  been  acute  over-distention  hap- 
pening on  some  one  occasion  when  for  a  long  period  it  was  impossible  for  the 
patient  to  find  an  opportunity  to  urinate.  In  these  instances  the  over-stretch- 
ing of  the  muscular  fibers  is  probably  the  active  factor.  In  any  event,  the 
result  is  that  the  patient  is  unable  to  void  his  urine,  and  that  a  certain  quan- 
tity is  retained  after  eacli  act  of  micturition. 

It  is  this  "residual  urine,"  as  it  is  called,  Avhicli,  both  in  cases  of  prostatic 
disease  and  in  vesical  atony,  constitutes  at  the  same  time  a  serious  difficulty 
and  a  guide  to  the  proper  treatment.  If  allowed  to  accumulate,  it  will  sooner 
or  later  result  in  over-distention  of  the  bladder,  or  it  may  decompose  and  set 
up  a  troublesome  cystitis.  It  should  always  be  evacuated  by  regular  catheteri- 
zation, which  should  be  performed  two,  three,  or  four  times  daily  according  to 
the  quantity  of  residual  urine.  This  is,  of  course,  a  form  of  retention  of  urine, 
but  that  expression  is  usually  associated  with  the  idea  of  complete  retention 
the  result  of  obstructive  disease  of  the  urinary  tract  or  of  an  absolute  paralysis 
of  the  bladder-wall.  When  this  is  acute,  it  is  readily  recognized  by  the  history 
of  non-evacuation  of  urine  and  by  the  presence  of  the  characteristic  hypogas- 
tric tumor,  which  soon  becomes  abdominal  if  no  relief  is  afforded.  But  there 
is  a  partial  retention  of  urine  w^hich,  though  not  so  immediately  dangerous,  is, 
by  reason  of  its  greater  frequency,  a  far  more  important  surgical  condition. 
In  its  lower  grades  it  is  often  not  recognized,  and  the  symptoms  of  frequent 
micturition,  loss  of  force  in  the  stream,  dribbling  of  urine,  etc.  are  referred  to 
cystitis  and  treated  accordingly.  Of  course  there  may  be  a  combination  of 
various  conditions  associated  with  atony  and  with  partial  retention  ;  in  other 
words,  the  original  lesion  may  have  been  a  stricture  of  the  urethra  or  an  acute 
prostatitis  or  a  prostatic  growth  or  an  impacted  urethral  calculus,  or  it  may 
occur  after  certain  operations,  particularly  those  upon  the  lower  end  of  the  rec- 
tum, as  the  ligation  of  hemorrhoids,  when  there  is  often  a  reflex  inhibition  of  the 
micturition-center  of  the  spinal  cord,  followed  by  retention  of  urine.  But  in  all 
these  cases  it  is  the  over-distention  and  atony  which  constitute  the  most  efficient 
cause  of  partial  retention  of  urine,  and  this  is  true  even  in  cases  of  prostatic 
enlargement  in  which  there  is  a  permanent  obstacle  to  the  free  passage  of  urine. 

The  methods  of  treatment  which  are  worthy  of  trial  may  be  grouped  under 
four  heads,  it  being  premised  that  if  there  is  marked  c^^stitis  a  preliminary 
course  of  treatment  may  be  necessary  before  the  other  methods  can  be  fairly 
put  into  application : 

(1)  Catlieterization. — The  patient  should  be  instructed  in  the  use  of  a 
catheter,  and  should  also  be  told  how  to  keep  that  instrument  aseptic,  and, 
for  greater  precaution,  how  to  disinfect  it  before  each  insertion.  In  cases 
where  four  ounces  of  urine  are  retained  he  should  use  it  twice  daily,  night  and 
morning ;  if  the  residual  urine  reaches  six  ounces,  he  should  use  the  catheter 
once  every  eight  hours ;  and  if  it  amounts  to  eight  ounces,  catheterization 
should  be  employed  every  six  hours.     (2)  Irrigation  of  the  bladder  with  cold 


860  AN  AMERICAN   TEXT-BOOK    OF  SURGERY. 

boric-acid  solutions,  beginning  at  a  temperature  of  90°  to  100°  nnd  gradually 
reduced,  or  potassium  permanganate,  in  the  strength  of  one  to  three  grains 
to  a  pint  of  sterile  water,  will  sometimes  be  found  of  great  use.  (3)  Elec- 
tricity is  often  of  considerable  benefit,  and  may  be  applied  in  the  manner  lonw 
ago  suggested  by  Sir  Henry  Thompson.  An*  insulated  electrode  is  carried 
into  the  bladder  and  the  other  moistened  electrode  placed  over  the  hvpogas- 
trium,  a  weak  current  being  passed  directly  through  the  walls  of  the  blad- 
der. The  strength  is  gradually  increased  until  slight  sensations  of  discom- 
fort are  experienced.  The  application  may  be  varied  occasionally  bv  putting 
the  other  electrode  in  the  rectum.  In  mild  cases  which  come  under  care  im- 
mediately after  the  occurrence  of  over-distention  this  is  of  much  benefit,  and 
in  later  and  more  serious  cases  it  may  be  a  useful  adjuvant.  (4)  Strychnin 
is  the  only  drug  which  produces  beneficial  results  in  these  cases,  and  even 
upon  it  but  little  dependence  can  be  placed.  It  may  be  given  in  combina- 
tion with  ergot,  cantharides,  or  tincture  of  the  chloride  of  iron. 

URINARY  CALCULUS. 

The  normal  urine  is  a  watery  solution  of  various  organic  and  inorganic 
materials  dissolved  in  water,  the  latter  constituting  about  90  per  cent,  of  the 
whole.  The  important  organic  constituents  are  urea  and  uric  acid ;  the  inor- 
ganic consist  of  the  bases,  chiefly  sodium,  potassium,  and  magnesium,  with 
which  the  uric  acid  unites.  Other  acids,  especially  phosphoric  and  sulphuric, 
form  salts  with  the  same  bases.  These  with  the  chlorides  make  up  the  bulk 
of  the  inorganic  substances  contained  in  urine. 

There  is.  of  course,  also  mucus  derived  from  the  kidneys  and  bladder,  and 
a  certain  amount  of  renal  and  vesical  epithelium.  When  urine  is  entirely 
normal  and  has  been  recently  passed,  it  shows  no  sediment  except  a  little  of 
this  mucus  containing  a  few  epithelial  cells.  After  fermentation  various  forms 
of  amorphous  urates  form  and  settle,  and  the  urine  becomes  turbid  from  the 
presence  of  the  products  of  decomposition. 

Uric  acid,  although  normally  present  in  the  proportion  of  only  about 
1  :  1000  in  the  urine,  is  of  great  importance  in  the  formation  of  calculi,  and 
with  the  urates,  especially  those  of  sodium  and  ammonium,  makes  up  the  bulk 
of  most  urinary  deposits. 

Oxalic  acid  is  sometimes  found  in  the  urine  in  combination  with  lime  in 
the  shape  of  octahedral  or  of  dumb-bell  crystals. 

The  phosphatic  deposits  in  the  urine  are  composed  of  admixtures  of  the 
alkaline  phosphates,  those  of  sodium  and  potassium,  with  the  earthy  phosphates, 
the  bases  of  which  are  calcium  and  magnesium.  In  fermenting  urine  in  which 
the  urea  has  been  decomposed  into  ammonium  carbonate  the  phosphoric  acid 
unites  with  the  ammonium,  and  deposition  of  the  triple  phosphates  takes  place, 
the  sediment  containing  the  ammoniaco-magnesium  phosphate  and  calcium 
phosphate.     The  alkaline  phosphates,  being  soluble,  do  not  occasion  deposits. 

Cystine  is  found  rarely  among  urinary  sediments,  and  is  in  the  form  of 
hexagonal  crj'stals,  smaller  than  those  of  uric  acid.  It  contains  a  large  amount 
of  sulphur  (25  per  cent.).  It  is  never  found  anywhere  else  in  the  body,  and  the 
mode  of  its  formation  and  the  circumstances  which  favor  it  are  unknown. 

The  general  conditions  which  favor  the  formation  of  an  excess  of  urinary 
deposits  do  not  vary  greatly  for  these  different  forms.  They  indicate,  as  a 
rule,  defective  digestion  and  assimilation,  insufficient  oxidation,  disproportion 
between  the  solid  and  the  fluid  constituents  of  the  diet,  excess  of  meats,  fats,  and 
sugars,  insufficient  exercise,  etc.  But,  while  these  are  important  factors,  they 
do  not  of  themselves,  as  a  rule,  bring  about  the  formation  of  calculi.     The 


SURGERY   OF    THE   QENITO- URINARY   TRACT.  801 

presence  of  the  colloids  is  necessary,  and  these  are  furnished  in  the  shape  of 
mucus  and  inuco-j)us  whenever  any  catarrhal  condition  of  the  urinary  tract  is 
superadded  to  the  excess  of  solids  contained  in  the  urine.  In  addition  to  these 
chief  predisposinji;  causes  there  are  others  of  minor  importance,  such  as  age, 
sex,  race,  etc.      These  may   be   briefly  considered  : 

Age. — Children  are  especially  liable  to  the  formation  of  uric-acid  calculi 
(primary  calculi) ;  old  persons,  to  the  development  of  phosphatic  stones 
(secondary  calculi).  In  the  former  the  uric  acid,  which  is  in  feeble  combina- 
tion witii  the  alkaline  bases,  is  liberated  })y  an  excess  of  acid  of  any  sort  in 
the  urine,  and  the  uric  acid  crystallizes  in  the  presence  of  the  renal  mucus  or 
of  the  vesical  mucus,  which  binds  the  crystals  together,  forming  a  concretion 
which  makes  the  nucleus  of  a  stone.  The  same  process  takes  place  in  the 
majority  of  cases  whenever  stone  forms  in  acid  urine,  the  stone  growing  by 
fresh  accretion  of  uric  acid  or  of  the  urates.  Oxalate  of  lime  may  in  the 
same  manner  crystallize  and  be  deposited  in  either  of  its  forms. 

In  old  persons,  especially  in  old  men  with  enlarged  prostates,  residual 
urine,  and  cystitis,  the  urine,  which  has  become  alkaline  from  fermentation 
and  decomposition  of  urea  into  ammonium  carbonate,  contains  all  the  materials 
for  the  formation  of  stone  around  a  given  nucleus  of  any  sort.  Sometimes,  espe- 
cially in  gouty  or  rheumatic  individuals,  the  nucleus  is  a  small  uric-acid  con- 
cretion descending  from  the  kidney  ;  sometimes  it  consists  simply  of  a  number 
of  phosphatic  crystals  glued  together  by  the  thick,  stringy  vesical  mucus ; 
sometimes  it  is  a  blood-clot,  a  spicule  of  bone,  a  piece  of  bougie,  or  a  foreign 
body  introduced  into  the  bladder  by  the  patient.  In  any  event,  continued 
precipitation  of  the  phosphates  in  the  alkaline  urine  goes  on,  and  secondary 
stone-formation  occurs. 

Sex. — Owing  to  the  shortness  of  the  female  urethra,  its  large  caliber,  the 
absence  of  obstructive  disease,  and  the  comparative  infrequency  of  vesical 
disease  in  women,  they  are  very  rarely  the  subjects  of  stone.  It  is  estimated 
that  only  about  5  per  cent,  of  all  cases  of  stone  are  seen  in  females. 

Race. — Negroes  seem  especially  free  from  the  liability  to  urinary  calculi. 
Statistics  show  that  in  this  country  less  than  4  per  cent,  of  the  cases  operated 
upon  for  stone  occur  in  negroes. 

Constitutional  disease,  particularly  gout  and  rheumatism  and  the  associated 
condition  known  somewhat  vaguely  as  lithemia,  favors  the  formation  of  calculi, 
especially  of  the  uric-acid  variety. 

Local  Disease. — As  already  stated,  prostatic  hypertrophy  with  consecutive 
bladder-changes  is  a  common  cause  of  secondary  stone-formation.  Urethral 
stricture  is  much  more  rarely  a  cause,  probably  because  the  expulsive  power 
of  the  bladder  is  unimpaired.  Atony  of  the  bladder  favors  the  retention  of 
small  fragments  of  gravel  or  of  urinary  deposits  of  any  description,  and  thus 
often  leads  to  the  development  of  calculi.  Any  disease  of  the  kidney  pro- 
ducing excessive  secretion  of  renal  mucus,  and  indeed  any  catarrhal  disease 
of  any  portion  of  the  urinary  tract,  will  favor  the  formation  of  calculi. 

Varieties  of  Urinary  Calculi. — Stones  may  be  classified  either 
according  to  their  chemical  composition  or  with  relation  to  the  circumstances 
attending  their  formation. 

Those  forming  in  acid  urine  (the  mucous  membranes  of  the  urinary  tract 
being  usually  unaffected  by  disease)  are  chiefly,  in  the  order  of  frequency,  the 
uric-acid  calculi,  the  oxalate-of-lime  calculi,  the  urates,  and  the  rarer  forms  of 
cystine,  xanthine,  indigo,  etc.  Those  forming  in  alkaline  urine  (secondary  to 
catarrhal  disease  of  the  kidneys  or  of  the  bladder)  are  the  phosphate  or  car- 
bonate of  lime,  which  usually  originates  in  the  kidney,  and  tiie  phosphatic  cal- 


862  AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 

culi — the  amiuoniaoo-inaguesian  variety — formed  only  in  anniioniaeal  urine, 
and  therefore  almost  always  originating  in  the  bladder. 

The  majority  (probably  two-thirds)  of  all  stones  have  nuclei  of  uric  acid; 
of  the  remainder,  a  considerable  proportion  have  nuclei  or  crystals  of  oxalate 
of  lime  or  of  the  urates ;  others  contain  lumps  of  inspissated  mucus  or  blood ; 
and  in  addition  an  endless  variety  of  foreign  bodies  introduced  by  accident, 
findintc  their  war  into  the  bladder  from  disease  of  neighborino;  bones  or  cav- 
ities  (as  -after  ulceration  of  a  dermoid  cyst,  or  after  the  formation  of  vesico- 
rectal fistula),  or  foreign  substances,  such  as  portions  of  whip-lashes,  shoe- 
strings, pen-holders,  etc.,  which  have  usually  been  introduced  by  the  patient 
under  the  influence  of  morbid  erotic  desire.  Such  patients  are  commonly 
either  boys  at  about  the  age  of  puberty  or  old  men  with  waning  sexual  powers. 

The  form,  size,  and  density  of  a  calculus  depend  upon  its  chemical  com- 
position, the  condition  of  the  bladder,  and  the  length  of  time  during  which 
the  stone  has  been  growing.  Usually,  however,  it  may  be  said  that  stones  are 
either  oval  or  rounded  in  shape,  flattened  on  several  surfaces,  and,  if  there  are 
other  calculi  in  the  bladder,  presenting  facets  worn  by  attrition  of  one  stone 
against  the  other.  The  surface  of  a  calculus  may  be  very  rough  and  irregular 
or  may  be  smooth  and  uniform. 

In  size  it  may  vary  from  that  of  a  bird-shot  or  a  pea  to  one  measuring 
many  inches  in  circumference  and  weighing  several  pounds.  In  this  country 
the  largest  stone  extracted  without  fragmentation,  without  sloughing  of  the 
parts,  and  with  recovery  of  the  patient,  weighed  nine  and  a  half  ounces  and 
measured  eight  and  a  half  inches  in  circumference  (White  of  Philadelphia). 

Symptoms  of  Vesical  Calculus. — In  many  cases  before  the  develop- 
ment of  vesical  symptoms  the  descent  of  the  nucleus  from  the  kidney  will 
have  been  announced  by  the  characteristic  phenomena  already  described  under 
the  head  of  Nephritic  Colic.  (See  p.  838.)  A  history  of  this  soi't  is  therefore 
an  important  indication  in  cases  of  suspected  stone,  and  if  cleai-  and  unmistak- 
able should  lead  the  surgeon  to  repeated  examinations  if  the  further  group  of 
symptoms  now  to  be  detailed,  or  the  majority  of  them,  be  present.  The  most 
important  of  these  symptoms  of  vesical  calculus  are  as  follows : 

(1)  Frequent  urination,  more  marked  by  day  than  by  night.  The  patient 
is  obliged  to  empty  the  bladder  at  intervals  varying  from  two  or  three  hours  to 
every  few  minutes.  The  desire  to  do  so  is  irresistible  and  sudden.  It  is  much 
increased  by  active  motion,  as  on  walking  or  riding  over  rough  roads  or  streets. 
It  varies  with  the  size  and  shape  of  the  stone,  and  is  often  greater  when  the 
stone  is  of  small  size  than  when  it  is  large,  as  in  the  former  case  the  degree  of 
motion  imparted  to  the  calculus  during  movements  of  the  body  is  greater  than 
when  the  stone  is  of  large  size  and  has  made  for  itself  a  place  in  the  bas-fond 
of  the  bladder.  Freijuent  urination  is  also  more  marked  if  the  stone  has  an 
irregular  surface  than  if  it  is  smooth  and  uniform.  A  stone  may  be  of  very 
considerable  bulk,  but  if  pa»tially  encysted  or  if  held  in  ])lace  by  bands  of 
organized  lymph  it  may  give  rise  to  astonishingly  little  disturbance.  Fre- 
quency of  urination  is  more  marked  in  young  than  in  old  persons.  In  the 
latter  there  is  often  some  prostatic  enlargement,  and  the  stone  is  apt  to  lie  in 
the  bas-fond  of  tlie  bladder,  removed  from  contact  with  its  most  sensitive  por- 
tion. In  these  cases  the  usual  nocturnal  frequency  of  urination  will  continue 
unmodified  by  the  presence  of  the  calculus.  It  is  for  this  reason  that  in  every 
case  of  enlarged  pi'ostate  a  careful  examination  for  stone  should  be  made  even 
when  special  symptoms  of  its  presence  are  not  to  be  noticed. 

(2)  Pain. — The  characteristic  pain  of  stone  is  darting  and  burning  in  cha- 
racter, is  felt  during  micturition,  but  is  most  severe  at  the  termination  of  the 


SUBOERY   OF   THE   GENITO-UBINARY   TRACT.  863 

act,  .ho„  ....  n-ntau...  o,-  i„.,a„.ea  -->- .r,:;!™;';  .It^a^ S  St 

r     t      l„         \ft cm1k,v  ,...  existed  for  some  time,  it  may  gradually  lesser,  m 
food  o    '•'"'';•  J;;'^'"  ;-Ji,,^,,,,ear.     In  these  cases  the  stone  has  probably 

wr  «r]  -  ;f f  "^  t™Su:;  'C;. 

/eVpnW -This -symptom  is  often  absent  in  adults,  and  of  course  ,s 
rari!n  o^d  TrsL.  It  is  'of  Lnsiderable  diagnostic  value  m  young  children^ 
it  s  due  to^ongestion  of  the  vessels  of  the^prostato-ves.eal  region.  In  boys 
•  1      1  +    f^o  fr^vmntinn  of  the  habit  of  masturbation. 

"  TtI  M«  ;t  «?  n  Snt  par:?  the  body  may  be  associated  .Uh  stone 

(g  lUJltx  iHuni>  m  ui»         1  rectum  or  m  the  perineum 

In  many  cases  these  pains  will  be  fdt  ^^^^^ J^J^^^^^^  f^.^^  tlfe  seat  of 
sometimes    however^  m  ^f^^ppei      xtrl'id:s/trb\ck,  thighs,  stomach, 

TT'^'^^ortrrfrelent  y'in    he  neigtborhood  of  the  ball  of  the  great 
F„e      f  mav  ext  nd  ovTr  the^  hole  sole  of  the  foot,  and  is  apt  to  be  asso- 

bv  symptoms  which  more  or  less  closely  simulate  those  of  stone.     The  d.f- 
^.entTatLHs  not  difficult  in  many  cases,  but  m  others  >t  .s  tmposs.ble. 


<S64  .l.V    AMERICAN    TEXT- BOOK    OF   smai'Jn'. 

The  existence  of  tlie  entire  group  of  symptoms  given  above  cannot  justify 
a  positive  diagnosis  of  vesical  calculus  unless  a  further  examination  is  made  and 
the  stone  found  and  touched  by  the  surgeon.  Even  then  its  presence  must  be 
made  evident  to  the  sense  of  hearing,  as  under  no  other  circumstances  can  all 
possibility  of  error  be  eliminated.  In  doubtful  cases  the  presence  or  absence 
of  stone  may  usually  be  determined  by  means  of  the  ./-rays.  This  may  be 
the  only  method  by  uhich  an  encysted  stone  can  be  detected. 

Different  forms  of  the  vesical  sound  have  been  recommended,  but  the  best 
and  simplest  has  a  straight  steel  shaft,  with  a  short  curve  near  the  tip  and  a 
smooth  flattened  handle.  Two  forms  should  be  used  habitually,  one  with  a 
very  slight  curve,  and  the  other  with  a  short  abru])t  curve,  permitting  it  to  be 
carried  into  the  pouch  behind  the  prostate.  They  should  be  about  twelve 
inches  in  length,  and  of  a  caliber  of  about  13  of  the  French  scale.  In  using 
these  sounds  the  patient  should  be  in  a  recumbent  or  semi-recumbent  position, 
the  abdominal  muscles  well  relaxed  by  slight  elevation  of  the  shoulders,  the 
knees  drawn  up,  and  the  thighs  somewhat  separated.  During  the  exploration 
the  bladder  should  be  moderately  distended  with  water.  The  sound  is  well 
warmed  and  oiled,  and  is  introduced  in  the  same  manner  as  a  catheter,  remem- 
bering, however,  the  fact  that  its  curve  does  not  correspond  with  the  normal 
curve  of  the  fixed  part  of  the  urethra,  and  that  therefore  it  is  especially  import- 
ant at  the  time  that  the  point  of  the  sound  is  made  to  traverse  this  region  that 
downward  pressure  should  be  made  with  the  fingers  at  each  side  of  the  root- 
of  the  penis  near  the  pubes,  so  as  to  elongate  and  straighten  out  the  urethral 
curve.  It  will  be  found  that  strict  attention  to  this  will  greatly  facilitate  the 
introduction  of  the  instrument.  Once  in  the  bladder,  the  cavity  should  be 
explored  in  a  systematic  manner.  The  sound  should  be  partially  withdrawn 
and  reinserted  in  a  straight  line,  the  handle  being  slightly  raised  and  depressed 
from  time  to  time.  The  beak  of  the  sound  should  then  be  turned  toward  one 
side  of  the  bladder,  and  should  be  made  to  traver.se  the  arc  of  a  circle  sweeping 
transversely  through  the  bladder  from  above  downward.  It  should  then  be 
turned  to  the  opposite  side  and  the  same  mananiver  repeated.  If  the  stone  is 
not  found  in  this  manner,  the  searcher  should  again  be  introduced  to  its  full 
length,  and  the  tip  turned  gently  toward  the  floor  of  the  bladder  and  then 
rotated  from  side  to  side,  while  the  instrument  is  gradually  withdrawn  until  it 
comes  in  contact  with  the  vesical  neck.  If  the  stone  is  not  detected  with  the 
first  instrument,  the  second  one,  of  diff'erent  curve,  should  be  introduced  and 
the  search  repeated.  Some  surgeons  prefer  a  hollow  searcher,  so  that  during 
the  exploration  the  urine  can  be  withdrawn  or  water  injected  (Fig.  346). 

Various  plans  may  be  adopted  for  increasing  the  thoroughness  of  this  exami- 
nation. The  surgeon  may  press  down  the  anterior  wall  of  the  abdomen,  so  as 
to  bring  the  upper  wall  of  the  bladder  well  Avithin  the  reach  of  the  tip  of  the 
instrument.  With  the  finger  in  the  rectum  the  bas-fond  of  the  bladder  may 
be  elevated,  so  as  to  be  brought  more  closely  in  contact  with  the  searcher. 
The  patient  may  be  instructed  to  stand  upright,  and  the  fluid  from  the  bladder 
gradually  withdrawn  through  the  hollow  searcher,  the  tip  of  which  is  at  the 
same  time  gently  turned  from  side  to  side  and  brought  from  the  base  toward 
the  vesical  neck.  This  is  an  excellent  plan  for  discovering  small  fragments 
which  elude  the  ordinary  method.  In  cases  of  enlarged  prostate  the  stone 
may  often  be  more  easily  discovered  if  the  buttocks  are  raised  so  as  to  roll 
back  the  stone  toward  the  fundus. 

Some  diff'erence  of  opinion  exists  as  to  the  degree  of  evidence  which  is 
necessary  before  an  operation  is  undertaken.  A  few  surgeons  consider  it  suf- 
ficient to  feel  the  stone  with  the  tip  of  the  instrument.     The  majority  prefer  to- 


SURGERY  OF   THE   GENITO- URINARY   TRACT.  865 

demonstrate  its  presence  by  eliciting  the  characteristic  click.  The  latter  is 
certainly  by  far  the  most  definite  and  satisfoctory  symptom  it  is  possible  to 
obtain,  and,  althoii^^h  even  tliat  docs  not  entirely  exclude  the  possibility  of 
error,  it  reduces  it  to  a.  minimum. 

Now  and  then  a  papilloma  or  other  growth  will  become  encrusted  with  uri- 
nary deposits,  and  will  give  a  most  deceptive  sensation  both  to  touch  and  to  hear- 
ing. Occasionally  a  small  scale  of  calcareous  matter  will  form,  Avhich  can  be 
felt  or  heard  once  by  the  sound  and  cannot  again  be  found.  With  these  excep- 
tions, however,  the  click  which  is  elicited  by  the  touch  of  the  sound  upon  the 
calculus  is  pathognomonic,  and  may  serve  as  a  basis  for  a  positive  diagnosis. 
The  statement  that  "  if  the  surgeon's  hand  is  not  delicate  enough  to  detect  the 
contact  of  his  searcher  with  the  stone  Avithout  the  aid  of  hearing,  it  will  be 
wiser  for  him  not  to  attempt  to  deal  further  with  surgery  of  the  bladder,"  is 
misleading.  We  prefer  rather  to  accept  the  teaching  of  Agnew,  who  states 
that  too  much  importance  cannot  be  attached  to  the  testimony  furnished  by 
the  ear,  which  is  far  more  reliable  than  the  sensation  communicated  by  touch ; 
and  he  is  certainly  quite  within  reason  when  he  adds  that  if  all  the  circum- 
stances attendant  upon  the  errors  of  diagnosis  in  consequence  of  which  patients 
have  been  cut  without  a  stone  being  found  in  the  bladder  could  be  learned,  it 
would  doubtless  be  found  that  the  operators  proceeded  more  on  Avhat  was  felt 
than  on  what  was  heard. 

A  fasciculated  condition  of  the  bladder  will  sometimes  cause  a  very  decep- 
tive sensation  to  be  communicated  to  the  hand  of  the  surgeon  as  the  tip  of  the 
instrument  sweeps  over  the  ridges  of  the  organ,  and  occasionally  bony  growths 
developed  from  the  pelvis,  tumors,  fecal  impaction  in  the  rectum,  undue  promi- 
nence of  the  promontory  of  the  sacrum,  etc.  have  given  rise  to  similar  error. 
In  all  these  cases,  however,  no  sound  is  elicited. 

Sources  of  failure  in  the  detection  of  stone  may  be  enumerated  as  follows : 
(1)  a  more  or  less  completely  encysted  condition  of  the  calculus,  leaving  little 
or  nothing  of  its  surface  exposed  to  the  immediate  touch  ;  (2)  the  presence  of  a 
diverticulum  containing  the  stone  and  communicating  with  the  bladder  by  a 
small  aperture,  the  calculus  in  such  a  case  being  practically  extra-vesical ;  (3) 
the  stone  may  be  suspended  by  a  thread  of  lymph  from  the  summit  of  the 
bladder,  or  may  even  be  fastened  to  the  anterior  wall  of  the  bladder  by  fibrin- 
ous adhesions ;  (4)  the  surface  of  the  calculus  may  be  so  covered  with  blood- 
clot  or  with  lymph  as  to  prevent  the  characteristic  sound  from  being  elicited. 
In  the  majority  of  these  cases,  however,  the  symptoms  will  be  such  as  to  war- 
rant at  least  an  exploratory  operation,  when  the  true  character  of  the  case 
will  be  revealed.  In  doubtful  and  obscure  cases  never  less  than  two  examina- 
tions should  be  made  before  the  surgeon  gives  a  positive  opinion,  and  if  there 
is  much  pain  or  spasm  excited  by  the  necessary  manipulations  on  the  first 
examination,  the  second  should  be  conducted  while  the  patient  is  anesthetized. 
The  various  plans  suggested  of  approximating  the  walls  of  the  bladder  should 
be  carefully  tried,  and  the  patient  put  in  different  positions  with  the  object  of 
dislodging  the  stone  and  bringing  it  Avithin  the  reach  of  the  searcher.  The 
bladder  should  be  kept  fully  distended  during  the  examination,  and  the 
urine  should  be  gradually  withdraAvn  later.  In  some  cases  straight  sounds 
will  prove  more  useful  than  those  with  even  a  slight  curve ;  occasionally  a 
very  small  stone  can  best  be  detected  by  means  of  the  Bigelow  evacuating 
tube  connected  Avith  a  Avash-bottle,  as  in  evacuation  of  the  bladder  after 
litholapaxy. 

The  size  of  the  stone  may  be  estimated  if  a  Thompson's  searcher  (Fig.  -346) 
is  used  by  slipping  the  collar  on  the  stem  of  the  instrument  to  the  meatus  after 

55 


86<j  AX  AMEIilCAX   TEXT-BOOK    OF  SURGERY. 

the  stone  is  first  touched,  and  tlieii  marking  tlie  |)oint  at  whicli  the  sound  ceases 
to  come  in  contact  witli  it  as  it  is  slowly  withdrawn,  gentle  tapping  being  kept  uji 

Fig.  34(j. 


Thompson's  Searcher. 

during  this  procedure.  The  measurements  on  the  scale  of  the  searcher  between 
the  collar  and  the  meatus  will  then  indicate  approximately  the  diameter  of  the 
stone.  In  females  the  search  for  stone  should  be  conducted  Avith  a  straight 
sound,  and,  if  there  is  any  doul)t  remaining,  the  urethra  should  be  dilated  and 
the  little  finger  of  the  surgeon  inserted  for  digital  ex])loration. 

Some  idea  of  the  composition  of  a  calculus  may  often  be  obtained  from  the 
fragments  passed  during  urination,  and  more  definitely  from  those  adhering  to 
the  blade  of  a  lithotrite  if  the  latter  is  introduced  for  the  purpose  of  measure- 
ment previous  to  selecting  the  form  of  operation.  Frequently,  however,  the 
urinary  deposit,  and  even  the  superficial  layer  of  the  calculus,  are  phosphatic 
and  derived  from  the  sediment  of  the  ammoniacal  urine  of  cystitis,  Avhile  the 
nucleus  and  the  bulk  of  the  underlying  stone  may  be  of  uric  acid  or  of  oxa- 
lates, and  very  dense. 

The  Treatment  of  Vesical  Calculus. — The  non-operative  treatment 
of  vesical  calculus  is  of  chief  importance  in  its  relation  to  prophylaxis.  The 
attempt  to  procure  solution  of  a  stone  already  in  the  bladder  has  been  perse- 
vered in  by  the  profession  since  the  earliest  days,  but  Avithout  practical  result. 
Neither  drugs  by  the  mouth  nor  vesical  injections  can  be  used  in  sufficient 
strength  to  exert  any  material  influence  upon  a  calculus.  It  is  conceivable 
that  a  verA'^  small  and  very  soft  phosphatic  stone  might  be  aff'ected  by  acid 
solutions  weak  enough  to  permit  of  their  being  thrown  into  the  bladder,  but 
litholapaxy  for  sucli  stones  is  so  immensely  superior  in  safety  and  certainty 
and  promptitude  of  cure  that  no  other  method  need  be  considered,  least  of  all 
one  of  such  doubtful  utility. 

When  it  comes  to  the  prevention  of  sto«ie,  hoAvever,  the  case  is  diffierent. 
The  advice  given  to  a  litheraic  patient  who  has  perhaps  had  one  or  more 
attacks  of  renal  colic,  or  who  is  habitually  passing  urine  of  high  specific  grav- 
ity containing  an  excess  of  uric  acid,  is  of  the  utmost  importance.  With  such 
a  patient  it  is  essential  to  regulate  the  diet,  the  exercise,  and  the  mode  of  life 
generally.  The  free  use  of  water  as  a  beverage  both  at  and  betAvecn  meals, 
and  especially  on  going  to  bed  and  on  rising,  should  be  insisted  upon.  The 
particular  sort  of  Avater  to  be  used  is  a  matter  of  minor  importance,  as  the 
results  are  equally  good  Avhether  ordinary  cistern-  or  rain-Avater  or  distilled 
water,  or  Poland.  Bedford,  or  any  other  of  the  still  spring-Avaters,  is  employed. 
The  dilution  of  the  urine,  and  the  consecjuent  increased  solvent  poAver,  seem 
to  be  secured  as  Avell  by  one  as  by  the  other,  provided  only  that  a  sufficient 
quantity  be  taken.  Many  other  beneficial  effects  folloAv  the  habitual  use  of 
large  quantities  of  Avater.  In  persons  Avhose  general  strength  is  beloAv  the 
average,  and  particularly  in  thin  or  emaciated  patients  with  imperfect  digestion, 
milk  may  to  a  large  extent  take  the  place  of  Avater.  It  should  be  used  ahvays 
with  special  care  as  to  the  effect  upon  the  gastro-intestinal  tract,  and  may  have 
to  be  peptonized  or  skimmed,  or  diluted  Avith  plain  Avater  or  Avith  lime-Avater 
to  meet  the  needs  of  the  particular  patient.     In  the  majority  of  persons  Avho 


SURGERY   OF   THE    GENI TO- URINARY   TRACT.  867 

habitually  pass  concentrated  urine  it  Avill  be  found  to  be  in  some  shape  the 
best  of  all  articles  of  diet,  and  a  persevering  effort  to  secure  its  employment 
should  bo  made  even  when,  as  is  so  frequently  the  case,  the  patient  protests 
that  milk   does  not  agree  Avith   him. 

As  to  the  general  dietary,  the  most  important  articles  to  cut  off  are  the 
sugars  and  fats,  and  the  most  important  to  restrict  are  meats  and  alcohol.  Such 
patients  should  be  directed  to  eat  meat  but  once  daily,  and  then  sparingly ;  to 
take  a  minimum  of  sugar  and  of  butter  or  other  fats ;  to  drink  little  but  water 
or  milk  or  Aveak  tea,  or  if  wine  be  taken  to  select  a  light  claret  or  white  wine 
and  drink  it  largely  diluted.  Green  vegetables,  salads,  and  fruits,  bread,  eggs, 
and  light  fish,  with  a  little  poultry,  may  be  said  to  constitute  the  staple  of  the 
diet  in  these  cases. 

The  occasional  use  of  a  mild  laxative  or  of  small  doses  of  calomel  and  soda 
in  patients  who  are  inclined  to  torpidity  of  the  liver  and  defective  bile-secre- 
tion will  be  found  advantageous,  but  the  prolonged  use  of  the  saline  purga- 
tives, such  as  Epsom  or  Glauber  salt,  or  of  the  waters  containing  them,  Fried- 
richshall,  Carlsbad,  Hunyadi,  etc.,  is  distinctly  contraindicated,  favoring  rather 
than  preventing  concentration  of  the  urine. 

Moderate  exercise  is  extremely  beneficial,  especially  if  it  can  be  taken  in 
the  open  air  and  systematically.  Excessive  exercise  to  the  point  of  great 
muscular  fatigue  and  profuse  sweating  should  be  avoided. 

As  to  drugs,  it  may  be  necessary  to  use  either  alkalies  or  acids,  according 
to  the  reaction  of  the  urine  and  the  character  of  the  sediment.  In  acid  urine 
with  excess  of  uric  acid  and  of  the  urates,  phosphate  of  sodium  in  full  doses, 
taken  with  a  large  quantity  of  fluid,  often  seems  to  be  of  great  benefit,  but 
occasionally  has  no  effect  whatever.  The  magnesium  salts  have  been  recom- 
mended, especially  the  boro-citrate,  where  the  indications  for  alkalies  were 
persistent.  If  the  oxalates  or  phosphates  are  the  predominent  elements  in  the 
urine,  or  are  intermingled,  which  is  often  the  case,  the  mineral  acids,  especially 
muriatic  and  nitro-muriatic,  and  to  a  less  extent  phosphoric,  are  of  extreme 
value ;  and  this  is  increased  if  they  are  given  in  conjunction  with  nerve-tonics 
and  with  bitter  stomachics.  In  these  cases  special  attention  must  be  paid  to 
the  surroundings  of  the  patient,  to  securing  proper  hygienic  conditions,  plenty 
of  exercise  and  fresh  air,  absence  of  mental  strain  or  overwork,  and,  more 
important  still,  avoidance  of  worry  and  trouble  as  far  as  possible.  Attacks 
of  stone  are  sometimes  coincident  with  a  certain  degree  of  nervous  break-down 
attributed  to  the  pain  and  distress  of  renal  colic  and  of  the  vesical  irritation, 
but  are  rather  to  be  regarded,  in  many  cases,  as  a  precedent  etiological  factor 
of  much  importance. 

In  the  preventive  treatment  of  stone  of  whatever  variety  the  avoidance 
of  catarrhal  conditions  of  the  urinary  tract  is  of  the  greatest  importance.  In 
the  absence  of  the  colloids,  the  crystalline  deposit  of  even  the  densest  urine 
will  remain  in  the  shape  of  fine  dust  or  sediment,  and  will  have  little  or  no 
tendency  to  adhere  or  consolidate  in  large  particles.  The  formation  of  stone 
depends  in  the  great  majority  of  cases  upon  the  presence  of  agglutinating 
material  binding  together  the  urinary  deposits.  This  is  found  in  the  vesical 
mucus,  which  is  in  great  excess  in  all  chronic  catarrhal  diseases  of  the  bladder, 
and  the  production  of  which  is  favored  by  the  existence  of  stricture  or  of 
hypertrophied  prostate  or  vesical  atony  with  residual  urine. 

The  treatment  of  these  conditions  and  of  the  chronic  cystitis  which  so 
often  accompanies  them  is  therefore  of  the  utmost  value  in  the  prophylaxis 
of  vesical  calculus. 

A  stone  having  once  formed,  the  operative  treatment  applicable  for  its 


868  ^^V  AMElilCAX    TEXT-BOOK    OF  .SlliaEIiY. 

removal  varies  according  to  a  number  of  factors,  chief  among  which  are — 1,  the 
size  of  the  stone;  -.  its  composition;  -3.  the  condition  of  the  kidneys:  4,  the 
presence  or  absence  of  obstructive  disease,  as  urethral  stricture ;  o.  the  con- 
dition of  the  prostate  and  bladder  ;  0,  the  age  of  the  patient.  . 

The  possible  methods  of  removing  a  given  stone  from  the  male  bladder 
are — 1.  perineal  lithotomy,  a,  lateral,  h,  median  :  2,  suprapubic  lithotomy ;  3, 
litholapaxy.  The  remarkable  change  brought  about  in  the  treatment  of  cal- 
culus by  the  introduction  of  the  last-named  method  has  greatly  reduced  the 
field  of  the  first  two.  The  limitations  of  their  emjdoyment  since  the  develop- 
ment of  litholapaxy,  and  especially  since  its  extension  to  children,  may  well  be 
indicated  by  the  experience  of  Thompson,  who  in  former  days  found  it  neces- 
sary to  cut  one  in  every  four  patients  with  calculus,  and  who  now  cuts  but  one 
in  thirty. 

It  is  safe  to  say  that  in  adults  perineal  Utlwtomy  should  be  done  chiefly 
under  the  following  circumstances  :  1.  In  cases  of  deep  urethral  stricture  rebel- 
lious to  dilatation,  in  which  by  selecting  the  median  method  the  stricture  may 
be  divided  at  the  same  time.  2.  In  cases  of  stones  of  moderate  size  and  of 
such  hardness  and  density  as  to  make  too  great  demands  on  the  strength  of  the 
lithotrite  or  of  the  operator.  This  condition  occurs  very  rarely,  o.  In  cases 
of  atony  of  the  bladder  where  there  is  little  or  no  expulsive  power,  where 
there  is  already  a  chronic  cystitis,  and  where  the  stone  is  of  medium  size.  In 
some  cases  a  preliminary  crushing  of  a  few  minutes'  duration  may  make  the 
operation  the  preferable  one  even  when  the  stone  is  of  considerable  size. 

Suprapubic  lithotomy  should  be  selected — 1,  when  the  stone  is  an  unusually 
large  one,  and  at  the  same  time  is  believed  to  be  of  exceptional  hardness ;  2, 
in  cases  of  marked  prostatic  hypertrophy  with  pouched  bladder,  chronic  cys- 
titis, and  large  stone :  and  3,  sometimes  w  hen  the  kidneys  are  diseased. 

Litholapaxy  is  the  method  appropriate  to  nearly  all  other  cases,  though  a 
few  exceptions  to  the  above  rules  may  result  from  the  presence  of  such  compli- 
cations as  advanced  renal  disease,  vesical  tumor,  etc. 

Preparatory  Treatment. — Whatever  operation  is  to  be  performed  on  a 
patient  with  vesical  calculus,  certain  preliminary  examinations  and  preparations 
are  invariably  necessary.  The  general  health  of  the  patient,  especially  in 
regard  to  the  condition  of  the  kidneys,  should  be  carefully  looked  into.  The 
quantity  of  urine  passed  daily  should  be  measured  for  some  days.  The  pres- 
ence of  albumen,  of  blood  or  pus,  of  fetor,  etc.  should  be  carefully  noted. 
Both  the  choice  of  operation  and  the  prognosis  and  post-operative  treatment 
will  be  influenced  by  the  results  of  this  inquiry. 

The  patient  should  be  put  to  bed  for  two  or  three  days  previous  to  opera- 
tion, to  reduce  as  much  as  possible  the  irritation  of  the  bladder  produced  by 
motion.  If  the  urine  is  extremely  fetid  and  ammoniacal,  as  in  old  cases  of 
atony  or  of  enlarged  prostate,  it  is  well  to  draw  it  every  eight  hours  and  irri- 
gate the  bladder  with  strong  boric-acid  or  weak  nitrate-of-silver  or  potassium- 
permanganate  solutions.  At  the  same  time  salol  or  boric  acid  in  five-grain 
doses  four  times  daih*  should  be  administered  by  the  mouth.  A  milk  diet  is 
advisable,  though  light  meals  may  also  be  allowed,  especially  in  old  persons. 

The  pubes  and  perineum  should  be  shaved,  no  matter  which  operation  is  to 
be  performed,  as  it  reduces  the  risk  of  infection  even  during  a  litholapaxy, 
permitting  thorough  asepsis  of  the  parts  that  have  to  be  handled  during  the 
introduction  and  manipulation  of  the  instruments.  A  laxative  should  be  given 
the  night  previous  to.  and  an  enema  about  four  hours  before,  the  operation. 

These  various  methods  may  now  be  described. 

Perineal  Lithotomy. — 1.  Lateral  Lithotomy. — This  operation,  popular- 


SURGERY   OF    THE    GENITO-URTNARY   TRACT. 


809 


i/,cd  about  the  end  of  the  seventeenth  century  by  Frerc  Jacques,  and  placed  on 
an  enduring  scientific  basis  by  the  labors  of  Cheselden  in  the  early  part  of  the 
eighteentli  century,  is  still  the  operation  of  ])reference  in  certain  cases  in  adults 
and  with  some  surgeons  in  almost  all  children.  In  ])erforming  it  the  incision 
is  made  in  the  left  side  of  the  perineum,  extending  through  the  left  lobe  of  the 
prostate  to  the  neck  of  the  bladder. 

The  following  anatomical  points  bear  upon  the  performance  of  all  forms  of 
perineal  lithotomy  :  The  perineum  is  a  lozenge-shaped  space,  the  four  angles  of 
which  are  at  the  symphysis  pubis,  the  tuberosities  of  the  ischia,  and  the  tip  of 
the  coccyx.  The  anus  is  in  the  middle  line  between  the  tuberosities,  and  its 
center  is  about  one  inch  and  a  half  from  the  tip  of  the  coccyx.  Midway  be- 
tween the  perineo-scrotal  junction  and  the  center  of  the  anus  is  the  "perineal 
center,"  which  corresponds  to  the  middle  of  the  lower  edge  of  the  triangular 
ligament.     The  bulb  with  its  artery  lies  in  front  of  the  point.     The  middle 

Fig.  347. 


Curved  Stone  Forceps  for  Lithotomy. 
Fig.  348. 


Straight  Stone  Forceps  for  Lithotomy. 
Fig.  349. 

5*1 


Lithotomy  Staff. 


line  of  the  perineum  is  not  crossed  by  any  vessels,  and,  like  the  median 
line  of  the  neck  and  abdomen,  is  comparatively  bloodless.  The  pelvic  fascia 
and  the  levator  ani  muscles  separate  the  perineal  space  from  the  cavity  of 
the  pelvis.  The  distance  from  the  skin  to  the  floor  of  the  pelvis  represents 
the  depth  of  the  perineum  and  varies  with  the  amount  of  subcutaneous  fat. 
It  varies  also  with  the  point  of  measurement,  being  from  two  to  three  inches  in 
the  posterior  part  and  less  than  one  inch  in  the  anterior  part  of  the  perineum. 
In  an  adult  of  ordinary  size  the  distance  from  the  skin  to  the  bladder  Avhen 
the  limbs  are  in  the  lithotomy  position  is  from  two  and  a  half  to  three 
inches.  The  membranous  urethra  is  about  three-fourths  of  an  inch  below  the 
symphysis. 

The  instruments  needed  in  the  performance  of  lateral  lithotomy  are  a 


»70 


.4.V  AMERICAN    TEXT-BOOK   OF  SURGERY. 


Fig.  350. 


lithotomy  knife,  a  grooved  staff,  a  ])robe-pointe(l  bistoury,  litliotomy  forceps 
(Figs.  347,  348),  scoop,  a  large-sized  gum  catheter,  and  a  catheter  en  cJiemise 
(Fig.  350).  The  staff  should  have  a  large  curve  with  a  lateral  groove, 
and  should  be  of  moderate  size,  so  as  not  to  interfere  with  the  introduction 
of  the  finger  (Fig.  349).  Various  forms  of  knife  are  preferred  by  different 
operators. 

A  lithotrite  should  be  at  hand  in  case  an  unexpectedly  large  stone  is  met 
with.  The  patient  having  been  placed  upon  a  narrow  table  and  fully  anesthe- 
tized, a  searcher  is  introduced  into  the  liladder  and  the  presence  of  the  calculus 
demonstrated  by  eliciting  the  characteristic  sound.  The  bladder  is  emptied  and 
washed  out  with  warm  boric-acid  solution,  six  to  eight 
ounces  of  Avhich  are  left  in  it.  The  thighs  are  flexed 
on  the  abdomen  and  the  legs  on  the  thighs,  the  lower 
limbs  being  then  given  in  charge  of  two  assistants, 
who  steady  them  in  that  position,  keeping  the  median 
line  of  the  perineum  exactly  vertical.  The  grooved 
staff  is  then  introduced  and  entrusted  to  an  assistant, 
who  holds  it  steadily  with  his  right  hand,  keeping  the 
handle  nearly  vertical,  but  inclined  a  little  toward  the 
right  groin,  while  the  concavity  of  the  staff  is  brought 
firmly  up  against  the  arch  of  the  pubes.  With  the  left 
hand  the  assistant  draws  up  the  scrotum.  The  ope- 
rator then  takes  his  place  kneeling  or  sitting  with  his 
face  opposite  to  and  on  a  level  Vith  the  patient's  peri- 
neum, lie  steadies  the  integument  of  the  perineum 
with  the  fingers  of  the  left  hand,  and  then  with  the 
knife  makes  an  incision  from  a  point  to  the  left  of  the 
raphe  and  about  one  inch  and  a  quarter  in  front  of  the 
anus  to  a  point  about  midway  between  the  tuber  ischii 
and  the  anus,  a  little  nearer  the  tuberosity  than  the 
gut.  so  as  to  avoid  wounding  the  rectum. 
This  incision  is  deepest  at  its  anterior  extremity.  It  divides  the  skin, 
superficial  fascia,  transverse  perineal  muscle,  nerve,  and  vessels,  the  lower 
edge  of  the  anterior  layer  of  the  triangular  ligament,  and  the  lower  or  exter- 
nal hemorrhoidal  vessels  and  nerves. 

The  surgeon  now  introduces  his  left  forefinger  into  the  depths  of  the  wound, 
feeling  for  the  staff  and  pressing  the  rectum  backward.  When  the  groove  in 
the  staff  is  found,  the  knife  is  carried  along  the  finger-nail,  which  should  rest 
against  the  inner  lip  of  the  groove  of  the  staff  (Fig.  351).  When  it  is  certain 
that  the  point  of  the  knife  is  safely  lodged  in  the  groove,  it  is  pushed  along 
it  with  the  blade  inclined  so  as  to  be  parallel  with  the  external  wound,  and  is 
made  to  enter  the  bladder.  This  will  usually  be  announced  by  a  gush  of 
urine.  As  the  knife  is  Avithdrawn,  the  incision  in  the  neck  of  the  bladder 
and  in  the  prostate,  which  is  directed  obliquely  downward  and  outward,  is 
gently  enlarged.  By  this  cut  the  membranous  and  prostatic  portions  of  the 
urethra  are  opened  and  the  compressor  urethr«>,  the  posterior  layer  of  the 
triangular  ligament,  a  few  of  the  anterior  fibers  of  the  levator  ani,  and  the 
left  lobe  of  the  prostate  are  divided. 

The  surgeon  now  carries  the  left  forefinger  along  the  groove  of  the 
staff  into  the  bladder  and  feels  for  the  stone.  When  the  finger  is  in  con- 
tact with  it,  and  not  before  then,  the  staff  is  taken  out,  the  forceps  are 
introduced  alongside  of  the  finger,  and  the  stone  is  seized  and  withdrawn. 
The  latter  portion   of  this   operation,  the   seizing   and    extraction   of  the 


Catheter  en  chemise. 


SURGERY   OF    THE    GENITO-URTNARY   TRACT.  ^71 

stone,  should  be  done  systematically,  the  forceps  being  fully  introduced 
before  they  are  opened,  and  the  blades  then  separated  and  closed  while  a 
rotary  motion  is  given  to  them.  If  they  fail  to  grasp  the  stone  after  they 
have  been  gently  swept  from  one  side  of  the  bladder  to  the  other,  it  may 

Fig.  351. 


Lateral  Lithotomy  (Tillmanns). 

be  soucrht  behind  the  prostate  by  withdrawing  the  forceps  slightly,  raising  the 
handle?  and  then  opening  and  closing  them.  When  the  calculus  is  grasped,  it 
should  be  withdrawn  slowly  and  gently  and  by  traction  in  the  axis  ot  the  pel- 
vis—that is,  in  the  recumbent  position,  upward  and  forward.  it  there  is 
much  resistance  from  the  tissues  near  the  neck  of  the  bladder  stretched  over 
the  stone,  they  may  be  pushed  back  with  the  finger  or  may  occasionally  re- 
quire further  division  by  a  light  touch  of  the  knife. 

If  possible,  the  calculus  should  be  extracted  without  fragmentation,  as  it  it 
crumbles  or  breaks  into  pieces  the  operation  is  prolonged  by  the  necessity  tor 
the  use  of  the  scoop  and  for  repeated  washing  out  of  the  bladder.  ^  Alter  the 
stone  has  been  removed  the  bladder  should  be  carefully  explored  with  the  fan- 
ger  to  make  certain  that  it  does  not  contain  a  second  calculus.  A  gum  or  solt- 
rubber  catheter  should  be  introduced  through  the  wound  into  the  bla<lder,  and  a 
stream  of  warm  boric-acid  solution  sent  through  it  forcibly  a  few  times  until  it 
comes  back  clear.  If  there  is  no  hemorrhage,  the  patient  may  then  be  put  in 
bed  with  the  hips  and  knees  flexed,  and  the  wound  lightly  covered  with  anti- 
septic absorbent  cotton  frequently  changed  or  with  a  large  soft  sponge  wrung 
out  of  warm  carbolic  solution.  The  slight  hemorrhage  which  invariably  tollows 
this  operation,  coming  from  the  transverse  perineal  and  hemorrhoidal  vessels, 
usually  ceases  spontaneouslv.  If  they  bleed  very  freely,  they  are  seized  with 
pressure  forceps  as  soon  as  the  stone  is  extracted,  and  upon  their  removal  when 
the  patient  is  prepared  for  bed  the  hemorrhage  will  usually  be  found  to  have 
ceased  permanentlv.  If  not,  they  can  readily  be  tied.  Hemorrhage  from  the 
artery  of  the  bulb' may  cause  considerable  trouble,  but  will  usually  admit  of  a 
ligature,  or  at  least  of  arrest  by  forceps,  which  may  be  left  in  position  for  a  day 


872 


.4.V   AMERICAN    TEXT-BOOK    OF  SURGERY. 


Fifi.  352. 


or  two.  The  internal  pudic,  altliou<rli  protected  by  tlie  lip  of  the  tuberosity 
and  the  margin  of  the  ramus  of  the  ischium,  has  occasionally  been  wounded  as 
the  result  of  carrying  the  incision  too  far  externally.  It  may  be  seized  with 
forceps,  which  are  left  in  position,  or,  better,  ligated  by  means  of  a  strong  awl- 
shaped  needle  with  an  eye  near  the  point  of  the  needle  carrying  a  strong 
thread.  The  needle  is  passed  along  the  inner  side  of  the  ramus  of  the  ischium 
half  an  inch  in  front  of  the  tuberosity,  and  brought  out  on  the  inner  side  of 
the  artery,  the  point  of  the  needle  being  directed  toward  the  surface,  so  that 
the  thread  may  be  disengaged  from  the  eye.  The  needle  is  then  withdrawn 
and  the  thread  tightened.  This  would  also  command  the  circulation  through 
the  artery  of  the  bulb.  In  case  of  venous  hemorrhage  it  may  be  necessary  to 
pack  the  wound.  This  may  be  done  either  by  the  catheter  en  chemise  (Fig.  350) 
or  bv  the  air  tampon  of  Buckston  Browne.  The  former  is  made  by  cutting 
an  opening  in  a  stjuare  of  muslin  or  stout  linen,  passing  a  gum  catheter  through 
it,  and  fastening  them  together  at  a  point  about  three  inches  from  the  end  of 
the  catheter  by  a  thread.  The  projecting  portion  of  the  catheter  is  then  passed 
into  the  bladder,  and  the  space  between  the  instrument  and  the  inner  portion 
of  the  muslin  is  packed  with  antiseptic  gauze.     The  Buckston  Browne  tampon 

consists  of  a  central  tube  acting  as  a  cathe- 
ter surrounded  by  a  soft-rubber  bag.  which 
admits  of  distention  with  air  or  water  (Fig. 
352). 

Other  accidents  may  occur  during  the 
operation.  "Wound  of  the  rectum  is  usu- 
ally the  result  of  the  knife  not  being  suf- 
ficiently lateralized,  or  is  sometimes  the 
consequence  of  sloughing  following  the 
withdrawal  of  an  exceptionally  large  cal- 
culus. In  either  case  it  ordinarily  heals 
spontaneously,  but  sometimes  a  fistula  is 
left.  The  urethra  has  occasionally  been 
missed  altogether,  and  still  oftener  in  chil- 
dren has  been  torn  completely  across.  In 
them  the  bladder  is  higher  and  more  mo- 
bile than  in  adults.  The  connective  tissue 
of  the  region  is  delicate  and  easily  lace- 
rated. The  wound  is  necessarily  a  small 
one,  and  during  the  effort  at  introduction 
of  the  finger,  therefore,  it  has  happened 
even  to  very  skilful  lithotomists  that  the 
urethra  has  been  torn  across  and  the 
finger  has  been  pushed  onward  into  the  loose  cellular  tissue  of  the  recto- 
vesical space,  where  by  its  pressure  an  artificial  cavity  is  formed  which  is 
then  mistaken  for  the  interior  of  the  bladder.  This  accident  is  likely  to  be 
followed  not  only  by  immediate  failure  of  the  operation,  but  )»y  pelvic  cellu- 
litis, peritonitis,  and  death.  It  may  be  avoided  by  making  the  incision  into  the 
urethra  sufficiently  large  at  first,  and  by  observing  that  as  the  finger  is  passed 
through  it  is  tightly  grasped  by  the  prostatic  urethra  and  the  neck  of  the 
bladder,  giving  a  sensation  very  different  from  that  experienced  if  it  is  in  the 
loose,  unresisting  tissue  of  the  recto-vesical  space.  When  the  mistake  is  made 
and  is  recognized  in  time,  it  can  be  remedied  by  withdrawing  the  finger,  rein- 
serting the  knife  into  the  groove  of  the  staff",  and  carefully  enlarging  the  incis- 
ion toward  the  neck  of  the  bladder.      If,  however,  the  latter  has  been  pushed 


Buckston  Browne's  Tampon. 


SURGERY   OF   THE    GENITO-URINARY   TRACT.  87;^, 

oft'  the  staff,  so  that  it  cannot  be  reachod,  it  Avould  bo  proper  to  perform 
at  once  a  suprapubic  litliotoniy,  to  pass  a  catheter  from  tlie  bhidder  out 
through  the  perineum,  and  to  phice  a  small  drainage-tube  in  tlie  recto-vesical 
space  alongside  of  it.  The  accident  can  be  avoided  in  the  majority  of  cases  if 
the  plan  fre(i[ucntly  followed  by  Agnew  in  very  young  children  with  entire  suc- 
cess be  adopted — namely,  to  (lis])ense  with  the  introduction  of  the  finger  and 
to  carry  a  pair  of  small  force})s  directly  along  the  groove  of  the  staff  after 
the  incision  has  been  made  into  the  bladder.  When  it  is  clearly  recognized 
that  they  have  grasped  the  stone,  the  staff  may  be  withdrawn  and  the  extrac- 
tion completed.  The  same  result  can  be  attained  by  passing  the  finger  along 
the  concavity  of  the  staff — i.  e.  along  the  roof,  the  more  fixed  portion  of  the 
urethra.  In  a  few  instances  the  urethra  has  been  missed  altogether  and  the 
bladder  opened  beliind  the  prostate,  and  in  others  the  knife  has  been  carried  on 
so  far  tliat  the  posterior  wall  of  the  bladder  itself  has  been  wounded.  Both  of 
these  accidents  are  likely  to  result  fatally  from  extravasation  of  urine,  pelvic  cel- 
lulitis, and  peritonitis.  Death  may  occur  after  lateral  lithotomy  from  any  of  the 
causes  which  have  been  mentioned ;  from  septicemia  following  sloughing  or  ab- 
sorption of  the  wound  products  or  of  decomposing  urine ;  or  from  suppurative  py- 
elo-nephritis,  especially  in  cases  in  which  the  kidneys  are  already  much  diseased. 

Median  Lithotomy. — This  operation  is  performed  by  means  of  an  incision 
made  through  the  raph^  betAveen  the  scrotum  and  the  anus.  The  patient  is 
placed  in  the  same  position  as  for  lateral  lithotomy,  and  a  grooved  staff  is  in- 
troduced and  held  carefully  in  the  median  line  well  up  under  the  arch  of  the 
pubes.  An  incision  is  then  made  in  the  line  mentioned,  and  deepened  until 
the  membranous  part  of  the  urethra  is  reached.  This  is  freely  opened  on  the 
groove  of  the  staff  for  the  space  of  about  three-quarters  of  an  inch.  The 
finger  is  then  introduced,  and  carried  with  a  boring  or  rotatory  motion  onward 
through  the  prostatic  portion  of  the  urethra  to  the  bladder.  When  the  stone 
is  touched  the  staff  is  Avithdrawn  and  a  pair  of  forceps  introduced,  or  a  director 
may  be  first  passed  along  the  groove  of  the  staff  into  the  bladder  and  the  staff 
withdrawn,  and  the  finger  then  passed  along  the  director  as  a  guide.  This 
has  the  advantage  of  allowing  more  room  for  the  finger  and  of  permitting  it 
to  follow  the  upper  wall  of  the  urethra,  which  is  more  firmly  fixed  than  the 
lower,  and  therefore  less  liable  to  be  torn  across.  The  parts  divided  in  this 
operation  are  the  skin,  superficial  fascia,  sphincter  ani,  perineal  center,  the 
lower  edge  of  the  triangular  ligament,  the  compressor  urethrae,  the  membranous 
urethra,  and  the  apex  of  the  prostate.  The  advantages  claimed  for  it  are  the 
slight  amount  of  hemorrhage,  as  there  are  no  vessels  of  any  size  in  the  line 
of  the  incision,  the  avoidance  of  the  risk  of  wounding  the  ejaculatory  ducts, 
the  lessened  probability  of  urinary  infiltration  from  disturbance  of  the  recto- 
vesical fascia,  and  finally  the  simplicity  of  the  operation  itself.  It  must  be 
remembered,  hoAvever,  that  at  the  anterior  end  of  the  incision  the  knife  is 
necessarily  in  close  proximity  to  the  bulb,  and  at  the  posterior  end  is  very 
near  the  anterior  wall  of  the  rectum. 

Suprapubic  Lithotomy. — Anatomical  Points. — The  peritoneum  is 
attached  to  the  bladder  at  its  summit,  extending  upon  the  anterior  surface 
as  far  as  the  insertion  of  the  remains  of  the  urachus.  Posteriorly  it  descends 
betAveen  the  bladder  and  the  rectum  to  a  loAver  level.  It  is  attached  firmly 
to  the  anterior  surface  and  summit  of  the  bladder,  but  ver}^  loosely  to  the 
abdominal  parietes  at  the  level  of  reflection  of  the  membrane,  thus  enabling 
it  to  folloAv  the  various  changes  in  the  size  and  position  of  the  bladder. 
When  empty  that  organ  is  flattened,  is  triangular  in  shape,  and  lies 
against  the  anterior  Avail  of  the  pelvis,  between  Avhich  and  it  is  a  quantity 


874 


J.V   AMERICAN    TEXT- BOOK    OF  SURGERY 


Fig.  353. 


of  loose  connective  tissue  containing  fat.  ^VLen  the  blatlder  and  rec- 
tum are  entirely  empty  the  peritoneal  fold  on  the  anterior  .surface  is  a 
little  below  the  upper  edge  of  tlie  .symphysis.  "When  the  .>^uniniit  of  the 
bladder  is  two  inches  above  the  pubes  and  the  organ  is  pre.«sed  again.st  the 

abdominal  wall,  the  reflection  of  perito- 
neum is  about  three-quarters  of  an  inch 
above  the  .symphysis.  Distention  of  the 
bladder  alone  will  elevate  the  fold  of  peri- 
toneum from  one-half  to  three-quarters 
of  an  inch.  Distention  of  the  rectum 
alone  will  elevate  the  ba.se  of  the  blad- 
der, but  will  have  little  or  no  effect  upon 
the  reflection  of  peritoneum.  It  ^>rovides, 
however,  a  firm  basis  for  the  fundus  of 
the  ])ladder.  prevents  the  latter  when 
dilated  from  extending  toward  the  peri- 
neum, and  pushes  the  whole  organ  for- 
ward against  the  anterior  abdominal  wall. 
Under  these  circumstances  the  same  quan- 
tity of  fluid  wliich  if  injected  into  the 
bladder  when  the  rectum  is  empty  would 
raise  the  pre-vesical  fold  three-quarters 
of  an  inch,  has  been  shown  to  increase 
the  elevation  to  from  one  and  a  half  to 
three  and  a  half  inches  (Fig.  353.)  The 
vesical  veins  which  run  from  the  apex 
of  the  bladder  and  pass  under  its  fun- 
dus are  compressed  when  the  rectum  is  distended. 

These  preliminary  anatomical  points  are  of  great  importance  in  the  operation, 
which  is  conducted  as  follows:  The  patient  is  prepared  as  for  lateral  lithotomy; 
an  empty  rectal  bag  (Fig.  354)  is  oiled,  introduced  into  the  rectum,  and  passed 
well  above  the  sphincter.  The  bladder  is  then  emptied  by  means  of  a  soft 
catheter  and  washed  out  with  a  warm  solution  of  boric  acid.  The  rectal  bag 
is  then  distended  with  about  eight  or  ten  ounces  of  fluid  when  the  patient  is 
an  adult :  larger  quantities  have  been  u.sed,  but  occasionally  Avith  serious 
results  from  laceration  of  the  mucous  membrane  or  the  peritoneum.  In 
children,  as  the  bladder  is  already  an  abdominal  organ,  the  distention  of 
the  rectum  can  often  be  dispen.sed  with  altogether.  The  next  step  con- 
sists in  the  injection  of  the  bladder,  which  can  usually  be  sufficiently  di.s- 
tended  in  an  adult  by  the  injection  of  ten  to  twelve  ounces  of  liquid,  and  in  a 
child  under  five  years  of  age  by  the  use  of  about  three  ounces.  Keen  and 
others  prefer  to  distend  the  bladder  with  air  filtered  through  cotton,  which  i.s 
tied  over  the  end  of  a  Davidson  syringe,  instead  of  fluid.  The  catheter  is 
then  withdrawn  and  a  soft  india-rubber  drainage-tube  tied  around  the  penis  to 
prevent  the  escape  of  the  fluid  from  the  bladder.  An  incision  three  inches  long 
is  then  made  in  the  middle  line,  beginning  half  an  inch  below  the  upper  edge  of 
the  pubes.  The  line  between  the  recti  or  pyramidales  having  been  found, 
the  muscles  may  be  separated  with  a  few  touches  of  the  knife  and  the  han- 
dle of  the  scalpel,  but  on  no  account  should  any  forcible  or  vigorous  tearing 
of  the  parts  be  employed.  It  is  better,  if  the  intermuscular  interval  is  not 
apparent  at  once,  to  carry  the  incision  directly  through  whatever  muscular 
fibers  make  their  appearance  in  the  wound,  adhering  to  the  median  line  and 
deepening  the   incision   until   the   transversalis   fascia   is  reached.     Ttis  is 


LiftiiiL'  up  the  Peritoneum  by  Rectal  and  Vesi- 
cal Distention  ;  JI,  bladder :  H,  rectum  dis- 
tended by  the  Petersen  bag;  A',  peritoneum 
(Hotter). 


SURGERY   OF    THE    GENITO- URINARY    Th'ACT. 


875 


tlioii  divided,  and  if  the  <Ml(rcs  of"  tlic  \vr)iiii(l  ;irc  licld  asunder  bv  retractors, 
a  layer  of"  loose  connective  tissue  and  fat,  freijuently  containing  large  veins, 
will  become  apparent.  This  lies  directly  over  the  wall  of  the  bladder  and 
conceals  it.  It  may  also  be  divided  with  light  touches  of  the  knife,  aided 
occasionally  by  sej)aration   with   the  handle   or   the   fingers,   the   same  pre- 


Petersen's  Iltrtal  i;i.>lii<_-uryiitL'r,  modified  by  Guyon 


caution  being  observed  not  unnecessarily  to  tear  or  break  up  the  connective 
tissue  in  this  region,  as  rough  manipulation  may  result  in  sloughing  or  in  uri- 
nary infiltration  after  the  operation.  A  portion  of  the  fat  may  be  gently 
pushed  upward  with  the  forefinger,  and  will  usually  carry  with  it  the  fold  of 
peritoneum  if  the  latter  descends  to  this  level.  It  is,  however,  not  often  seen 
during  the  operation.  There  may  be  at  this  stage  profuse  bleeding  from  the 
veins  running  in  the  connective  tissue  lying  upon  the  front  of  the  bladder. 
All  bleeding  should  be  checked  by  the  use  of  hemostatic  forceps,  but  no  time 
need  be  lost  in  applying  ligatures,  as  the  bleeding  is  almost  entirely  venous, 
and  Avill  usually  cease  promptly  when  the  rectal  bag  is  emptied. 

The  anterior  surface  of  the  bladder  having  been  recognized  by  its  color, 
by  the  presence  of  the  muscular  fibers,  and  by  its  fluctuation,  it  should  be 
transfixed  with  a  sharp  hook  inserted  transversely  near  the  upper  angle  of 
the  wound.  The  surgeon,  holding  this  in  the  left  hand  or  entrusting  it  to  an 
assistant  who  fixes  the  bladder,  opens  the  organ  by  thrusting  a  scalpel  verti- 
cally through  the  wall  just  below  the  hook,  and  precisely  in  the  median  line, 
and  cutting  downward  toward  the  pubes.  The  edges  of  the  opening  may  then 
be  seized  with  tenacula,  or  loops  of  silk  may  be  passed  and  given  to  assistants 
to  hold  so  as  to  steady  the  organ.  The  hook  may  then  be  withdrawn  and  the 
surgeon  may  introduce  the  right  forefinger  into  the  bladder.  The  wound 
should  be  large  enough  to  admit  easily  of  two  fingers,  which  may  be  employed 
instead  of  lithotomy  forceps,  or  the  latter  may  be  introduced  and  the  stone 
extracted.  The  rectal  bag  is  then  emptied  and  withdrawn.  The  India-rubber 
tube  encircling  the  penis  must  not  be  forgotten.     If  the  bladder  is  healthy 


<S7G  AN   AMJJRICAy    TEXT-BOOK    OF   SlliOEUY. 

and  iminfoctod,  and  ospocially  if  the  operation  has  been  carried  out  in  a  cliild 
or  in  a  healthy  adult,  suture  of  the  bladder  may  be  employed.  The  wound  is 
brought  ^vitllin  reach  of  the  surgeon  by  two  blunt  liooks,  one  inserted  at  cacn 
of  its  extremities.  With  them  it  is  brought  forward  to  the  surface  and  the 
margins  of  the  incision  kept  steady  and  parallel  with  each  other.  Very  fine 
ehromicized  catgut  should  be  employed.  The  sutures  should  be  interrupted, 
should  not  include  the  mucous  membrane,  should  be  introduced  by  means  of  a 
curved  needle  in  a  holder,  and  should  be  very  closely  applied.  Many  methods 
have  been  devised,  but  this  appears  to  be  the  best  (Treves).  A  small  drainage- 
tube  is  introduced  into  the  lower  part  of  the  wound  in  the  parietes,  and  the 
rest  of  the  wound  is  then  closed.  In  such  a  case  the  after-treatment  is  con- 
ducted in  the  same  manner  as  after  any  abdominal  section. 

If  the  case  is  one  which  does  not  permit  of  suture  of  the  liladder,  a  few- 
stitches  may  be  placed  at  tlie  two  extremities  of  the  wound  in  the  aljdominal 
wall,  including  all  the  tissues  which  have  been  divided.  It  is  thought  import- 
ant by  some  surgeons  to  stitch  the  slit  in  the  bladder  to  the  fascial  and  deeper 
€dges  of  the  wound,  two  or  three  sutures  being  placed  on  each  side,  and  one 
below  at  the  lower  end  of  the  incision,  so  as  to  shut  oft"  the  tissue  behind  the 
pubes.  It  is  said  greatly  to  lessen  the  danger  of  urinary  infiltration.  A  large- 
sized  tube  also  is  introduced  into  the  bladder  and  retained  for  from  thirty-six  to 
forty-eight  hours.  Others  dispense  with  both  these  procedures,  which  thev  con- 
sider useless,  and  employ  no  form  of  drainage-tube,  using  a  catheter  introduced 
through  the  urethra  if  there  is  retention  of  urine.  During  the  after-treatment 
the  patient  may  turn  upon  his  side  from  time  to  time  so  as  to  lessen  the  exco- 
riation of  the  parts.  The  skin  in  the  neighborhood  should  be  protected  by 
antiseptic  ointment,  the  edges  of  the  wound  should  be  frequently  lightly 
dusted  with  iodoform,  and  a  pad  of  antiseptic  absorbent  cotton,  or,  better,  a 
soft,  clean  sponge,  should  be  lightly  fastened  over  the  wound  itself.  The 
patient  Avill  require  constant  attention  to  prevent  troublesome  excoriation,  but 
may  be  allowed  a  considerable  range  of  motion,  and  should  be  encouraged  to 
sit  up  comparatively  early. 

LiTHOLAPAXY. — ^fhe  Operation  of  lithotrity,  by  which  the  stone  was  crushed 
usually  at  several  sittings  and  the  fragments  were  left  for  unaided  evacuation 


Fig.  355. 


Bigelow's  Litliotrite. 

by  the  patient,  has  Iteen  completely  supplanted  ])y  the  modern  o])eration  of 
litliola])a\y,  in  which  the  crushing  and  the  removal  of  the  fragments  are  both 
:'ompleted  at  one  sitting.  This,  Avhich  is  the  greatest  advance  in  the  treatment 
of  vesical  calculus  which  has  been  made  in  the  history  of  surgery,  we  ow-e  to 
an  American  surgeon,  Professor  Bigelow  of  Boston,  who  in  1878  proposed  the 
method  and  described  the  instruments  which  after  long  experimentation  and 
careful  study  he  had  devised.  These  consist  of  lithotrites  for  crushing  the 
stone  and  evacuators  for  removing  the  debris.  The  litliotrite  is  made  in  a 
variety  of  forms,  the  two  most  useful  being  those  which  are  represented  in 
Figs.  355,  856.  The  surgeon  may  use  the  kind  which  he  prefers,  but  in 
all  cases  should  be  certain  that  the  instrument  has  been  made  by  a  thoroughly 


SURGERY  OF  THE  GENITO-URINARY  TRACT. 


877 


careful  and  rc'lia))k'  maker,  and  that  it  lias  tlic  strength  requisite  for  the  great 
strain  to  which  it  is  often  subjected.     The  evacuators  are  also  now  of  great 


Fig.  356. 


Fig.  357. 


Thompson's  Lithotrite. 

variety.  That  of  Dr.  Bigelow  is  represented  in  Fig.  3o8,  and  in  the  opinion 
of  many  surgeons  has  not  yet  been  improved  upon.  It  consists  of  a  large 
elastic  bulb  with  a  detachable  glass  bot- 
tle at  its  lower  end,  and  with  a  stop- 
cock at  the  summit  for  the  purpose  of 
filling  the  bulb,  and  one  at  its  lower  ex- 
tremity for  connection  with  the  evacuating 
tube.  A  perforated  tube  which  extends 
from  the  lower  stopcock  into  the  center  of 
the  bulb  is  so  made  that  the  area  of  the 
fenestra  in  its  walls  is  greater  than  the 
area  of  its  transverse  section.  Therefore, 
during  the  process  of  evacuation  of  the 
debris,  Avhen  the  bulb  is  compressed  the 
current  of  fluid  flowing  back  into  the 
bladder  tends  to  go  through  the  small 
openings  in  the  walls  of  the  perforated 
tube  rather  than  through  its  main  chan- 
nel. In  this  way  any  fragments  floating 
in  the  reservoir,  which  have  not  yet  set- 
tled in  the  glass  receiver  at  the  bottom, 
are  arrested,  and  are  less  likely  to  be 
thrown  back  into  the  bladder.  The 
coiled  tube,  figured  in  the  cut,  connects 
with  the  stopcock  at  the  summit  of  the 
bulb,  and,  by  dropping  the  sinker  at  the  other  end  into  a  basin  of  warm  anti- 
septic solution,  may  be  used  to  increase  the  quantity  of  water  in  the  bulb 
whenever  desirable. 

The  patient  should  be  prepared  as  for  the  other  operations  for  stone.  The 
bladder  should  be  emptied  and  washed  out  several  times  before  the  operation 
if  it  is  infected  and  contains  fetid  urine,  and  in  any  event  at  the  time  of 
operation,  after  which  about  six  to  eight  ounces  of  boric-acid  solution  should 
be  injected  and  retained.  The  surgeon  should  ascertain  that  the  urethra  will 
admit  full-sized  instruments.  The  patient  should  lie  upon  the  back  with  the 
shoulders  slightly  elevated  and  the  thighs  somewhat  separated. 

The  lithotrite  should  be  gently  introduced,  as  in  catheterism,  until  the  beak 
reaches  the  bulbous  portion  of  the  urethra.  The  shaft  will  then  be  perpendic- 
ular. If  it  is  held  for  a  few  seconds  in  that  position,  the  penis  at  the  same 
time  being  drawn  upward,  the  blades  will  pass  through  the  narrow  orifice  of 
the  membranous  urethra,  and  if  then  the  handle  be  gently  and  slowly  depressed 
the  instrument  w^ll  pass  through  the  prostate  and  enter  the  bladder.  The  blades 
should  be  allowed  to  slide  down  the  inclined  plane  of  the  trigone  until  they 
touch  the  posterior  wall  of  the  viscus.  They  should  rest  there  for  a  few 
seconds  until  all  currents  in  the  contained  fluid  have  subsided,  and  then  the 


Beak  of  Bigelow  s  Litbutritt,  c 


pen. 


878 


AN  AJflJIilCAN  TEXT-BOOK  OF  SURGERY. 


male  blade  should  be  gently  drawn  out  until  a  very  slight  resistance  from  its 
contact  with  the  neck  of  the  bladder  is  observed.     After  another  pause  of  a 


Fi«.  3o8. 


Bigelow's  Evacuator. 

few  seconds  it  should  be  pressed  back,  and  in  many  cases  the  stone  will  be 
found  in  the  grasp  of  the  instrument.  If  it  is  not,  the  blades  should  be  rotated 
first  to  the  left,  then  to  the  right,  the  shaft  of  the  instrument  remaining  in  the 
median  line,  and  the  same  manoeuver  repeated.  The  degree  of  rotation  may 
be  varied  if  need  be,  or  if  there  is  a  post-prostatic  pouch  the  blades  may  be 
turned  directly  toward  the  floor  of  the  bladder.  This  may  be  done  most  easily 
and  safely  by  depressing  the  handle  of  the  lithotrite  so  that  the  shaft  is  hori- 
zontal instead  of  directed  upward.  All  these  movements  should  be  gentle. 
The  rule  laid  down  by  Thompson  is  an  excellent  one :  viz.  that  the  more 
powerful  the  lithotrite — that  is,  the  longer  and  larger  its  blades — the  less 
ready  should  we  be  to  adopt  the  reversed  positions  of  the  blades,  and  the  more 
fluid  is  it  desirable  to  have  in  the  bladder. 

The  stone  having  been  seized,  the  instrument  is  then  to  be  partly  with- 
drawn, so  that  its  blades  occupy  the  center  of  the  cavity  of  the  bladder ;  the 
screw  is  then  turned,  gradually  at  first,  so  that  if  the  calculus  is  hard  it  may 
not  fly  out  from  between  the  blades.  As  it  becomes  apparent  that  it  is  firmly 
grasped  the  power  is  increased,  and  continued  until  the  stone  is  felt  to  break, 
usually  into  several  fragments.  The  male  blade  is  screwed  home  so  as  to 
pulverize  the  smaller  fragments,  and  the  process  of  seizing  and  crushing  is 
repeated  until  no  large  pieces  can  be  felt.  This  should  usually  occupy  from 
fifteen  to  thirty  minutes,  according  to  the  size  and  hardness  of  the  stone. 
The  lithotrite  is  then  withdrawn,  of  course  with  the  blades  well  closed,  and 
an  evacuating  tube  introduced.  For  an  adult,  one  of  the  caliber  of  28  to  30 
(French)  will  do  in  the  majority  of  cases.  It  is  connected  with  the  bulb,  the 
stopcock  turned,  and  then  gentle  compression  of  the  rubber  l»all  made  with 
the  right  hand  while  the  evacuating  tube  is  steadied  with  the  left  hand. 
Firm  pressure  may  be  made,  followed  by  a  delay  of  three  or  four  seconds 


SURGERY  OF  TIIK  GENITO-URINARY  TRACT.  879 

after  expansion  of  tlio  l)ull)  is  completer  (Thompson),  or  compression  may  be 
made  more  (juickly  and  trcMiuently  and  less  forcibly  (Bigebjw). 

If  there  is  much  debris  in  the  ))ladder,  the  end  of  tiie  evacuating  tube 
shouhl  not  be  inserted  as  far  as  the  fundus,  but  as  the  quantity  diminishes  it 
may  be  h)wered  so  as  to  pick  up  the  hist  fragments. 

Sometimes  the  tube  will  become  suddenly  blocked  by  a  fragment  and  the 
bulb  will  cease  to  expand.  Quick,  forcible  pressure  will  generally  dislodge  the 
obstructing  body.  Sometimes  the  bladder  wall  will  come  in  contact  with  the 
eye  of  the  tube,  giving  a  peculiar  sensation  not  urdike  the  nibbling  of  a  fish 
at  tlie  end  of  a  line,  and  hence  called  by  Bigelow  the  "  fish-bite."  It  indi- 
cates that  the  bladder  is  not  sufficiently  distended  and  that  more  fluid  must  be 
thrown  in.  This  can  be  done  by  using  the  rubber  tube  (Fig.  808),  dropping 
one  end  in  a  basin  of  warm  boric-acid  solution  ;  then,  after  slowly  compressing 
the  bulb,  the  way  to  the  bladder  being  open,  the  stopcock  of  the  evacuating 
tube  is  closed  and  that  communicating  with  the  rubber  tube  is  opened.  On 
relaxing  pressure  the  bulb  will  promptly  refill  from  the  boric  solution  outside. 
When  no  further  pieces  of  stone  can  be  heard  or  felt,  it  is  well  to  withdraw  the 
lithotrite,  introduce  a  vesical  sound,  and  make  a  final  exploration  of  the  blad- 
der. If  a  fragment  is  found,  a  smaller  lithotrite  may  be  used  to  crush  it,  and 
the  debris  then  extracted  in  the  usual  manner.  Auscultation  over  the  hypo- 
gastrium  while  the  bulb  and  evacuator  are  in  place  may  aid  in  determining  the 
presence  of  a  final  fragment. 

The  only  complication  of  the  operation  worthy  of  mention  is  the  possible 
clogging  of  the  blades  of  the  lithotrite,  so  that  they  cannot  be  approximated 
sufficiently  to  permit  of  their  safe  withdrawal.  In  such  an  event  (which  is 
naost  unlikely  to  occur  if  the  fenestrated  lithotrite  be  used)  the  blades  must  be 
made  to  protrude  in  the  perineum  or  above  the  pubes,  and  then  cut  down  upon 
as  in  median  perineal  lithotomy  or  suprapubic  lithotomy,  freed,  and  withdrawn, 
the  remainder  of  the  calculus  being  extracted  as  in  the  above  operation. 

Rest  in  bed  on  the  back,  milk  diet,  warm  fomentations  to  the  epigastrium, 
boric  acid  or  salol  by  the  mouth,  and  moderate  doses  of  quinine,  constitute  the 
essentials  of  the  after-treatment. 

In  children  the  principles  governing  the  selection  of  the  form  of  operation 
for  stone  have  lately  undergone  marked  change.  Until  comparatively  recent 
times  the  very  low  mortality  of  perineal  lithotomy  in  children  in  the  hands  of 
skilful  operators  made  it  seem  a  work  of  supererogation  to  seek  for  a  better 
method  of  operation  :  a  safer  could  scarcely  be  found.  A  high  rate  of  mortal- 
ity after  lithotomy  was  almost  always  due  to  deaths  among  elderly  adults.  Fer- 
gusson  long  ago  said  that  it  would  be  difficult  to  name  any  single  operation  of 
magnitude  which  was  more  successful  on  young  subjects  than  lithotomy,  quot- 
ing a  series  of  105  cases  operated  on  at  the  Norwich  Hospital,  with  only  3 
deaths,  as  evidence  of  the  correctness  of  his  statements.  Brodie  said :  "  In 
boys  under  the  age  of  puberty  lithotomy  is  so  simple  and  so  generally  success- 
ful that  we  ought  to  hesitate  before  we  abandon  it  for  any  other  kind  of  ope- 
ration." These  opinions  were  reiterated  by  surgical  teachers  almost  without 
exception  from  those  days  until  some  six  or  seven  years  ago.  Velpeau  enu- 
merated as  the  objections  to  lithotrity  before  puberty  "the  want  of  develop- 
ment of  the  sexual  organs,  the  small  diameter  of  the  urethra,  the  indocility  of 
the  patients,  and  the  extreme  sensibility  of  the  parts."  In  1884.  Surgeon- 
Major  Freyer,  an  accomplished  lithotritist  and  a  lithotomist  who  had  cut  for 
stone  in  boys  132  times  consecutively  without  a  single  death,  repeated  Vel- 
peau's  assertions  almost  in  the  same  words,  objecting  to  the  crushing  of  stone 
in  boys  on  account  of  the  undeveloped  condition  of  the  geni to-urinary  organs, 


880  .l^V  AMERICAN  TEXT-BOOK  OF  SURGERY. 

the  smallness  of  the  bladder,  tlie  narro\vnes.s  of  the  urethra,  and  the  liability 
to  laceration  of  the  vesical  and  urethral  mucous  membrane,  lie  added  that 
no  instruments  had  boon  invented  by  which  lithola|)axy  could  be  performed 
with  safety  in  male  chihhcn. 

Other  objections  have  liccn  advanced  from  time  to  time,  maiidv.  however, 
relatin<^  to  the  same  anatomical  points  and  (before  the  introduction  of  lithol- 
apaxy)  to  the  difficulty  of  getting  rid  of  the  fragments.  As  late  as  1888, 
Keyes  wrote  that,  on  account  of  the  limited  proportions  of  the  male  urethra 
before  puberty,  the  excessive  sensibility  of  the  child's  bladder,  and  the  want 
of  docility  and  self-control  at  that  time  of  life,  lithotomy  is  to  be  preferred  in 
male  children  under  the  age  of  fourteen.  He  made  exception  in  favor  of 
very  small  stones. 

Many  similar  expressions  could  be  quoted  from  the  writings  of  surgeons 
of  all  degrees  of  experience,  but  they  emphasize  chiefly  the  same  points,  the 
majority  of  which  are  now,  in  the  light  of  the  modern  improvements  in  lithot- 
rity,  without  applicability.  Anesthesia  has  made  the  "extreme  sensibility" 
of  the  parts  and  the  '' indocility  "  of  the  patients  of  little  moment.  Otis  has 
shown  that  in  children,  as  in  adults,  the  "small  diameter  of  the  urethra"  may 
be  greatly  increased  with  entire  safety  ;  antisepsis  during  and  after  the  opera- 
tion has  minimized  the  danger  of  laceration  of  the  mucous  membrane ;  instru- 
ments have  been  made  which-are  at  the  same  time  small  enough  to  permit  of 
their  introduction  into  the  urethra  and  bladder  of  young  infants,  and  strong 
enough  to  deal  with  very  large  and  very  hard  calculi ;  Bigelow  has  overcome 
the  difficulty  of  getting  rid  of  the  fragments ;  and  the  argument  from  .statistics 
is  at  least  neutralized  by  the  records  of  Keegan  and  Freyer,  the  former  having 
performed  59  litholapaxies  in  children  with  but  1  death  ;  the  latter,  influenced 
by  his  colleague's  results,  having  adopted  the  operation  and  performed  49  con- 
secutive litholapaxies  without  a  death. 

In  the  fjice  of  these  undisputed  facts  there  is  but  one  argument  remaining 
which  has  any  weight  as  urged  against  the  operation  of  lit]iola])axy  in  children, 
and  that  is  the  alleged  greater  probability  of  recurrence.  As  regards  the  two 
great  classes  of  operative  procedures  for  the  removal  of  calculus,  the  cutting 
and  the  crushing  operations,  all  forms  of  lithotomy  as  compared  with  all  forms 
of  lithotrity,  and  at  all  ages,  there  can  be  little  doubt  that  the  statistical  evi- 
dence in  relation  to  recurrence  is  at  present  in  favor  of  lithotomy.  But  it 
should  not  be  accepted  without  reservation.  Many  of  the  tables,  notably  those 
of  Sir  Henry  Thompson  and  Mr.  Cadge,  are  based  on  an  experience  extending 
over  many  years  and  antedating  the  introduction  of  litholapaxy.  Those  tables 
make  the  proportion  of  recurrence  after  lithotrity  about  1  in  7  or  1  in  8,  and 
after  lithotomy  about  1  in  20 ;  but,  like  so  much  of  the  statistical  matter  which 
our  text-books  and  journals  contain,  they  are  useless  or  misleading  at  the  pres- 
ent day.  The  two  principal  causes  which  lead  to  recurrence  are:  a.  the  failure 
to  remove  every  portion  of  stone  at  the  first  operation  ;  h,  the  new  formation 
of  stone  in  the  kidney  and  its  descent  into  the  bladder.  In  the  tables  of 
Mr.  Donald  Day,  based  on  the  records  of  the  Norwich  Hospital,  the  first  class 
includes  two-thirds  of  all  the  cases  of  recurrence.  But  circumstances  have 
altered.  The  employment  of  a  large-sized  evacuating  tube,  the  immediate  and 
thorough  emptying  of  the  bladder,  the  minute  pulverization  usually  possible 
with  completely  fenestrated  lithotrites,  the  increased  knowledge  of  the  great 
tolerance  of  the  bladder  to  prolonged  manipulations  if  they  are  gentle  and 
skilful,  have  all  combined  to  place  the  question  of  recurrence  upon  a  very 
different  level,  and  to  make  the  collection  of  a  new  set  of  statistics  ab.solutely 
necessary  before  venturing  to  draw  any  positive  conclusions. 


SUItGERY  OF   THE  GEXJTO-URINARY   Tit  ACT.  881 

But  if,  for  the  sake  cif  argument,  we  investigate  existing  statistics  on  this 
subject,  we  find  that  the  great  majority  of  cases  of  relapse  or  recurrence  have 
taken  place  in  patients  past  middle  life,  and  especially  in  very  old  persons  with 
eidarged  prostates  and  feeble  or  atonic  bladders.  It  will  be  recognized  at 
once  that  these  conditions  do  not  prevail  in  children.  The  prostate  is  unde- 
veloped;  the  bladder  is  almost  an  abdominal  organ  ;  no  pouch  exists  at  the 
fundus  ;  sacculation  is  nearly  or  (juite  unknown  ;  cystitis  is  a  comparatively 
manageable  complication  ;  the  ex])ulsive  power  is  proportionately  greater  than 
in  the  male  adult,  in  whom  a  ''physiological  atony"  is  not  at  all  infrequent. 
In  addition  to  these  reasons  for  not  anticipating  the  formation  of  new  calculi 
in  children  around  nuclei  of  vesical  origin,  it  may  be  reasonably  expected 
that  the  conditions  favoring  the  development  of  renal  calculi  will  be  more 
easily  treated  and  controlled  in  children  than  in  adults.  Certainly  among 
well-to-do  people  who  can  carry  out  a  proper  system  of  diet  and  medication  it 
is  fair  to  suppose  that  the  lithic  diathesis,  of  whatever  variety,  will  be  more 
readily  combated  in  children,  whose  diet  and  drugs  and  mode  of  life  can  be 
rigidly  ordered,  than  in  adults  with  fixed  and  often  very  prejudicial  habits. 

For  these  reasons,  while  admitting  that  the  question  of  recurrence  is  still 
%uh  judiee^  there  is  little  probability  that  there  will  be  enough  difference 
between  the  proportions  of  relapses  in  children  after  lithotomies  and  after 
litholapaxies  to  justify  any  decided  preference  on  that  ground  alone. 

The  position  of  litholapaxy  as  applied  to  children  is  moreover  strengthened 
by  a  review  of  the  history  of  lithotomy,  which,  unlike  the  operation  with  which 
we  contrast  and  compare  it,  has  undergone  but  little  change  for  many  years.  The 
improvements  in  suprapubic  lithotomy  have,  it  is  true,  rendered  it  applicable 
to  a  much  wider  range  of  cases,  and  it  is  equally  true  that  its  most  favorable 
results  have  been  attained  in  children ;  but  thus  far  the  statistics  of  supra- 
pubic lithotomy  in  children  do  not  compare  favorably  with  those  of  either 
litholapaxy  or  lateral  lithotomy.  This  is  probably  due  to  the  fact  that  in  a 
large  proportion  of  cases  the  operation  was  selected  only  after  litholapaxy  had 
been  attempted  and  failed,  or  else  was  originally  chosen  on  account  of  the 
unusual  character  of  the  calculus.  It  will  probably  always  be  employed  in 
preference  to  lateral  or  median  lithotomy  in  cases  of  extremely  large  or  excep- 
tionally hard  stones ;  but  when  we  remember  that  Freyer  has  removed  by  lithol- 
apaxy a  calculus  weighing  808  grains  from  a  boy  of  nine,  and  Keegan  one  of 
TOO  grains  (and  of  uric  acid)  from  a  boy  of  nine  and  a  half,  it  is  evident  that 
neither  size  nor  hardness  offers  an  insuperable  bar  to  the  latter  operation. 

Median  lithotomy  in  children,  although  advocated  by  some  surgeons,  is 
objectionable  on  account  of  the  great  danger  of  wounding  the  bulb  or  the  rec- 
tum, and  the  difficulty  in  obtaining  space  through  which  to  pass  the  finger  into 
the  urethra  and  the  bladder.  It  is  indeed  true  that  the  passage  of  the  finger 
is  not  absolutely  necessary,  although  it  has  always  been  one  of  the  time-honored 
rules  of  lithotomy  not  to  withdraw  the  staff  until  the  finger  is  in  contact  with 
the  stone.  Agnew's  method  (p.  873)  avoids  this  difficulty,  and  Mr.  Cadge 
recommends  almost  precisely  the  same  method  as  both  safe  and  efficient.  It  must 
be  remembered,  however,  that  its  adoption  places  the  surgeon  in  almost  the  same 
situation,  in  regard  to  the  possibility  of  leaving  debris  or  unnoticed  stones  in 
the  bladder,  that  he  occupies  after  litholapaxy.  If  the  stone  is  soft  and  breaks 
down  under  the  forceps,  or  if  there  are  multiple  calculi,  he  will  be  dependent 
on  the  touch  and  sound  elicited  by  the  vesical  explorer,  just  as  after  the  other 
operation.  If,  then,  the  introduction  of  the  finger  be  dispensed  with  in  either 
median  or  lateral  lithotomy  in  children,  these  operations  lose  one  of  their 
alleged  advantages — viz.  the  assurance  of  the  absolute  removal  of  all  calculous 

o  o 

56 


882  .l.V  AMERICAN  TEXT-BOOK  OF  SURGERY. 

fragment?.  If  it  be  insisted  upon,  it  constitutes  in  a  small  proportion  of  cases 
an  unavoidable  source  of  both  difficulty  and  danger.  Sir  William  Fergusson, 
Keith,  Thompson,  Cadge,  and  many  others  have  recorded  occasional  trouble 
with  this  step  of  the  operation. 

niese  facts  and  the  other  special  dangers  of  lateral  lithotomy  in  children 
have  already  been  described,  but  one  further  possible  contraindication  should 
not  be  lost  sight  of.  If  the  incision  be  prolonged  a  little  too  far  backward,  the 
left  ejaculatory  duct  can  hardly  escape  division  and  subsequent  obliteration, 
an<l,  although  this  may  not  be  a  serious  accident  in  cases  in  which  the  integ- 
rity of  the  opposite  half  of  the  genitalia,  the  testicles,  duct.  etc..  is  unimpaired, 
yet  it  leaves  the  patient  entirely  dependent  on  that  one  side  for  fertility,  if  not 
for  potency.  Mr.  Teevan  has  reported  four  cases  of  sterile  husbands  among 
lithotomized  patients.  Langenbeck  and  Sir  William  MacCormac  have  called 
attention  to  the  same  danger,  and  Keegan  believes  the  lateral  operation  to  be 
frequently  followed  by  emasculation.  Dennis  quotes  Dr.  Charles  Leale  in  rela- 
tion to  several  cases  coming  under  his  own  observation  in  which  such  patients 
grew  up  with  shrill  voices,  atrophied  testicles,  absence  of  hair  upon  the  face, 
etc. ;  in  fact,  with  all  the  characteristics  of  eunuchs.  The  evidence  as  to  this 
point  is  as  yet  fragmentary  and  inconclusive,  but  is  of  sufficient  importance  to 
deserve  careful  consideration. 

These  objections  to  perineal  lithotomy  in  children  are  at  least  as  weighty 
as  any  that  have  been  urged  against  litholapaxy.  Most  recent  writers,  basing 
their  opinion  on  the  foregoing  facts,  express  the  conviction  tliat  the  field  of  lith- 
olapaxy in  children  is  likely  to  be  considerably  enlarged  in  the  near  future.  It 
seems  probable  that  the  following  statements  will  be  generally  accepted  as  cor- 
rect :  In  every  case  of  calculus  in  male  children  litholapaxy,  on  account  of 
ease  of  performance,  low  mortality,  speedy  recovery,  and  absence  of  danger 
of  emasculation,  should  be  the  operation  of  predilection,  division  of  the  meatus 
being  freely  resorted  to  if  that  portion  of  the  urethra  offers  an  obstacle  to  the 
introduction  of  instruments.  The  lithotrite  and  evacuating  tube  should  be  of 
a  size  which  can  be  inserted  into  the  bladder  without  much  effort  or  over- 
distention,  and  great  gentleness  should  be  observed  in  passing  these  instru- 
ments. They  should  be  withdrawn  and  reintroduced  as  seldom  as  possible,  the 
stone  being  finely  pulverized  before  the  lithotrite  is  taken  out  at  all.  In  seek- 
ing for  or  attempting  to  seize  the  stone,  care  should  be  taken  to  avoid  such  wide 
separation  of  the  blades  as  would  bring  the  male  blade  in  frequent  contact  with 
the  vesical  neck.  The  crushing  should  invariably  be  done  only  after  rotating 
the  blades  into  the  center  of  the  bladder.  Every  particle  of  the  resulting 
debris  should  be  evacuated.  Rest  in  bed.  milk  diet,  and  sterilization  of  the 
urine  by  boric  acid  or  salol,  given  internally  both  before  and  after  the  opera- 
tion, are  valuable  adjuncts.  During  the  operation  every  antiseptic  precaution 
should  be  observed.  The  exceptional  cases  of  calculi  which  are  both  large  and 
hard  may  be  best  treated  by  suprapubic  lithotomy,  but  neither  unusual  size  nor 
a  moderate  degree  of  density  should  of  itself  alone  be  thought  positively  to  con- 
traindicate  litholapaxy. 

Perineal  lithotomy  in  chihlren  has  now  a  much  more  limited  field  than 
heretofore,  and  should  be  employed  chiefly  in  those  cases  of  stones  thought  to 
be  of  small  or  medium  size  in  which  no  lithotrite,  however  small,  can  be  intro- 
duced with  safety. 

Vesical  Calculus  in  Females. — The  rarity  of  vesical  calculus  in  the  female 
is  due  to  the  shortness  and  dilatability  of  the  urethra  and  to  the  comparative 
infrequency  of  vesical  disease  in  that  sex — conditions  which  favor  the  sponta- 
neous escape  of  small  stones  descending  from  the  kidneys,  and  which  do  not 


SURGERY  OF  THE  GENITO-rinXARV  TIIM'T.  883 

furnish  the  agglutinatincr  material  in  the  form  of  vesical  mucus  necessary  to 
the  development  of  calculi  from  urinary  sediments.  The  proportion  ot  calculi 
in  females  as  compared  with  males  is  about  as  one  to  twenty-two. 

The  causes,  symptoms,  and  methods  of  diagnosis  are  essentially  the  same. 

The  treatjnent  of  stone  in  women  is  at  the  present  time  confined  to  three 

procedures :  ,  i     i       .1  •    ^ 

1  If  the  stone  is  quite  small,  the  urethra  may  be  stretched  to  the  required 
extent  first  by  suitable  dilators,  then  bv  the  little  finger,  and  then  Ijy  the  fore- 
fin.-er.  If  this  is  done  slowlv,  there  will  be  but  little  laceration  of  the  mucous 
membrane,  and  the  incontinence  that  follows  will  be  of  short  duration,  ihe 
stone  may  be  extracted  with  the  finger  or  by  means  of  a  scoop  or  a  pair  ot 
forceps  2  If  it  be  too  large  to  extract  in  this  manner,  the  dilatation  ot  the 
urethra  should  be  carried  to  a  sufficient  extent  to  permit  of  the  introduction  of 
a  lithotrite  :  litholapaxv  should  then  be  performed  in  the  usual  manner.  Ji.  it 
the  stone  is  at  once  extVemely  large  and  exceptionally  hard,  suprapubic  lithot- 
omy should  be  employed,  but  is  very  rarely  necessary. 

*The  same  rules  are  applicable  to  cases  of  stone  m  female  children,  although, 
of  course,  the  dilatation  of  the  urethra  cannot  be  carried  to  the  same  extent. 
Incision  of  the  urethra  and  neck  of  the  bladder  should  not  be  employed  in 
any  case,  on  account  of  the  risk  of  permanent  incontinence       Vaginal  lithot- 
omy, while  it  still  has  its  advocates,  is  inferior  to  the  methods  above  described. 

CYSTITIS. 

Inflammation  of  the  bladder  may  be  acute  or  chronic. 
Acute  cystitis  mav  result  from  injury,  as  in  the  rough  use  of  sounds  ;  trom 
the  use  of  drucrs,  as  cantharides  ;  from  the  presence  of  a  foreign  body,  as  a  cal- 
culus •  from  the  extension  of  urethral  inflammation,  as  m  cases  of  stricture ; 
from  'infection  with  micro-organisms,  as  with  the  gonococcus  or  the  pyo- 
genic staphylococci  in  specific  urethritis,  or  with  the  bacillus  tuberculosis ;  or 
from  new  Growths,  as  epithelioma.  In  the  milder  degrees  of  acute  cystitis 
the  vesicaf  mucous  membrane  is  congested,  thickened,  and  swollen,  the  epi- 
thelium detached  in  places,  leaving  raw  or  abraded  surfaces.  In  the  more 
severe  forms  the  bladder  is  lined  with  tough,  tenacious  lymph ;  there  may  be 
ulceration  and  occasionally  even  sloughing.  The  submucous  connective  tis- 
sue and  sometimes  even  the  entire  thickness  of  the  bladder-wall,  are  infiltrated 
with  pus.  Occasionally  organization  of  the  exudate  covering  the  mucous  sur- 
face takes  place,  and  large  fragments,  or  even  casts,  of  the  interior  ot  the  blad- 
der are  passed  per  uvethrain  (membranous  cystitis). 

Cystitis  if  lon<?  continued  or  of  the  severer  grades,  is  very  apt  to  spread 
by  continuity  along  the  ureters,  and  to  involve  the  kidney,  producing  first  a 
pyelitis,  and'^then'^a  pyelo-nephritis,  not  infrequently  fatal. 

Symptoms.— Increased  Frequency  of  Urination.— "IXws  is  one  ot  the 
earliest  symptoms,  often  preceding  the  development  of  actual  pain  by  some 
hours  ihe  desire  to  void  urine  occurs  with  increasing  frequency  until  in 
bad  cases  it  becomes  almost  constant.  The  relief  aff-orded  by  passing  a  few 
drams  of  urine  continues  for  but  a  few  moments,  or  the  urine  may  be  passed 
in  quantities  not  exceeding  a  few  drops,  and  with  no  relief  whatever  to  the 
distressing  and  urgent  desire.  Tenesmus.-'&iv^mmg  is  extremely  severe. 
The  patient  will  lean  over  the  vessel  or  urinal,  quivering  with  the  muscular 
eifort.  Often  the  bowels  are  involuntarily  evacuated  at  the  same  time,  and 
hemorrhoids  are  not  infrequently  developed  as  a  complication.  Pa?'«.— The 
pain  may  be  referred  to  the  neck  of  the  bladder,  to  the  hypogastrium,  or  to 


884  ^l.V  AMERICAN  TEXT-BOOK  OF  SURGERY. 

the  perineum,  and  may  radiate  into  the  loins  or  down  the  thighs.  It  dimin- 
ishes as  the  acuteness  of  tlie  attack  subsides.  C/nDif/es  in  tlw  urine  take  phice 
soon  after  the  development  of  the  attack.  It  becomes  turbid,  with  a  heavy 
deposit  of  mucus,  then  scanty,  then  blood-tinged.  Pure  blood  in  lesser  or 
greater  quantities  will  often  follow  the  expulsion  of  the  last  fcAv  drops  of 
urine.  Constitutional  JJisturhance. — This  is  often  slight  in  comparison  with 
the  intensity  of  the  local  symptoms.  Occasionally  a  marked  febrile  movement 
occurs  and  persists  during  the  heiglit  of  the  attack. 

Chronic  Cystitis. — The  causes  of  chronic  inflammation  of  the  bladder 
are  all  those  which  have  been  enumerated  as  producing  acute  cystitis,  though 
the  latter  is  not  necessarily  a  precedent  condition  in  every  case  of  chronic 
cystitis.  The  latter  is  more  apt,  however,  to  result  from  a  combination 
of  mechanical  and  chemical  causes,  such  as  enlarged  prostata',  stricture,  new 
growths,  stone,  or  atony  or  paralysis  of  the  bladder  accompanied  by  retained 
or  decomposing  urine.  Obstructive  disease  alone  or  mere  loss  of  expulsive 
power  may  continue  for  a  long  time  without  causing  an  appreciable  degree  of 
inflammation.  They  produce,  however,  a  chronic  congestion  of  the  mucous 
coat  and  degenerative  changes  in  it  and  in  the  muscular  wall  of  the  bladder, 
and  if  subsequently,  by  the  use  of  a  catheter  or  other  instrument  not  per- 
fectly sterile,  microbic  infection  occurs,  the  field  is  prepared  for  an  obstinate 
and  often  incurable  inflammatory  process. 

The  changes  in  the  walls  of  the  bladder  may  result  in  atony  or  atrophy, 
with  thinning  of  the  mucous  membrane,  fatty  degeneration  of  the  muscular 
fibers  almost  to  the  point  of  disappearance,  and  great  distention  of  the 
organ,  or  may  be  followed  by  hypertrophy  of  the  muscular  coat,  the  fibers 
forming  ridges  or  fasciculi  standing  out  in  the  interior  of  the  bladder  and 
separated  by  lozenge-shaped  spaces,  the  organ  itself  being  contracted,  so  that 
its  cavity  can  contain  but  a  few  drams  of  fluid.  Sometimes  between  these 
muscular  bars  pouches- of  mucous  membrane  protrude,  forming  distinct  sacculi 
communicating  with  the  interior  of  the  bladder  by  narrow  mouths  and  re- 
maining permanenL     Occasionally  they  contain  calculi. 

Symptoms. — The  phenomena  due  to  acute  CA'stitis  are  present  in  a  modi- 
fied fonn.  Urination  is  not  so  frequent ;  tenesmus  is  much  less  or  is  absent ; 
pain  is  frequently  very  slight ;  and  the  constitutional  symptoms  are  marked  only 
when  consecutive  renal  changes  have  occurred  or  when  sapremia  has  followed 
absorption  of  the  products  of  urinary  decomposition.  The  urine  is  not  apt  to 
contain  blood,  but  becomes  loaded  with  a  thick,  tenacious  mucus  which  is  some- 
times one-half  its  bulk,  and  which  has  jriven  rise  to  the  term  catarrh  of  the 
bladder  which  is  often  used  synonymously  with  chronic  cystitis.  It  is  almost 
always  more  or  less  ammoniacal,  and  is  apt  to  be  fetid  and  to  contain  a  great 
excess  of  phosphates. 

Treatment. — Removal  of  the  causes,  when  possible,  is  of  course  indicated. 
A  cystitis  due  to  calculus  or  to  new  growths  or  to  a  retained  catheter  can  be 
but  little  influenced  by  treatment  until  the  stone  or  the  tumor  or  the  instru- 
ment is  removed. 

If  the  cystitis  be  due  to  the  administration  of  cantharides  or  tincture  of 
the  chloride  of  iron  or  other  drug,  withdrawal  of  that  article  and  the  substitu- 
tion of  an  alkaline  diuretic  will  effect  a  prompt  cure.  In  cases  of  cystitis 
following  rough  instrumentation,  but  in  which  no  infection  has  taken  place, 
rest  in  bed,  restricted  diet,  anodynes  or  opiates  to  relieve  tenesmus,  and  the 
administration  of  diluent  and  alkaline  drinks  will  usually  bring  about  a  return 
to  health. 

When  microbic  infection  has  occurred,  however,  the  case  is  apt  to  be  much 


SURGE  in'  or  nil-:  arxiro-rRixMiv  thact.  885 

more  serious  :ind  prolonged.  The  treatment  then  Avill  depend  on  the  duration 
of  the  attack.  In  the  stage  of  ncutc  intiamniation  the  plan  above  mentioned 
should  be  rigidly  followed  out.  The  diet  for  some  days  should  consist  almost 
exclusively  of  milk  :  the  patient  should  remain  in  bed  with  the  hips  elevated*, 
the  bowels  should  be  moved  by  salines  and  enemata  ;  opium  by  suppository 
should  be  used  to  control  spasm  and  tenesmus  ;  an  alkaline  mixture  may  be 
administered  with  advantage.  Ordinai'ily,  the  intensity  of  the  symptoms  will 
subside  under  this  treatment  in  a  few  days,  and  sometimes  recovery  will  then 
be  complete. 

Often,  however,  the  condition  passes  into  the  cl ironic  for  in  ^  which  is  more 
intractable  and  obstinate.  The  same  symptoms  continue  in  a  somewhat  les- 
sened degree.  The  urine  becomes  loaded  with  mucus  and  is  voided  Avitli  in- 
creased frequency,  but  with  lessened  tenesmus  as  compared  with  the  acute 
variety  of  the  disease.  The  treatment  should  consist  at  first  in  removal  of  the 
cause.  If  this  is  mechanical — that  is,  resulting  from  calculus,  urethral  strict- 
ure, prostatic  hypertrophy,  tumor,  etc. — the  treatment  of  the  cystitis  includes 
that  of  the  condition  which  originated  it.  The  treatment  of  vesical  calculus, 
of  stricture,  of  enlarged  prostate,  and  of  new  growths  of  the  bladder  will  be 
found  elsewhere. 

For  a  chronic  cystitis  which  persists  after  the  removal  of  a  calculus  or  of  a 
neoplasm,  or  after  the  dilatation  of  a  stricture,  or  the  careful  Avitlidrawal  of 
residual  urine  in  cases  of  atony  or  prostatic  hypertrophy,  a  great  variety  of 
methods  of  treatment  may  be  employed,  and  may  be  classified  under  (1)  the 
administration  of  remedies  by  the  mouth  ;  (2)  the  use  of  vesical  injections  or 
irrigations.  In  the  former  class  are  included  the  Avell-known  balsams  of 
copaiba  and  cubebs  and  the  large  class  of  terebinthinates.  with  buchu,  uva  ursi, 
triticum  repens,  etc.  Under  this  head  should  also  be  included  the  adminis- 
tration of  antiseptics,  which,  when  excreted  through  the  kidneys,  sterilize  the 
urine  and  prevent  or  retard  the  development  in  it  of  micro-organisms.  The 
most  useful  of  these  are  salol  and  boric  acid  in  five-grain  doses  three  or 
four  times  daily.  Among  the  materials  which  Avill  be  found  valuable  for  vesi- 
cal irrigation  may  be  included  solutions  of  nitrate  of  silver,  J  to  2  per  cent., 
or  stronger  according  to  the  sensitiveness  of  the  patient ;  peroxide  of  hydro- 
gen, from  25  per  cent,  to  full  strength ;  permanganate  of  potassium,  from  J  to 
3  or  4  per  cent. ;  boric  acid,  from  2  to  10  per  cent. ;  creolin,  from  1  to  5  per 
cent.  ;  corrosive  sublimate,  from  1  :  15,000  or  20,000  to  1  :  5000 ;  carbolic  acid, 
1 :  500  ;  and  many  others,  chiefly  belonging  to  the  same  class  of  antiseptics. 
It  is  useful  to  employ  the  weaker  solutions  in  large  quantities,  and  to  precede 
their  introduction  by  irrigation  of  the  bladder  with  boiled  Avater,  or,  in  the  case 
of  the  silver  and  permanganate  salts,  by  distilled  water.  In  cases  which  fail  to 
yield  to  these  methods  of  treatment,  and  in  which  frequent  urination  and  pain- 
ful tenesmus  are  prominent  symptoms  and  are  accompanied  by  gradual  failure 
of  the  general  strength,  a  perineal  cystotomy  followed  by  permanent  drainage 
will  often  be  required,  and  will  usually  give  marked  relief,  and  occasionally 
result  in  entire  cure.  It  permits  not  only  of  the  constant  drainage  which  is 
so  important  in  endeavoring  to  overcome  sepsis,  but  also  of  the  freer  use  of  the 
irriorations  above  described. 


TUMORS  OF   THE   BLADDER. 

The  benign  tumors  of  the  bladder  include  the  fibromata,  the  fibro-myxo- 
mata,  and  the  papillomata.  The  latter  are  by  far  the  most  frequent,  and 
indeed  all  vesical  growths  tend  to  assume  a  papillomatous  character,  although 


886 


^.V  AMEI^ICAX  TKXr-BOOK  OF  SUJiUERY. 


there  are  no  ].a]iill{«  in  tlie  mucous  membrane.  It  has  been  suggested  that 
this  occurrence  may  be  exphiined  by  the  embryonic  relation  of  the  bladder 
and  allantois,  the  foetal  villi   being  partially  dependent  on  the  latter. 

Fibromata  smiX  lihro-myromata  grow  from  the  submucous  coat  of  the  blad- 
der, are  either  sessile  or  pedunculated,  and  are  covered  by  unaltered  mucous 
membrane  or  by  villi. 

PapiUomata  spring  from  the  superficial  layer  of  the  mucous  membrane,  and 
constitute  red  vascular  masses,  sometimes  with  long  pedicles,  occasionally  ses- 
sile ;  their  surface  is  soft,  smooth,  and  rounded,  and  is  often  indistinguishable 
by  touch  from  the  healthy  mucous  membrane ;  they  sometimes  bleed  very 
freelv.  Occasionally  they  undergo  ulceration,  and  there  is  reason  to  believe 
that  a  growth  originally  purely  papillomatous  may  become  malignant  in  its 
later  stages. 

Malignant  Tumors  of  the  Bladder  may  be  sarcomatous,  but  the  epithelio- 
mata  are  bv  far  the  most  frequent.  They  originate  in  any  portion  of  the  blad- 
der, grow  with  great  rapidity,  and  are  soon  followed  by  ulceration  of  the  mucous 
surface,  and  often  by  involvement  of  the  entire  thickness  of  the  bladder-wall. 
Enlargement  of  the  pelvic  glands  and  secondary  deposits  in  other  viscera  are 
common. 

Symptoms  of  Tumors  of  the  Bladder. — The  chief  symptoms  are 
vesical  irritability  and  hemorrhage.  Either  may  precede  the  other.  In  papil- 
lomata  profuse  bleeding  may  be  the  very  first  indication  of  disease.  In  the 
fibromata  and  carcinomata  there  is  apt  to  be  a  period  during  which  the  symp- 
toms are  those  of  cystitis,  but  at  first  without  marked  alteration  of  the  urine. 
Later  hemorrhage  occurs,  and  still  later  the  urine  becomes  fetid  and  ammoniacal. 
Diagnosis. — The  recognition  of  new  growths  in  their  early  stages  is  often 
verv  difficult.  The  most  valuable  diagnostic  symptom  is  the  hemorrhage, 
which,  when  free  and  spontaneous  and  recurring  at  intervals,  the  urine  in  the 
mean  time  remaining  clear,  is  extremely  suggestive.  Free  hemorrhage  after 
gentle  sounding,  the  symptoms  of  cystitis  in  the  absence  of  stone  or  of  any 
infective  cause,  severe  vesical  pain  radiating  to  other  regions,  are  all  valuable 
aids  to  diagnosis. 

Certainty  can  be  reached  only  by  the  recognition  of  the  villi  of  a  papilloma, 
detached  portions  of  a  fibroma,  or  cell-nests  and  small  sloughs  from  an  epithe- 
lioma,  or  by  the  aid  of   the 
Fig.  359.  cystoscope,   which  is  here  of 

the  greatest  usefulness. 

This  instrument,  as  im- 
proved by  Leiter,  consists  of  a 
Ions  hollow  shaft  of  larcje  cal- 
iber,  with  an  obtuse  angle  a 
short  distance  from  its  extrem- 
ity. At  the  angle  is  a  pris- 
matic window,  so  arranged  that 
the  rays  of  light  entering  it  are 
reflected  along  the  shaft  to  the 
eye  of  the  surgeon,  and  near 
the  end  of  the  beak  there  is 
another  window  covering  in  a 
small  incandescent  electric  lamp  (Fig.  359).  The  tube  contains  magnifying 
lenses.  Adjustable  ends  carry  windows  on  the  concavity  or  convexity  of  the 
curve,  so  that  either  the  anterior  surface  of  the  bladder  or  the  bas-fond  and 
trigone  may  be  conveniently  observed. 


Leiter's  Cystoscdy 


liiial  section;  a,  metal  tube; 


b.openinc  for  light  iroin  the  small  electric  lamg^;  d,  loop  of 
current  from  c;  II,  enlargement   of  extremity  of  tube 

(Tillmanns). 


SURGERY  OF  THE  GENITO- URINARY  TRACT.  887 

In  using  the  instrument  it  should  be  lubricated  with  glycerin ;  the  bladder 
should  be  washed  out  and  filled  with  a  clear  li(|uid  ;  the  current  should  not  be 
turned  on  until  the  instrument  is  in  position.  If  the  inspection  has  been  at 
all  prolonged,  so  tliat  the  lamp  may  have  become  hot,  the  precaution  shouhl  be 
taken  to  turn  off  the  current  a  half-minute  to  a  minute  before  the  instrument 
is  withdrawn,  so  that  there  may  be  no  risk  of  burning  the  urethra. 

The  value  of  the  cystoscope  in  the  recognition  of  new  growths  is  unques- 
tioned, but  is  as  yet  confined  within  narrow  limits.  Such  growths  may  undoubt- 
edly be  seen  in  many  cases  by  its  help,  and  their  exact  size  and  site  outlined, 
but  often  an  almost  equally  accurate  diagnosis  of  location  can  be  made  with 
the  vesical  sound,  and  a  far  more  precise  knowledge  of  the  character  of  the 
growths  can  be  obtained  by  microscopic  examination  of  fragments  removed  by 
forceps  or  passed  spontaneously.  The  presence  of  foreign  bodies  unsuited  for 
litholapaxy  and  requiring  lithotomy  has  been  demonstrated  by  the  cystoscope. 
The  determination  of  the  side  from  which  renal  hemorrhage  is  taking  place 
can  also  be  made  in  some  instances  in  this  way. 

Extravagant  claims  have  been  made  as  to  the  usefulness  of  the  instrument, 
and  are  not  likely  to  be  fully  realized,  but  it  has  taken  an  assured  place  in  the 
armamentarium  of  genito-urinary  surgeons.  Its  congener,  the  electric  urethro- 
scope, is  of  far  less  value,  and  has  been  much  abused  by  novices  and  over- 
eager  investigators,  who  have  thus  far  added  but  little  by  its  means  to  our 
knowledge  of  urethral  conditions. 

Treatment. — The  operative  treatment  of  tumors  of  the  bladder  should 
be  by  means  of  either  a  perineal  or  a  suprapubic  incision. 

The  former  is  preferred  by  some  surgeons,  but  is  applicable  only  to  single 
small  pedunculated  tumors  situated  near  the  neck  of  the  bladder.  The  latter 
is  equally  useful  in  these  growths,  and  permits  of  the  free  exposure  and  inspec- 
tion of  all  tumors  and  of  comparatively  ready  access  to  them.  It  is  the  opera- 
tion of  preference  in  by  far  the  larger  number  of  cases. 

If  the  perineal  route  is  for  any  reason  selected,  the  bladder  is  opened  just 
as  in  the  operation  of  median  lithotomy.  (See  p.  873.)  The  finger  of  the 
surgeon  having  recognized  the  situation  and  limitations  of  the  groAvth,  a  pair 
of  forceps  is  introduced,  the  tumor  seized,  and  partly  bitten,  partly  twisted  off. 
Too  much  direct  traction  should  not  be  made,  for  fear  of  injuring  the  bladder- 
wall,  nor  should  the  manipulations  with  the  forceps  be  carried  out  while  much 
suprapubic  pressure  is  being  made,  as  a  double  fold  of  the  bladder-wall  might  be 
thus  included  with  the  growth  in  the  grasp  of  the  forceps  and  gravely  injured. 
The  risk  of  this  taking  place  is  much  increased  if  the  tumor  is  sessile. 

In  the  suprapubic  operation  the  bladder  is  opened  as  in  suprapubic  lithot- 
omy. The  following  methods  of  dealing  with  the  growth  may  be  mentioned 
(Treves) :  The  growth,  when  exposed  and  carefully  examined  by  the  finger 
and  also  by  inspection,  may  be  dealt  with  in  the  same  manner  as  like  growths 
in  more  accessible  parts  would  be  treated.  A  small  electric  lamp  is  of  con- 
siderable service.  Growths  with  slender  pedicles  may  be  pinched  or  twisted 
off.  If  the  pedicle  be  stouter,  it  may  be  grasped  and  fixed  close  to  the 
bladder-wall  by  means  of  a  pair  of  pressure  forceps  bent  at  a  suitable  angle. 
The  neck  is  then  grasped  by  a  straight  pair  of  pressure  forceps  at  a  little 
distance  from  the  first  pair,  and  is  twisted  off  by  rotating  the  instrument  last 
introduced.  In  other  instances  an  ecraseur,  carrying  a  cord  or  a  fine  wire, 
may  be  employed.  If  the  growth  have  a  broader  base,  it  may,  if  it  be  well 
defined,  be  transfixed  close  to  the  bladder-wall  by  means  of  a  rectangular 
needle  in  a  handle,  and  be  then  ligatured  with  silk  in  two  segments.  Some 
of  the  softer  and  more  diffused  growths  can  be  scraped  away  with  the  finger- 


888 


AX  AMERICAN  TEXT- HOOK  OF  SURGERY. 


nail  or  with  a  curetto  or  a  sliarp  sj)ooii.      Others,  of  ^'rcater  substance,  can  b 
removed  piecemeal  ^vith  Tiioiui)soiis  forceps  (Fig.  360)  and  the  resulting  stumi 


ting  stump 


Fiii.  aoo. 


Thoiiii).>on's  Vesical  Forceps  for  removing  Growths  in  Bladder. 

then  well  scraped  with  Volkniann's  spoon.     This  is  the  method  which  would 
be  applied  to  epithelioraatous  growths. 

After  the  removal  of  extensive  growths  the  bladder  mav  l)e  well  rubbed 
out  with  a  Turkey  sponge,  which  will  remove  all  detached  or  partly-detached 
fragments.  Bleeding  may  be  checked  by  the  pressure  of  a  firm  piece  of 
sponge  or  by  injections  of  either  cold  or  hot  boric-acid  solution.  The  cases 
must  be  few  in  which  an  appeal  to  the  actual  cautery  is  necessary.  The  pres- 
sure of  the  rectal  bag  causes  venous  engorgement,  and  the  sooner  that  appliance 
can  be  dispensed  with  the  better.  Two  fingers  introduced  into  the  rectum  by 
an  assistant  will  often  bring  the  growth  more  readily  into  view  than  will  the 
rectal  bag.  The  after-treatment  of  the  case  is  the  same  as  is  proper  after 
suprapubic  lithotomy. 

PAKT  III.— DISEASES  AND  INJURIES  OF  THE  URETHRA. 
The  normal  male  urethra  is  about  nine  inches  in  length,  and  is  divided 
into  three  portions.  The  spongy  or  penile  portion  is  about  seven  inches  long, 
is  contained  within  the  erectile  tissue  of  the  corpus  spongiosum,  and  extends 
from  the  meatus  to  the  posterior  extremity  of  the  bulb.  "When  the  penis  is 
flaccid,  it  constitutes  a  curve  the  concavity  of  which  is  downward,  but  when 
the  organ  is  raised  or  is  erect  the  curve  is  obliterated  and  becomes  a  straight 
line.  The  memhranons  urethra  is  found  between  the  two  layers  of  the  tri- 
angular ligament,  about  an  inch  below  the  under  surface  of  the  symphysis 
pubis.     It  is  a  half  to  three-quarters  of  an  inch  in  length,  and  is  surrounded 


SURGERY  OF  THE   GEXITO-rRTXARY  TRACT. 


889 


by  the  compressor  urethrjB  muscle,  which,  taking  its  origin  on  each  side  from 
the  unner  part  of  the  descending  pubic  ramus,  serves  to  support  and,  wlien  it 
contracts,  to  compress  this  portion  of  the  urethra.  The  prontatic  urethra  runs 
through  the  prostate  ghmd  at  the  junction  of  its  upper  an<l  its  middle  third 
It  is  from  one  and  a  half  to  one  and  three-quarters  inches  in  length  (tig.  obi). 


Fig.  3(51. 


naS  ifthe  comm^^^^^  duct ;  16,  prostatic  plexus  receiving  17,  dorsal  vein  of  penis ;  19,  bulb , 

20,  Cowper's  gland  (Owen). 

The  urethra  is  narrow  at  the  meatus,  enlarges  within  the  glans  at  the  fossa 
navicularis,  has  a  variable  caliber,  with  normal  points  of  constriction  in  the 
spongy  portion,  enlarges  again  in  the  region  of  the  bulb,  is  narrow  at  the 
bulbS-membranous  junction  and  between  the  layers  of  the  ligament,  and  again 
widens  as  it  penetrates  the  prostate,  so  that  this  portion  of  the  urethra  has 
normally  the  largest  caliber  and  is  the  most  dilatable.  •    ■        d 

The^fixed  curve  of  the  urethra— z.  e.  the  curve  assumed  by  the  majority  ot 
adult  urethrre— in  a  condition  of  rest  is  measured  from  just  in  front  of  the 
triangular  ligament  to  the  neck  of  the  bladder.  It  is  that  of  a  circle  three 
and  a  quarter  inches  in  diameter,  and  is  represented  by  an  arc  of  such  a  cn-cle 
subtended  by  a  chord  two  and  three-quarter  inches  m  length  (l^ig.  db2).  ihis 
curve  may  be  lessened  somewhat  by  depressing  the  urethra  by  means  ot  a 
fincrer  at  each  side  of  the  root  of  the  penis:  it  is  always  lengthened  in  cases 
of  hypertrophy  of  the  prostate  or  when  the  bladder  is  greatly  distended.  It 
may  be  temporarily  obliterated,  as  when  a  perfectly  straight  instrument  is 
introduced  into  the  bladder.  ^         ^^  .\ 

Oatheterism.— The  passage  of  a  properly-made  steel  sound  or  silver  cathe- 
ter, the  curve  of  which  corresponds,  as  it  should  do,  with  that  gn-en  above,  is  one 
of  the  minor  operations  of  surgery  most  frequently  required.  For  its  pertorm- 
ance  the  patient  should,  whenever  possible,  be  placed  in  a  recumbent  position, 
the  head  and  shoulders  slightly  elevated,  the  knees  a  little  separated,  the  mus- 


890 


AX  A  ^^ ERIC  AX  TEXT-BOOK  OF  SURGERY. 


Fig.  362. 


ck'S  relaxed.  The  surgeon,  if  riglit-lianded.  stands  at  the  left  side  of  the 
patient.  The  sound  or  catheter,  tlioroughly  sterilized,  well  warmed,  and  lubri- 
cated with  some  aseptic  oil  or  oint- 
ment, is  taken  in  the  right  hand, 
the  penis  between  the  tliunib  and 
fingers  of  the  left  hand. 

The  organ  is  gently  put  on  the 
stretch,  care  being  taken  to  keep  the 
dorsum  facing  the  abdominal  wall, 
and  to  avoid  any  twists  in  the  ure- 
thra which  would  constitute  obsta- 
cles to  the  instrument,  the  point  of 
which  is  then  engaged  within  the 
meatus.  At  this  time  the  shaft  of 
the  sound  or  catheter  should  be  par- 
allel to  the  line  of  the  groin.  This 
direction  is  important  chiefly  in 
catheterism  of  persons  with  large 
protuberant  bellies,  in  whom,  if  it  is 
not  followed,  the  point  of  the  instru- 
ment will  be  made  to  catch  in  the 
upper  wall  of  the  triangular  liga- 
ment, owing  to  the  elevation  of  the 
handle  necessitated  by  the  protrusion 


yd 


)l';a 


Instrument  with  faulty  curve.  O  d  fB6niqu6).    Correctly-curved  conical  instrument,  0  b.    Leiifrth  of  natu- 
ral  curve  of  urethra,/  0  k.    Length  of  cord  of  curve  of  sound,  h  0,  2,^5  inches  (Van  Buren  aixi  Ktyes). 

of  the  abdomen.     The  handle  should  in  any  event  be  kept  low  until  the  tip 
of  the  instrument  is  about  to  enter  the  membranous  urethra.     The  penis  is 

Fig.  363. 


Faulty  Curves  (Van  Bureu  and  Kcycs;. 

drawn  up  with  the  left  hand  while  the  instrument  is  gradually  pushed  onward, 
the  handle  being  finally  swept  around  to  the  median  line,  the  shaft  being  kept 
parallel  to  the  anterior  plane  of  the  body  and  nearly  touching  the  integument. 
The  instrument  is  now  pressed  downward  toward  the  feet,  while  the  left  hand 
still  steadies  the  penis  and  makes  slight  upward  traction.  After  four  or  five 
inches  of  the  shaft  have  disappeared  witliin  the  urethra,  it  will  be  found  that  the 
downward  motion  of  the  instrument  is  arrested  (Fig.  ;3G">).  The  fingers  of  the 
left  hand  can  then  be  shifted  to  the  perineum,  where  the  curve  of  the  instrument 


SUBGERY  OF  THE  GENirO-URINARY  TRACT. 


891 


Fici.  3G4, 


can  bo  felt  ])(.'liiii(I  tlie  scrotmii.  The  liandle  may  then,  and  not  until  then,  be 
litt('(l  from  its  close  relation  with  the  anterior 
alxlominal  "wall  and  swept  gently  over  in  the 
median  line,  describing  the  arc  of  a  circle, 
while  the  left  hand  acts  as  a  fulcrum  over 
which  the  curve  of  the  instrument  glides  (Fig. 
o()G).  It  often  facilitates  the  final  step  in 
catheterism  if  after  the  shaft  has  reached  and 
passed  the  perpendicular  the  handle  is  taken  in 
the  left  hand,  and  the  index  and  middle  finrjers 
of  the  right  hand  are  placed  one  on  each  side 
of  the  root  of  the  penis,  making  doVnward  pressure,  while  the  left  hand,  depress- 
ing the  handle,  carries  the  point  of  the  instrument  through  the  membranous  and 


^ 


Proper  Curve    (\u.\i  Buren  and  Keyes). 


Fig.  365. 


Passing  a  Catheter  (to  the  membranous  urethra):   A,  rectum:  B.  bladder;  C,  pubes:  D,  intestines: 
E,  scrotum :  F,  bulb ;  G,  prostate ;  H,  neck  of  bladder ;  P,  tip  of  catheter  (Albert). 


prostatic  urethra  into  the  bladder.  Its  entrance  into  that  organ  will  be  recog- 
nized by  the  free  motion  that  can  be  given  the  tip  of  the  instrument  when  the 
handle  is  rotated,  and  by  the  latter  remaining  exactly  in  the  median  line  and 
pointing  away  from  the  pubes  when  the  hold  upon  it  is  relaxed.  The  whole 
manoeuver  should  be  done  with  gentleness ;  no  force  whatever  is  necessary. 

If  there  is  spasm  of  the  circular  fibers  of  the  urethra  at  any  point,  or,  as 
is  often  the  case,  of  the  compressor  urethrae  at  the  bulbo-membranous  junction, 
a  little  delay  will  be  followed  by  relaxation.  At  this  same  region,  where  the 
larore  and  movable  bulbous  urethra  contracts  as  it  passes  through  the  ligament, 


892 


^.V  AMERICAN  TEXT- BOOK  OF  SURGERY. 


the  onward  pressure  of  a  bougie  or  catheter  is  more  often  arrested  on  account 
of  unskilfulness  on  the  part  of  the  operator  than  at  any  other  point.     If 


Fig.  366. 


Passing  a  Catheter  into  the  bladder  (Albert).    (For  references  see  Fig.  365.) 

the  handle  be  lifted  too  soon  from  the  proximity  to  the  abdominal  wall,  the  tip 
of  the  instrument  catches  in  the  subpubic  ligament  above  the  urethral  orifice ; 
if  the  handle  is  not  raised  at  the  proper  time  or  if  the  fingers  in  the  perineum 
do  not  give  the  curve  of  the  instrument  the  gentle  upward  pressure  that  it 
needs,  the  tip  buries  itself  in  the  loose  and  movable  floor  of  the  urethra  below 
the  orifice.  In  either  case  the  curve  protrudes  unnaturally  in  the  perineum. 
The  withdrawal  of  the  instrument  for  an  inch  or  two  and  its  gentle  reintro- 
duction,  raising  or  lowering  its  tip  as  may  be  required,  will  usually  suffice  to 
overcome  this  obstacle. 

If  the  catheter  is  a  small  one  and  is  used  roughly  and  unskilfully,  it  may 
be  made  to  penetrate  the  wall  of  the  urethra  instead  of  following  the  canal 
itself  Such  wounds  leading  into  the  peri-urethral  or  submucous  tissues  are 
known  as  false  passar/es.  Tliey  are  most  apt  to  occur  in  the  bulbous  and  in 
the  prostatic  regions,  for  obvious  anatomical  reasons.  AVhen  recent  they  are 
attended  by  profuse  hemorrhage,  are  often  followed  by  chill  and  fever,  and, 
especially  if  the  patient's  kidneys  are  already  diseased,  may  result  fatally. 

The  introduction  and  retention  of  a  catheter,  frerjuent  irrigation  of  bladder 
and  urethra  with  antiseptic  solutions,  and  the  administration  of  salol,  boric 
acid,  and  quinine  are  the  essentials  of  treatment.  If  suppuration  follows  and 
chill  and  fever  are  recurrent  or  persistent,  it  may  be  necessary  to  drain  through 
the  perineum. 

Old  false  passages  are  often  sources  of  difficulty  during  catheterism.  This 
may  sometimes  be  overcome  by  inserting  into  the  abnormal  channel  one  or 
several  filiform  bougies,  after  which  it  often  becomes  easier  to  pass  one  into 
the  bladder. 

In  cases  of  enlarged  prostate  a  catheter  with  a  much  longer  shaft  and 
larger  curve  will  be  required,  or  a  Mercier  catheter  will  be  found  useful. 
In  stricture  a  large  variety  of  sizes  and  shapes  may  be  employed.     If  the 


SURGERY  OF   THE    GEXITO-URINARY   TRACT.  893 

contraction  is  small  an<l  tortuous,  the  most  useful  instruments  are  the  whale- 
bone filiform  bougies,  which  may  be  used  straight,  or,  better,  with  a  slight 

Fig.  007. 


Filiform  Whalebone  Bougies. 


angle  given  them  near  the  tip  (Fig.  -307),  as  the  orifice  of  a  stricture  is  usually 
eccentric,  i.  e.  not  in  the  middle  or  center  of  the  obstruction.     It  happens  very 


Fig.  3(38. 


Gouley's  Tunnelled  Catheter. 


rarely  that  one  of  these  will  not  pass.  The  tunnelled  catheter  (Fig.  368)  and 
the  ordinary  steel  sound  are  indispensable  instruments  in  the  treatment  of 
these  cases.  The  indications  for  their  employment  will  be  found  in  the  sec- 
tion on  Strictures. 

Urethral  Fever,  Catheter  Fever,  Urinary  Fever,  Acute  and  Chronic. — 
Following  the  introduction  of  an  instrument,  even  when  it  has  been  done  with 
skill  and  care,  the  patient  may,  after  an  interval  varying  from  a  few  moments 
to  several  hours,  have  a  chill,  followed  by  a  rise  of  temperature.  In  many 
cases  this  is  not  repeated.  Warmth  to  the  surface,  a  full  dose  of  quinine,  and 
the  immediate  administration  of  a  urinary  antiseptic  are  usually  the  only  treat- 
ment required.  The  patho^nesis  is  not  certainly  determined.  In  this  form — 
acute  urinary  fever — it  may  be  that  a  nervous  element  enters  to  a  considerable 
extent  into  the  causation  of  the  chill ;  but  in  the  recurring  form — chronic 
urinary  fever — we  have  a  true  toxemia,  always  dependent  on  bacterial  infec- 
tion, and  often  to  be  avoided  by  thorough  instrumental  asepsis  and  proper 
preparation  of  the  patient,  When  it  does  occur,  the  same  line  of  treat- 
ment as  for  any  other  form  of  infection  of  the  urinary  tract  is  appro- 
priate. The  more  severe  forms  of  urinary  fever  are,  however,  so  apt  to 
terminate  fatally  that  every  possible  prophylactic  measure  should  be  em- 
ployed to  prevent  its  occurrence. 


INJURIES  OF  THE  UEETHEA. 
Ruptures  of  the  pendulous  portion  of  the  urethra  are  rare,  and  are  not 
apt  to  be  extensive,  nor,  although  troublesome  in  regard  to  treatment  and 
cure,  are  they  usually  dangerous.  In  most  cases  the  rupture  occurs  during 
sexual  intercourse,  and  has  been  accompanied  by  immediate  pain  and  swelling, 
followed  by  ecchymotic  discoloration  of  the  entire  pendulous  portion  of  the 
penis  and  by  more  or  less  severe  hemorrhage  from  the  meatus.      They  usually 


894  ^l^y  A^fKRICAX    TEXT-JiOOK    OF  SURClKliY. 

do  well  iiiuler  the  use  of  evaporatiiif^  lotions  and  rest,  followed  by  gentle 
catheterization  after  the  blood  has  disappeared  and  the  swelling  subsided. 
Ruptures  affecting  the  deeper  portions  of  the  urethra  are,  however,  much 
more  serious.  Excluding  those  which  result  from  instrumental  violence — 
that  is,  false  passages — and  those  which  result  from  the  giving  way  of  the 
softened  and  distended  urethra  behind  a  stricture,  which  are  described  else- 
where, they  are  caused  almost  invariably  by  some  form  of  traumatism  applied 
to  the  urethra,  most  of  the  recorded  examples  having  been  the  result  of  falls 
astride  of  hard  or  resistant  bodies.  The  mechanism  of  rupture  of  the  urethra 
has  been  variously  explained.  Franc,  Velpeau,  and  Poncet  have  attributed 
the  urethral  laceration  to  the  crushing  of  the  membranous  portion  of  the 
urethra  between  the  offending  body  and  the  lower  border  of  the  pubic  arch. 
If  the  accident  occurred  with  the  patient  in  a  leaning  position,  the  body 
directed  forward,  they  believe  that  the  posterior  part  of  the  spongy  urethra 
could  be  crushed  against  the  pubes,  and  think  that  when  the  force  which  pro- 
duces the  injury  acts  in  the  lateral  direction  the  urethra  is  more  probably 
pressed  against  the  upper  portion  of  the  descending  pubic  ramus.  Oilier 
refers  lacerations  of  the  membranous  urethra  to  the  pressure  of  the  canal 
against  the  sharp  edges  of  the  subpubic  ligament,  Avhich  in  his  experiments 
seemed  to  have  divided  the  upper  wall  of  the  urethra.  Terillon  believes  that 
when  the  body  which  is  fallen  upon  is  narrow  the  urethra  is  crushed  against 
the  ramus  of  the  pubes,  and  thinks  the  injury  is  likely  to  be  found  about  the 
region  of  the  bulb ;  and  when  the  fall  is  upon  a  broader  substance  the  urethra 
is  crushed  against  the  anterior  surface  or  inferior  edge  of  the  pubes,  and  the 
lesion  is  found  more  anteriorly.  Guyon  says  that  in  this  accident,  whether 
the  cause  is  a  fall  or  a  blow,  the  mechanism  is  the  same :  the  urethra  and  the 
soft  parts  which  immediately  surround  it  are  pressed  and  crushed  against  the 
resisting  pubic  symphysis,  whilst  the  superficial  tissues,  more  supple  and  more 
elastic,  escape  or  are  scarcely  involved.  He  believes,  as  does  Terillon,  that 
such  ruptures  are  frequently  only  partial,  and  that  they  are  commonly  situated 
in  the  spongy  portion  of  the  urethra,  an  inch  or  less  in  front  of  the  anterior 
layer  of  the  triangular  ligament ;  and  in  this  opinion  he  is  supported  by  Iver- 
sen,  who  has  recently  analyzed  twenty-nine  cases  of  this  accident.  Duplay 
thinks  that  in  a  certain  proportion  of  cases  the  urethra  is  ru)iture<l  by  a  tem- 
porary dislocation  of  the  symphysis  pubis,  the  soft  bones  springing  back  into 
their  proper  relation  after  the  crushing  force  is  removed,  and  leaving  no  trace 
of  the  accident  except  the  urethral  lesion.  He  thinks  that  this  (''  rupture  by 
traction  ")  may  also  occur  in  case  of  fracture  of  the  pelvis  with  a  displace- 
ment of  a  portion  of  the  pubic  arch  ;  and  it  is  of  course  evident  that  the 
urethral  Avail  could  be  wounded  directly  by  a  fragment  of  bone  after  such  a 
fracture. 

In  attempting  to  diagnosticate  a  rupture  of  the  urethra  we  must  depend 
chiefly  upon — 1,  the  history  of  the  accident;  2,  the  phenomena  connected  with 
urination,  which  is  usually  difficult  or  impossible ;  3,  the  appearance  of  blood 
either  at  the  meatus  or  beneath  the  skin  or  in  both  situations  ;  4,  the  develop- 
ment of  a  swelling  due  to  extra vasated  urine.  As  in  the  majority  of  cases  all 
these  symptoms  are  present,  the  diagnosis  in  general  terms  of  a  rupture  of  the 
urethra  can  hardly  be  said  to  be  difficult,  but  in  exceptional  cases,  where  one 
or  more  are  absent,  it  may  be  a  matter  of  great  uncertainty.  So,  too,  the 
recognition  of  the  precise  seat  of  the  rupture  may  be  comparatively  easy  if 
the  case  is  an  uncomplicated  one,  or  under  some  circumstances  may  be  almost 
impossible.  The  anatomical  peculiarities  of  the  part  explain  the  usual  course 
of  urinary  extravasation.     (See  Stricture  of  the  Urethra.) 


SURGERY   OF    THE    GENITO-URINARY   TRACT.  895 

Treatment. — The  important  question  of  treatment  in  these  cases  may  be 
sinipliiifd  by  adopting  a  cUissification  simihir  to  that  employed  by  Guyon  and 
Duphiy,  Avliich  is  based  upon  symptoms  rather  than  u|)on  the  anatomical  seat 
of  the  injury.  All  cases  may  be  divided  into  three  classes — mild,  moderate, 
and  grave. 

In  mild  cases — i.  e.  in  those  where  after  such  an  injury  there  is  an  appear- 
ance of  blood  at  the  meatus,  with  difficult  urination  or  Avith  retention,  but  -with 
no  evidence  of  extravasation  and  no  general  alarming  symptoms,  and  in  which 
catheterization  is  easy — the  surgeon  may  be  content  with  regular  evacuation 
of  the  bladder  by  means  of  a  soft  instrument  well  greased  with  carbolized  oil, 
and  with  prescribing  absolute  rest,  the  patient  being  carefully  watched  for  the 
onset  of  fever  or  the  appearance  of  local  swelling. 

In  cases  of  a  more  severe  type,  in  which,  in  addition  to  urethral  hemorrhage 
and  retention  of  urine,  there  are  evidences  of  extravasation,  and  in  which  cathe- 
terism,  though  difficult,  is  possible,  it  is  wisest  to  leave  a  full-sized  catheter  in 
the  bladder,  and  at  the  same  time  freely  to  lay  open  the  perineum  and  scrotal 
tissues  or  any  which  have  been  involved  in  the  extravasation. 

In  cases  of  greater  gravity,  in  which  catheterism  is  impossible,  careful  peri- 
neal section  should  at  once  be  made,  the  rent  in  the  urethra  sought  for,  and  a 
catheter  passed  through  it  into  the  bladder.  This  is  sometimes  one  of  the 
most  difficult  procedures  in  operative  surgery,  particularly  if  it  has  been  delayed 
until  inflammatory  change  or  local  gangrene  has  altered  the  appearance  and 
relations  of  the  parts  involved.  If  persevering  and  careful  search  fails  to 
reveal  the  proximal  end  of  the  torn  urethra,  suprapubic  cystotomy,  for  the 
purpose  of  retrograde  catheterization,  is  justifiable  for  that  purpose,  the  distal 
end  of  the  torn  urethra  being  almost  always  easily  discoverable.  Except  as 
to  the  latter  point,  surgeons,  as  a  rule,  are  agreed  upon  the  above-described 
methods  of  treatment,  and  a  number  of  them  endorse  the  propriety  of  the 
suprapubic  operation  in  such  cases. 

In  cases  of  complete  rupture  the  following  indications  exist  after  the  intro- 
duction of  the  catheter :  1st,  to  open  a  large  passage  for  the  accumulating 
fluids;  2d,  to  keep  up  a  free  flow  of  urine;  3d,  to  encourage  rapid  union  of 
the  two  ends  of  the  urethra  and  the  walls  of  the  cavity  formed  by  the  extrav- 
asation into  the  perineum  ;  4th,  to  prevent  the  formation  of  a  cicatricial  stric- 
ture of  the  urethra.  Suprapubic  aspiration  (Lefort,  Molliere)  is  palliative  and 
meets  none  of  the  indications.  External  urethrotomy  (Guyon  and  others) 
does  not  provide  for  prompt  union  of  the  canal  and  does  not  prevent  consecu- 
tive contraction.  Antiseptic  measures,  carried  out  by  allowing  an  elastic 
catheter  to  remain  in  the  perineal  wound,  which  is  tamponed,  or  by  suturing 
its  borders,  produce  more  rapid  union,  but  are  likewise  followed  by  urethral 
coarctation.  The  stitching  of  the  proximal  end  of  the  urethra  into  the  wound, 
and  catheterizing  only  after  healthy  granulations  have  formed,  while  reducing 
risks  to  the  life  of  the  patient,  is  followed  by  the  same  results. 

Suturing  of  the  divided  ends  of  the  urethra  has  now  been  done  in  a  suf- 
ficient number  of  cases  (Erasme,  Guyon,  White,  Keyes,  Barling,  and  others) 
to  justify  its  employment  whenever  they  can  be  brought  together.  Catgut  is 
the  preferable  suture-material.     The  mucous  membrane  should  not  be  included. 

GOXOERHEA  ( URETHRITIS j. 

The  word  gonorrhea,  although  etymologically  inaccurate  as  a  designation 
of  the  disease  in  question,  is  still  so  universally  employed  and  so  well  under- 
stood that  it  has  been  retained  here  for  the  sake  of  convenience. 


896  AX   A.}f/JRICAN    TEXT-BOO  A'    OF  SURGERY. 

Authorities  are  iioav  practically  a  unit  in  the  belief  that  the  gonococcus 
is  the  cause  of  gonorrhea.  At  the  same  time  a  urethritis  niav  be  set 
up  by  other  causes — bacterial,  chemical,  mechanical,  or  constitutional.  The 
term  "urethritis"  ((ualified  by  the  a])propriatc  adjective,  according  to  the 
cause,  is  the  proper  one  to  designate  these  cases.  Clinically,  the  two 
forms  may  be  indistinguishable ;  but  the  microscope  should  make  the  sepa- 
ration possible.  The  distinction  is  unimportant  therapeutically,  but  may 
assume  great  importance  from  the  medico-legal  standpoint.^  AVe  may 
assume,  however,  that  in  the  majority  of  cases  of  acute  urethritis  gono- 
cocci,  the  microbes  of  suppuration,  and  other  bacteria  -will  be  found  inter- 
mingled. 

Inflammation  of  the  male  urethra  may  be  thus  either  simple,  in  which 
infection  with  only  pyogenic  microbes  has  taken  place,  or  specific,  in  which 
gonococci  are  also  present. 

Simple  urethritis  may  be  due  to  a  great  variety  of  causes.  Authentic 
cases  are  recorded  of  well-marked  urethritis  following  accidental  or  experi- 
mental exposure  to  leucorrheal  discharges ;  to  the  pus  from  a  healthy  abscess 
or  from  a  purulent  bronchial  catarrh ;  to  the  secretion  from  an  endocervicitis 
or  endometritis ;  to  the  discharge  resulting  from  ulceration  or  malignant  dis- 
ease of  the  uterus ;  to  the  menstrual  fluid  or  acrid  vaginal  discharges  ;  to 
powerful  injections ;  to  the  passage  of  gravel ;  to  catheterism  ;  and  to  many 
other  undoubtedly  non-specific  causes.  The  condition  thus  evoked  is  often 
indistinguishable  clinically  from  that  following  sexual  intercourse  with  a  person 
already  having  a  similar  disease,  many  severe  and  complicated  cases  of  gonor- 
rhea being  derived  from  one  or  the  other  of  these  sources.  As  a  rule,  however, 
it  is  somewhat  less  severe  and  less  protracted  than  the  specific  variety,  due  to 
infection  with  the  gonococci,  though  great  caution  should  be  observed  in  draw- 
ing any  inference  as  to  causation  from  the  character  of  a  particular  attack,  as 
the  variations  observed  in  the  different  tirades  of  urethritis  are  no  greater  than 
those  which  prevail  among  inflammations  of  other  mucous  passages,  and  which 
are  due  to  individual  idiosyncrasy  or  to  differences  in  the  power  of  the  original 
irritant. 

The  facts  that  urethritis  of  either  variety  does  not  protect  from  subsequent 
attacks,  that  its  pathology  is  that  of  any  catarrhal  inflammation,  and  that 
it  may  be  reawakened  or  re|)roduced  by  local  irritation,  by  indiscretion  in 
diet,  etc.,  afforded  strong  ground  for  the  assertion  that  it  is  not  a  specific 
disease. 

Late  bacteriological  discoveries  have,  however,  as  above  stated,  outweighed 
these  arguments,  though  for  convenience  we  may  still  differentiate  the  varieties 
of  urethritis  according  to  their  clinical  course,  dividing  them  into  (1)  typical 
or  acute  inflammatory  gonorrhea ;  (2)  subacute  or  catarrhal  gonorrhea ;  (3) 
irritative  or  abortive  gonorrhea. 

We  may  begin  with  a  description  of  acute  inflammatory  gonorrhea, 
"which  is  the  variety  most  frecjuently  encountered,  particularly  in  those  persons 
who  are  for  the  first  time  affected. 

The  interval  of  incubation,  or  the  time  which  elapses  between  exposure 
and  the  development  of  urethral  symptoms,  is  a  variable  one,  extending  from 
a  few  hours  to  twelve  or  fourteen  days.  In  the  great  majority  of  cases,  how- 
ever, the  disease  appears  during  the  fii'St  week.  The  patient  notices  a  drop  of 
milk-and-watery-like  fluid  at  the  meatus,  which  is  slightly  red  and  puffed  or 
everted ;  a  tickling  sensation  is  often  felt  in  this  locality,  and  the  next  act  of 
urination  is  attended  with  a  feeling  of  warmth  at  the  end  of  the  canal  or  Avith 
actual  scalding.     After  this   the  symptoms  increase  rapidly  in  number  and 


SURGERY   OF   THE    GENITO- URINARY  TRACT.  897 

severity,  so  that  within  forty-eight  hours,  or  even  sooner,  the  disease  may  be 
described  as  having  passed  into  its  first  or  "  increasing"  stage,  the  cha- 
racteristic phenomena  of  ^v•hich,  with  their  respective  causes,  are  as  follows : 

Changes  in  the  Meatus. — There  are  redness,  eversion,  and  often  erosion 
of  the  lips  of  the  meatus ;  sometimes,  but  rarely,  so  much  swelling  as  to 
constitute  a  distinct  obstacle  to  the  passage  of  urine,  w^hich  escapes  only 
by  drops. 

Ardor  Urince. — Scalding  at  each  act  of  urination,  or  ardor  urinae,  is  the 
symptom  which  gives  the  disease  in  French  its  popular  name  of  "  chaude- 
pisse."  This  is  due  partly  to  the  distention  of  the  inflamed  and  swollen 
mucous  folds  of  the  urethra  during  the  passage  of  the  stream,  but  chiefly  to 
the  contact  of  the  salts  of  the  urine  with  the  inflamed  surface. 

Chordee. — Painful  erection,  or  chordee,  is  present  to  a  greater  or  less  extent 
in  all  such  cases.  It  may  occur  at  any  time  during  the  twenty-four  hours,  but 
is  most  frequent  after  the  patient  has  become  warm  in  bed.  He  is  awakened 
or  kept  awake  by  an  intractable,  persistent  priapism,  which  is  associated  with 
pain  felt  along  the  under  surface  or  often  along  the  sides  of  the  penis.  In  well- 
marked  cases  the  organ  is  bent  or  curved,  usually  in  a  downward  direction, 
more  rarely  upAvard  or  .laterally.  The  corpus  spongiosum,  situated  beneath 
and  between  the  corpora  cavernosa  and  surrounding  the  urethra,  is  more 
directly  involved  in  the  inflammatory  process  than  the  other  portions  of  the 
penis.  The  urethritis  extends  by  contiguity  to  the  submucous  connective  tis- 
sue, and  thence  continuously  to  the  trabecule  of  the  erectile  tissue  of  the 
spongy  body.  The  lympL  which  is  exuded  in  these  localities  blocks  or  fills 
up  the  intertrabecular  spaces  or  meshes  containing  the  intricate  venous  plexus 
which  by  its  engorgement  and  distention  furnishes  the  essential  mechanical 
element  of  normal  erection.  When  the  organ  becomes  erect,  the  ccfi'pora  cav- 
ernosa expand  normally  and  fully,  but  the  blood  is  unable  to  find  its  way  into 
the  partially  obliterated  erectile  tissue  of  the  corpus  spongiosum,  which  remains 
rigid  and  inflexible.  The  pain  along  the  sides  is  produced  by  the  pressure  on 
the  nerves  caused  by  the  unnatural  position,  and  that  along  the  under  surface 
by  the  attempted  distention  of  the  spongy  body. 

Frequent  Urination  and  Vesical  Tenesmus  are  other  symptoms  which 
occur  about  this  time  in  many  cases.  They  generally  indicate  an  extension 
of  the  inflammation  to  the  deep  urethra,  and  are  the  most  obvious  diagnostic 
symptoms  between  anterior  and  posterior  urethritis,  the  latter  term  signify- 
ing that  the  infective  inflammation  has  spread  to  the  region  behind  the  com- 
pressor urethrse  muscle.  The  same  symptoms  may  exceptionally  be  due  to 
reflex  influence  from  a  disturbance  as  yet  localized  at  or  near  the  meatus.  In 
either  event  the  irritability  of  the  neck  of  the  bladder  is  shown  by  the  in- 
ability of  that  organ  to  retain  more  than  a  very  small  quantity  of  urine,  the 
urgency  of  the  calls  to  evacuate  it,  the  difficulty  in  starting  the  stream,  and 
the  bearing-down,  expulsive  efforts  Avhich  accompany  or  follow  the  dribbling 
of  the  last  few  drops. 

The  discharge  during  this  period  has  been  growing  more  and  more  pro- 
fuse. At  first  thin  and  of  a  bluish-white  hue,  like  city  milk,  it  has  become 
white,  then  yellow,  and  then   greenish  or  streaked  with  blood. 

There  are,  then,  certain  conditions — ardor  urinte,  profuse  purulent  discharge, 
chordee,  and  frequent  urination — which  characterize  the  first  or  increasing  stage 
of  inflammatory  gonorrhea. 

The  Complications  of  tFie  First  Stage. — Balanitis. — When  the 
inflammation,  instead  of  remaining  within  the  urethra  or  involving  only  the 
lips  of  the  meatus,  extends  over  the  surface  of  the  glans  penis,  we  have  the 

57 


898 


AX  AMERICAN    TEXT- BOOK    OF  SURGERY. 


condition  known  as  balanitis.  This  is  usually  caused  ))y  a  neglect  of  cleanli- 
ness, but  it  occasionally  occurs  from  extension  of  intlanunatory  action  by  con- 
tinuity and  in  spite  of  the  greatest  care.  Its  symptoms  are  those  of  superficial 
inflammation — viz.  heat,  redness,  burning  or  itching,  and  finally  exfoliation  of 
epithelium,  leaving  an  eroded  or  sometiuies  a  superficially  ulcerated  surface. 
Not  infre(iuently  little  crops  of  herpetic  vesicles  aj)pear,  and  may  remain 
discrete  until  tiiey  desiccate,  or  may  pustulate,  coalesce,  and  leave  an  ulcer 
which  is  sometimes  mistaken  for  a  chancre  or  chancroid. 

The  form  of  the  initial  lesion  of  syphilis  known  as  the  chancrous  erosion 
may  be  mistaken  for  a  superficial  balanitis.  The  period  of  incubation,  the 
absence  of  urethral  discharge,  the  abrupt  limitation  of  the  erosion,  the  presence 
at  its  base  of  "parchment"  induration,  the  enlargement  of  the  inguinal  lym- 
phatics, and  the  lack  of  an  infiaminatory  element  are  symptoms  of  the  former 
condition  which  should  render  it  easily  distinguishal)le  from  a  solution  of  con- 
tinuity due  to  balanitis. 

Balano-postJdtis. — An  extension  of  the  inflammation  from  the  surface  of 
the  glans  to  the  inner  or  mucous  layer  of  the  prepuce  gives  rise  to  what  is 
known  as  balano-posthitis.  It  has  no  special  clinical  significance,  except 
that  it  is  almost  invariably  followed  by,  or  associated  with,  an  inability  to 
retract  the  foreskin  so  as  to  uncover  the  glans  penis.  This  is  due  to  an  exten- 
sion of  the  inflammation  to  the  loose  cellular  tissue  uniting  the  two  surfaces  of 
the  foreskin,  which  rapidly  becomes  oedematous,  and  in  some  cases  is  the  seat 
of  an  eff"usion  of  plastic  lymph. 

Phimosis  (Fig.  369). — The  phimosis  thus  produced  is  an  extremely  objec- 
tionable complication,  as  it  interferes  with  treatment,  necessitates  most  vigilant 

and  unremitting  care  as  to  cleanliness, 
Fig.  369.  and  obscures  the  diagnosis   and  prog- 

nosis. If  the  case  has  not  been  watched 
from  the  beginning,  and  the  patient 
comes  under  observation  for  the  first 
time  witli  a  vague  history  and  with  an 
oedematous,  swollen  prepuce,  from  the 
orifice  of  which  pus  or  pus  and  blood 
exude,  it  is  not  always  easy  to  deter- 
mine the  exact  underlying  condition. 
An  indurated  chancre  can  generally  be 
discovered  without  trouble  by  its  hard- 
ness, and  moreover  is  not  often  complicated  in  this  manner.  A  soft  or  chan- 
croidal sore,  hoVever,  or  a  balanitic  ulceration  may  not  be  so  readily  recognized. 
The  main  points  of  distinction  may  be  tabulated  as  follows  : 


Phimosis  from  Gonorrli'ca  (Cullcricr). 


Phimosis  from  Gonorrhea. 

No  hi.story  of  sore  on  glans  or  prepuce. 
Swellini;;  in  foreskin  at  first  almost  entirely 

oedematous. 
Discharge  usually  purulent. 
No  definite  area  more  tender  or  harder  than 

the  rest. 
Chordee  often  present. 
Ardor  urinae  extends  along  the  whole  length 

of  the  canal. 

Vesical  symptoms  not  infrequent. 
Bubo  very  rare. 


Phimosis  -with  Subpreputial  Chan- 
croid. 

History  of  sort;. 

Swelling  often  due  to  plastic  lymph  around 
the  ulcer. 

Discharge  often  sanguinolent. 

A  distinct  spot  usually  discoverable  by  pal- 
pation. 

Never  any  true  chordee. 

Ardor  urina?  only  when  the  urine  comes  in 
contact  with  the  inflamed  or  ulcerated 
foreskin. 

No  vesical  symptoms  in  uncomplicated  cases. 

Bubo  common. 


SURGERY   OF   THE    GEXITO- URINARY   TRACT.  899 

Paraphimosis  (Fig.  870),  a  condition  in  uliich  the  prepuce,  retracted  and 
caught  behind  the  projecting  corona  glandis,  cannot  be  brought  forward,  is  a 
less  frequent  but  more  annoying  and  danger- 
ous conijdication.  The  tense  and  rather  in-  I^'^o- 
elastic  edge  of  the  preputial  orifice  constitutes 
the  cause  of  the  constriction,  "which  grows 
tighter  as  swelling  increases.  The  neighbor- 
ing parts,  at  first  oedematous,  soon  become 
infiltrated  with  lymph,  the  return  of  blood 
from  the  glans  is  interfered  with,  and,  in  ex- 
treme cases,  ulceration  or  even  sloughing  of 
the  head  of  the  penis  has  occurred.  The  line 
of  constriction  is  situated  a  short  distance  be- 
hind the  glans,  immediately  back  of  which  is 
a  furrow  due  to  the  normal  depression  existing 
there,  intensified  by  the  surrounding  oedema.  Paraphimosis  (Cuiierier). 
Back  of  this  is  a  swollen  fold  of  mucous  mem- 
brane, which  is  the  part  of  the  inner  layer  of  the  prepuce  normally  in  contact 
with  the  posterior  face  and  edge  of  the  corona.  Then  is  found  a  second  and 
very  deep  furrow,  Avhich  is  the  actual  seat  of  the  trouble,  and  behind  this 
another  prominent  collar  of  swollen  integument.  Paraphimosis  is  attended 
with  severe  pain,  which  does  not  disappear  until  either  the  prepuce  has  been 
replaced  or  the  constriction  has  been  relieved  by  division  or  by  ulceration.  It 
is  often  productive  of  deformity  from  cicatricial  contraction  in  those  cases  in 
which  surgical  interference  has  been  delayed  or  ineff'ective.  These  complica- 
tions— balanitis,  balano-posthitis,  phimosis,  and  paraphimosis — are  by  far  the 
most  frequent  of  those  which  make  their  appearance  during  this  early  period  of 
the  disease,  and  have  accordindv  been  described  in  their  usual  clinical  order. 
The  first  stage,  or  that  in  which  there  is  a  progressive  increase  in  the  severity  of 
the  symptoms,  is  of  variable  duration,  but  under  well-directed  treatment  com- 
monly terminates  in  from  five  days  to  a  week,  after  which,  for  a  short  time,  the 
condition  appears  to  remain  stationary. 

Symptoms  and  Complications  of  the  Second  or  Stationary 
Stage. — The  discharge  is  still  profuse,  and  the  ardor  urinaj  and  chordee 
marked  and  in  some  cases  agonizing.  Patients  will  complain  bitterly  that 
their  comfort  during  the  day  is  interfered  with  by  urgent  calls  to  urinate, 
which  they  resist  to  the  last  possible  moment  in  a  vain  endeavor  to  avoid  the 
pain  occasioned  by  it,  and  that  their  rest  at  night  is  disturbed  by  frequently 
recurring  erections,  which  are  no  less  painful,  and  which  often  will  not  subside 
until  some  means  has  been  adopted  for  their  reduction.  During  this  period, 
which  may  be  said  to  extend  on  an  average  from  the  seventh  or  eighth  day 
to  the  end  of  the  second  week,  the  inflammation  is  gradually  extending  back- 
ward and  may  give  rise  to  other  complications. 

Follicular  and  Peri-urethral  Abscess. — Dipping  down  from  the  urethral 
membrane  into  the  follicles  which  empty  upon  its  surface,  the  inflammation  of 
gonorrhea  occludes  their  mouths  by  causing  swelling  of  their  lining  membrane, 
and  converts  them  into  little  bags  or  pockets  of  pus — follicular  abscesses — which 
appear  as  small,  round,  tender  tumors  along  the  under  surface  of  the  urethra. 
They  very  often  open  internally,  but  now  and  then  adhesion  to  the  skin  takes 
place,  pointing  occurs  outwardly,  and  they  discharge  upon  the  cutaneous  surface. 
Fortunately,  they  are  not  followed  by  urinary  fistulse.  If  the  suppurative  pro- 
cess involves  the  loose  connective  tissue  around  the  urethra,  a  peri-urethral  ab- 
scess is  formed.     This  is  most  frequent  at  precisely  the  points  which  on  a  priori 


900  ^l.V  AMERICAN    TEXT-UO(jK    OF  SUltGERY. 

grounds  would  liave  been  selected — those  at  which  frouorrhea  is  most  persist- 
ent, the  fossa  navioularis  and  the  anterior  j)art  of  the  nieinhrftnous  urethra. 

Ljimphnntfith. — In  a  certain  projjortiun  of  cases  of  gonorrhea  a  sinijjle 
lymphangitis  occurs  as  a  result  of  infection  with  pyogenic  microbes.  It  aflects 
most  commonly  the  lymphatics  of  the  dorsum  of  the  penis,  and  is  almost  inva- 
riably associated  with  neglect  of  cleanliness  and  retention  of  the  discharge 
between  the  prepuce  and  the  glans.  This  is  what  might  be  expected  on  ana- 
tomical groun<ls  from  the  group  of  lymphatics  involved,  those  directly  connected 
with  the  urethra  itself  belonging  to  the  deeper  set,  and  running  beneath  the 
pubic  arch  to  join  the  deep  lymphatics  of  tiie  pelvis  and  to  terminate  in  the 
lumbar  glands.  The  symptoms  consist  in  a  thickened,  cord-like  line  of  indu- 
ration extending  from  the  prepuce  to  the  root  of  the  penis,  usually  tender  to 
the  touch,  easily  isolated  from  the  surrounding  structures,  and  often  traceable 
upon  the  surface  by  a  faint  red  linear  blush. 

Gonorrheal  Bubo. — Either  with  or  without  lympliangitis  as  a  forerunner, 
inflammation  of  one  of  the  glands  of  the  groin  may  be  the  result  of  gonorrhea. 
The  gland  affected  is  usually  one  of  the  superficial  set,  lying  just  below' Poupart's 
ligament,  imbedded  in  the  subcutaneous  cellular  tissue  and  above  the  foscia  lata. 
A  small,  painful  tumor  makes  its  appearance  in  the  groin  :  it  is  at  first  freely 
movable  beneath  the  skin,  but  afterward  contracts  adhesions  to  the  latter  and 
to  the  surrounding  parts,  and  becomes  doughy  in  feel  and  reddish  or  purplish 
in  hue.  In  the  majority  of  cases,  after  reaching  this  condition,  it  wmII  subside 
under  appropriate  treatment,  disappearing  by  resolution.  In  others,  however, 
suppuration  ensues,  the  connective  tissue  which  surrounds  the  glands  liquefy- 
ing first.  Indeed,  very  often  the  glandular  structure  itself  is  not  involved  in 
the  suppurative  action. 

Another  group  of  complications  may  be  mentioned  as  possible  occurrences 
toward  the  end  of  the  third  week,  some  of  them,  however,  often  appearing 
much  later.     They  are  cowperitis,  prostatitis,  and  cystitis. 

Cowperitis. — Inflammation  of  one  or  both  of  Cowper's  glands  is  a  result  of 
extension  of  the  urethritis  by  continuity  along  their  ducts,  which  empty  into 
the  posterior  portion  of  the  spongy  urethra.  The  fij'st  symptom  usually  devel- 
oped is  pain  in  the  perineum,  much  increased  by  pressure  and  rendering  sitting 
or  walking  markedly  painful.  The  inflammatory  SAvelling  of  the  glands  is 
resistec"  by  the  two  layers  of  the  triangular  ligament  between  which  they  are 
situated  and  by  the  deep  perineal  fascia,  and  this  resistance,  associated  with  the 
determination  of  blood  to  the  part  by  gravitation,  imparts,  as  in  other  inflam- 
mations where  the  same  conditions  exist,  a  throbbing  element  to  the  pain  which 
renders  it  peculiarly  distressing.  Suppuration  in  the  periglandular  tissue  some- 
times occurs,  in  w  hich  case  the  usual  signs  of  the  formation  of  pus  are  jiresent. 

Prostatitis. — After  gonorrhea  has  spread  backward  as  ftn*  as  the  prostatic 
urethra,  it  may,  and  in  some  cases  unavoidably  does,  involve  the  prostate  gland 
in  spite  of  the  best-directed  treatment.  The  follicles  and  the  glandular  elements 
of  this  body  are  primarily  and  chiefly  affected,  the  muscular  tissue  which 
composes  the  larger  portion  of  its  mass  remaining  in  mild  cases  uninvaded. 
The  anatomical  and  physiological  relations  of  the  gland  furnish  a  key  to  the 
symptoms  produced  by  its  inflammation,  the  earliest  of  which  will  ])robably  be 
a  feeling  of  weight  and  distention  in  the  perineum  and  rectum.  This  is  soon 
followed  by  frequent  urination,  due  to  the  inability  of  the  bladder  completely 
to  empty  itself,  the  exit  of  the  urine  being  interfered  with  by  the  engorged 
gland.  The  end  of  the  act  is  painful.  Defecation  is  also  painful,  markedly 
so  if  the  feces  are  inspissated,  and  the  finger  inserted  into  the  rectum  feels  the 
anterior  wall  pushe<l  into  the  center  of  the  bowel,  hot,  unnaturally  firm,  and 


SURGKRV  OF  rill-:  <;i:Nrn)-i'jiL\Mn'  tract.        901 

tender  to  the  touch,  while  throii<fh  it  the  outlines  of  the  greatly  enlarged 
prostate  ean  be  felt.  As  the  disease  progresses  the  pain  increases,  becomes 
throbbing,  particularly  when  tlie  i)atient  is  erect  or  in  the  sitting  posture,  radiates 
along  the  cords  of  the  hypogastric  plexus  to  all  the  n.eighl)oring  regions,  and 
is  very  greatly  aggravated  by  any  evaetuition  of  the  bladder  or  rectum.  The 
frecjueney  and  difheulty  of  micturition  both  increase,  the  latter  sometimes  pro- 
ceeding to  comj)lete  retention.  The  disease  may  terminate  by  resolution,  the 
most  frequent  Avay,  or  by  suppuration.  If  suppuration  occurs,  it  is  usually 
due  to  the  coalescence  of  several  inflamed  follicles,  which,  lying  in  proxim- 
ity to  one  another,  have  broken  down  into  a  common  cavity.  The  pus  is 
frequently  discharged  into  the  urethra,  but  occasionally  pointing  takes  place 
in  the  direction  of  the  rectum.  In  either  event  evacuation  gives  great  relief. 
In  most  cases  the  prostate  is  left  with  some  fibrous  thickening — a  hyperplasia 
of  its  cellular  tissue — which  is  often  the  groundwork  for  future  trouble,  but 
which  should  not  be  confounded  with  the  hypertrophy  of  the  same  tissue  and 
of  the  muscular  elements  which  so  frequently  takes  place  in  advanced  life. 
An  acute  prostatitis  may  run  into  a  chronic  condition,  which  is  very  annoying 
and  intractable.  The  same  symptoms  exist  in  a  modified  and  much  subdued 
form  :  the  pain  is  replaced  by  a  sense  of  weight  and  fulness ;  micturition  is 
rather  too  frequent  and  is  feeble,  the  last  drops  dribbling  from  the  meatus ;  a 
mucoid  discharge  like  the  white  of  raw  egg,  but  occasionally  milky,  may  be 
squeezed  from  the  urethra  by  deep  pressure  from  behind  forward,  and  the 
same  discharge  appears  at  the  meatus  after  every  evacuation  of  the  rectum. 
By  examination  through  the  latter  the  gland  is  found  to  be  somewhat  enlarged 
and  slightly  tender  on  firm  pressure. 

Cystitis. — A  greater  or  less  involvement  of  the  neck  of  the  bladder  is  often 
a  concomitant  of  acute  prostatitis,  and  is  indicated  by  increased  urinary  trou- 
ble and  by  the  appearance  of  a  drop  or  two  of  blood  at  the  end  of  micturition. 
This  prostato-cystitis,  which  is  the  form  of  vesical  disease  usually  encountered 
in  gonorrhea,  may  subside  under  treatment  or  may  pass  into  a  well-developed 
inflammation  of  the  mucous  membrane  of  the  vesical  neck.  In  this  case  (gon- 
orrheal cystitis)  there  are  certain  well-marked  symptoms,  chief  among  which 
are  very  frequent  urination,  the  patient  not  being  able  to  retain  his  water  for 
more  than  a  few  moments,  and  the  desire  to  expel  it  becoming  intense  and 
irresistible  on  the  slightest  delay ;  excessive  vesical  tenesmus  at  the  end  of  the 
act,  which  is  characterized  by  severe  burning  pain  instead  of  a  sense  of  relief, 
blood  and  pus  following  the  stream  of  urine,  the  latter  part  of  which  is  turbid 
or  milky.  There  are  few  constitutional  symptoms,  little  or  no  fever,  no  rigors, 
and  but  slight  deterioration  of  the  general  health  unless  the  disease  runs  a  pro- 
tracted course.  The  diagnosis  between  prostatitis  and  cystitis,  Avhich  are  the 
only  complications  of  gonorrhea  likely  to  be  confounded,  may  be  made  by 
attention  to  the  following  points : 

Prostatitis.  Cystitis. 

Perineal  and  rectal  pain.  Possibly  a  little  tenderness  of  the  perineum 

on  pressure,  but  no  rectal  pain. 
Pain  violent  and  throbbing,  aggravated  dur-     Pain  burning,  not  especially  affected  by  def- 

ing  defecation.  ecation. 

Tenesmus  not  always  present.  Tenesmus  constant  and  severe  ;  very  charac- 

teristic. 
Stream  of  urine  diminished  in  size.  Size  of  stream  not  always  affected. 

Retention  of  urine  common.  Retention  of  urine  rare. 

Urine  not  much  changed  in  appearance.  Urine  turbid  and  ropy,  last  drops  mixed  with 

blood. 
Rectal  examination  shows  enlargement  and     No    prostatic     enlargement    or    tenderness 
great  tenderness  of  the  prostate.  recognizable  on  rectal  examination. 


902  AX  AMERICAX    TEXT-BOOK    OF  SURGERY. 

These  complications  belong  in  the  majority  of  cases  to  the  stationary  period 
of  gonorrhea,  wliich  extends  from  one  to  two  weeks,  rarelv  longer,  ami  during 

C  ■•'Co 

which  the  acute  symptoms  of  the  first  stage,  the  ardor  urinre,  chordee,  etc., 
remain  nearly  or  tiuite  unaltered. 

At  the  termination  of  this  stage  that  of  subsidence  begins,  and  in  uncompli- 
cate<l  cases  progresses  rapidly  until  com))lete  recovery  has  taken  place. 

Symptoms  and  Complications  of  the  Third  Stage,  or  that  of 
Subsidence. — Urination  becomes  painless  and  less  frequent ;  the  discharge 
grovvs  thinner,  becomes  watery  and  scanty,  or  dries  up  altogether;  erections 
no  longer  occur  with  abnormal  frequency,  and  do  not  give  rise  to  curvation  of 
the  penis  or  to  pain.  If  any  of  the  complications  which  have  been  described 
has  existed,  the  last  vestiges  of  it  fade  away. 

But  until  this  stage  is  actually  completed,  as  long  as  any  of  the  symptoms 
of  urethritis  are  still  evident  there  are  yet  certain  dangers  to  be  avoided  and 
serious  difficulties  which  may  present  themselves. 

JEpoUdt/niitis. — Chief  among  these,  in  respect  to  frequency  of  occurrence, 
is  epididymitis,  or  swelled  testicle,  which  is  a  complication  usually  supervening 
in  the  fifth  or  sixth  week  of  the  disease,  sometimes  coming  much  earlier,  and 
sometimes  as  late  as  the  end  of  the  second  month  or  even  in  the  third  month. 
In  the  great  majority  of  instances  it  is  obviously  the  result  of  the  extension  of 
the  urethral  inflammation  along  the  ejaculatory  ducts  and  spermatic  canal  to 
the  epididymis  itself.  The  first  symptom  is  an  aching,  occasionally  a  neuralgic, 
pain  along  the  line  of  the  groin,  more  frequently  on  the  left  side.  If  the  cord 
be  taken  between  the  thumb  and  finger  and  rolled  gently,  it  will  be  found  to 
be  tender  on  pressure.  If  the  inflammation  progresses  and  the  epididymis  ia 
involved,  this  preliminary  pain  is  soon  followed  by  a  feeling  of  weight  and  a 
dull  ache  in  the  aff'ected  testicle,  which  begins  to  increase  in  size  and  rapidly 
becomes  of  great  bulk  and  exceedingly  painful.  The  nauseating  quality  pos- 
sessed by  this  pain  is  peculiar  to  it,  and  serves  greatly  to  aggravate  its  un- 
pleasantness.    The  scrotum  becomes  purplish  in  color. 

The  patient,  particularly  if  the  testicle  be  not  supported  so  that  its  weight 
is  withdrawn  from  the  cord,  will  walk  in  a  slightly  stooping  posture  with  the 
legs  apart.  The  dragging  of  the  heavy  tumor  upon  the  spenuatic  vessels 
prevents  the  free  return  of  blood  from  the  testicle  and  serves  to  increase  the 
tension,  and  by  additional  pressure  upon  the  nerves  to  add  to  the  pain.  Under 
proper  treatment  the  acute  inflammatory  symptoms  subside  by  resolution  in  a 
few  days,  but  the  enlargement  disappears  very  gradually,  a  small  portion  of 
the  globus  i»inor  often  remaining  perceptibly  indurated  throughout  life.  In  a 
still  smaller  number  of  cases  suppuration  occurs  in  the  subcutaneous  cellular 
tissue,  and  sometimes  involves  a  large  portion  of  the  scrotum.  Persistent  indu- 
ration of  the  globus  minor,  which  consists  of  a  single  tube  for  the  passage  of 
semen,  may  interfere  with  or  entirely  prevent  the  exercise  of  its  function,  and 
if  both  testicles  have  been  involved  sterility  more  or  less  permanent  may  result. 
There  may  be  all  the  indications  of  virility  ;  there  is  no  diminution  in  desire 
nor  in  ability  to  perform  the  sexual  act,  which  is  accompanied  by  emission 
of  fluid  derived  chiefly  from  the  prostate  and  the  seminal  vesicles,  and  is 
attended  by  the  customary  amount  of  pleasure.  In  other  words,  the  patient, 
though  sterile  by  reason  of  the  absence  of  spermatozoa  from  the  fluid  which  he 
emits,  is  not  by  any  means  impotent.  Time  and  suitable  remedies  will  sometimes 
remove  this  condition,  but  the  prognosis  in  this  respect  should  be  guarded. 

That  the  left  testicle  is  aff'ected  twice  as  often  as  the  right  is  usually  attrib- 
uted to  the  fact  that  as  a  rule  it  hangs  lower,  and  thus  receives  less  support 
from  the  scrotum.     It  is  more  probably,  however,  the  result  of  the  position  of 


SURGERY   OF   THE    GENITO-URINARY   TRACT.  903 

the  left  spermatic  vein  behind  the  sigmoid  Ik-xurt',  and  also  of"  its  indirect  com- 
munication -with  the  vena  cava  through  the  renal  vein,  ^vhich  it  enters  at  a 
right  angle,  the  right  spermatic  vein  emptying  into  the  cava  at  an  acute  angle. 
These  causes  are  sufficient  to  produce  local  congestion.^  a  po^verflll  predisj)Osing 
cause  of  inflammatory  attacks.  As  a  result  of  pressure  on  the  efl'erent  vessels 
by  inflammatory  products,  or  as  a  consequence  of  extension  of  the  inflammatory 
action  itself,  acute  hydrocele  may  and  often  does  complicate  epididymitis,  adding 
to  the  size  of  the  swollen  organ  and  increasino;  the  feelin*'  of  tension  to  both 
the  patient  and  the  surgeon.  It  requires  no  special  treatment,  and  usually 
subsides  uhen  the  declining  stage  is  reached. 

Subacute  or  Catarrhal  Gonorrhea. — This  occurs  most  commonly  in 
persons  >vho  have  had  previous  attacks  of  gonorrhea,  and  is  an  example  of  the 
tendency  manifested  by  all  mucous  structures  to  take  on  inflammation  upon 
slight  provocation  after  having  once  been  aff"ected.  It  is  particularly  notice- 
able in  the  urethra  for  several  reasons :  the  canal  affords  periodical  passage  to 
a  secretion,  the  urine,  -which  is  especially  liable,  by  reason  of  changes  in  its 
constitution,  to  become  an  actual  irritant;  it  is  exposed  at  times  of  erection  to 
intense  congestion  of  all  its  vessels, — the  converse  also  being  true,  that  a  con- 
gested or  irritated  spot  along  the  urethra  predisposes  to  erection ;  gravitation, 
the  proportionately  excessive  supply  of  blood  to  the  region,  and  the  absence  of 
extra-vascular  resistance,  due  to  the  loose  character  of  the  spongy  tissue,  all 
favor  the  persistence  of  any  congestion  left  after  a  first  attack  of  urethritis ; 
the  approximation  of  the  mucous  surfaces  of  the  urethral  walls  during  the 
intervals  between  the  acts  of  micturition  is  here,  as  elsewhere,  unfavorable  to 
the  disappearance  of  granular  or  injected  areas  or  other  traces  of  inflammation. 
For  these  reasons,  among  men  Avho  have  had  gonorrhea  once,  many  have  sub- 
secjuent  manifestations,  a  predisposing  cause  being  usually  present,  although 
some  additional  irritant,  such  as  contact  with  menstrual  fluid  or  with  a  leucor- 
rheal  secretion,  is  generally  necessary  to  bring  on  marked  symptoms. 

Symptoms. — A  patient  with  this  variety  of  urethritis  will  present  him- 
self, after  a  suspicious  or  an  unaccustomed  connection,  with  a  free  muco- 
purulent or  purulent  urethral  discharge.  He  will  complain  of  very  little 
pain,  possibly  only  of  a  sensation  of  warmth  during  urination.  Chordee  is 
absent  or  very  slight,  there  is  no  vesical  irritability,  and  complications  are 
infrequent.  The  only  afl"ection  for  which  this  form  of  gonorrhea  is  likely  to  be 
mistaken  is  urethral  chancre,  the  possibility  of  which  should  never  be  forgotten.^ 
Under  treatment  the  discharge  rapidly  diminishes  until  only  a  drop  or  two  of 
muco-pus  can  be  seen,  and  that  chiefly  in  the  mornings.  This  symptom  is  apt 
to  linger  in  spite  of  all  efforts  to  remove  it,  and  is  perhaps  the  most  persistent, 
and  by  reason  of  its  long  continuance  the  most  annoying,  consequence  of  this 
form  of  gonorrhea.  There  are,  hoAvever,  some  complications  which,  although 
they  may  likewise  appear  during  an  acute  attack,  are  often  associated  with  this 
catarrhal  condition  of  the  urethra,  and  are  of  considerable  gravity.  These  are 
gonorrheal  rheumatism,  gonorrheal  ophthalmia,  and  gonorrheal  conjunctivitis. 

Complications  of  Catarrhal  Gonorrhea. — Gonorrheal  Rheuma- 
tism, or  urethral  synovitis,  or  Post-Gonorrheal  Arthritis  as  it  has  been 
better  called,  may  appear  at  any  time  during  the  existence  of  a  purulent  dis- 
charge from  the  urethra.  It  is  much  more  common  in  men  than  in  women. 
It  develops  suddenly,  and  is  usually  accompanied  by  some  abatement  of  the 
discharge,  more  rarely  by  its  entire  disappearance.  The  disease  has  been 
ascribed  to  various  causes — metastasis,  reflex  agency,  identity  of  gonorrhea 

'  The  diagnosis  between  infecting  chancre  of  the  urethra  and  gonorrhea  may  be  found  in 
the  chapter  on  Syphilis. 


904  .l.V   AMERICAN    TEXT- HOOK    OF  SURGERY. 

und  syphilis,  development  of  a  pre-existing  rheumatic  diathesis,  and,  finally,  a 
form  of  septicemic  infection,  the  last  hypothesis  being  the  one  now  generally 
accepted -as  correct. 

The  symptoms  of  this  complication  come  on  rapidly,  usually  during  the 
later  stages  of  either  an  acute  or  a  catarrhal  g(jnorrhoa.  The  j)atient,  without 
any  premonitory  signs,  or  perhaps  after  a  slight  chill  or  ''  creep  "  and  a  little 
febrile  disturbance,  notices  pain  and  swelling  in  an  articulation,  commonly  the 
knee,  ankle,  wrist,  or  elbow,  the  degree  of  frequency  being  in  the  order  of 
mention.  Within  a  few  hours  the  swelling,  due  to  synovial  exudation,  increases, 
the  joint  becomes  moderately  red  and  hot  and  very  tender,  the  suffering  on 
touch  or  movement  being  great.  It  may  remain  in  this  condition  for  some 
time,  may  involve  neighboring  tissues,  producing  a  general  arthritis,  or  may 
in  a  very  few  cases  subside  rapidly.  There  are  few  if  any  constitutional  symp- 
toms. The  disease  in  a  certain  number  of  cases  develops  only  vague  travel- 
ling pains  in  joints,  bones,  and  muscles,  and  does  not  produce  rt'ell-marked  local 
symptoms.  Ordinary  rheumatism  is  the  only  disease  for  which  this  form  of 
joint-affection  is  likely  to  be  mistaken.  The  diagnosis  should  be  based  upon 
the  following  points,  which,  for  convenience'  sake,  may  be  tabulated  thus : 

Post-Gonorrbeal  Arthritis  or 
Gonorrheal  Rheumatism.  Ordinary  Rheumatism. 

Associated  with  urethritis.  Not  associate.]  with  urethritis. 

Very  infrequent  in  women.  Not  very  rare  in  women. 

Constitutional  symptoms  transient  and  not  Constitutional  symptoms  marked  and  pro- 
severe,  longed. 

Very  little  fever.  High  fever. 

No  sweating.  Profuse  sweating. 

Urine  unaltered.  Urine  high-colored  and  loaded  with  urates. 

Often   associated    with   sclerotitis,    bursitis,  Not  complicated  with  sclerotitis,  bursitis,  or 
and  teno-synovitis.  teno-synovitis. 

Cardiac  lesions  rare.  Cardiac  lesions  frequent. 

Inflammation  remains  fixed  ;  involves  one  or  Inflammation    jumps     from    one    joint    to 
a  few  joints.  another,  involving  many. 

Local  pains  rather  less  than  in  true  rheu-  Pains  always  severe. 
matism. 

Efi'used  fluid  is  absorbed  very  slowly.  Eflfused    fluid    absorbed    with    comparative 

rapidity. 

Tendency  to  hydrarthrosis  after  acute  stage  Tendency    to    chronic     hydrarthrosis     less 
has  passed.  marked. 

Great  tendency  to  relapse  during  subsequent  Relapses  have  no  association  with  urethral 
gonorrheas.  conditions. 

Anti-rheumatic  remedies  are  of  little  value.  Artti-rheumatic  remedies  are  evidently  useful. 

Gonorrheal  Ophthalmia  and  Gonorrheal  Conjunctivitis. — See 
puruh'ut  eijnjanctiviti.'i,  p.  lU-lT. 

Irritative  or  Abortive  Gonorrhea. — There  remains  to  be  considered 
the  third  variety  of  so-called  ''gonorrhea,"  the  irritative  or  "abortive."  Not 
infrequently  after  a  suspicious  connection  a  patient  will  complain  of  a  slight 
pain  on  urination  and  a  little  itching  at  the  meatus.  An  examination  discloses 
a  reddening  of  the  lips  of  that  orifice,  and  a  little  transparent  secretion  coming 
from  the  anterior  half-inch  of  the  urethra.  These  symptoms  are  very  similar 
to  those  of  the  earliest  stage  of  an  acute  urethritis,  and  indeed  are  altogether 
indistinguishable  from  them — a  fact  of  importance  in  deciding  as  to  the  pro- 
priety of  "abortive"  treatment.  Instead,  however,  of  increasing  in  inten- 
sity, they  remain  stationary  for  some  days,  and  then,  if  not  aggravated  by 
improper  treatment,  subside  entirely,  the  whole  duration  of  the  case  not 
exceeding  a  week  or  ten  days.     There  are  no  sequelae  and  no  complications 


SURGERY    OF    THK    O EXITO-URIXARY    TRACT. 


905 


associated  with  this   c-ondition,  Avhich  is  siin])ly  one  of  mucous  irritation  and 
consequent  hypersecretion. 

The  three  varieties  of  urethritis  which  have  thus  been  described  may  be 
contrasted  as  foHows,  it  being  understood  that  such  accurate  clinical  differentia- 
tion does  not  invariably  occur,  but  that  in  many  cases  the  characteristics  of 
the  different  classes  are  intermingled.  The  tabular  form  will  be  useful  in 
enabling  us  to  recognize  at  a  glance  the  main  points  of  difference : 


Acute  Inflammatory 
Urethritis. 
Usually  a  first  attack. 

Begins  with  a  little  redness, 
|iouting,  and  tinglinii,  itch- 
ing, or  smarting  at  the 
meatus. 

Rapidly  develops  free  dis- 
charge, ardor  urinas,  chor- 
dee,  and  other  symptoms. 

Discharge  thick,  yellow, 
greenish,  or  bloody. 

Usual  complications :  prosta- 
titis, cystitis,  bubo,  etc. 

Treatment  at  first  actively 
sedative  and  antiphlogistic 
or  mildly  antiseptic. 


Catarrhal  Urethritis. 

Usually  a  second  or   subse- 
quent attack. 
The  same. 


Most  of  these  symptoms,  with 
the  exception  of  the  dis- 
charge, are  absent. 

Discharge  milky  or  watery. 

Most  common  complications : 
rheumatism,  ophthalmia. 

Treatment  may  soon  be 
'■  anti-blennorrhagic :"  cu- 
bebs,  copaiba,  etc.,  with 
injections. 


Irritative  Urethritis. 

No  relation  to  previous  ure- 
thral disease. 

The  same,  but  to  a  much  les8 
degree. 


All  these  symptoms  absent; 

does  not  progress  beyond 

this  point. 
Almost  no  discharge. 

No  complications. 

No  treatment  necessary. 


Chronic  Urethral  Discharges. — As  a  direct  continuation  or  prolonga- 
tion of  the  acute  affections  of  the  urethra,  or  as  more  or  less  remote  sequelae, 
a  number  of  chronic  urethral  discharges  are  met  with.  These  may  for  con- 
venience be  divided  into  three  classes :  those  due  to  a  urethral  catarrh,  a  con- 
dition often  left  after  the  subsidence  of  an  acute  urethritis ;  those  dependent 
upon  a  chronic  gonorrhea,  the  inflammation  having  localized  itself  in  some 
portion  of  the  urethra,  producing  a  granular  or  even  superficially  ulcerated 
surface :  and  those  commonly  known  as  gleet,  which  in  almost  every  instance 
will  be  found  associated  Avith  urethral  coarctations,  often  of  the  sort  known  as 
"strictures  of  laro;e  caliber."  Nearly  all  chronic  discharges  arising  from  the 
urethra  proper  will  be  found  to  fall  under  one  or  the  other  of  these  heads,  and, 
as  it  is  a  matter  of  much  therapeutic  importance  to  be  able  to  distinguish  them, 
their  chief  diagnostic  points  may  be  briefly  considered. 

Urethral  Catarrh, — In  many  cases  of  gonorrhea,  for  some  time  after 
the  disappearance  of  the  last  drops  of  muco-purulent  discharge  there  will  still 
be  found  a  condition  of  excessive  secretion  or  of  increased  "urethral  moisture,'' 
which  will  often  be  a  source  of  unnecessary  anxiety  to  the  patient  and  the 
surgeon.  The  symptoms  associated  with  this  mucous  catarrh  vary  from  a  mere 
feeling  of  wetness  about  the  meatus  to  the  pos.sible  production,  by  "stripping  " 
the  urethra,  of  a  drop  or  two  of  clear,  albuminoid  liquid,  slightly  tenacious  and 
resembling  that  resulting  from  a  prostatorrhea,  with  which,  indeed,  it  is  often 
associated.  There  is  no  subjective  symptom,  except  a  sensation  of  dampness 
at  the  extremity  of  the  penis.  This  is  often  so  marked  as  to  lead  the  patient 
to  useless  examinations  of  the  organ,  or  to  induce  the  belief  that  a  free  dis- 
charge exists,  but  is  absorbed  by  the  dressings  or  by  the  under-clothing. 
Treatment  of  any  sort,  as  a  rule,  serves  only  to  aggravate,  or  at  least  to  per- 
petuate, this  condition,  which,  in  nineteen  cases  out  of  twenty,  will  subside 
spontaneously  in  a  few  days  or  weeks. 

Chronic  Gonorrhea. — In  other  cases,  after  all  marked  symptoms  have 


906 


AN  AMERICAN    TEXT-BOOK    OF  SURGERY. 


vanished  there  .will  yet  remain  a  milky,  or  rather  creamy,  droj),  which  can  be 
pressed  out  of  the  meatus  whenever  a  few  hours  have  elapsed  after  urination. 
This  may  come  from  any  portion  of  the  urethra,  but  will  usually  be  found  to 
proceed  from  the  fossa  navicularis  or  from  the  anterior  membranous  portion. 
By  "stripping"  the  urethra  an  inch  or  so  at  a  time,  gradually  working  back- 
ward, or  by  proper  use  of  a  bulbous  bougie,  as  will  be  described  under  the 
head  of  Treatment,  or  by  means  of  the  urethroscope,  a  very  definite  idea 
of  the  exact  site  of  the  trouble  may  be  obtained.  The  meatus  will  be 
found  a  little  reddened  or  swollen ;  there  will  be  an  undue  warmth  or  even  a 
slight  scalding  on  urination ;  erections  will  be  accompanied  with  a  dull  ache, 
and  all  these  symptoms  will  be  much  increased  by  venereal,  alcoholic,  or  other 
excesses,  especially  by  prolonged  and  ungratified  sexual  excitement  and  by  the 
free  use  of  spirituous  liquors.  There  is  no  interval  between  this  condition  and 
the  last  stage,  or  rather  the  preceding  stage,  of  an  acute  urethritis. 

Gleet. — In  some  cases,  and  especially  in  those  in  which  the  gonorrhea  has 
been  of  long  continuance  or  has  fre(|uently  been  repeated,  there  will  occur 
another  group  of  symptoms,  chief  among  which  is  a  "gleety  "  or  muco-puru- 
lent  discharge.  In  the  mornings  the  lips  of  the  meatus  will  be  found  glued 
more  or  less  tightly  together,  and  on  separating  them  a  drop  of  opalescent, 
whitish  fluid  will  become  apparent  or  may  be  squeezed  out.  The  discharge 
may  be  more  profuse,  but  cannot  usually  be  found  during  the  day  in  sufficient 
quantity  to  be  made  apparent  at  the  meatus,  owing  to  the  frequent  washing 
out  of  the  urethra  by  the  stream  of  urine.  There  Avill  often  be  found  asso- 
ciated with  this  discharge  a  dribbling  of  urine  at  the  end  of  micturition,  an  . 
increased  frequency  of  the  latter  act,  and  a  few  vague  lumbar  or  hypogastric 
pains  or  aches — a  group  of  symptoms  which  should  always  suggest  the  exist- 
ence of  a  stricture  of  large  caliber. 

We  may  now  bring  together  the  main  points  of  difference  between  the 
various  chronic  urethral  discharges : 


Urethral  Catarrh. 

Follows  immediately  on  sub- 
sidence of  ";onorrhea. 


Discharge  watery  ;  thin  mu- 
cus. 


Chronic  Gonorrhea. 

Continuous    with    attack    of 
gonorrhea,  often  a  first  one. 

Discharge  creamy ;  pus. 


Not  much  afiFected  by  habits.     Greatly  aggravated  by  excess 

in  drink  or  by  sexual  ex- 


Gleet. 

Usually  a  variable  interval 
after  subsidence  of  gonor- 
rhea ;  generally  after  sev- 
eral attacks. 

Discharge  milky  or  milk-and- 
w-atery ;  mu co-pus. 

Increased  by  the  same  causes, 
but  not  to  the  same  degree. 


No  subjective  symptoms. 


Affects  no  special  portion  of 
the  urethra. 


Cause :  loss  of  tone  and  dila- 
tation of  capillaries  of  part. 

Prognosis :  subsides  without 
treatment. 

Expectant  treatment. 

With  bulbous  bougie  urethra 
is  found  to  be  normal. 


citement. 

Warmth  or  scalding  on  urin-     Dribbling     after    urination  \ 
ation ;  very  slight  tendency         frequency    of     urination; 


junc- 


to  chordee. 

Lingers  chiefly  about  the 
navicular  fossa  and  the 
bulbo-membranous 
tion. 

Persistence  of  low  grade  of 
inflammation.  Circum- 

scribed    congestion     with 
small  granulations. 

Requires  local  treatment. 


by    local    injec- 


Treatment 

tions. 

Point  of  sensitiveness,  from 
which  bougie  brinirs  nus. 


hypogastric     and    lumbar 
pains. 
Source     of     Ww      discharge 
always  back  of  the  coarc 
tation. 

Submucous  deposit  around 
urethra,  interfering  more 
or  less  with  its  caliber. 

If  cause  be  not  removed, 
almost  certainly  grows 
worse. 

Treatment  by  dilatation  and 
injections. 

Point  of  moderate  resistance. 


SURGERY    OF    THE    GEXITO- URINARY   TRACT.  007 

Prostatorrhea. — There  is  a  form  of  discharge  dependent  upon  chronic  fol- 
licular proHtatitix  in  Avhich  tiie  chief  diaijjnostic  points  arc  as  foHows:  1.  Undue 
frecjuency  of  micturition,  with  pain  felt  in  or  near  the  end  of  the  penis  at  the 
termination  of  the  act.  The  prostatic  nerve-plexus,  supplying  the  vesical  neck 
and  the  gland  itself,  becomes  the  cavernous  plexus,  and  is  continued  to  the  end 
of  the  penis,  terminating  at  the  proximal  side  of  the  fossa  navicularis.  This 
nervous  supply  sufficiently  explains  the  above  symptom.  2.  A  feeling  of 
weight  or  of  fulness  in  the  perineum  and  rectum,  sometimes  amounting  to 
absolute  pain,  especially  during  the  passage  of  hardened  feces.  The  relations 
of  the  pelvic  plexus  of  the  sympathetic,  which  supplies  the  rectum  as  well  as 
the  skin  of  the  buttocks,  perineum,  and  external  genitals,  in  addition  to  fur- 
nishing the  nerves  for  the  mucous  surfaces  and  muscular  portions  of  the  bladder, 
prostate,  and  urethra,  of  course  explain  the  occurrence  of  this  symptom.  3. 
Diminution  in  the  force  of  the  stream,  associated  with  dribblino;  toward  the 
end  of  the  act.  The  frequency  of  this  symptom  shows  that  in  the  majority 
of  cases  of  this  kind  the  inflammatory  trouble  does  not  remain  localized  in 
the  mucous  membrane,  but  extends  into  the  prostatic  ducts,  and  even  into  the 
substance  of  the  gland  itself.  This  is  further  shown  by  the  fact  that  in  the 
great  majority  of  such  cases  the  volume  of  the  prostate,  as  examined  through 
the  rectum,  is  appreciably  increased,  while  there  is  often  slight  tenderness  upon 
pressure.  4.  The  first  portion  of  urine  passed,  if  collected  in  a  glass,  will  be 
found  more  turbid  than  the  second  portion.  This  aids  in  diagnosticating  the 
condition  under  consideration  from  a  primary  cystitis,  although  the  symptom 
has  not  the  practical  value  Avhich  Ultzmann  has  attached  to  it.  5.  The  sedi- 
ment in  the  urine  will  be  found  to  consist  of  prostatic  epithelium,  muco-pus, 
and  a  few  mucous  shreds.  These  are  often  associated  with  casts  of  the  folli- 
cles and  prostatic  ducts,  which  are  sometimes  deceptively  like  hyaline  casts  of 
renal  origin.  This  resemblance  is  most  frequent  in  cases  of  chronic  trouble. 
6.  There  is  often,  but  not  invariably,  associated  with  these  conditions  a  certain 
amount  of  sexual  excitability,  frequent  erection,  and  premature  ejaculation 
during  attempts  at  intercourse. 

This  group  of  symptoms  is  characteristic  of  follicular  prostatitis  or  pros- 
tatorrhea, and  is  not  so  apt  to  be  found  in  uncomplicated  cases  of  stricture  of 
the  urethra,  but  the  condition  is  frequently  diagnosticated  and  treated  as  one 
of  gleet  depending  upon  stricture. 

TREATMENT   OF   GONORRHEA. 

In  determining  the  proper  treatment  for  existing  gonorrhea  it  is  necessary, 
in  the  first  place,  to  understand  clearly  the  character  and  stage  of  the  case 
with  which  Ave  are  dealing.  The  classification  which  has  been  given  will  be 
found  a  good  one  for  practical  purposes,  and  nearly  all  cases  can  be  assigned 
to  one  or  other  of  the  three  classes — acute,  subacute,  or  abortive. 

To  take  them  up  seriatim,  we  may  suppose  that  a  patient  belonging  to  the 
first  or  acute  inflammatory  class  presents  himself  for  treatment  with  the  symp- 
toms characteristic  of  the  early  stage  :  a  red,  swollen  meatus,  a  little  pain  on 
urination,  and  a  muco-purulent  discharge.  The  propriety  of  employing  in 
such  a  case  the  so-called  "  abortive  "  treatment  at  once  suggests  itself,  but 
should  not  be  seriously  considered.  There  is  a  strong  practical  objection  to 
the  adoption  of  this  method  in  the  impossibility  which  exists  of  accurately  dis- 
tinguishing at  the  outset  between  the  different  varieties  of  urethritis  ;  one 
of  which,  beyond  question,  would  be  greatly  aggravated  by  this  treatment. 
As  the  most  ardent  advocates  of  the  abortive  treatment  recommend  it  only 


908  ^.V   AMERICAN   TEXT-BOOK    OF  SrnaEIiV. 

at  the  earliest  appearance  of  symptoms,  it  is  evident  tiiat  in  manv  cases  a 
slight  local  irritation,  limited  to  the  extremity  of  the  urethra  and  likely  to 
subside  spontaneously  in  a  few  days,  -would  be  converted  into  a  general 
urethritis.  This  treatment,  then,  which  consists  in  the  injection  once  or  twice 
of  a  strong  solution  of  nitrate  of  silver,  or  in  the  very  frequent  injection  of 
weaker  solutions  of  the  same  salt  or  of  some  astringent  such  as  tannin,  need 
not  here  be  further  described.  The  first  care  should  be  to  remove  as  far  as 
possible  all  sources  of  irritation,  chief  among  which  are  (1)  the  influence  of 
motion,  friction,  and  gravitation  in  increasing  the  amount  of  blood  in  the  part; 
(2)  the  similar  effect  produced  by  sexual  stimulus ;  and  (3)  the  character  of  the 
urine,  which  must  necessarily  come  in  contact  with  the  irritated  surface. 

(1)  To  overcome  the  first,  rest  in  the  recumbent  position  is  obviously  the 
most  important  means  at  our  command,  and  its  power  in  limiting  and  sub- 
duing the  intensity  of  acute  urethritis  can  hardly  be  over-estimated.  The 
patient  should  be  told  to  avoid,  in  every  possible  numner,  physical  exertion, 
to  ride  instead  of  walking,  to  sit  instead  of  standing,  and  at  such  times  as 
may  be  convenient  to  lie  on  his  back  with  his  hips  elevated.  (2)  The 
patient  should  carefully  avoid  the  companionship  of  women  of  any  class,  as 
under  the  circumstances  there  is  apt  to  be  an  exaltation  of  sexual  impulse 
which  renders  even  the  mere  proximity  of  females  more  or  less  provocative 
of  erection,  or  at  least  of  a  very  harmful  hyperemia  of  the  parts.  (-3)  In  order 
to  render  the  urine  as  bland  and  innocuous  as  possible,  rigid  attention  to  cer- 
tain dietary  rules  is  indispensable.  A  skimmed-milk  diet  is  beyond  question 
the  one  best  adapted  to  this  stage  of  the  disease.  A  few  farinaceous  articles  or 
a  little  stale  bread  and  butter  may  be  added,  but  the  more  nearly  the  diet  is 
made  to  consist  of  skimmed  milk  the  more  likely  is  it  that  the  patient  will 
escape  the  severe  ardor  urinjB  and  troublesome  chordee  of  the  first  week  or 
two.  In  most  cases,  however,  we  are  compelled  to  be  content  with  a  modifica- 
tion of  the  ordinary  regimen,  and  should  instruct  the  patient  to  reduce  his 
animal  food  to  the  minimum,  to  avoid  all  greasy,  fried,  or  highly-seasoned 
articles,  to  abstain  from  the  use  of  pepper,  vinegar,  salt,  coffee,  and  tea.  Salad 
dressings,  asparagus,  acid  fruits,  tomatoes,  strawberries,  etc.,  pastry  of  all 
kinds,  and  indeed  any  article  of  food  difficult  of  digestion,  should  be  strictly 
prohibited,  as  should  all  malt,  vinous,  and  spirituous  liquors.  The  patient 
should  be  expressly  warned  against  the  use  of  beer  and  champagne.  Apolli- 
naris,  seltzer,  and  soda  water  are  permissible  drinks  and  may  be  taken  in 
large  quantities,  serving  then  the  double  purpose  of  diluting  the  urine  and 
at  the  same  time  of  reducing  the  appetite,  so  as  to  render  more  easy  the 
observance  of  moderation  in  eating.  Ordinary  drinking-water  may  be  taken 
in  the  same  way,  to  the  amount  of  three  or  four  (juarts  daily,  with  great 
advantage  :  and  to  meet  the  same  indication,  the  reduction  of  the  salts  con- 
tained in  the  urine,  it  is  well  to  prescribe  some  alkaline  hydragogue  diuretic, 
combining  with  it  an  arterial  sedative  and  an  anodyne  directed  especially  to 
the  genital   functions. 

Instructions  should  next  be  given  as  to  the  best  method  of  retaining  such 
dressings  as  will  serve  to  collect  and  absorb  the  discharge.  If  the  foreskin 
quite  covers  the  glans  penis,  the  very  best  dressing  consists  of  a  little  morsel 
of  absorbent  cotton  placed  over  the  meatus  and  retained  within  the  preputial 
orifice.  If  it  nearly  covers  the  glans,  but  does  not  extend  to  the  meatus,  a 
small  aperture  should  be  cut  in  the  center  of  a  piece  of  patent  lint  or  old 
linen,  two  and  a  half  to  three  inches  square  ;  this  should  be  stretched  gently 
with  the  fingers  until  just  large  enough  to  slip  over  the  head  of  the  penis 
and  back  of  the  corona.     The  ends  should  then  be  turned  forward  and  the 


SURGERY    OF    THE    G  ENlTO-riUXARY    Tit  ACT.  909 

foreskin  brought  in  the  same  direction,  when  it  will  serve  to  hold  the  lint 
or  linen  in  place.  If  the  glans  penis  be  entirely  uncovered,  it  will  be 
necessary  to  support  the  dressing  in  some  other  manner.  A  good  plan 
then  is  to  take  the  foot  of  an  old  stocking  or  a  bag  of  old  muslin  made  large 
enough  to  hold  the  organ  comfortably,  and  pin  it  to  the  front  of  the  under- 
clothing. "  Gonorrhea  bags"  of  antiseptic  wood  wool  constitute  an  excellent 
dressing. 

Tlie  foregoing  directions  all  ])ertain  to  the  first  visit  of  the  patient.  If 
the  case  belong  to  the  third  (irritative  or  abortive)  class,  all  the  symptoms  will 
subside  in  a  few  days  ;  if  to  the  second  (subacute  or  catarrhal),  the  discharge 
will  become  more  profuse,  but  no  marked  subjective  symptom  will  develop;  if 
to  the  first  (acute  inflammatory),  the  phenomena  already  described  will  make 
their  appearance  with  an  intensity  proportionate  chiefly  to  the  lesser  or  greater 
strictness  with  which  the  directions  given  have  been  observed.  In  the  first 
case  (irritative  gonorrhea)  no  further  treatment  is  required  ;  in  the  second 
(catarrhal  gonorrhea)  we  may  at  once  begin  with  the  use  of  such  injections  as 
will  be  hereafter  described  as  appropriate  to  the  declining  stage  of  inflam- 
matory urethritis  ;  but  if  we  are  dealing  with  a  case  of  the  acute  inflammatory 
variety,  w^e  must  continue  to  watch  for  and  treat  the  symptoms. 

Treatment  of  Ardor  Urinae. — For  the  relief  of  the  ardor  urinae  and 
tendency  to  frequent  urination  such  a  diuretic  mixture  as  that  suggested 
above  is  very  useful,  and  should  be  persevered  in  or  given  in  larger  doses  and 
more  frequently.  In  addition,  the  patient  may  be  instructed  to  immerse  the 
penis  in  hot  Avater  during  each  urination,  which  is  often  followed  by  extraordi- 
nary relief,  probably  due  to  the  equalization  of  the  blood-supply  caused  by  it, 
the  temporary  distention  of  the  superficial  vessels  relieving,  to  a  certain  extent, 
the  congested  and  swollen  mucous  membrane,  and  thereby  diminishing  the 
resistance  to  the  passage  of  the  stream  of  urine  and  the  friction  betAveen  it  and 
the  sensitive  walls  of  tlie  urethra. 

Treatment  of  Chordee. — In  the  treatment  of  chordee  attention  must 
be  paid  to  the  folloAving  points,  the  first  of  which  is  the  most  important  as  a 
prophylactic  measure:  Before  going  to  bed  the  bowels  should  invariably  be 
evacuated.  The  bedroom  must  be  cool  and  well  ventilated,  the  mattress  hard, 
and  tRe  bed-clothing;  light.  No  late  meals  should  be  taken,  and  anv  tendencv 
of  the  thoughts  toward  sexual  matters  should  be  resolutely  combated.  The 
medicinal  treatment  of  chordee  has  embraced  a  great  variety  of  remedies,  of 
which  none  is  at  the  present  time  generally  recognized  as  of  pre-eminent  value. 
Opium  in  the  form  of  suppositories,  used  at  bedtime,  is  very  efiicacious,  but  not 
without  its  disadvantages,  the  constipation  induced  by  it  being  prejudicial.  It 
may  be  necessary  to  employ  it,  however,  in  which  case  the  following  formula 
may  be  used : 

I^  Pulv.  opii,  gr.  vj  ;  _ 

Pulv.  camphorse,  gr.  xviij  ; 

01.  theobromse,  q.  s. 

M.  et  ft.  suppositoria  No.  vj. 
Sig.  Use  one  at  bedtime. 

Camphor  may  be  given  internally  in  doses  of  a  fluidram  of  the  tincture  or 
in  the  form  of  the  monobromide  in  from  three-  to  five-grain  doses.  Lupulin 
in  fifteen-  to  twentv-grain  doses  and  gelsemium  in  the  dose  of  three  minims  or 
more  of  the  fluid  extract,  repeated  every  time  the  patient  wakes  with  chordee, 
have  been  extremely  useful.     None  of  these  remedies  are,  however,  so  certain 


910  AX   AMKIilCAX    TEXT-llOOK    OF  SllidKliY. 

i 

in  their  effects  as  is  bromide  of  potassium.  Its  employment  as  an  alkali,  as  an 
arterial  sedative,  and  as  an  anaphrodisiac,  is  especially  indicated  in  the  early 
stages  of  gonorrhea,  and  should  never  be  neglecte<l  even  when  the  symptom  of 
chordee  is  absent.  When  that  complication  exists,  the  dose  of  bromide  should 
be  increased  until  decided  drowsiness  is  produced,  and  it  should  be  given  at 
intervals  during  the  day.  with  a  double  dose,  combineil  with  ten  or  fifteen  drops 
of  tincture  of  l)cllad()nna.  at  bedtime,  and  repeated  if  the  patient  awakes  dur- 
ing the  night  with  chordee.  Under  this  treatment,  pushed  vigorously,  the 
patient  will  rarely  have  any  erections,  painful  or  otherwise.  If,  however,  in 
spite  of  the  free  use  of  bromides,  the  employment  of  camphor  and  opium  sup- 
positories, and  attention  to  the  hygienic  rules  laid  down,  the  chordee  is  per- 
sistent and  very  painful,  it  is  well  to  adopt  more  active  measures  for  its  repres- 
sion, not  onlv  to  free  the  patient  from  pain,  but  also  because  each  recurrence  of 
chordee  aggravates  the  tendency  to  inflammation,  and,  pio))ably,  increases  the 
liability  to  subsequent  stricture.  In  such  cases  nothing  is  so  effectual  as  the 
free  abstraction  of  blood  from  the  perineum  by  means  of  leeches.  From  a 
healthy  adult  eight  or  ten  ounces  should  be  taken,  and  for  the  next  day  or  two 
he  should  occupy  a  strictly  recumbent  position  with  the  hips  elevated. 

Urethral  Injections  in  the  Early  Stage. — When  the  surgeon  has 
decided  to  begin  the  use  of  injections  he  should  order  for  the  patient  a  l)lunt- 
pointed,  hard-rubber  urethral  syringe  large  enough  to  hold  three  fluidrams. 
At  this  stage  the  disease,  although  often  extending  a  few  inches  backward,  has 
reached  its  greatest  intensity  at  or  near  the  fossa  navicularis,  a  point  at 
which  the  nozzle  of  an  ordinary  syringe  may  act  as  a  mechanical  irritant 
and  serve  to  increase  or  perpetuate  the  inflammatory  action.  Having  j)ro- 
cured  his  syringe,  the  patient  should  be  taught  how  to  use  it,  and,  although 
it  gives  a  little  more  trouble,  it  is  always  Avell  personally  to  inspect  this  pro- 
cedure at  least  once.  In  using  the  injection  the  patient  should  sit  upon  the 
edge  of  a  hard  chair,  the  buttocks  projecting  slightly  o¥er  it,  the  feet  separated, 
and  the  thighs  relaxed.  In  this  way  all  pressure  or  tension  upon  the  perineal 
muscles  is  removed  and  the  injected  fluid  finds  its  way  backward  to  a  sufficient 
depth.  In  those  cases  in  which  the  disease  is  clearly  localized  anteriorly,  or 
in  which  any  injection  reaching  the  prostatic  urethra  or  the  neck  of  the  l)lad- 
der  gives  rise  to  vesical  irritability,  the  patient  may  sit  upright,  with  a  hand- 
kerchief or  towel  rolled  up  and  placed  just  back  of  the  scrotum,  thus  occluding 
the  urethra  at  that  point.  The  syringe,  having  been  nearly  <»r  (juite  filled 
according  to  the  depth  to  which  it  is  thought  necessary  to  throw  the  injection, 
is  held  betAveen  the  thumb  and  middle  finger  of  the  right  hand,  the  tip  of  the 
index  finger  resting  on  the  end  of  the  piston.  The  conical  extremity  of  the 
syringe  is  then  inserted  from  a  quarter  to  a  half  inch  within  the  meatus, 
which  is  held  open  for  that  purpose  by  the  thumb  and  fingers  of  the  left  hand, 
and  which  is  then  drawn  tightly  around  the  syringe,  the  ])ressure  being  made 
laterally,  so  as  to  narrow  the  aperture  instead  of  broadening  it  as  when  it  is 
compressed  in  an  antero-posterior  direction.  If  this  is  done  ])r()])erly  while 
the  syringe  is  depressed  so  that  the  piston  points  toward  the  umbilicus  and  is 
gently  forced  home,  every  drop  of  the  liquid,  to  the  amount  of  at  least  two 
fluidrams,  will  be  deposited  within  the  urethra.  The  patient  should  then 
use  the  injection  in  this  manner  after  each  urination,  and  should  hold  the 
injected  fluid  within  the  urethra  for  two  or  three  minutes  before  suft'ering  it  to 
escape.  It  may  be  laid  down  as  a  rule  that  any  injection  which  gives  rise  to 
more  pain  than  might  be  described  as  a  very  slight  smarting  is  likely  to  do 
harm  rather  than  good,   and  should  be  diluted  or  discarded. 

In  selecting  the  drugs  to  be  used  by  injection  and  by  the  mouth  in  the 


SURGERY   OF    THE    GENITO- URINARY    TRACT.  911 

treatment  of  the  form  of  urethritis  avc  are  <loscribin;f — viz.  recent  anterior 
specific  urethritis — our  description  of  its  etiology  should  not  be  lost  sight  of. 
As  this  form  of  gonorrhea  is  often  an  instance  of  mixed  infection,  the  treat- 
ment should  be  more  or  less  thoroughly  antiseptic. 

The  application  of  the  principle  of  antisepsis  to  the  treatment  of 
urethritis  may  be  made  for  one  of  two  reasons  and  in  one  of  two  ways.  The 
drugs  employed  may  be  given  on  account  of  their  supposed  action  upon  either 
the  microbes  of  suppuration  or  the  alleged  specific  microbe  of  gonorrhea — the 
gonococcus  of  Neisser.  They  may  be  used  locally  or  may  be  administered  by 
the  mouth,  although  even  when  given  in  the  hitter  way  their  action  is  largely 
a  local  one.  As  to  the  reason  for  their  employment,  in  the  light  of  modern 
pathology  it  is  not  necessary  to  believe  in  an  invariable  and  essential  relation 
between  the  gonococcus  and  gonorrhea  to  see  a  clear  indication  for  the  use  of 
germicidal  agents.  The  successful  treatment  of  suppuration  anywhere  demands 
the  employment  of  some  such  agent,  though  it  must  be  admitted  that  when  the 
pus  is  furnished  by  a  mucous  surface  the  difficulties  of  treatment — i.  e.  of  suc- 
cessful antisepsis — are  greater  than  under  most  other  circumstances ;  and  it 
must  likewise  be  admitted  that  those  difficulties  are  much  increased  when  the 
suppurative  process  is  established  in  a  canal  like  the  male  urethra,  the  ana- 
tomical peculiarities  of  which  favor  so  markedly  microbic  growth  or  multipli- 
cation. 

While  the  employment  of  antiseptics  in  urethritis  or  a  -belief  in  their 
efficacy  does  not  necessitate  a  corresponding  belief  in  the  gonococcus  as  the 
sole  cause  of  gonorrhea,  yet  a  consideration  of  the  rationale  of  such  treatment 
undoubtedly  involves  an  inquiry  into  the  natural  history  of  that  microbe,  w'hich 
is  certainly  present,  whether  as  cause  or  as  effect,  in  the  large  majority  of  cases 
of  acute  gonorrhea.  Unfortunately,  the  results  of  culture  experiments  and  of 
experiments  as  to  the  influence  of  germicides  upon  gonococci  external  to  the 
body  do  not  afford  satisfactory  evidence  as  to  the  effect  of  the  same  agents  when 
applied  to  the  same  germs  imbedded  in  the  depths  of  an  inflamed  urethral  mucous 
membrane.  Bumm's  investigations  appear  to  show  that  at  first  they  multiply 
by  preference  in  the  papillary  layer,  and  find  their  way  to  the  surface  only  dur- 
ing the  latter  part  of  the  purulent  and  during  the  subsiding  (or  muco-purulent) 
stage,  and  Finger  uses  this  as  a  theoretical  argument  against  the  early  admin- 
istrattion  of  either  asti'ingents  or  antiseptics.  Enough  is  knoAvn,  however,  to 
enable  us  to  state  with  certainty  that  the  agents  which  are  effectual  against  the 
microbes  of  suppuration  are  not  equally  destructive  of  the  gonococci,  several 
competent  observers  having  noted  the  fact  that  antiseptic  solutions,  when 
applied  to  gonorrheal  secretions  outside  of  the  body,  have  seemed  to  exert 
but  little  effect  upon  the  gonococcus  even  when  strong  enough  to  destroy  pus- 
cells  and  the  pyogenic  microbes  almost  immediately. 

Considering  topical  remedies  first,  and  excluding  a  large  number  which 
have  little  or  no  claim  to  occupy  time  or  attention,  we  may  divide  the  remainder 
into  three  classes : 

1.  Those  which  when  strong  enough  to  exert  a  sufficient  germicidal  action 
are  locally  so  irritating  as  to  be  harmful  or  unbearable.  This  class  includes 
nitrate  of  silver,  carbolic  acid,  chloride  of  zinc,  iodine,  chloral,  potassium  per- 
manganate, salicylic  acid,  and  creasote,  all  of  which  have  been  faithfully  tried 
in  many  cases  and  by  competent  surgeons,  the  concurrent  testimony  being  that 
when  used  in  sufficient  strength  to  sterilize  the  discharges  they  produce  an 
amount  of  irritation  and  swelling,  ardor  urinse,  chordee,  and  even,  exception- 
ally, urethral  ulceration,  that  far  outweighs  any  advantage  to  be  derived  from 
their  antiseptic  properties. 


912  AN   AMKHICAX    TKXT-BOOK    OF  SLRGERY. 

2.  Those  which  are  such  feeble  aritisej)tic  agents  that  they  cannot  be  de- 
pended upon  to  destroy  all  the  bacteria  found  in  urethi-ai  discharges.  Among 
these  may  be  mentioned  resorcin,  thallin,  quinine,  sulphate  and  acetate  of 
zinc,  lanolin,  sulphur  waters,  tannin,  alum,  hydro-naphtiio),  and  cadmium  sul- 
phate. The  clinical  evidence  and  the  experimental  evidence  coincide  as  to 
most  of  these  drugs.  Each  has  had  its  more  or  less  enthusiastic  advocates,  but 
when  given  a  wider  trial  has  been  found  disappointing,  while  bacteriologists 
have  shown  that  the  germicidal  action  is  either  limited  to  a  very  few  varieties 
of  bacteria  or  is  slow  and  uncertain. 

3.  The  third  class  includes  a  number  of  agents  which,  while  open  to  the 
same  objection  of  too  feeble  or  too  limited  antiseptic  action,  have  the  additional 
drawback  of  insolubility  in  ordinary  media,  and  of  occasionally  becoming 
mechanically  irritating  from  the  formation  of  concretions.  Among  these  are 
iodoform,  calomel,  bismuth  subnitrate,  oxide  of  zinc,  and  other  insoluble 
powders. 

It  must  not  be  supposed  that  this  list  is  intended  to  be  even  approximately 
complete.  It  might  be  increased  literally  a  hundred-fold ;  and  nothing  could 
better  demonstrate  the  absurdity  of  empirical  methods  than  the  dozens  of 
ridiculous  formulae  and  the  hundreds  of  useless  drugs  which  have  from  time  to 
time  been  recommended  for  use  in  the  various  forms  of  urethritis.  So  far, 
however,  as  they  are  antiseptics,  they  would  be  found  in  one  or  the  other  of 
the  above  classes. 

There  are  certain  agents  which  have  been  purposely  omitted  from  this 
classification,  but  which,  as  ordinarily  employed,  might  with  considerable  pro- 
priety have  been  included.  These  are  corrosive  sublimate,  sulpho-carbolate 
of  zinc,  boric  acid,  peroxide  of  hydrogen,  and  salicylate  of  bismuth,  which  in 
various  combinations  are  of  practical  value  in  attempting  by  topical  treatment 
to  secure  asepsis  in  an  inflamed  urethra.  They  may  be  used  in  different  pro- 
portions and  either  singly  or  in  combination.  A  useful  prescription  is  as 
follows : 

I^   Ilydrarg.  chlorid.  corros.,  gr.  -^^^ 

Zinci  sulpho-carholat.,  gr.  xviij  ; 

Glyceriti  boroglycerini  (31  per  cent,  boric  acid),  f.^ij  ; 
Aquse  rosse,  foiv. — M. 

S.  Use  locally;  dilute  if  painful. 

To  this  may  be  added  from  18  to  24  grains  of  the  watery  extract  of  opium  if 
the  urethra  is  especially  irritable. 

Argonin  and  protargol,  new  preparations  of  silver,  are  at  ))resent  on  trial 
by  the  profession.  It  is  generally  conceded  that  silver  is  one  of  the  most 
actively  destructive  agents  to  the  gonococcus,  and  for  these  new  compounds 
the  manufacturers  claim  the  maximum  germicidal  power  with  the  minimum 
of  irritation  to  the  urethral  mucous  membrane.  Either  may  be  employed  in 
watery  solutions  of  from  1  to  5  per  cent. 

The  so-called  blennorrhagics,  of  which  cubebs  and  copaiba  are  the  chief, 
may  be  used  with  advantage  very  early  in  all  cases  except  those  of  high  inflam- 
matory type.  There  can  be  little  doubt  that  the  beneficial  action  of  these 
drugs,  as  well  as  that  of  their  congeners,  gurjun,  .sandal-wood,  kava-kava, 
eucalyptus,  and  the  various  terebinthinates,  is  chiefly  due  to  their  antiseptic 
powers,  which  not  only  deprive  the  altered  and  partially  sterilized  urine  con- 
taining them  of  many  of  its  harmful  properties,  but  cause  it  to  exert  a  posi- 
tively curative  eff'ect  upon  the  suppurating  mucous  membrane.  They  may  with 
marked  benefit  be  combined  with  salol,  which  by  its  decomposition  into  sali- 


SURGERY   OF    THK    (iKNITO-imiNAllY    TltACT.  913 

cylic  and  carbolic  acids,  to  be  excreted  through  the  kidneys,  aids  powerfully 
in  renderiiK--  the  urine  not  only  aseptic,  but  also  antiseptic. 

A  usefuT  prescription  is  for  a  capsule  containing  salol  5  grs. ;  oleoresin  ot 
cubebs,  5  grs.  ;  l»ara  balsam  of  copaiba,  10  grs.  ;  pepsin,  1  gr.  ;  four  to  six 
capsules  daily  being  given,  'riiesc  are  now  prepared  commercially  and  are 
known  as  compound  salol  capsules.  In  cases  where  the  irntation  of  the  whole 
urinarv  tract  is  so  great  as  to  contraindicate  the  use  of  cubebs  or  copaiba  the 
salol  may  be  given  alone  in  ten-grain  doses  four  times  daily,  or  boric  acid  may 
be  administered  in  some  such  combination  as  the  following: 

^  Acid,  boric, 

Potassii  bromidi,  ''^^  ^^'".1  ' 

Tinct.   aconiti,  ^?"..^^j''^ 

Liq.  potass,  citrat.,  f^vnj. — M. 

S.  One  tablespoonful  in  water  every  two  hours. 
In  certain  cases  where  these  preparations  disagree  or  seem  to  lose  their  effect 
it  will  be  well  to  substitute  sandal-wood  oil  in  doses  of  ten  minims  four  times 
daily  This  amount  may  be  dropped  upon  a  lump  of  sugar  and  swallowed 
with  a  little  water,  or  it  may  be  given  in  capsules.  A  commercial  article  is 
sometimes  sold  by  druggists  which  has  not  by  any  means  the  same  thera- 
peutic value  as  the  genuine  oil,  being  a  decided  irritant  to  both  the  genito-uri- 
nary  and  the  digestive  tract.  It  may  be  known  by  its  turbidity  or  cloudiness, 
the  pure  oil  being  perfectly  translucent  and  of  a  pale  amber  color.  A  little 
later  in  any  case  an  injection  containing  an  insoluble  sediment  may  be  substi- 
tuted for  the  antiseptic  injection  given  above,  as,  for  example, 

Vf  Zinci  acetat.,  __    . 

Acid,  tannic,  ^^  ^'\ 
Acid,  boric,  |"J  ; 

Aquge  hydrogenii  dioxidi,  fsvj.     M. 

S.  For  local  use. 

Sometimes,  especially  in  the  first  few  days,  no  injection  can  be  borne 
except  an  almost  purely  sedative  one,  and  then  the  following  may  be  tried: 

Bi   Acid,  boric,  3iJ  ?      _ 

Ext.  opii  aq.,  gr-  xviij  ; 

Liq.  plumbi  subacet.  dil.,  f5vj. — M. 

While  using  the  injections  containing  insoluble  sediments  the  patient  will 
often  be  unable  accurately  to  estimate  the  character  and  amount  of  his  discharge. 
After  a  time,  therefore,  it  is  well  to  substitute  for  them  a  watery  solution  ot 
some  simple  astringent,  preferably  of  sulpho-carbolate  of  zinc,  beginning  with 
about  two  grains  to  the  ounce,  and  combining  it,  if  there  be  any  lingering  sen- 
sitiveness or  scalding,  with  morphine  or  dilute  hydrocyanic  acid,  as  in  the 
following  prescriptions : 

i^  Morphinse  sulphat.,  gr.  j  ; 

Zinci  sulpho-carbolat.,  9j  I 

Aquae  rosae,  f  oiv. — M. 

"B^  Zinci  sulpho-carbolat.,  ^J  '     .. 

Acid,  hydrocyanic,  dil.,  gtt.  xij  ; 

Aquifi  roste,  f^iv. — M. 

58 


914  J.v  AMi:nicA\   TKXT-nooK  OF  SI  /:(i i:i:y. 

In  this,  a.s  in  ;ill  other  c-iscs,  it'  tlie  injection  proves  to  be  painful,  it  sliouhl  be 
diluted ;  if  painless  and  it"  it  does  not  entirely  control  the  discharge,  it  should 
be  strengthened. 

Under  this  treatment  in  many  instances  the  discliarjie  \vill  disappear,  and 
no  further  symptoms  manifest  themselves,  unless,  as  often  occurs,  treatment  is 
prematurely  discontinued.  The  only  safe  rule  to  follow  is  to  instruct  the  jiatient 
gradually  to  sto])  the  use  of  injections  and  to  decrease  the  dose  of  medicines, 
omitting  first  the  mid-day  portions,  then  those  of  the  morning,  and  last  of  all 
those  taken  just  before  going  to  bed;  the  whole  process  should  extend  over 
ten  days.  lie  should  also  be  cautioned  against  frequent  or  vigorous  "strip- 
ping" of  the  urethra  for  purposes  of  inspection. 

Irrigation  with  various  antisejjtic  solutions,  usually  thrown  in  by  the  aid 
of  gravity,  are  in  much  favor  with  some  practitioners.  It  is  probable  that 
their  systematic  use  in  large  numbers  of  cases  Avould  show  a  reduction  in  the 
average  time  of  cure.  A  considerable  proportion  of  private  patients  are,  how- 
ever, unable  or  unwilling  to  employ  them  at  their  homes.  Recently  the 
method  recommended  by  Janet  has  been  given  extended  trial  by  a  few  genito- 
urinary specialists.  It  consists  in  copious  irrigations  of  the  urethra  with  a 
solution  of  potassium  permanganate.  If  the  anterior  urethra  only  be  atfected, 
a  fountain  syringe,  placed  two  feet  above  the  patient's  body  and  supplied 
with  sufficient  rubber  tubing  to  which  is  attached  a  meatus  nozzle,  is  em- 
ployed. If  it  is  intended  to  irrigate  the  posterior  urethra  and  bladder,  the 
reservoir  is  raised  four  and  a  half  feet  above  the  patient's  body.  The  strength 
of  the  solution  should  not  be  greater  than  1  :  7000  or  1  :  5000  in  beginning 
the  treatment;  but  may  be  gradually  increased  to  1  :  2000  or  even  1  :  1000. 
The  irrigations  are  carried  out  once  or  twice  daily.  Distilled  water  should 
be  employed  in  making  the  solutions. 

Some  very  favorable  rejiorts  upon  this  method  have  appeared  in  the  jour- 
nals;  but  it  has  not  received  the  approval  of  those  most  experienced  in  this 
line  of  work.  There  are  objections  to  its  general  ado})tion,  and  some  sur- 
geons believe  they  have  observed  harmful  eflects  following  its  use. 

Treatment  of  Persistent  Urethral  Discharges. — If,  in  spite  of  the 
injections  above  given,  the  discharge  continue,  recourse  may  be  had  to  stronger 
solutions,  the  sensibility  of  the  urethra  being  taken  as  an  index.  In  this  way 
five  or  six  grains  of  zinc  sulphate  to  the  ounce  will  often  effect  a  cure  when 
weaker  injections  have  failed.  Or  acetate  of  zinc,  tannin,  sulphate  of  copjjcr, 
nitrate  of  silver,  alum,  tincture  of  catechu,  hydrastin,  and  various  other  drugs 
may  be  employed  occasionally  with  advantage. 

Treatment  of  Urethral  Catarrh. — If  the  characteristics  of  what  we 
have  called  urethral  catarrh  are  present,  a  little  attention  to  the  general  health, 
fifteen  drops  of  the  syruj)  of  iodide  of  iron  after  meals,  fresh  air  and  moderate 
exercise,  a  free  diet,  with  an  occasional  glass  of  claret  or  burgundy  at  meals, 
Avill  usually  be  sufficient,  without  local  treatment,  to  terminate  the  case.  Per- 
severance in  the  use  of  astringent  injections  and  in  the  introduction  of  bougies 
will  sometimes  hasten  a  cure,  but  quite  as  often  seems  to  retard  it.  These  con- 
stitute the  majority  of  those  chronic  urethral  cases  which  are  often  reported  by 
patients  as  having  been  cured  by  honuxsopathic  treatment,  the  negative  charac- 
ter of  which  leaves  free  play  to  that  vis  medicatrix  naturce  which  is  really  all 
that  is  needed. 

Treatment  of  Chronic  Gonorrhea. — In  other  cases,  ])articularly  when 
the  attack  is  the  first  one,  the  discharge  persists,  creamy  or  yellowish  in  appear- 
ance, associated  with  a  few  mild  subjective  symptoms  indicative  of  a  localized 
inflammation,  which  proves  to  be  easily  aroused  into  a  state  of  activity  ;  a  con- 


,s (/,'(,■  hh'y  or  THE  (iKXiTo-i  liiyAJiY  ruArr.         !)15 

ditioii  Avliicli  it  is  convciiieiit  to  dt'si<fii:ite  as  chronic  goiionlica.  To  (letcrniiiie 
this  beyond  question,  a  bulbous  bougie,  three  or  four  sizes  smaller  than  the 
normal  caliber  of  the  urethra,  should  be  gently  inserted  into  the  bladder,  the 
surgeon  noting  as  it  goes  in  the  exact  situation  of  any  point  of  unusual  sensi- 
tiveness, and  looking  for  this  or  siniihir  })oints  during  its  Avitlidraval.  He  must 
not  be  misled  by  the  normal  sensitiveness  of  the  ])rostatic  urethra.  He  should 
look  at  the  shoulder  of  the  bulb,  and  oljserve  •whether  it  Ijrings  out  any  dis- 
charge, and,  if  so,  notice  its  character.  The  urethroscope  may  occasionally  be 
of  use  in  these  cases.  If  the  symptoms  and  appearances  which  have  been 
described  as  characteristic  of  chronic  gonorrhea  are  present,  it  may  be  assumed 
that  the  sensitive  spot  corresponds  to  a  small  patch  of  granular  urethritis  to 
which  it  is  necessary  to  a])])ly  appropriate  remedies  directly.  For  this  purpose 
the  patient  should  be  ordered  a  prostatic  syringe  of  hard  rubber  having  a  long 
curved  nozzle  with  a  bulbous  tip.  He  should  be  instructed  in  what  manner  and 
to  what  depth  to  insert  this  instrument,  and  the  surgeon  should  himself  admin- 
ister the  first  two  injections.  For  this  it  is  well  to  use  about  one-half  fluidram 
of  a  1  or  2  per  cent,  solution  of  nitrate  of  silver  in  distilled  water,  or,  if  this  does 
not  give  rise  to  pain  on  the  first  injection,  a  still  stronger  solution.  The  dis- 
charge and  pain  may  be  increased  for  a  short  time  after  these  injections,  which 
should  then  be  followed  by  gradually  strengthened  solutions  of  sulpho-carbolate 
of  zinc,  tannin,  sulphate  of  copper,  or  some  other  astringent  carried  to  the  exact 
spot  in  the  same  manner.  If  the  discharge  diminishes,  but  does  not  disappear, 
the  same  process  may  be  repeated;  and  this  will  almost  invariably  result  in 
permanent  cure.  It  should  never  be  forgotten  that  in  certain  cases  the  progress 
of  the  injection  backward  may  be  cut  off  by  spasmodic  contraction  of  some  of 
the  circular  muscular  fibers  surrounding  the  urethra.  This,  occurring  as  soon 
as  the  first  drops  of  the  injection  reach  the  locality,  will  effectually  prevent 
the  liquid  from  passing  any  farther,  and  thus  from  coming  in  contact  with 
the  surface  which  is  the  source  of  the  discharge.  In  these  cases  the  use  of 
full-sized  sounds  is  imperatively  indicated,  all  other  treatment  being  worse 
than  useless. 

Irrigation  of  the  urethra  with  various  medicated  liquids  has  been  recom- 
mended, and  is  a  useful  procedure  in  cases  in  which  the  foregoing  treatment 
proves  ineffectual.  A  moderate-sized,  short,  flexible  rubber  catheter — preferably 
a  "  N^laton  " — with  large  bevelled  eyelets,  should  be  inserted  nearly  into  the 
bladder,  and  then  connected  with  a  syringe  like  the  ordinary  "  Mattson  "  or 
"  Davidson  "  syringe.  A  pint  or  more  of  the  preferred  solution,  usually  of 
one  of  the  antiseptics  or  astringents  above  mentioned,  may  then  be  passed 
through  the  urethra  without  withdrawing  the  catheter,  the  lotion  finding  its 
way  between  the  instrument  and  the  Avails  of  the  urethra  and  making  its 
exit  at  the  meatus.  In  one  or  the  other  of  these  ways  chronic  gonorrhea  is 
always  curable. 

Treatment  of  Gleet. — In  a  case  of  true  gleet,  with  a  history  of  sev- 
eral previous  attacks  of  gonorrhea  or  one  which  has  been  very  protracted, 
with  dribbling  after  urination,  etc.,  we  should  carefully  examine  the  ure- 
thra with  a  bougie  a  boule,  when  we  shall  probably  find  the  condition  described 
as  indicative  of  the  presence  of  a  submucous  deposit  or  a  "  stricture  of  large 
caliber"  or  commencing  stricture.  The  fact  that  in  every  normal  urethra  the 
bulb  of  the  instrument  will  meet  with  some  resistance  as  it  passes  under  the 
posterior  layer  of  the  triangular  ligament  (White)  seems  worthy  of  reiteration, 
as  failure  to  recognize  it  has  been  a  frequent  source  of  error  in  diagnosis  and 
treatment.  Another  source  of  error,  already  referred  to,  is  spasm  of  the  mus- 
cular fibers  occurring  at  some  point  along  the  urethra  and  imparting  to  the 


916  AN  AMEJiJCAN    TEXT- BO  OK    OF  SUItGERV. 

bougie  the  precise  sensation  felt  in  passing  a  stricture.  The  possible  associa- 
tion of  spasms  of  this  character  with  strictures  of  large  caliber  situated  ante- 
riorly should  not  be  forgotten.  The  treatment  of  gleet  in  the  great  majority 
of  cases  thus  becomes  that  of  the  stricture  upon  which  it  depends.  (See  section 
on  Stricture  of  the  Urethra.) 

Treatment  of  Complications. — Balanitis  usually  requires  for  its  treat- 
ment only  perfect  cleanliness  and  the  use  of  some  desiccant  sedative  powder, 
such  as  opium  Bj,  lycopodium  ^ij,  and  acid,  boric.  3J.  Three  or  four  times 
daily  this  should  be  dusted  on  the  inflamed  surface,  which  should  be  previously 
washed  and  gently  dried.  Strips  of  dry  lint  inserted  between  the  glans  and 
foreskin,  and  changed  whenever  they  become  moist  from  the  discharge,  will 
often  effect  a  cure. 

Balano-posthitis,  when  accompanied  by  oedema  of  the  prepuce,  is  best 
reduced  by  a  lotion  of  lead-water  and  laudanum  continuously  applied.  The 
dry  dressing  may  be  used  with  advantage  after  the  swelling  has  subsided. 
Good  in  both  cases  follows  from  painting  over  the  inflamed  glans  and  the  inner 
surface  of  the  foreskin  with  a  30-  or  40-grain  solution  of  nitrate  of  silver. 

Phimosis  may  be  relieved  by  circumcision  or  by  splitting  open  the  fore- 
skin along  the  dorsum,  completing  the  operation  at  some  later  period ;  but 
both  of  these  procedures  are  undesirable  if  it  is  possible  to  avoid  them.  In 
nearly  every  case  lead-water  and  laudanum  externally,  with  subpreputial 
injections  of  soap  and  water,  followed  first  by  clean  water,  and  then  by 
lead-water  and  laudanum,  will  reduce  the  swelling,  so  that  the  glans  may  be 
uncovered. 

Paraphimosis  (Fig.  370),  if  seen  at  first  while  the  preputial  swell- 
ing is  a'deraatous  and  not  inflammatory  in  its  character,  should  be  imme- 
diately reduced. 

The  ordinary  procedure,  which  usually  suffices,  consists  in  oiling  the  parts, 
locking  the  index  fingers  of  the  two  hands  above  and  behind  the  corona 
glandis,  and  the  middle  fingers  below  and  beneath  it,  and  gradually  com- 
pressing the  glans  itself  with  the  thumbs,  emptying  its  congested  vessels,  and 
finally  forcing  it  backward  while  the  fingers  bring  forward  the  swollen  foreskin. 
Or  the  body  of  the  penis  may  be  encircled  with  the  thumb  and  index  finger 
of  one  hand  while  with  the  other  the  glans  is  gradually  compressed  and  pushed 
into  the  preputial  orifice.  It  must  be  remembered  that  not  only  the  glans  but 
also  a  ring  of  swollen  mucous  membrane  is  to  be  returned  through  that  orifice. 
When  these  means  fail,  or,  indeed,  in  preference  to  them  in  many  cases,  the 
method  of  Mr.  Eddowes  has  been  most  satisfactory.  It  consists  in  wrapping 
the  glans  and  prepuce  with  a  slip  of  wet  lint  two  inches  wide  and  extending  a 
little  in  front  of  the  glans,  and  then  winding  around  the  glans  from  before 
backward  a  piece  of  round  elastic  ligature.  By  the  time  the  corona  is  reached 
the  glans  will  be  reduced  in  size,  and  it  will  be  often  possible  to  slip  the  end 
of  a  grooved  director  beneath  the  constricting  band.  Then,  withdrawing  the 
ligature  rapidly,  the  shrivelled  glans  may  be  pushed  backward  and  the  prepuce 
drawn  forward  to  its  natural  position.  If  the  chief  obstacle  to  reduction  be  the 
amount  of  oedema,  it  will  be  proper  to  evacuate  the  serum  by  several  minute 
punctures  with  an  exploring  needle. 

AYhen  the  paraphimosis  has  been  of  longer  duration  and  an  effusion  of 
plastic  lymph  is  present,  more  permanent  compression  may  be  required,  and  in 
that  case  the  glans  and  foreskin  should  be  "  strapped  "  with  pieces  of  adhesive 
plaster.  In  twenty-four  hours  reduction  usually  becomes  possible.  If  not, 
the  dressing  should  be  removed.  If  all  these  means  fail,  we  may  divide  the 
constriction  on  the  dorsum  of  the  penis  by  inserting  beneath  the  prepuce  a  flat- 


SURGERY   OF    THE    GENITO- URINARY    TRACT.  917 

tenod  sharp-pointed  bistoury  an.l  then  turnin-  its  edge  and  cutting  upward ; 
or  the  stricture  may  be  cut  down  upon  from  without  inward,  always  remen.ber- 
in<.  to  look  for  it  in  the  furrow  which  divides  the  mucous  membrane  from  the 
infe-ument,  the  first  one  behind  the  furrow  of  the  cervix  glandis. 

Follicular  Abscess  often  opens  spontaneously  into  the  urethra  and 
requires  no  surgical  interference.  When  the  skin  becomes  thinned  and  dis- 
colored over  such  a  swelling,  it  is  well  to  incise  it  freely. 

Peri-urethral  Abscess  should  be  evacuated  more  promptly--as  soon, 
indeed,  as  suppuration  is  established,  as  a  spontaneous  opening  in  these  cases 
Ly  be  followed  by  urinary  extravasation.  In  their  earliest  stages  these 
Tbs^cesses  may  sometimes  be  aborted  by  the  use  of  sedative  lotions  with 
absolute  rest  in  bed,  moderate  elevation  of  the  organ,  and  free  purgation. 

Lymphangitis  rarely  requires  any  special  treatment  Evaporating  and 
sedative  lotions  and  rest  will  usually  relieve  any  pain  which  may  be  associated 

^'^  Bubo  mav  be  aborted  by  the  use  of  pressure  or  iodine,  or,  if  these  fail,  may 
be  poulticed  and  opened  as  in  any  case  of  glandular  suppuration.     It  is  never 

'  "cowperlSs'renuires    rest,   elevation    of  the   buttocks,   leeches   to    the 
perin^:^    hof sitzlfhs,  poultices,  and  prompt  evacuation  if  suppuration 

''''''prostatitis,  Prostaio-cystitis,  and  Cystitis  must  all  be  treated  in 
very  much  the  same  manner.  Uoon  the  first  development  of  the  early  symp- 
toms-frequent urination,  vesical  tenesmus,  etc.-the  patient  should  be  placed 
at  absolute  rest  in  the  recumbent  position,  with  the  hips  elevated  upon  a  hair 
p  How  his  diet  for  a  few  days  should  be  limited  to  skimmed  milk,  of  which 
Te  may  take  any  desired  quantity  ;  an  alkaline  diuretic  --ture  shou  d  be 
fieely  administered;  three-ounce  cnemata  of  hot  water,  or  of  hot  staich- 
waLr  containing  a  few  drops  of  laudanum,  should  be  given  every  two  or  three 
hours  six  or  efght  ounces'  of  blood  may,  with  advantage,  be  taken  by  leeches 
from  the  perineum,  which  should  afterward  be  covered  with  hot  fomenta  ions ; 
and  finally  opium,  combined  with  belladonna  or  hyoscyamus,  m  suppositories 
should  be^edai  bedtime  and  at  intervals  during;  the  night  if  t^e  call  to 
urinate  are  frequent.  Bromide  of  lithium  in  five-grain  doses  every  three  hours, 
or  dtrtte  of  caffeine  in  three-gram  doses,  may  be  added  to  the  diuretic  mixture 
if  the  urine  remain  scanty  and  high-colored.  j  i   ^i,         ^-^^^ 

All  urethral  injections  should  be  immediately  stopped,  and  the  patient 
should  be  instructed  to  resist  as  long  as  possible  the  desire  to  urinate,  and  also 
the  inclination  to  strain  and  bear  down  at  the  end  of  the  act. 

Retention  of  Urine.— If  retention  of  urine  should  occur  as  an  additional 
complication,  place  over  the  hypogastrium  a  large,  mushy,  hot  hop  poultice 
covered  with  oiled  silk,  and  renew  every  two  hours;  give  an  enema  of  hot 
water  and  soapsuds.  If  the  symptoms  of  retention  and  of  distention  of  the 
bladder  become  serious,  the  urine  should  be  drawn  a.^y  -^^h- J^^  ^r^rder" 
eter  usino-  the  greatest  possible  tenderness  in  its  insertion.  It  must  be  under- 
tood  thaf  the  evils  of  the  gentle  introduction  of  a  soft  -*h^^7^;y- ^/^^^^ 
as  every  six  or  eight  hours,  are  less  than  those  produced  by  the  intense  and 
:imost  Untinuous^enesmus.  Of  course,  if  a  tight  stnctui.  -  P--^  -d 
there  is  difiiculty  in  introducing  a  soft  instrument,  other  instruments  must  be 
tried,  and  occasionally  external  urethrotomy  or  perineal  section  may  become 

""'' Prostatic   Abscess.— When  during  an  attack  of  acute  prostatitis  the 
patient  suddenly  has  rigors,  followed  by  increased  fover  and  sweating,  it  is 


i)lS  J.V   yiMKIilCAN    TEXT- HOOK    OF  smoKllY. 

probable  that  suppuration  has  occurred  in  the  ghind.  If  the  abscess  opens 
into  the  urethra,  as  it  usually  does,  no  special  treatment  is  necessary ;  if  it 
points  toward  the  rectum,  however,  or  if,  with  unniistnkable  symptoms  of  sup- 
puration, the  abscess  shows  no  disposition  to  point  in  either  of  these  directions, 
it  becomes  necessary  to  evacuate  it.  An  incision  should  be  made  in  the 
median  line  of  the  perineum  nntil  the  pus-cavity  is  reached,  care  being  taken 
not  to  Avound  either  the  urethra  or  the  rectum. 

Chronic  Prostatitis. — When  prostatitis  becomes  chronic  the  treatment 
is  difficult  and  prolonged.  It  may  be  summarized  as  follows  :  Kemoval  of 
stricture,  contracted  meatus,  phimosis,  or  other  predisposing  cause  ;  restricted 
diet ;  avoidance  of  all  liquors,  except  some  form  of  light  red  wine  ;  careful  atten- 
tion to  the  bowels,  cold-water  enemata  once  a  day  being  often  of  great  service ; 
daily  cool  hip-baths  of  a  temperature  and  duration  governed  by  the  sensations 
of  the  patient,  and  persisted  in  as  long  as  they  are  followed  by  relief  of  sub- 
jective symptoms  ;  counter-irritation  to  the  perineum,  preferably  by  iodine  ; 
normal  exercise  of  the  genital  functions.  Cauterization  of  the  prostatic  urethra 
is  unquestionably  useful  in  many  cases,  but  should  be  employed  only  after 
the  foregoing  measures  have  failed.  A  few  drops  of  a  30-  or  40-grain  solu- 
tion of  nitrate  of  silver  should  be  deposited  in  the  prostatic  urethra,  and  the 
immediate  effect,  which  is  a  more  or  less  marked  inflammatory  action,  watched 
and  controlled  by  rest  and  appropriate  remedies.  The  operntion  may  be 
repeated  if  no  benefit  result  from  the  first  application. 

In  the  form  of  urethral  discharge  dependent  upon  chronic  follicular 
prostatitis,  which  has  been  described  (p.  907),  attention  to  the  following 
rules  of  treatment  Avill  give  the  most  satisfactory  results  in  a  large  proportion 
of  cases  :  Limited  diet,  especially  as  regards  nitrogenous  articles  of  food  ;  absti- 
nence from  sexual  excitement,  particularly  if  ungratified  ;  great  attention  to  the 
condition  of  the  rectum,  which  should  never  be  allowed  to  contain,  even  for  a 
few  hours,  a  mass  of  hardened  inspissated  feces.  To  avoid  this,  white  wheat- 
gluten  suppositories  or  weak  glycerin  suppositories  used  at  bedtime  are  most 
satisfactory.  A  free  application  of  a  mixture  of  tincture  of  iodine  and  tincture 
of  belladonna  should  be  made  to  the  perineum,  and  repeated  night  and  morn- 
ing until  the  skin  becomes  tender,  resuming  it  at  once  when  the  tenderness 
passes  away.  This  is  better  than  the  actual  blisters  recommended  by  Sir 
Henry  Thompson  and  others,  on  account  of  the  long-continued  irritation  which 
can  be  kept  up  in  this  manner.  Careful  attention  should  be  paid  to  the  condi- 
tion of  the  urine.  As  a  routine  treatment  a  mixture  of  bromide  and  citrate 
of  potassium,  with  small  doses  of  aconite,  belladonna,  and  ergot,  will  be  found 
useful. 

The  prostate  is  so  situated  anatomically  that  congestions  and  inflammations 
once  occurring  in  it  are  powerfully  favored  by  the  influence  of  gravitation. 
In  nearly  every  position  of  the  body  it  is  at  the  lower  extremity  of  a  portion 
of  the  circulatory  system  which  is  peculiarly  apt,  in  bipeds,  to  suft"er  from 
chronic  congestion  and  vascular  dilatation.  Hemorrhoids  are  chiefly,  if  not 
exclusively,  a  disease  of  the  human  and  anthropoid  species,  and  prostatic 
hypertrophy,  simply  as  a  result  of  advancing  years,  is  found  almost  exclu- 
sively in  these  species,  and  is  possibly  due  to  the  same  cause.  In  all  ordinary 
postures  the  blood  which  has  entered  the  prostate  must  make  its  exit  against 
the  attraction  of  gravitation.  Whenever  we  find  this  mechanical  condition  in 
the  body,  we  are  apt  to  find  also  dilatation  of  the  blood-ve.ssels  and  hyper- 
trophic tis.«uc-change.  To  prevent  this,  and  to  restore  both  the  vessels  and 
the  tissues  to  their  normal  size  and  caliber,  there  is  no  better  remedy  than  the 
application  of  cold,  especially  in  the  form  of  a  jet  or  stream  of  water.     In  the 


.scA'aijRv  Of  Till-:  aKMro-nuxAin'  tract.         mo 

cases  in  question  the  persistent  and  thorough  use  of  the  hidct  is  of  tlie  greatest 
benefit  (White).  The  j)atient  should  use  it  for  ten  or  fifteen  minutes  at  least 
twice  daily,  once  after  his  usual  evacuation  of  the  howels  and  once  before  going 
to  bed.  It  is  Aveil  at  ])oth  tliese  times  to  wash  out  the  rectum  witli  tepid  or  warm 
Avater,  and  to  employ  the  cold  jet  directed  against  the  perineum.  The  powerful 
contraction  of  all  the  muscular  and  vascular  structures  in  the  neighborhood  is 
well  shown  in  the  effects  of  this  treatment  upon  hemorrhoids,  prolapsus  ani, 
and  similar  conditions,  and  is  participated  in  by  the  vessels  and  muscular 
structure  of  the  prostate. 

Epididymitis,  at  its  onset,  should  be  treated  as  follows:  Put  the  patient 
to  bed  in  the  recumbent  position  ;  elevate  the  scrotum  above  the  level  of  the 
thighs.  Apply  directly  over  the  painful  testicle  a  piece  of  patent  lint  soaked 
in  the  following  lotion,  with  which  it  should  be  kept  continually  wet : 

i^  Tinct.  aconiti, 
Tinct.  opii, 

Liq.  plumbi  subacetat.  dil.,  ad  fsj  ; 
Aqufe,  f.si'j- — ^I- 

Shave  the  hair  from  the  groin  on  the  affected  side,  and  take  about  six  ounces 
of  blood,  by  means  of  leeches,  along  the  line  of  the  cord.  Administer  a  half 
bottle  of  the  effervescing  citrate  of  magnesium,  place  the  patient  on  restricted 
diet,  stop  all  urethral  treatment,  give  him  a  drop  of  tincture  of  aconite  and 
five  grains  of  bromide  of  potassium  every  two  hours,  or  more  frequently  if 
there  be  any  febrile  reaction.  Often  this  treatment  at  an  early  stage  will 
prevent  any  further  manifestations :  the  symptoms  will  subside,  and  in  two  or 
three  days  the  patient  may  be  permitted  to  walk  around,  keeping  the  testicle 
still  enveloped  in  the  lotion  and  well  supported  by  a  suspensory.  When  the 
swelling,  either  in  spite  of  treatment  or  in  its  absence,  has  progressed  to  a 
considerable  extent  and  the  testicle  presents  a  large  solid  mass,  the  pain  hav- 
ing become  dull  and  aching,  and  severe  only  upon  motion  or  in  walking,  great 
relief  may  be  obtained  by  the  application  of  compression. 

In  strapimig  a  testicle  the  scrotum  should  be  shaved,  the  testicle  drawn 
down  as  far  as  possible,  and  a  strip  of  adhesive  plaster  about  half  an  inch  in 
width  made  to  encircle  its  upper  extremity,  so  as  to  retain  it  in  that  position 
in  the  form  of  a  tense  tumor,  pear-shaped  and  purplish  in  color.  This  is  then 
tightly  covered  in  with  successive  strips  of  plaster,  placed  first  circularly  until 
the  greatest  circumference  of  the  tumor  is  reached  and  they  refuse  to  adapt 
themselves  neatly  to  the  surface,  and  then  longitudinally  so  as  to  cover  in  the 
lower  segment  completely.  The  testicle  may  then  be  placed  in  a  suspensory 
bandage,  and  in  most  cases  the  patient  is  able  to  go  about  with  little  or  no  pain. 
The  dressing  should  be  replaced  every  day  or  two,  since  it  will  loosen  as  the 
swelling  disappears.  An  ointment  of  belladonna  and  iodoform  may  then  be 
applied  upon  a  piece  of  lint  worn  beneath  the  suspensory. 

The  induration  of  the  epididymis  Avhich  remains  after  all  inflammatory 
action  has  disappeared  is  usually  permanent  and  is  not  much  affected  by  treat- 
ment. It  may,  however,  diminish  under  the  use  of  belladonna  and  mercurial 
ointment  and  the  internal  administration  of  iodine  and  a  mercurial.  In  cases 
of  double  epididymitis  followed  by  sterility  it  is  well  to  pursue  this  method  of 
treatment  for  a  long  period,  as  the  re-establishment  of  the  spermatic  canal  to 
ever  so  slight  a  degree  is  then,  of  course,  a  matter  of  great  importance. 

Gonorrheal  Rheumatism  is  considered  to  be  a  peculiarly  obstinate  and 
intractable  form  of  joint-trouble,  and  treatment  is  pronounced,  by  all  author- 


920  j.v  a.u/:r/('AX  Ti:xT-iinoK  of  sr'narjn'. 

ities  on  the  subject,  to  be  in  the  highest  degree  unsatisfactorv.  It  is  due  to 
infection  with  the  gonococci ;  or,  when  it  accompanies  a  simple  urethritis,  to 
infection  with  pyoi;eiiic  bacteria,  or  often,  doubtless,  to  a  mixed  infection. 
It  is  occasionally  tlie  local  evidence  of  absorption  of  bacterial  or  chemical 
products  and  their  presence  in  the  fluids  and  tissues  of  the  joints.  For  the 
symptoms  and  treatment  see  the  section  on  the  Arthritis  of  infective  Disease 
(p.  399). 


GONORRHEA   IN    THE    P^EMALE. 

Gonorrhea  in  the  female  is  not  so  frequent,  so  limited  in  its  situation,  so 
protracted  in  its  course,  or  so  serious  in  its  results  as  in  the  male.  The  ana- 
tomical arrangement  of  the  genito-urinary  organs  in  women  permits  gonor- 
rheal inflammation  to  develop  in  the  vulva,  vagina,  urethra,  or  uterus,  which 
are  involved  with  a  frequency  indicated  by  the  order  of  mention.  Vaginitis 
is,  however,  described  by  some  writers  as  the  most  common  of  these  varieties 
of  gonorrhea.  The  uterus  is  insensitive,  not  prone  to  inflammatory  action  from 
external  irritants,  and  in  a  position  where  such  irritants,  especialh'  when  de- 
rived from  sexual  intercourse,  are  not  retained  in  contact  with  it  for  any  length 
of  time.  The  delicate  urethral  mucous  membrane  is  protected  from  frequent 
contamination  by  its  sheltered  position  and  its  situation  above  the  genital  canal, 
fluids  deposited  in  or  flowing  from  the  latter  not  necessarily  coming  in  contact 
with  it.  The  vulva  and  vagina  are  obviously  much  more  exposed  to  irritating 
or  traumatic  agencies,  any  one  of  Avhich,  whether  a  purulent  secretion  from  the 
male  urethra,  violence,  inordinate  masturbation,  etc.,  is  capable  of  exciting  in 
these  parts  a  severe  inflammation. 

Vulvitis. — Causes. — A''ulvitis  may  be  produced  in  any  of  the  ways  men- 
tioned, may  be  secondary  to  a  vaginitis,  may  be  due  to  worms,  to  the  secre- 
tions of  mucous  patches,  to  uncleanliness  and  the  accumulation  of  sebaceous 
matter,  to  criminal  violence,  or  to  any  traumatic  or  infective  cause.  It  some- 
times arises  spontaneously  in  infants  during  dentition,  and  is  said  by  Dupuy- 
tren,  who  cites  cases  in  proof,  occasionally  to  ])e  epidemic  in  very  young  chil- 
dren. However  caused,  vulvitis  begins  with  an  itching  sensation  and  a  feeling 
of  heat  and  burning,  soon  followed  by  tumefaction  of  the  parts,  Avhich  are 
bathed  in  a  secretion  at  first  muco-purulent,  then  thick,  yellowish  or  greenish, 
acrid,  and  oftensive.  If  the  i)arts  be  inspected  a  day  or  two  after  the  onset  of 
the  disease,  the  labia  will  be  found  red,  abraded,  and  excoriated,  and  the  nym- 
phse  sometimes  swollen  so  as  almost  completely  to  occlude  the  entrance  to  the 
vagina.  The  parts  are  sensitive  to  pressure  and  painful  upon  motion.  The 
vulva  is  often  surrounded  by  an  area  of  congestion  which  extends  beyond  the 
vulvo-femoral  folds  and  may  be  seen  for  some  distance  down  the  thigh.  The 
passage  of  the  urine  across  the  inflamed  surfaces  gives  rise  to  an  intense  burn- 
ing, which  may  be  mistaken  for  the  ardor  m-'nvx  of  urethritis,  and  is  often 
quite  as  severe. 

Complications. — Bnho. — The  inguinal  glands  are  apt  to  be  enlarged  and 
tender,  and  sometimes  suppurate.  Bubo  is,  however,  also  less  common  in  the 
female  than  in  the  male,  and  when  it  does  occur  is  almost  always  associated 
with  a  vulvitis  or  a  urethritis. 

Vulvo-vaginal  Abscess. — In  some  cases  inflammation  follows  the  ducts  of 
Bartholin's  glands,  and  excites  suppuration  or  abscess  in  these  ])odies,  which 
are  compound  tubular  glands,  surrounded  by  a  fibrous  envelope,  and  situated 


suRd Eli y  OF  Tin:  a i:m to- i  /:/\. i // }'   7/.'. i (  t. 


021 


one  on  t'acli  .side  of  the  entrance  of  the  vai^ina.  In  acute  cases  there  are 
heat,  redness,  and  tenderness  of  the  inflamed  part;  which  signs,  together  with 
the  peculiar  pyrifonn  swelling,  servo  to  facilitate  the  recognition  of  the  condi- 
tion. In  the  early  stages  the  swelling  can  most  readily  he  recognized  hy  put- 
ting a  finger  in  the  vagina  and  pressing  outward  toward  the  ranms  of  the 
isciiium.  The  ahscess  will  sometimes  evacuate  itself  spontaneously  through 
the  duct  of  the  gland  or  at  the  inner  surface  of  the  nympluie,  or  the  pus  may 
work  its  way  hetween  the  layers  of  the  ischio-pubic  fascia  and  escape  just 
within  the  labium  majus:  but  its  cure  can  usually  be  hastened  by  a  prompt 
and  free  incision  made  through  the  mucous  membrane  at  the  inner  and  lower 
aspect  of  the  tumor.  Suppuration  in  these  glands  has  a  peculiar  tendency 
to  recur,  and  accumulation  of  i)us  and  the  conse(iuent  swelling  will  often  take 
place,  after  a  first  attack,  without  any  marked  symptoms  of  inflammation. 
Under  these  circumstances — particularly  if  pressure  on  the  tumor  does  not 
cause  the  appearance  of  pus  at  the  orifice  of  the  duct — it  is  possible,  in 
exceptional  cases,  to  mistake  the  condition  for  a  pudendal  hernia,  for  a  cyst, 
for  a  hydrocele  of  the  round  ligament,  or  for  oedema  of  the  cellular  tissue  of 
the  labium  or  vice  versa. 

The  differential  points  in  the  diagnosis  of  vulvo-vaginal  abscess  from  the 
first  three  mentioned  affections  may  be  contrasted  as  follows  : 


Chronic  Vulvo- 
vaginal Ab- 
scess. 

History  of  previous 
iutiammation. 

Swellint^  pyriform ; 
base  downward ; 
greatest  swelling 
inward. 

Fluctuation. 

Irreducible. 


No  impulse  on  cough- 
ing. 
Dull  on  percussion. 

Most  common  in  old 
prostitutes. 


Pudendal  Hernia. 


Sudden  appearance. 

Shape  very  similar, 
but  greatest  pro- 
jection outward. 

Doughy  or  elastic. 

Reducible  by  pres- 
sure near  ramus  of 
ischium. 

Distinct  impulse. 


Cyst  of   the 
bium. 


La- 


Slow,  painless 
growth. 

More  distinctly  cir- 
cumscribed; some- 
times peduncu- 
lated. 

Elastic. 

Irreducible. 


No  impulse. 


Resonant  if  an  enter-     Dull. 

ocele. 
Seen  at  any  age.  Seen  at  any  age. 


Hydrocele  of  the 
Round  Liga- 
ment. 

No  ))revious  inflam- 
mation. 

General,  diffused 
swelling. 


Doughy. 

Partially  reducible. 


No  impulse. 

Dull. 

Seen       oftenest      in 
young  persons. 


(Edema  of  the  vulva  is  usually  symmetrical,  and  in  nearly  every  case  is 
either  a  result  of  pregnancy  or  parturition  or  of  the  presence  of  an  abdominal 
tumor,  or  accompanies  a  vulvitis,  and  is  then,  of  course,  easily  recognized  by 
the  inflammatory  symptoms. 

Vaginitis. — Causes. — Vaginitis  has  for  its  most  frequent  cause  a  puru- 
lent discharge  from  the  male  urethra.  In  other  words,  gonorrhea  in  the  female 
is  usually  due  to  direct  infection  by  the  male.  It  may,  however,  result  from 
violent  or  excessive  copulation,  from  masturbation,  from  contusions,  from 
inflamed  hemorrhoids,  or  in  various  other  ways.  Females  already  affected  with 
leucorrhea  sometimes  develop  a  vaginitis  after  protracted  exertion.  It  may 
result  from  an  extension  upward  of  a  vulvitis,  although  the  reverse  is  met 
with  quite  as  often.  Children  and  young  girls  are  especially  subject  to  inflam- 
mation of  the  vagina,  which  is  sometimes  found  as  a  complication  of  dentition 
or  of  the  eruptive  fevers,  and  sometimes  as  a  sequel  of  the  first  approaches  of 
the  male.  Vaginitis,  which  is  apt  to  be  of  a  leucorrheal  character,  sometimes 
occurs  in   the  early  stages  of  syphilis  as  a  result  of  the  extension  of  inflam- 


1)22  A.\    AMLL'KAy    TEXT-liOOK    OF   SLUUKllY. 

luation  from  mucous  patches  seated  ujion  tlic  vulva  or  of  cliaiiircs  whit-li  take 
place  in  the  os  uteri.  Tiie  neck  of  the  uterus  is  frcijuently  the  seat  of  certain 
lesions  in  the  secondary  stages  of  sy}>hilis  which  may  he  the  medium  of  propa- 
gating inflammation  to  the  vagina. 

Symptoms  and  CompUcationsf. — Vaginitis  following  purulent  infection 
usually  begins  at  the  lower  and  posterior  aspect  of  the  canal.  It  is  at  first 
attended  with  a  feeling  of  weight  and  fulness,  sometimes  referred  to  the  rec- 
tum, and  with  a  dry,  glazed,  congested  appearance  of  the  mucous  membrane. 
After  the  lapse  of  a  few  hours  a  mucoid  discliarge  appears,  rapidly  becomes 
purulent,  and.  when  the  disease  involves  an  increasing  extent  of  surface,  as  it 
generally  does,  is  very  profuse,  soiling  the  posterior  portion  of  the  patient's 
linen  and  trickling  down  her  thighs  and  over  her  perineum  uidess  absorbed 
bv  suitable  dressings.  The  subjective  symptoms,  although  not  often  as  marked 
as  in  vulvitis,  are  occasionally  very  characteristic,  and  are  due  in  the  first 
place  to  the  proximity  of  the  bladder  and  rectum  to  the  inflamed  canal,  and 
in  the  second  to  the  nervous  connections  of  the  region,  giving  rise  to  certain 
reflex  phenomena.  Under  the  first  of  these  classes  may  be  enumerated  vesical 
irritability  and  tenesmus,  aching  or  throbbing  pelvic  or  hypogastric  pain, 
hemorrhoids,  dysenteric  symptoms,  prolapsus  uteri,  etc.  :  under  the  latter, 
sciatic,  crural,  lumbar,  and  abdominal  pains.  Sometimes,  when  the  inflam- 
mation has  been  very  intense  and  the  discharge  has  been  retained,  extensive 
though  superficial  ulceration  of  the  vagina  occurs,  the  pus  becomes  mingled 
with  blood,  the  pain  is  considerably  increased,  and  the  disease  assumes  a  very 
obstinate  and  rebellious  form. 

Chronic  Vaginitis. — In  the  chronic  variety  of  vaginitis  the  presence  of 
the  discharge,  tliickening  of  the  vaginal  mucous  membrane,  and  enlargement 
of  its  papilliie  are  almost  the  only  symptoms  met  with.  Now  and  then  a  ca.se 
is  seen  in  which  the  inflammation  has  become  strictly  localized,  a  small  patch 
of  strawberry-red  granulations  being  found,  analogous  to  those  seen  in  the 
urethra  in  chronic  gonorrhea,  and  on  other  mucous  membranes,  as  the  con- 
junctiva, when  iuflanmiation  assumes  this  form 

Cases  of  chronic  vaginitis  in  young  persons  are  observed  in  which  the 
vagina  is  hard  and  small,  its  ruga?  well  seen,  yet  evidently  swollen,  cedematous, 
and  with  either  no  secretion  or  covered  over  by  an  old,  grayish-white  accumu- 
lation of  epithelial  detritus. 

Urethritis. — Causes. — Urethritis  in  the  female  is  commonly  classed  as  a 
venereal  aftection.  and  is  unquestionably  due  in  a  majority  of  cases  to  extension 
of  inflammation  from  the  vulva  or  vagina,  but  it  is  unsafe  to  assume  that  any 
■woman  with  a  urethritis  has  necessarily  acquired  it  by  contagion  and  as  a  result 
of  exposure  to  the  discharge  resulting  from  a  similar  inflammation  in  the  male. 
It  may  be  admitted,  however,  that  the  existence  of  a  urethritis  in  a  female 
is  presumptive  evidence  of  impure  connection,  particularly  in  those  cases  in 
which  it  exists  independently  of  any  vulvar  or  vaginal  aft'ection.  "When  these 
regions  are  involved  the  (juestion  of  original  causation  reverts  to  them,  as  their 
inflammations  almost  invariably  precede  the  urethral  trouble. 

Symptoms. — The  shortness  of  the  female  urethra,  its  downward  inclina- 
tion from  the  neck  of  the  bladder  to  the  meatus,  and  the  comparatively  small 
amount  of  mucous  membrane  involved  prevent  at  the  same  time  the  formation 
of  any  large  amount  of  discharge  and  the  development  of  any  extremely  pain- 
ful symptoms. 

Ardor  in'mse  does  exist  in  nearly  all  cases,  and  is  sometimes  quite  marked, 
but  is  not  comparable  in  severity  to  the  same  symptom  as  observed  in  the 
male.     The  proximity  of  the  inflamed  area  to  the  neck  of  the  bladder  ren- 


srnai:!!)'  or  riii:  t; i:.\rri>-rh'i.\Mn'  ruAcr.         !)2:'> 

ders  some  dej^ret'  ot"  iiivolvciiicnt  of  tliat  viscus  (juite  coninion,  but,  although 
urination  may  be  much  too  tVecjuent,  the  degree  of  tenesmus  and  the  associated 
spasm  and  pain  are  less  distressing  than  uhen  cystitis  occurs  as  a  complication 
of  male  urethritis.  In  many  eases  the  spontaneous  emptying  of  the  urethra 
by  gravitation  or  its  washing  out  by  the  stream  of  urine  is  so  complete  that  to 
obtain  evidence  of  the  existence  of  a  discharge  it  is  necessary  to  insert  a  finger 
into  the  vaginal  outlet  and  gently  *' strip"  the  urethra  from  behind  forward, 
compressing  it  against  the  under  surface  of  the  pubic  arch.  This  should  be 
done  some  time  after  urination.  Occasionally  the  meatus  will  be  found  red, 
pouting,  or  everted,  and  it  is  sometimes  surrounded  by  a  ring  of  vegetations. 

Uterine  Gonorrhea. — The  form  of  uterine  inflammation  set  up  by  gon- 
orrhea is  usually  cndocervicitis.  In  nearly  every  case  in  which  the  upper  por- 
tion of  the  vagina  is  implicated  in  the  disease  the  os  uteri  is  bathed  almost 
constantly  during  the  height  of  the  inflammation  in  an  acrid,  irritating  pus. 
In  many  cases  the  irritation  thus  engendered,  instead  of  limiting  itself  to  the 
production  of  congestion,  abrasions,  superficial  ulcerations,  and  other  changes 
in  the  os,  extends  into  the  neck  and  sometimes  into  the  body  of  the  uterus, 
producing  in  each  instance  its  characteristic  symptoms. 

In  the  former  case  there  will  be  seen  upon  examination  with  a  speculum  a 
red,  swollen,  ulcerated  os,  from  between  the  lips  of  which  protrudes  an  albu- 
minous, mucous,  or  muco-purulent  discharge  so  viscid  and  coherent  that  it  is 
detached  with  difficulty.  When  the  disease  extends  to  the  lining  membrane  or 
to  the  body  of  the  uterus  itself,  when  it  advances  through  the  Fallopian  tube 
to  the  peritoneal  cavity  or  to  the  ovaries,  or  when  in  other  cases  it  extends 
from  the  submucous  connective  tissue  of  the  vagina  to  that  which  lines  the 
pelvis,  it  produces  complications  which  are  of  extreme  gravity. 

A  description  of  metritis,  salpingitis,  ovaritis,  peritonitis,  and  pelvic  celluli- 
tis, when  those  affections  result  from  gonorrhea,  will  be  found  in  the  chapter  on 
the  Diseases  of  the  Female  Genito-urinary  Organs. 

TEEATMEXT  OF  GONORRHEA  IN  WOMEN. 

Treatment  of  Vulvitis. — The  speedy  cure  of  a  case  of  vulvitis  depends 
upon  attention  to  the  following  points : 

The  patient  should  be  placed  at  absolute  rest,  with  the  pelvis  elevated :  this 
is  more  important  in  this  than  in  any  other  variety  of  gonorrhea  in  the  female, 
gravitation  and  the  friction  produced  by  movement  operating  powerfully  and 
prejudicially  if  the  patient  insists  upon  walking.  Perfect  cleanliness  and  dr^-ness 
of  the  parts  are  essentials  of  success  in  treatment.  The  labia  should  be  gently 
washed  every  two  hours  Avith  a  strong  solution  of  bicarbonate  of  sodium,  which 
will  dissolve  and  remove  all  accumulated  sebum  and  mucus,  and  will  at  the  same 
time  often  prove  to  be,  in  itself,  a  very  soothing  application.  In  using  this  the 
labia  should  be  gently  separated  with  the  thumb  and  fingers  of  one  hand,  while 
with  the  other  a  stream  of  the  alkaline  solution  is  squeezed  out  of  a  sponge 
held  a  short  distance  above.  After  this  operation  is  completed  a  soft  old  linen 
rag  should  be  held  in  contact  Avith  the  vulva  until  all  the  fluid  is  absorbed,  the 
parts  should  be  dusted  Avith  a  fine  poAvder  of  starch  and  oxide  of  zinc  or  of 
opium  and  lycopodium,  a  piece  of  patent  lint  should  be  carefully  interposed 
between  the  labia,  and  absolute  quiet  should  be  preserA^ed  until  it  is  time  to  re- 
peat the  dressing.  In  certain  cases  the  inflammation  runs  so  high,  and  the  swell- 
ing, pain,  and  discharge  are  so  excessive,  that  these  gentle  measures  do  not  suf- 
fice. It  Avill  then  be  necessary  to  purge,  to  employ  prolonged,  general  hot-baths 
— not  sitz-baths — to  folloAv  them  with  a  lotion  of  opium  and  lead-water  kept  con- 
tinually on  the  inflamed  region,  or  to  paint  the  entire  vulva  with  a  forty -grain 


924  A^"   AMi:in('AX    TEXT- HOOK    OF  SURGERY. 

solution  of  nitrate  of  silver.  This  last  expedient  may  be  adopted  earlier,  and 
rarely  fails  to  produce  a  fiood  effect.  Wlien  tlio  burning  and  tliroljbing  are 
very  great,  and  particularly  if  there  is  .some  constitutional  disturbance,  the  ab- 
straction of  blood  by  leeches  placed  along  the  lines  of  the  groins  and  on  the 
perineum  is  clearly  indicated.  The  diet  during  this  period  should  be  restricted, 
consisting  chiefly  of  milk  and  farinaceous  articles. 

When  it  becomes  apparent  that  a  vulvo-vaginal  gland  is  involved,  timely 
local  bleeding  may  arrest  the  inflammation,  but  if  it  fail  to  do  so  suppuration 
may  be  hastened  by  warm  fomentations,  cloths  wrung  out  of  hot  water  and  laid 
over  the  affected  labium  being  preferable  to  poultices.  The  incision  should  be 
made  on  the  inner  and  lower  aspect  of  the  swelling,  as  in  that  manner  it  is  pos- 
sible to  obtain  the  best  drainage.  In  chronic,  frequently-recurring  abscesses 
of  this  region,  instead  of  dissecting  out  the  capsule  of  the  gland,  as  has  been 
recommended,  or  of  putting  in  a  seton,  it  will  be  sufficient  to  lay  open  the 
cavity  by  a  free  incision,  and,  after  curetting,  to  pack  the  wound  with  iodo- 
form gauze. 

Treatment  of  Vaginitis. — Vaginitis  requires  the  same  general  manage- 
ment as  vulvitis,  rest  in  bed,  elevated  buttocks,  restricted  diet,  and  attention 
to  cleanliness  being  all  valuable  adjuvants  to  treatment.  The  confinement  to 
bed  is  hardly  so  imperatively  necessary  as  when  the  vulva  is  the  seat  of  the 
disease,  and  motion,  through  friction  or  in  any  other  way,  does  not  so  greatly 
aggravate  the  symptoms.  The  patient  should,  hoAvever,  be  particularly  cau- 
tioned against  undue  exercise  and  also  against  indulgence  in  sexual  intercourse. 
In  markedly  inflammatory  cases  this  will  not  be  necessary,  as  the  pain  induced 
by  attempts  at  intromission  will  be  a  sufficient  preventive.  In  cases  of  acute 
vaginitis  Avith  profuse  purulent  discharge,  tumefaction  of  the  mucous  membrane, 
etc.,  the  routine  treatment  should  be  as  follows : 

The  patient,  being  in  bed  with  the  buttocks  resting  upon  a  hair  pillow  or  a 
folded  sheet,  the  bowels  having  been  opened  with  a  saline  laxative,  should  be 
instructed  to  wash  out  the  vagina  every  two  hours  with  an  injection  of  a  pint 
or  two  of  soap  and  water,  or,  if  that  prove  irritating,  with  an  alkaline  solu- 
tion ;  to  folloAV  this  with  a  pint  of  simple  Avater ;  and  to  conclude  with  the  use 
of  a  pint  of  some  medicated  solution,  preferably  at  this  stage  one  of  acetate 
of  lead. 

The  materials  used  as  injections  are  various,  but  belong  chiefly  to  the  classes 
of  astringents  and  antiseptics.  In  the  great  majority  of  cases  it  Avill  be  found 
best  to  use  at  first  the  acetate  of  lead ;  to  folloAV  this,  as  the  pain  subsides  and 
the  inflammation  becomes  less  acute,  Avith  alum  or  the  acetate  or  sulphate 
of  zinc,  or  Avith  sublimate  solution  1  :  10,000  or  1  :  20,000,  or  Avith  peroxide 
of  hydrogen  in  combination  with  sulpho-carbolate  of  zinc ;  and,  Avhen  under 
this  treatment  the  pain  has  entirely  disappeared  and  the  discharge  has  become 
Avatery,  to  pack  the  vagina  Avith  tannin  or  to  use  suppositories  according  to  cir- 
cumstances. In  prescribing  vaginal  injections  for  Avomen  it  is  ahvays  Avell  to 
order  the  material  in  poAvder,  telling  the  patient  hoAv  much  to  dissolve  in  a 
given  quantity  of  water.  For  use  in  a  pint  of  water,  for  instance,  she  should 
employ  of 

Acetate  of  lead,  one  teaspoonful  =  three  drams  ; 
Acetate  of  zinc,  tAvo  teaspoonfuls  =  three  drams  ; 
Sulphate  of  zinc,  one  teaspoonful  =  tAvo  drams  ; 
Alum,  one  teaspoonful  =  two  drams  ; 
Tannin,  four  teaspoonfuls  =  tAvo  drams. 

These  should  be  diluted  Avhen  it  is  found  that  they  occasion  pain. 


SURGERY   OF   THE    GENITO-URINARY   TRACT.  925 

The  subsiding  stage  of  a  vaginitis  Avill  be  best  treated  with  vaginal  sup- 
positories, wliich  may  be  used  thrice  (hiily,  the  sui)ine  position  being  observed 
for  at  least  an  hour  after  the  introduction  of  each  one.  As  examples  of  useful 
formulne  the  following  may  be  given  : 

^,  Ext.  opii,  gr.  iij  ; 

Acidi  tannici,  3J  ; 

01.  theobroma?,  q.  s. 

M.  et  ft.  suppositoria  No.  xij. 

"S^  Pulv.  aluminis, 

Cerat.  plumbi  subacet.,  da  oiij  ; 
01.  theobrorafe,  q.  s. 

M.  et  ft.  suppositoria  No.  xij. 

In  ordering  these  the  patient  should  be  informed  that  they  will  stain  her  linen 
if  the  discharge  is  allowed  to  come  in  contact  with  it. 

In  some  women  w^ith  whom  oily  applications  prove  objectionable,  or  in 
those  too  poor  to  use  suppositories,  it  will  be  well  to  pack  the  vagina  with 
strips  of  patent  lint  into  the  meshes  of  which  tannin  or  powdered  alum  has 
been  rubbed. 

Occasionally,  Avhen  the  vagina  remains  irritable  and  raw,  bleeding  easily, 
it  will  be  Avell  to  apply  to  its  surface  very  thoroughly  a  strong  solution  of  nitrate 
of  silver,  40  to  60  grains  to  the  ounce  of  water.  This  is  best  done  by  inserting 
a  cylindrical  speculum,  elevating  its  outer  extremity,  pouring  into  it  two  or  three 
fluidrams  of  the  silver  solution,  and  then  gently  withdrawing  it.  As  the  w^alls 
of  the  vagina  fall  across  the  end  of  the  tube  they  will  be  thoroughly  bathed  in 
the  liquid. 

At  night  in  all  cases  of  vaginitis  it  will  be  found  convenient  to  employ 
little  pledgets  of  absorbent  cotton  into  which  some  medicated  powder  has  been 
rubbed.  The  patient  should  keep,  on  a  chair  or  table  beside  the  bed,  two  or 
three  of  these  little  rolls,  and  on  waking  during  the  night  should  insert  one 
as  far  as  the  finger  w^ill  carry  it,  first,  of  course,  withdrawing  the  previous  one. 
Lead,  zinc,  and  tannin  may  be  used  in  this  way,  the  first-named  usually  with 
the  greatest  advantage. 

Treatment  of  Urethritis. — Urethritis  in  females,  as  a  rule,  runs  its 
course  very  rapidly  and  requires  but  little  attention.  Injections  may  be  used 
by  the  surgeon,  their  strength  being  carefully  adapted  to  the  sensibility  of 
the  mucous  membrane,  and  the  probability  of  their  entering  the  bladder  being 
remembered.  The  same  principles  of  treatment  hold  good  and  the  same  solu- 
tions are  useful  as  in  urethritis  in  the  male.  Copaiba,  cubebs,  and  sandal- 
wood oil  may  also  be  administered  with  advantage,  acting  as  usual  through  the 
urine.  No  mention  has  been  made  of  their  employment  in  speaking  of  the 
treatment  of  other  forms  of  gonorrhea  in  the  female,  as  in  them  the  anti-blennor- 
rhagics  are  worse  than  useless.  Occasionally  it  may  be  necessary,  in  chronic 
cases,  to  wipe  out  the  urethra  with  a  probe  wrapped  in  cotton  and  dipped  in  a 
solution  of  from  20  to  40  grains  of  nitrate  of  silver,  and  in  some  instances  the 
solid  stick  has  been  employed. 

Treatment  of  Uterine  GonorrFiea. — The  affections  of  the  uterus  pro- 
duced by  gonorrhea  require  no  distinctive  or  peculiar  therapeutic  management. 
Nitrate  of  silver  for  abrasions,  leeches  for  congestion,  tampons  or  suppositories 
applied  through  a  speculum  and  retained  in  contact  with  the  os  by  elevation 
of  the  hips,  iodoform,  iodine,  and  all  the  well-known  articles  of  the  gyneco- 
logical armamentarium,  are  useful  here  as  in  other  uterine  affections ;  and  the 


f)26  AiY   AMEJiJCAy    TEXT- HOOK    OF  sriUiKllY. 

same  remark  applies  to  the  other  pelvic  and  ahdominal  trouhles  ^vhit•h  may 
complicate  or  follu\r  a  vaginitis. 

STRICTURE  OF  THE   URETHRA. 

To  consider  philosophically  the  treatment  of  urethral  stricture  Ave  should 
first  have  a  clear  idea  of  the  exact  pathological  conditions  which  are  to  be 
overcome.  Definitions  arc  rarely  at  the  same  time  comprehensive  and  precise, 
but  it  is  probably  a  close  approximation  to  the  truth  to  describe  stricture  as  an 
abnormal  lessening  of  the  caliber  or  of  the  dilatability  of  the  urethral  canal, 
associated  with  changes  in  the  mucous,  muscular,  or  subnmcous  structures  con- 
stituting its  walls.  This  definition  includes  the  following  chief  varieties  of 
stricture  :  (1)  inflammatory  ;  (2)  spasmodic  ;  (3)  organic. 

(1)  The  existence  of  Inflammatory  Stricture  has  been  denied  by  emi- 
nent authorities,  who  assert  that  without  congestion  of  the  prostate,  spasm  of 
the  circular  fibers,  or  pre-existent  organic  stricture  no  swelling  of  the  mucous 
membrane  alone  is  competent  to  give  rise  to  retention  of  urine.  While  this  is 
true,  it  cannot  be  disputed  that  occasionally  in  cases  of  acute  anterior  ure- 
thritis, with  no  suspicion  of  previous  stricture  and  with  the  prostate  unaffected, 
there  is  great  diminution  in  the  size  of  the  stream  of  urine,  manifestly  fi'om 
the  unnatural  approximation  of  the  swollen  urethral  Avails.  Although  the 
condition  is  almost  ahvays  of  short  duration  and  never  goes  on  to  retention,  it 
is  often  the  first  step  in  the  formation  of  organic  stricture.  The  treatment  is 
that  appropriate  to  the  form  of  urethritis  in  question. 

(2)  Spasmodic  Stricture  depends  on  a  contraction  of  the  muscular 
fibers  surrounding  the  urethra,  either  the  unstriped  or  the  compressor  urethrse, 
and  is  always  due  to  some  irritative  cause,  direct  or  reflex,  often  aided  by  such 
predisposing  causes  as  the  uric-acid  or  oxalic  diathesis,  sexual  plethora  or 
excess,  etc.  It  sometimes  depends  upon  and  complicates  organic  stricture 
situated  in  advance  of  the  seat  of  spasm.  The  immediate  treatment  consists 
in  the  use  of  a  warm  bath,  the  administration  of  morphia  or  atropia,  preferably 
by  the  rectum  or  hypodermatically,  the  use  of  diluent  drinks,  and,  of  course, 
the  removal  of  the  exciting  cause  if  it  can  bo  discovered.  The  retention  of 
urine  so  common  after  operations  \jpon  the  anus  and  rectum,  as  in  cases  where 
hemorrhoids  have  been  tied,  and  occurring  more  rarely  from  reflex  irritation 
from  a  greater  distance,  is  the  result  of  vesical  inhibition  rather  than  of  ure- 
thral spasm. 

(3)  Organic  Stricture  is  always  the  result  of  some  antecedent  injury  or 
disease:  in  the  vast  majority  of  cases  it  is  due  to  a  previous  urethritis,  and  is 
especially  apt  to  follow  those  cases  in  which  the  urethral  inflammation  has 
reached  an  exceptionally  high  grade  of  intensity,  oi",  still  more,  cases  which 
have  run  a  very  protracted  course.  The  pathological  condition  varies  from  an 
induration  and  thickening  of  the  mucous  membrane,  with  connective-tissue  pro- 
liferation occurring  in  its  depths,  to  the  formation  of  a  dense  mass  of  cica- 
tricial tissue  occupying  the  submucous  region  and  extending  into  the  meshes 
of  the  corpus  spongiosum.  The  strictured  portion  of  the  urethra  varies  greatly 
in  extent,  from  a  mere  cord-like  band,  the  so-called  linear  stricture,  to  one 
slightly  broader,  annular  stricture,  and  from  that  to  a  contraction  which  may 
involve  as  much  as  two  or  three  inches  of  the  canal,  converting  it  into  a  devious 
irregular  channel.  This  has  been  called  the  tortuous  stricture.  Many  classi- 
fications have  been  adopted,  but  this  answers  well  for  practical  purposes. 

The  situation  of  a  stricture  also  varies  greatly,  but  there  can  be  no  doubt 
that  the  great  majority  are  to  be  found   in    the   bulbo-membranous  region, 


SURGERY   OF    THE    GEXITO-rRIXA  liY    TRAi'T.  927 

which  includes  a  spnce  from  about  one  incli  in  front  of  the  anterior  hiyer  of 
the  triangular  ligament  to  the  prostato-membranous  junction.  The  next  most 
frequent  seat  is  in  the  first  two  and  a  half  inches  of  the  urethra,  and  the 
smallest  number  are  found  in  the  middle  of  the  spongy  urethra.  These 
remarks  apply  to  the  forms  of  stricture  produced  ]>y  urethritis.  Travimatic 
stricture  usually  aftects  the  membranous  urethra,  and  it  is  asserted  that  stricture 
produced  by  masturbation  is  to  be  found,  as  a  rule,  in  the  same  region.  As  a 
matter  of  fact,  however,  strictures  from  this  latter  cause  are  exceedingly  rare. 
This  is  shown  by  the  comparative  infrequency  of  strictures  among  adult  males 
of  any  community  as  compared  with  the  number  who  have  at  some  period  of 
their  lives  been  addicted  to  the  habit  of  masturbation,  and  still  more  forcibly 
by  the  history  of  persons  in  prisons,  asylums,  and  hospitals  for  the  insane, 
who  have  been  known  to  practise  the  habit  to  excess  over  long  periods,  but 
in  whom  stricture  is  not  unusually  frequent. 

If  stricture  is  no  more  common  in  such  patients  than  among  their  associates, 
it  may  safely  be  assumed  that,  at  least  as  ordinarily  practised,  masturljation 
can  only  be  productive  of  organic  stricture  with  such  rarity  as  to  make  it 
scarcely  worth  considering  as  an  etiological  factor.  The  dictum  of  Sir  James 
Paget  may  still  be  said  to  express  the  view  of  the  profession,  namely,  "  that 
masturbation  does  neither  more  nor  less  harm  than  sexual  intercourse  prac- 
tised with  the  same  frequency  in  the  same  conditions  of  general  health,  age, 
and  circumstance." 

Strictures  are  further  divided  into  irritable,  when  they  are  readily  inflamed 
and  bleed  easily  upon  the  touch  of  an  instrument,  and  resilient,  when  they  are 
elastic  and  contractile,  returning  with  great  rapidity  to  their  former  size  after 
being  dilated.  They  are  also  divided  into  those  of  small  caliber,  which  may 
be  arbitrarily  assumed  to  include  strictures  which  will  admit  only  instruments 
less  in  circumference  than  15  millimeters,  and  those  of  large  caliber,  or  strict- 
ures which  will  take  instruments  from  that  size  upward. 

These  preliminary  remarks  are  necessary  to  a  consideration  of  the  proper 
method  of  treating  strictures,  as  is  also  some  inquiry  into  the  functional 
importance  of  strictures  of  large  caliber.  That  every  urethral  coarctation 
following  urethritis  must  at  some  time  have  been  a  stricture  of  larcre  caliber 
is  self-evident,  but  just  when  such  a  stricture  becomes  an  active  pathological 
factor  and  is  able  to  give  rise  to  symptoms  is  an  unsettled  point.  Indeed,  it 
is  not  probable  that  it  ever  can  be  definitely  determined  in  a  mathematical 
sense.  The  idea  that  any  particular  fixed  caliber  represents  the  normal  con- 
dition of  the  urethra  has  for  a  long  time  been  abandoned,  the  observed  varia- 
tions of  that  canal  being  such  that  no  special  dimensions  can  be  assigned  to  it 
as  representing  the  precise  dividing-line  between  health  and  disease.  The  old 
method  of  regarding  the  size  of  the  meatus  as  an  indication  of  the  normal  cal- 
iber of  the  canal  behind  it  is  also  unquestionably  fallacious,  it  having  been 
conclusively  shown  that  no  more  definite  relation  exists  between  them  than 
between  any  other  mucous  canal  and  its  corresponding  outlet,  the  mouth  and 
the  oesophagus,  for  example,  or  the  anus  and  the  sigmoid  flexure.  That  there 
is  a  certain  correspondence  between  the  size  of  the  urethra  and  that  of  the 
flaccid  penis  is  true,  the  caliber  of  the  one  increasing  with  the  circumference 
of  the  other,  but  that  this  ratio  is  present  in  any  absolutely  unvarying  manner 
has  not  yet  been  demonstrated.  At  most,  the  size  of  the  penis  may  be  said 
to  furnish  a  general  indication  of  the  urethral  dimensions,  but  one  which  is 
approximate  merely.  On  the  other  hand,  it  has  been  shown  that  there  are 
usually  certain  normal  variations  even  in  the  spongy  portion,  and  that  it  is 
often  impossible  Avith  any  of  the  means  at  our  command  to  distinguish  between 


928  AN  AMERICAN   TEXT- BOOK   OF  SURGERY. 

these  natural  irregularities  and  coarctations  of  cfjual  caliber  due  to  incipient 
stricture. 

Those  surgeons  who  follow  the  teachings  of  Dr.  Otis  of  New  York,  whose 
valuable  work  has  added  greatly  to  our  knowledge  of  the  subject  in  question, 
accept  his  scale  of  the  relation  of  the  caliber  of  the  urethra  to  tlie  circumfer- 
ence of  the  flaccid  penis,  any  interference  with  which  they  regard  as  evidence 
of  the  existence  of  stricture.  The  figures  wliicli  Dr.  Otis  gives,  while  they 
doubtless  represent  accurately  the  distensibility  of  the  male  urethra,  do  not  by 
any  means  represent  what  can  fairly  be  called  its  normal  caliber,  and  fail  alto- 
gether to  recognize  the  ftict  that  there  are  points  of  physiological  naiTowing, 
notably  along  the  course  of  the  pendulous  urethra,  where  some  of  his  disciples 
find  the  greatest  number  of  contractions.  Sir  Everard  Home,  De  Camp,  Rey- 
bard,  and  others  long  ago  demonstrated  the  variations  in  size  and  dilatability 
of  the  different  portions  of  the  urethra,  and  Civiale  observed  that  in  the  middle 
of  the  spongy  urethra  there  is  a  notable  diminution  of  elasticity.  Weir  and 
Sands  of  New  York  confirmed  by  casts  of  the  urethra  these  older  observations, 
and  there  can  now  be  no  doubt  of  the  existence  of  such  ])liysiological  points  of 
constriction  or  of  diminished  distensibility.  Otis  in  effect  assumes  that  the 
urethra  should  be  a  tube  of  uniform  caliber,  at  least  anterior  to  the  triangular 
ligament.  The  ingenious  instrument  which  he  has  devised,  the  urethrometer, 
when  used  under  the  guidance  of  Otis's  table,  will  detect  apparent  strictures  in 
the  majority  of  normal  urethras,  and  should  be  employed  only  in  exceptional 
cases. 

The  most  valuable  urethral  instruments  for  the  purpose  of  diagnosis  are  the 
go-called  '-bougies  a  boule."  They  may  be  made  of  metal,  with  slender  stems, 
having  small  expanded  ends  or  handles,  upon  which  the  number  of  the  instru- 
ment may  be  marked,  the  opposite  end  being  tipped  with  an  acorn-shaped 
bulb  :  this  should  represent  in  millimeters  the  circumference  of  the  shoulder 
of  the  bulb.  More  satisfactory  instruments  are  the  flexible  gum  bougies 
a  boule.  The  base  of  the  acorn-shaped  bulb  should  join  the  shaft  at  almost 
a  right  angle,  and  not  at  the  large  obtuse  angle  often  found  in  impro])erly- 
shaped  instruments.  The  size  selected  for  exploration  should  be  determined 
approximately  in  the  manner  already  mentioned  by  noting  the  circumference 
of  the  flaccid  penis.  A  scale  which  diff'ers  from  that  published  by  Dr.  Otis  in 
giving  a  lower  grade  of  numbers  is  as  follows : 

A  penis  3  inches  in  circumference  at  the  middle  of  the  spongy  portion 
indicates  a  urethra  which  should  normally  admit  an  instrument  of  about  26 
to  28  millimeters  in  size ;  when  it  is  3^  inches,  the  urethra  should  have  a 
caliber  of  from  28  to  30  mm.  ;  3^  inches,  30  to  32  mm. ;  3|  inches,  32  to  34 
mm. ;  4  inches,  34  to  36  mm. ;  beyond  which  size  it  is  seldom  necessary  to  gc 
(White). 

If  the  meatus  be  too  small  to  admit  of  the  introduction  of  a  bulbous  bougie 
of  the  required  size,  it  should  be  enlarged  by  incision.  The  penis  should  then 
be  grasped  just  behind  the  corona  and  held  gently  between  the  thumb  and 
first  finger  of  the  left  hand,  the  foreskin,  if  redundant,  having  been  retracted 
The  dorsum  of  the  penis  should  ftice  the  abdominal  wall.  The  bougie,  well 
oiled,  should  then  be  passed  gently  into  the  bladder.  If  arrested,  the  point  on 
the  shaft  corresponding  to  the  meatus  should  be  marked,  the  distance  from  that 
to  the  bulb  representing  the  position  of  the  anterior  fiice  of  the  stricture.  If 
that  instrument  or  a  smaller  size  passes  through,  it  should  then,  after  a  moment's 
delay,  be  withdrawn,  and  if  during  its  outward  passage  any  contraction  is  found 
other  than  at  the  triangular  ligament  (which  has  been  shown  to  be  normal),  it 
is  probably  due  to  stricture,  though  spasm,  Avhieh  often  rehixes  after  a  few  sec- 


SURGERY    OF    THE    GENITO-URINARY    TRACT.  929 

onds  or  shifts  its  position  in  the  canal  as  measured  from  the  meatus,  may  give 
rise  to  errors  in  diagnosis.     It  cannot  always  be  recognized  with  certainty. 

By  this  smaller  scale  the  probability  of  mistaking  physiological  narrowing 
for  stricture  is  greatly  diminished,  and  cases  which  present  definite  symptoms, 
such  as  gleety  discharge,  fre(|U('nt  urination,  dribbling  at  the  end  of  mictu- 
rition, etc.,  and  in  Avhicli  sucli  an  examination  discloses  a  distinct  contraction, 
may  Avith  propriety  be  considered  as  cases  of  organic  stricture.  This  is  not 
unduly  conservative,  but  represents  fairly  the  views  of  the  majority  of  modern 
surgeons,  including  many  of  those  who,  from  special  study  and  experience, 
have  the  right  to  speak  with  authority  on-  the  subject  of  genito-urinary 
diseases. 

We  may  now  consider  the  treatment  appropriate  to  the  different  varieties 
of  organic  stricture. 

(1)  Strictures  of  Large  Caliber,  tliat  is,  of  more  than  No.  15  (French), 
situated  at  or  behind  the  bulbo-membranous  junction. 

The  stricture  having  been  located  and  measured  by  the  bulbous  bougie  in 
the  manner  above  described,  a  conical  steel  sound  a  few  sizes  larger  than  the 
bulb  which  has  passed  the  stricture  should  be  sterilized  by  heat  or  by  a  car- 
bolic lotion,  or  at  least  thoroughly  polished  by  friction  with  a  clean  towel,  and, 
after  having  been  warmed  to  the  temperature  of  the  body  and  oiled  with  1 :  40 
carbolized  oil,  should  be  carefully  introduced  through  the  stricture.  If  the 
instrument  is  used  with  ordinary  care  and  gentleness  and  has  been  properly 
sterilized,  and  if  in  passing  it  through  the  deep  urethra  the  fingers  of  the  left 
hand  of  the  surgeon  are  used  as  a  fulcrum  in  the  perineum,  and  the  long  end 
of  the  lever  is  depressed  with  slowness,  while  the  conical  point  representing  the 
short  end  is  made  to  follow  accurately  the  subpubic  curve  of  the  urethra,  the 
production  of  prostatitis,  epididymitis,  or  urethral  fever,  the  three  most  com- 
mon complications  of  rough  or  clumsy  instrumentation,  will  occur  with  extreme 
rarity.  In  the  majority  of  cases  these  complications  are  due  to  the  use  of  force 
in  the  introduction  of  the  bougie  (when  it  practically  becomes  a  divulsor,  and 
is  very  objectionable)  or  to  a  slovenly  disregard  of  antiseptic  details  in  the  use 
of  urethral  instruments. 

Sometimes  a  few  drops  of  blood  will  follow  the  withdraAval  of  the  instru- 
ment. Usually  the  next  act  of  urination  will  be  slightly  painful,  and  often  the 
gleety  discharge  which  has  caused  the  patient  to  seek  treatment  will  increase 
for  a  day  or  two.  The  use  of  an  instrument  in  this  manner  is  always  followed 
by  a  slight  and  transitory  hyperemia  of  the  region  about  the  stricture,  during 
which  condition  in  many  cases,  particularly  recent  ones,  appreciable  softening 
and  absorption  of  stricture-tissue  occur.  This  period  lasts  for  from  three  to  four 
days,  and  only  when  it  begins  to  subside  should  the  instrument  be  reintroduced. 
Ordinarily,  an  advance  of  one  or  two  numbers  of  the  French  scale  may  be 
made  each  time,  but  occasionally  the  same  instrument  must  be  introduced  at 
several  sittings  before  it  can  be  exchanged  for  a  larger  one.  This  should  be 
determined  by  the  degree  of  resistance  experienced  during  its  introduction,  the 
pain  which  it  excites  at  the  time  and  subsequently,  and  the  presence  or 
absence  of  bleeding.  Personal  experience  soon  becomes  the  safest  guide  as 
to  the  degree  to  which  dilatation  may  be  carried  at  any  particular  sitting.  The 
feelings  of  the  patient  should  always  be  consulted.  When  the  full  size  has 
been  reached  (following  the  table  given  above  as  an  approximate  guide), 
the  symptoms  will  usually  disappear,  and  after  this  it  is  necessary  only  to 
carry  on  the  dilatation  at  longer  and  longer  intervals  to  maintain  the  cure. 
Most  surgeons  have  no  difficulty  in  teaching  patients  of  average  intelli- 
gence to  use  such  an  instrument  for  themselves,  and  the  great  majority  of 

59 


980  AX   AMERICAN    TEXT-JiOOK    OF  SURGERY. 

patients  do  so  Avitliout  the  least  discomfort  or  inconvenience.  A  certain  [iro- 
portion  of  cases  under  this  plan  of  treatment  will  get  entirely  Avell,  so  that 
years  afterward  no  trace  of  stricture  can  l)e  discovered.  Others,  if  the  inter- 
vals between  the  introduction  of  the  sound  are  too  long,  will  have  slight  recon- 
traction,  shown  possibly  by  a  recurrent  gleet;  l)ut  the  rule  is  that  with  ordi- 
nary care  a  practical  cure  is  attained  by  this  method  in  the  great  majority  of 
cases.  Its  advantages  are  obvious,  and  have  for  many  years  held  for  it  the 
first  place  in  the  estimation  of  those  surgeons  whose  aim  is  to  effect  a  cure,  or  at 
least  to  cause  the  disappearance  of  all  symptoms,  while  they  at  the  same  time 
minimize  the  danger  and  inconvenience  to  the  patient,  who  even  in  those  cases 
in  which  an  entire  cure  is  not  brought  about  remains  by  this  method  master  of 
the  situation. 

In  contrast  to  this  are  presented  the  claims  of  internal  urethrotomy, 
the  merits  of  which  are  somewliat  extravagantly  vaunted  by  its  advocates, 
while  its  undoubted  dangers  are  sometimes  ignored.  We  do  not  by  this  mean 
the  danger  to  life  itself,  although  that  exists  in  a  definite  percentage  of  cases, 
but  rather  the  curvation  of  the  penis,  the  excessive  hemorrhage,  the  defective 
expulsive  power  causing  dribbling  after  urination,  etc.,  which  not  infrequently 
follow  extensive  urethrotomy. 

It  must  be  remembered  that  no  special  advantage  is  claimed  for  this  opera- 
tion unless  it  is  extensive,  the  figures  of  Otis  being  usually  adopted  by  the 
practitioners  who  habitually  employ  dilatating  urethrotomy  in  stricture  of  large 
caliber.  We  are  justified  in  saying  that  as  applied  to  the  class  of  strictures 
under  consideration  (those  of  the  deep  urethra)  the  operation  is  not  believed  by 
the  profession  nor  by  the  majority  of  those  having  special  experience  in  genito- 
urinary disease  to  be  either  safe  or  curative. 

(2)  Strictures  of  Large  Caliber  occupying  the  Pendulous  Ure- 
thra.— In  this  region  all  the  risks  of  cutting  operations  are  much  reduced, 
and,  if  scrupulous  attention  to  antiseptic  details  be  observed,  need  scarcely  be 
considered.  The  probability  of  permanent  cure  seems  also  to  be  correspond- 
ingly increased.  These  statements  are  borne  out  by  the  experience  of  many 
independent  and  unprejudiced  observers,  and  the  greatest  difterences  of  opinion 
which  exist  at  present  as  regards  these  strictures  have  reference  rather  to  their 
diagnosis,  the  frequency  of  their  occurrence,  and  their  pathological  importance 
than  to  their  treatment.  The  physiological  variations  in  the  caliber  of  the 
normal  spongy  urethra  are  considerable;  and  this  fact,  taken  in  conjunction 
with  the  excessive  estimate  of  what  constitutes  normality,  serves  to  explain  the 
extraordinary  number  of  strictures  found  in  this  region  and  operated  upon  by 
a  few  practitioners. 

As  to  the  diagnosis  of  strictures  of  large  caliber,  even  the  bougie  a  boule 
may  be  misleading  if  used  in  the  deep  urethra,  on  account  of  the  normal  points 
of  obstruction  both  to  its  introduction  and  to  its  withdrawal  which  are  there  met 
with,  while  the  urethrameter  is  similarly  misleading  in  the  pendulous  urethra, 
especially  if  its  revelations  are  interpreted  according  to  an  unnecessarily  large 
standard.  In  the  latter  region  the  normal  variations  account  satisfactorily  for 
a  certain  proportion  of  the  statements  of  a  few  writers  on  this  subject  who 
find  an  extraordinary  number  of  strictures  in  this  region.  In  the  deep  ure- 
thra it  has  been  necessary  for  them  to  account  for  their  frequent  discovery 
of  strictures,  even  in  cases  without  antecedent  history  of  venereal  disease,  by 
constituting  masturbation  an  active  etiological  factor.  Some  years  ago  it  was 
demonstrated  that  the  "deep-seated  stricture  usually  of  large  caliber  found  at 
the  subpubic  curvature  and  its  vicinity,"  and  descrii)ed  as  "an  essential  lesion 
of  masturbation,"  was  in  reality  the  point  of  normal  resistance  to  the  with- 


SURGERY    OF    THE    GEXITO-UJilXA  R  V    TRACT.  931 

drawal  of  biillious  bouizics  ottered  ])y  the  posterior  layer  of"  the  triaiiguhir  liga- 
ment (White). 

The  prostatic  urethra  being  at  once  more  movable  and  more  dilatable  than 
the  membranous  ])ortion,  the  bulb  slips  smoothly  along  it  until  the  point  is 
reached  at  -which  this  layer  of  fascia  closely  embraces  the  posterior  part  of  the 
membranous  urethra  and  the  outer  surface  of  the  prostate.  Here,  for  obvious 
reasons,  it  is  arrested,  and  it  is  at  this  moment  that  the  deceptive  sensation 
which  may  he  considered  indicative  of  the  existence  of  organic  stricture  is 
communicated  to  the  hand.  A  series  of  observations  and  dissections  u}»on  the 
cadaver  have  established  this  view,  and  eliminated  the  possibility  of  the  resist- 
ance being  due  to  a  spasm  of  the  compressor  urethrae  muscle,  which  surrounds 
the  canal  at  this  point.  Arrest  of  the  instrument  occurs  as  invariably  after 
death  as  before.  Avoiding  these  errors,  then,  and  accepting  the  lower  scale 
which  has  been  given,  the  existence  of  strictures  in  the  region  under  consider- 
ation may  be  determined  in  the  usual  way. 

As  to  treatment,  internal  urethrotomy  is  to  be  preferred  when  a  stricture 
of  the  pendulous  urethra  is  of  long  standing,  distinctly  fibrous  in  character,  or 
non -dilatable.  Resiliency  or  resistance  to  dilatation  is  indeed  the  chief  indi- 
cation for  a  cutting  operation  on  strictures  at  any  portion  of  the  urethral  tract, 
and  is  far  more  important  in  determining  the  choice  of  treatment  than  their 
caliber,  but  internal  urethrotomy  in  the  pendulous  urethra  is  particularly  satis- 
factory on  account  of  the  comparative  freedom  from  danger  which  has  already 
been  mentioned.  As  to  the  probability  of  eff'ecting  thereby  a  permanent  cure, 
while,  as  has  been  said,  it  is  much  greater  here  than  elsewhere,  such  a  cure  can 
be  expected  in  only  a  limited  proportion  of  cases.  It  is  not  in  accord  with  other 
pathological  observations  to  suppose  that  the  mere  division  of  a  dense  and  old 
contractile  band  of  fibrous  tissue  will  result  in  its  absorption  ;  and  the  majority 
of  the  true  strictures  of  the  spongy  urethra  which  are  cured  by  internal  ure- 
throtomy are  those  in  which  the  division  of  the  stricture  is  supplemented  by  the 
use  for  some  time  of  full-sized  bougies.  The  relief  of  tension  aftbrded  by  the  sec- 
tion of  the  stricture  gives  full  play  to  "  inflammatory  atrophic  dilatation,"  and 
in  a  certain  pi'oportion  of  cases  retrograde  metamorphosis  and  absorption  take 
place  or  at  least  a  thinning  and  weakening  of  the  fibrous  band,  which  results 
in  its  practical  disappearance  as  a  cause  of  obstruction.  It  is  probable,  how- 
ever, on  both  clinical  and  pathological  grounds,  that  the  great  majority  of 
so-called  strictures  of  the  pendulous  urethra  which  are  cut  by  the  extremists 
in  urethrotomy  are  merely  points  of  physiological  narrowing,  and  the  so-called 
"cures"  are  merely  illustrations  of  the  fact  that  by  a  linear  incision  into  its 
long  axis  we  can  put  in  the  normal  urethra  a  longitudinal  splice  of  fairly 
healthy  tissue  which  has  but  little  tendency  to  contract  afterward,  and  can 
thus  more  or  less  permanently  enlarge  the  urethral  caliber.  This  fact  also 
explains  the  freedom  from  fiital  results  claimed  by  some  surgeons  who  find 
strictures  and  do  urethrotomies  in  the  great  majority  of  their  cases  of  chronic 
urethral  discharge.  As  there  has  been  no  real  interference  with  the  genito- 
urinary functions,  there  has  been  no  development  of  renal  or  vesical  disease, 
and  the  urethra  can  be  operated  upon  and  the  "splice"  introduced  with  com- 
parative impunity.  It  is  difficult  to  see,  however,  how  such  a  splice  would 
prevent  the  steady  contraction  of  a  mass  of  old  cicatricial  tissue,  such  as  occu- 
pies the  wall  of  the  canal  and  the  peri-urethral  space  in  strictures  of  some 
standing. 

The  proportion  of  cases  in  which  true  strictures  of  large  caliber  in  the 
pendulous  urethra  require  internal  urethrotomy  varies  largely  with  the  character 
of  the  patients  among  whom  the  surgeon  practises.     In  hospital  and  dispensary 


932  AN  AMERICAN    TEXT-BOO  A'    OF  SURGERY. 

services,  and  among  the  poorer  classes  generally,  strictures  quite  frequently 
will  be  found  to  have  been  neglected,  and  almost  always  will  be  of  long  stand- 
ing before  the  patient  presents  himself  for  treatment,  even  if  they  are  not 
of  small  caliber.  They  will,  therefore,  recjuire  urethrotomy  in  a  much  larger 
percentage  of  cases  than  will  be  found  among  private  patients  of  good  social 
position.  Among  the  latter  perhaps  not  more  than  one  in  eight  or  ten  needs 
such  operative  measures,  gradual  dilatation,  as  above  described,  amply  suf- 
ficing in  the  remainder  to  cause  the  disappearance  of  all  symptoms,  and  some- 
times of  the  stricture  itself  when  it  is  soft  and  of  recent  formation.  Indeed, 
even  in  older  cases  a  notable  amount  of  absorption  of  the  indurated  band  con- 
stituting the  stricture  can  often  be  observed,  and  its  diminution  from  dav  to 
day  can  be  verified  by  the  touch  when  the  urethra  is  stretched  over  a  full- 
sized  sound. 

The  exact  time  at  which  a  urethral  coarctation  becomes  of  definite  patho- 
logical importance  is,  as  has  been  said,  still  unsettled ;  but  that  strictures  of 
large  caliber  are  occasionally  the  cause,  not  only  of  gleet,  frequent  micturition, 
dribbling,  and  other  urinary  symptoms,  but  also  of  reflex  pains  and  of  impo- 
tence and  other  forms  of  sexual  disorders,  is  certainly  true. 

The  increased  friction  and  resistance  resulting  from  even  a  slight  fibrous 
peri-urethral  deposit  disturb  the  normal  relations  of  the  bladder,  and  by 
rendering  it  irritable  bring  on  the  symptom  of  frequent  micturition.  The 
imperfect  closure  of  the  tube,  the  muscular  action  of  which  at  the  point  of 
deposit  is  materially  interfered  with,  causes  the  equally  imperfect  expulsion 
of  the  last  drops  of  urine  and  produces  another  characteristic  symptom,  drib- 
bling at  the  end  of  micturition  ;  the  retention  and  decomposition  of  these  last 
drops,  together  with  the  abnormal  friction  between  the  stream  of  urine  and 
the  urethral  walls,  give  rise  to  a  subacute  inflammation  of  the  mucous  mem- 
brane, accompanied  by  a  catarrhal  or  muco-purulent  discharge,  constituting 
the  condition  of  gleet ;  by  reflex  irritation  transmitted  from  the  area  of  inflam- 
mation pains  in  remote  organs  and  situations  are  developed,  notably  in  the 
lumbar  and  hypogastric  regions. 

This  relation  of  cause  and  eff'ect  has  been  in  the  main  accepted  as  correct 
by  the  profession  for  many  years.  The  difl"erences  of  opinion  which  now  exist 
are  chiefly  as  to  the  amount  of  urethral  contraction  which  is  sufficient  to  pro- 
duce noticeable  eff'ects ;  and  here  the  evidence  must  rest  upon  clinical  observa- 
tions supported  by  the  results  of  autopsies. 

(8)  Strictures  of  the  Meatus  and  of  the  Neighborhood  of  the 
Fossa  Navicularis. — In  this  region  dilatation  is  peculiarly  unsatisfactory. 
Owing  to  the  intimate  relation  between  the  spongy  tissue  of  the  glans  and  the 
urethra,  to  the  exceptionally  rich  nerve-supply  to  the  part,  and  to  the  extreme 
sensibility  characteristic  of  muco-cutaneous  outlets,  the  stretching  of  the  stricture 
by  means  of  sounds  gives  rise  to  pain,  irritation,  and  inflammation.  For  these 
reasons,  and  on  account  of  the  absolute  safety  of  the  procedure,  it  is  better  to 
divide  all  such  strictures  than  to  attempt  to  dilate  them.  But  while  the  cutting 
of  true  strictures  in  the  anterior  urethra  is  good  surgery,  the  division  of  every 
narrower  point  at  the  meatus  and  in  the  first  few  inches,  simply  Ijccause  those 
points  are  (as  they  should  be  normally)  of  smaller  caliber  than  other  ]»oints  in 
the  canal,  is  routine  surgery  of  a  very  unprofitable  sort. 

The  operation  of  meatotomy  is  best  done  with  a  probe-pointed  tenotome 
with  the  usual  convex  cutting  edge.  The  incisio«  should  be  made  upon  the 
floor  of  the  urethra,  and  should  be  sufficient  to  remove  entirely  all  sense  of 
resistance  upon  the  withdrawal  of  a  full-sized  Inilbous  bougie.  It  should  be  a 
little  larger  than  the  caliber  which  it  is  desired  to  establish  permanently,  so  as 


SURGERY    or    TIU-:    GEXITO-URIXARY    TRACT.  933 

to  allow  for  subsequent  contraction.  Like  all  other  operations  upon  the  ure- 
thra, it  should  be  done  with  scrupulous  attention  to  antiseptic  details.  A  short, 
straight,  conical  bougie,  the  so-called  meatus  sound,  should  be  gently  inserted 
once  in  twenty-four  hours  during  the  healing  process.  Deeper  troubles,  unless 
urgent  in  their  character,  should  be  ignored  until  healing  is  complete.  Some- 
times, but  much  more  i-arely  tlian  is  generally  supposed,  such  troubles,  although 
previously  thought  to  be  organic,  will  be  found  to  have  disappeared.  In  those 
cases  they  have  probably  been  due  to  reflex  irritation,  but  this  condition  never 
occurs  except  in  conjunction  with  a  pinhole  meatus  or  with  a  distinctly  stric- 
tured  condition  of  the  urethra  in  its  vicinity.  The  production  of  deep  urethral 
spasm  as  a  result  of  the  so-called  anterior  stricture  of  large  caliber,  either  at 
the  meatus  or  elsewhere,  is  open  to  grave  doubt. 

(4)  Strictures  of  Small  Caliber  (less  than  15  French)  situated  in 
advance  of  the  bulbo-membranous  junction. — Strictures  of  this  cal- 
iber in  this  region,  unless  seen  very  early  and  found  to  be  unusually  soft  and 
dilatable,  furnish  the  typical  condition  for  internal  urethrotomy,  that  in  which 
it  is  attended  with  the  minimum  of  danger  and  with  the  greatest  prospect  of 
effecting  a  permanent  cure.  The  operation  may  be  performed  with  the  instru- 
ment which  the  surgeon  happens  to  prefer,  the  essentials  to  success  being  a 
linear  division  in  the  roof  of  the  urethra  of  every  portion  of  strictured  tissue,  the 
incision  extending  from. the  normal  parts  behind  to  the  normal  parts  in  front 
of  the  stricture.  If  the  contraction  is  of  very  small  caliber,  a  Maisonneuve 
urethrotome  may  be  passed  through  it  over  a  filiform  guide,  and  a  preliminary 
urethrotomy  done,  so  that  one  of  the  various  forms  of  dilating  urethrotomes 
may  be  passed  through  it  and  the  stricture  freely  divided  from  behind  for- 
ward. A  bougie  a  boule  should  then  be  used  to  demonstrate  the  complete 
division  of  the  stricture,  a  large-sized  gum  catheter  passed  and  tied  in  the 
bladder,  and  bleeding  controlled,  if  necessary,  by  the  application  of  a  firm 
bandage.  The  moderate  risk  attending  this  operation  is  reduced  to  its  smallest 
proportion  by  the  employment  of  sterilized  instruments  ;  the  use  of  urethral 
irrigation  before,  and,  if  necessary,  after,  the  operation ;  the  administration 
of  internal  remedies  which  tend  to  sterilize  the  urine ;  and  attention  to  the 
various  details  of  antisepsis  as  applied  to  genito-urinary  surgery. 

A  few  days  after  the  operation  a  full-sized  bougie  should  be  gently  passed, 
and  should  be  used  afterward,  as  in  cases  of  dilatation,  for  some  weeks.  Often 
it  will  be  necessary  to  pass  it  at  intervals  for  a  much  longer  period.  In  a 
fair  proportion  of  cases  an  apparent  cure  follows. 

(5)  Strictures  of  Small  Caliber  (less  than  15  French)  situated  at 
or  deeper  than  the  bulbo-membranous  junction. — The  diagnosis  of 
these  strictures,  which  are  surgically  most  important,  can  be  made  either  by 
means  of  a  bulbous  bougie,  if  it  is  possible  to  pass  one  through  them,  or  by 
introducing  a  sterilized  sound,  well  warmed  and  oiled,  down  to  the  anterior 
face  of  the  contraction.  They  will  usually  be  accompanied  by  gleet  and 
marked  vesical  symptoms,  increasing  in  severity  with  the  tightness  of  the 
stricture.  The  choice  of  treatment  lies  between  dilatation  and  some  form  of 
urethrotomy.  Divulsion  is  so  clumsy,  so  uncertain,  and  so  dangerous  as  to 
have  to-day  almost  no  advocates,  and  to  enter  into  argument  against  it  would 
be  therefore  a  waste  of  time. 

In  beginning  the  treatment  of  such  a  stricture  as  we  are  considering  we 
should  attempt,  first,  with  great  gentleness,  to  pass  through  it  a  steel  sound, 
provided  its  introduction  re([uires  no  force  Avhatever.  Below  8  or  10  of  the 
French  scale  we  should  not  go,  as  a  rule,  in  the  use  of  metal  instruments,  as 
in  the  most  skilful  and  experienced  hands  there  is  a  distinct  and  unavoidable 


i>34  ^.V    AMi:in<AX    TEXT- HOOK    OF   SVllOEHY. 

danger  of  laceration  of  tlie  inHanictl  an<l  degenerated  mucous  membrane  around 
the  strictured  region,  and  of  tlie  formation  of  a  ''false  passage" — i.  e.  of  per- 
foration of  the  urethral  wall.  If  a  sound  (jf  whatever  size  is  passed  through 
the  stricture,  it  should  be  allowed  to  remain  for  from  five  to  ten  minutes  and 
then  withdrawn.  If  it  is  the  first  ex|»erience  witli  the  patient,  it  is  best  to 
avoid  further  instrumentation  for  from  twenty-four  to  seventy-two  hours,  in  the 
mean  time  administering  five-grain  doses  of  salol  or  boric  acid  four  times  daily, 
with  a  full  dose  of  quinine  night  and  morning.  At  the  next  sitting  it  is 
often  well  to  recommence  with  the  same  instrument,  after  which  one,  two,  or 
three  larger  sizes  may  be  used  in  succession  if  their  introduction  is  easy  and 
is  not  accompanied  by  pain  or  followed  by  bleeding.  Pain  and  hemorrhage  are 
unmistakable  indications  for  lengthening  the  intervals  and  for  proceeding  with 
greater  slowness  in  the  use  of  larger  instruments. 

Once  fairly  established,  however,  the  treatment  by  dilatation  is  carried  on 
as  described  above,  the  full  normal  caliber  being  usually  reached  in  two  or 
three  weeks.  If  the  stricture  is  not  resilient  or  irritable  or  traumatic  in  its 
origin,  it  will  be  found  that  all  symptoms  have  disappeared,  unless,  perhaps, 
the  gleet  persists  for  a  time,  but  this,  too,  will  finally  subside.  If  the  stricture  be 
a  recent  one,  it  also  may  undergo  absorption,  but  in  any  event  the  occasional  in- 
troduction by  the  patient  of  a  steel  sound  will  always  keep  the  case  under  control. 

In  the  case  of  resilient,  irritable,  or  traumatic  stricture  in  this  region,  or 
of  stricture  which  for  any  reason,  as  the  occurrence  of  rigors,  is  non-dilatable, 
external  ])eriiieal  nrethrotomy  is  the  operation  of  choice. 

(6)  Strictures  of  the  Deep  Urethra  permeable  only  to  Filiform 
Bougies. — In  certain  cases  no  steel  sound  and  no  ordinary  soft  instrument  can 
be  made  to  pass  the  stricture,  but  a  persevering  trial  with  filiform  bougies  made 
of  whalebone  will  result  in  the  pa.ssage  of  one  into  the  bladder.  This  trial 
should  be  made  persistently  and  patiently,  and  in  the  absence  of  retention  of 
urine  may  be  repeated  on  successive  occasions.  At  the  first  sitting,  if  a  fili- 
form having  been  passed  down  to  the  stricture  refuses  to  enter  it.  it  should  be 
withdrawn  and  bent  to  an  angle  of  45°  bv  Ijcnding  it  across  the  thumb-nail  from 
one-quarter  to  one-third  of  an  inch  from  the  end  (Fig.  8(57).  The  orifice  of  a 
tight  stricture  is  frequently  not  in  the  middle  of  the  obstructed  urethi-a,  but  is  to 
be  found  at  some  point  around  its  circumference  ;  and  the  little  manoeuver  above 
described  will  often  enable  the  surgeon  to  enter  it  when  with  a  perfectly  straight 
filiform  he  cannot  do  so.  If  this  does  not  succeed,  several  filiforms  should  be 
passed  by  the  side  of  the  first  one,  so  as  to  impinge  upon  the  irregular  ante- 
rior face  of  the  stricture  at  a  number  of  points.  By  attempting  to  pass  first 
one  and  then  another  of  these,  the  instrument  bearing  the  right  relation  to 
the  orifice  will  often  be  found  and  passed  into  the  bladder.  If  this  fails,  or  if 
one  filiform  can  merely  be  engaged  in  the  stricture,  but  cannot  be  made  to 
pass  through  it,  it  is  proper,  in  the  absence  of  retention,  to  tie  it  in  jilace  and 
allow  it  to  remain  in  situ  for  twenty-four  hours.  In  the  great  majority  of  cases 
at  the  end  of  that  time  it  can  be  passed  with  comparative  ease  into  the  bladder. 
There  is  no  objection  to  still  longer  delay  or  to  repeated  trials  if  no  urgent 
symptoms  be  present. 

After  the  first  instrument  is  introduced  in  such  a  case,  four  courses  are 
open  to  the  surgeon  :  (1)  lie  may  allow  it  to  remain  in  place,  with  the  cer- 
tainty that  in  one  or  two  days  others  may  be  sli|)pe(l  alongside  of  it,  and  may 
be  used  as  guides  for  the  introduction,  first,  of  a  tunnelled  catheter,  and  later 
of  the  ordinary  soft  or  steel  bougies;  (2)  he  may  attempt  to  conduct  a  tun- 
nelled catheter  over  it  into  the  bladder  at  once,  to  be  followed  by  gradual 
dilatation  ;  (3)  he  may  conduct  over  jt  a  tunnelled  and  grooved  staff  and  pro- 


sc/!<; /■:/:)■  or  ////■:  (;/:\/To-r/u\A/n'  t/^act.         935 

ceed  to  tlie  pcrfonnanof  of  external  j»eriiieal  iiietlircttdiuy  ;  (4)  lie  may  use  it 
as  a  guide  for  a  Maisonneuve  urethrotome,  an<l  may  immediately  perform  in- 
ternal urethrotomy. 

These  procedures  have  hccii  menti(»ned  in  the  ftrder  of  preference  and  of 
safety.  If  the  stricture  which  is  heing  dealt  with  is  not  of  traumatic  origin 
and  is  not  known  to  be  specially  resilient  or  irritable,  the  first  method  will 
lead  up  to  the  adoption  of  gradual  dilatation,  with  the  greatest  degree  of  com- 
fort and  absence  of  anxiety  to  both  patient  and  surgeon.  Even  if  there  has 
been  moderate  retention,  it  is  absolutely  certain  that  the  urine  will  pass  with 
increasing  freedom  by  the  side  of  the  filiform,  and  that  the  danger  of  the  case, 
so  far  as  retention  is  concerned,  is  at  an  end.  If  retention  has  been  complete 
for  a  long  time  and  is  threatening,  and  the  need  for  immediate  relief  is  marked, 
it  is  well  to  adopt  the  second  method  and  endeavor  to  catheterize  at  once. 
Failing  in  this,  the  third  procedure  should  be  employed  in  all  cases  of  urgency 
and  in  all  cases  of  traumatic,  resilient,  or  irritable  stricture,  as  well  as  in  cases 
in  which  there  is  a  history  of  fre(iuent  rigors  after  instrumentation.  The  ope- 
ration is  simple,  is  easily  performed,  and  has  a  very  small  mortality.  If  the 
median  line  of  the  perineum  be  rigidly  followed,  hemorrhage  is  insignificant, 
and  in  no  event  is  likely  to  be  dangerous.  The  stricture  is  freely  divided, 
and,  although  not  frequently  cured,  may  be  left,  as  in  a  successful  dilatation, 
entirely  under  the  control  of  the  patient  and  the  surgeon,  the  urethra  having 
been  restored  to  its  full  caliber.  The  fourth  procedure  should  be  employed 
onlv  in  those  cases  in' which  the  patient  refuses  to  have  the  external  operation 
performed.  It  is  attended  in  the  best  hands  with  a  distinctly  larger  mortality 
than  any  of  the  other  methods  mentioned,  and  there  is  no  reliable  evidence 
that  it  is  followed  by  any  larger  percentage  of  permanent  cures. 

(7)  Impassable  Strictures  of  the  Deep  Urethra. — If  the  methods 
of  procedure  which  have  been  described  are  adopted,  very  few  strictures  will 
fall  into  this  class,  but  occasionally,  in  spite  of  the  most  persistent  efi"orts,  no 
instrument  can  be  made  to  enter  the  bladder.  Sometimes  the  distended  and 
chronically  inflamed  urethra  behind  such  strictures  will  have  given  way  and 
permitted  the  leakage  of  a  greater  or  less  quantity  of  urine  into  the  surround- 
ing structures.  In  either  of  these  events  the  operation  of  perineal  section 
becomes  imperatively  necessary. 

There  has  alwavs  been  more  or  less  confusion  in  the  nomenclature  of  the 
perineal  operation  for  the  relief  of  strictures.  The  old  '*  houtonniere  opera- 
tion "  of  Desault  (of  which  the  so-called  "  Cock's  operation  "  is  a  modifica- 
tion) had  for  its  object  the  establishment  of  an  opening  from  the  perineum 
into  the  bladder,  was  usually  effected  by  opening  the  urethra  behind  the 
obstruction,  Avas  purely  palliative,  and,  if  it  ever  resulted  in  a  cure,  did  it  by 
accident,  as  the  procedure  itself  did  not  include  of  necessity  any  division  or 
enlargement  of  the  strictured  portion  of  the  canal.  It  was  an  "  external 
urethrotomy,"  to  be  sure,  but  it  was  not  related  either  in  its  purpose  or  in 
its  method  to  the  other  operations  known  by  that  name.  Since  Syme  revived 
and  popularized  the  operation  of  external  urethrotomy — the  division  of  a 
stricture  upon  a  grooved  staff  pa.?sed  through  it  into  the  bladder — more  system 
has  been  introduced  into  the  terms  employed,  but  there  is  still  much  objection- 
able looseness.  Hunter,  Grainger,  C.  Bell,  and  others  had,  before  Syme's 
time,  formulated  the  operation  known  as  ^'■perineal  section,"  which  was  also 
an  external  urethrotomy,  but  which  was  then  restricted  to  those  eases  in  which 
no  instrument  whatever  could  be  made  to  pass  the  stricture.  The  term  should 
still  be  reserved  for  such  ca.ses,  and  on  account  of  its  brevity  is,  perhaps,  pref- 
erable to  its  synonym,  "external  perineal  urethrotomy  without  a  guide." 


936  .l.V    A.VERICAN    TEXT-JIOOK    OF  SURGERY. 

As  to  the  symptoms  of  extravasation  ^vllicll  indicate  the  immediate 
performance  of  this  operation,  the  urethra  may  be  divided  into  four  re<rions. 
In  all  that  part  from  the  meatus  to  the  scrotal  curve  extravasation  is  accom- 
panied by  a  swelling  of  the  penis,  greatest  in  the  immediate  neighl)orhood  of  the 
point  of  escape.  In  the  region  included  between  the  attachment  of  the  scrotum 
and  the  anterior  part  of  the  bull),  the  course  of  extravasated  urine  is  governed 
by  the  attachments  of  the  deep  layer  of  the  superficial  fascia  or  the  fascia  of 
Colles.  Extravasation  of  urine  occurring  through  a  solution  of  continuity  in 
the  bulbous  region  of  the  urethra  will  first  follow  the  space  enclosed  by  this 
fascia  in  front  and  below  and  by  the  anterior  layer  of  the  triangular  ligament 
posteriorly,  and,  as  it  cannot  reach  the  ischio-rectal  space  on  account  of  the 
attachment  of  the  fascia  to  the  base  of  the  ligament,  and  cannot  reach  the 
thighs  on  account  of  the  insertion  of  the  fascia  into  the  ischio-pubic  line,  it  is 
directed  into  the  scrotal  tissues,  and  thence  up  between  the  pubic  spine  and 
symphysis  until  it  reaches  the  abdomen. 

Fig.  371. 


A'i*" 


The  Fascia  of  the  L'rethra,  Prostate,  and  Bladder :  r,  rectum ;  s,  symphysis  pubis ;  b,  bladder ;  p,  prostate 

(Macalister). 

If  it  escapes  from  the  membranous  urethra,  the  extravasated  urine  will 
be  confined  to  the  region  included  between  the  layers  of  the  triangular  liga- 
ment, and  will  gain  access  to  other  parts  only  after  suppuration  and  sloughing 
have  given  it  an  outlet,  and  the  consecutive  symptoms  will  then  depend  upon 
the  portion  of  the  aponeurotic  wall  which  first  gives  way.  If  the  opening  is 
situated  behind  the  posterior  layer  of  the  triangular  ligament — i.  e.  in  the  pros- 
tatic urethra — the  urine  either  may  follow  the  course  of  the  rectum,  making 
its  appearance  in  the  anal  perineum,  or,  as  it  is  separated  from  the  pelvis  only 
by  the  thin  pelvic  fascia,  may  make  its  way  through  the  latter  near  the  pubo- 
prostatic ligament,  where  it  is  especially  weak,  and  may  spread  rapidly  through 
the  subperitoneal  connective  tissue.  Fig.  371  shows  the  fascire  influential  in 
dii'ecting  extravasated  urine. 

Urethral  Fistul.*;. — The  extravasation  of  urine  behind  a  stricture  may 


SURGERY    OF    THE    GENITO- URINARY    TRACT.  937 

be  small  in  amount  and  may  take  place  almost  unol)serve<l  by  the  patient. 
At  first  a  mere  leakage  of  a  drop  or  two  of  urine,  it  later  causes  suppuration 
in  the  peri-urethral  tissues,  and  there  results  an  abscess,  which,  if  it  breaks 
externally,  causes,  according  to  its  location,  a  urethro-penile,  urethro-perineMl, 
or  uri'thro-rcctaJ  fistula.  Other  causes  may  operate  to  produce  these  condi- 
tions, but  stricture  is  by  far  the  most  common.  The  diagnosis  is  usually  easily 
made  by  observation  of  the  exit  of  urine  through  the  abnormal  channel,  and 
by  careful  probing  from  without  inward  through  the  fistula  while  a  steel  sound 
is  in  the  urethra.  The  treatment  when  the  stricture  is  passible  consists,  first, 
in  restoring  the  normal  caliber  of  the  urethra,  and  then  curetting  or  laying 
open  the  fistulous  tract ;  after  which  the  urine  should  be  drawn  either  by 
means  of  a  retained  catheter  or  by  regular  catheterization. 

Perineal  Section. — In  the  presence  of  retention  or  extravasation  of 
urine  in  a  case  of  stricture  in  which  catheterization  is  impossible  there  can  be 
no  doubt  as  to  the  proper  procedure.  Immediate  perineal  section  is  so  evi- 
dentlv  the  only  operation  which  meets  all  the  indications  that  no  other  can  be 
seriously  considered.  The  steps  of  the  procedure  are  obvious  and  beyond  dis- 
pute, except  as  to  a  few  points  which  may  be  mentioned. 

In  all  cases  in  which  perineal  section  is  performed  for  stricture  impass- 
able, but  without  other  complications,  the  method  of  Mr,  Wheelhouse  of 
Leeds  seems  to  meet  every  indication.  The  passage  of  the  staff"  to  the 
stricture  shows  the  exact  site  of  the  latter ;  the  insertion  of  the  threads  into 
the  divided  urethra  not  only  serves  to  hold  it  open  and  give  an  opportunity 
for  the  discovery  of  the  proximal  portion,  but  also  fixes  the  anterior  end  and 
renders  it  easily  recognizable  during  the  operation.  The  least  useful  direction 
which  Mr.  Wheelhouse  gives  is  that  of  turning  the  staff"  with  the  concavity  of 
the  curve  upward,  so  as  to  hook  it  into  the  upper  portion  of  the  urethral  wound. 
The  instrument  is  sometimes  in  the  way,  has  to  be  held  by  an  assistant,  and 
does  not  aff"ord  much  help  during  the  operation. 

If  persevering  search  fails  to  reveal  the  proximal  end  of  the  ui'ethra  in 
cases  of  traumatic  stricture  with  practical  obliteration  of  the  canal,  are  supra- 
pubic cystotomy  and  retrograde  catheterization  justifiable?  This  may  be 
answered  affirmatively,  though  such  failure  should  be  very  exceptional.  If 
the  bladder  contains  urine,  and  particularly  if  it  is  distended,  pressure  on  the 
hypogastriura,  or  bimanual  pressure  with  the  fingers  of  one  hand  on  the  abdo- 
men and  of  the  other  in  the  rectum,  will  often  cause  a  jet  of  urine  to  issue 
from  the  proximal  end,  and  thus  at  once  disclose  its  situation.  Hemostasis  in 
the  whole  wound  by  very  hot  water  will  sometimes  reveal  the  urethra  by 
emphasizing  the  difference  between  its  color  and  the  surrounding  parts,  the 
urethra  generally  being  much  paler.  The  relation  to  the  pubes  and  to  the 
lower  edge  of  the  triangular  ligament  should  be  most  carefully  borne  in  mind, 
the  search  for  the  torn  end  in  ruptures  or  for  the  portion  behind  the  stricture 
in  those  cases  being  frequently  carried  too  near  the  pubes.  The  membranous 
urethra  in  the  adult  usually  runs  through  the  ligament  about  one  inch  below 
the  symphysis  and  about  three-quarters  of  an  inch  above  the  perineal  center. 
All  guides,  however,  fail  occasionally  in  certain  of  these  cases,  and  it  is  then 
that  suprapubic  cystotomy  is  warranted,  as  an  operation  with  so  small  a  mor- 
tality that  the  slight  additional  risk  is  far  outweighed  by  the  advantages  to 
the  patient  of  having  even  an  imperfect  restoration  of  the  urethral  canal. 

Much  difference  of  opinion  exists  as  to  the  value  of  a  retained  catheter 
after  perineal  operations  opening  the  urinary  tract.  Many  authorities  advise 
that  in  cases  of  section  for  stricture  no  instrument  be  employed,  or  that, 
at  most,  a  short  perineal  drainage-tube  be  used.     Others   direct  that  it  be 


iK]H  AX  AMr.L'icAX  TEXT-iujoK  (jF  sri:(;i:ny. 

kt'j>t  in  fur  forty-eight  hours  and  then  withdnuvn.  The  retained  catheter  is, 
however,  of  great  value  in  all  operations  connecting  the  bladder  with  the 
surface  of  the  body,  not  excepting  certain  cases  of  lithotomy  witli  purulent 
cystitis.  If  Spence's  caution  is  observed  and  it  is  not  allowed  to  fjroject  far 
into  the  bladder,  and  if  it  is  kept  clean  and  sweet  by  regular  antiseptic  injec- 
tions, it  is  of  tlic  utmost  advantage  in  aiding  in  the  prevention  of  urethral 
fever,  as  has  been  shown  by  Keyes,  Harrison,  Diday,  Shield,  Davies,  Hill, 
White,  and  many  others.  Of  equal  importance  is  regular  catiieterization  at  short 
intervals,  begun  after  the  removal  of  the  catheter  first  introduced.  A  decided 
febrile  movement  after  urethral  operations  will  often  disappear  or  reappear 
in  accord  with  the  employment  or  the  neglect  of  the  catheter.  The  traumatic 
urethritis  to  wliich  the  retained  catheter  or  the  frequent  use  of  the  instrument 
is  said  to  give  rise  will  almost  disappear  from  one's  practice  if  antiseptic  irri- 
gation is  employed  in  such  cases,  and  particularly  if  especial  attention  is  paid 
to  the  sterilization  of  the  urine  by  the  internal  administration  of  antiseptics. 
The  sterilization  of  urine  by  boric  acid  or  by  salol  is  of  great  in.portance  in 
the  after-treatment  of  all  these  cases,  and  should  never  be  omitted.  These 
remedies  are  more  effective  if  combined  with  full  doses  of  quinine,  but  either 
of  them  is  far  more  useful  than  quinine  alone.  They  should  be  given  with 
more  freedom  and  more  regularity  in  urethral  and  vesical  operations. 

The  conclusions  as  to  the  treatment  of  organic  strictures  of  the  urethra 
may  be  summed  up  as  follows : 

1.  Strictures  of  large  caliber — tliat  is,  more  than  15  French — situated  at 
or  behind  the  bulbo-membranous  urethra  are  to  be  treated,  almost  without 
exception,  by  gradual  dilatation. 

2.  Strictures  of  large  caliber  occupying  the  pendulous  urethra  are  to  be 
treated  by  gradual  dilatation  wlien  very  recent  and  soft,  and  by  internal 
urethrotomy  when  of  longer  standing,  distinctly  fibrous  in  character,  or  non- 
dilatable.  It  is  to  be  I'emembered  that  the  great  majority  of  so-called  strictures 
of  large  caliber  of  the  pendulous  urethra  are  merely  points  of  physiological 
narrowing. 

3.  Strictures  of  the  meatus  and  of  the  neighborhood  of  the  fossa  navicu- 
lars should  be  divided  upon  the  floor  of  the  urethra  wlienever  it  is  evident 
that  they  are  real  pathological  conditions  producing  definite  symptoms,  and 
not  normal  points  of  narrowing. 

4.  Strictures  of  small  caliber  (less  than  15  French)  situated  in  advance 
of  the  bulbo-membranous  junction,  unless  seen  very  early  and  found  to  be 
unusually  soft  and  dilatable,  furnish  the  typical  condition  for  internal  ure- 
throtomy, which  should  be  done  preferably  with  a  dilating  urethrotome,  and 
invariably  Avith  all  possible  antiseptic  precautions. 

5.  Strictures  of  small  caliber  (loss  than  15  French)  situated  at,  or  deeper 
than,  the  bulbo-membranous  junction  should  be  treated  Avhenever  possible  by 
gradual  dilatation.  In  a  case  of  resilient,  irritable,  or  traumatic  stricture  in 
this  region,  or  of  stricture  which,  for  any  reason  (as  the  occurrence  of  rigors), 
is  non-dilatable,  external  perineal  urethrotomy  is  the  operation  of  choice. 

6.  Strictures  of  the  deep  urethra  permeable  only  to  filiform  bougies  should 
be  treated  by  gradual  dilatation  when  possible,  the  filiform  being  left  in  xitti 
for  some  time,  and  followed  by  the  introduction  of  others  or  used  as  a  guide 
for  a  tunnelled  catheter.  If  the  stricture  be  not  suitable  for  dilatation,  exter- 
nal perineal  urethrotomy  should  be  performed. 

7.  Impassable  strictures  of  the  deep  urethra  always  require  the  performance 
of  perineal  section. 


suiKiEnv  or  Till':  ajJXiTo-cjijyAny  tract. 


939 


PART  IV— DISEASES  OF  TIIP:  PROSTATE  GLAND. 

Anatomy. — Tlio  prostate,  "whicli  l)oth  in  structure  and  in  function  is  rather 
a  muscle  tluin  a  gland,  is  situated  at  the  neck  of  the  bladder  and  around  the 
first  inch  of  the  urethra.  It  is  composed  chiefly  of  unstriped  muscular  fibers, 
the  inner  or  circular  layer  of  Avhich  is  continuous  in  front  with  those  surround- 
ing the  membranous  urethra,  and  behind  with  the  muscular  coat  of  the  blad- 
der. An  outer  layer  beneath  the  fibrous  capsule  forms  a  sheath  for  the  gland, 
while  between  them  the  glandular  structure  is  imbedded.  This  is  composed  of 
a  number  of  follicles  lined  with  columnar  epithelium  and  emptying  by  from 
fifteen  to  twenty  excretory  ducts  in  the  floor  of  the  prostatic  portion  of  the 
urethra.  It  is  divided  into  two  lateral  lobes  by  a  deep  notch  behind  and  by 
a  furrcw  at  the  upper  and  lower  surfaces.  The  so-called  middle  or  third  lobe  is 
the  portion  which  is  between  the  tAvo  lateral  lobes  at  the  under  and  posterior 
part  of  the  gland  just  beneath  the  neck  of  the  bladder.  The  uretlira  usually 
passes  through  the  gland  at  about  the  junction  of  its  upper  and  middle  thirds. 
The  ejaculatory  ducts  traverse  it.  Its  chief  function  is  genital  and  ejaculatory. 
It  contracts  at  the  beginning  of  the  sexual  orgasm,  after  the  semen  has  dis- 
tended the  prostatic  sinus,  and  forces  it  out  in  jets  or  spurts.     It  is  supported 


Vertical  Section  of  a  Male  Pelvis :  a,  rectus  abdominis  muscle ;  h,  bladder ;  c,  symphysis  pubis ;  d,  suspen- 
sory ligament  of  penis  ;  e,  dorsalis  penis  vein;./',  Cowper's  gland;  g,  rectum;  h,  rectum;  i,  seminal 
vesicle;  k,  ejaculatory  duct;  I,  prostate;  m,  transverse  perineal  muscle;  n.  external  sphincter  ani;  o, 
internal  sphincter  ani;  p,  internal  sphincter  ani;  q,  external  sphincter  ani  (Braune;. 

and  held  in  position  by  the  posterior  layer  of  the  triangular  ligament,  the 
deep  layer  of  the  perineal  fascia,  and  the  pubo-prostatic  ligament.     It  is  in 


IMO 


,i.v  AMHL'K  .\.\    riixr- HOOK  OF  sri:<;i:i:y. 


fcliition  \vitli  till'  j)ubt's  in  front  and  the  rectiiiii  bi'liind.      It  is  iiljont  tlic  >i/.u 
of  ii  liurse-cbe-stnut,  iiiid  weigLs  a  lialf-ounce  (Fig.  'JT-j. 


Vui.  -MW. 


Vertical  Section  of  Pelvis  in  a  Case  of  I'njstatic  Hyijertrophy  :  P,  firostatc ;  D,  openings  of  vesical  diver- 
ticula; I ',  bladder  (Koenigi. 

Wounds  of  the  Prostate  are  very  rare.  They  occur  occasionally  in 
penetrating  wounds  of  the  perineum  or  of  the  rectum,  but  are  then  usually 
secondary  in  importance  to  more  serious  injuries.  The  gland  is  of  course 
wounded  during  the  performance  of  lithotomy,  but  unless  the  incision  extends 
beyond  its  capsule  no  evil  results  follow.  Whenever  that  is  opened  there  is 
great  risk  of  pelvic  cellulitis  and  peritonitis. 

Atrophy  of  the  Prostate  has  been  said  to  occur  after  wasting  disease, 
after  double  castration,  and  as  a  result  of  old  age.  The  condition  has  no 
recognizable  symptoms. 

IIypertuophy  of  the  Prostate. — In  about  one-third  of  all  males  who 
have  passed  middle  life  some  enlargement  of  the  {)rostate  has  taken  place.  In 
about  one-tenth  of  all  males  over  fifty-five  this  enlargement  becomes  of  patho- 
logical importance. 

Pathology. — The  hypertrophy  varies  in  some  of  its  features,  but  as  a  rule 
consists  of  a  general  enlargement  of  the  gland  in  all  directions,  together  with 
the  development  within  it  of  separate  tumors  resembling  uterine  fil)ro-myomata. 
The  increase  in  size  is  due  to  overgrowth  of  the  fibrous  and  muscular  constit- 
uents of  the  organ,  the  glandular  elements  remaining  almost  unaifected.     The 


(JEMTO-rKlNAKY    DISEASES.  Pi.ATK  XXI, 


2.  Hypertrophy  of  the  median  lobe  of  the  prostate  (Watson). 


SUnaKIiV    OF    THE    iiKXlT()-l'RI.\'M:Y    TliACT.  i)41 

size  and  shape  of  tlu-  j)rostate  gland  itself"  and  of  the  tumors  it  contains  vary 
exceedingly.  Either  the  lateral  lohes  or  the  median  lobe  may  enlarge  more 
than  the  rest  of  the  gland  (I'l.  XXI,  Fig.  2,  and  PI.  XXII) ;  the  latter  may 
constitute  a  bar  extending  up  into  the  bladder  and  blocking  the  orifice;  the 
former  may  compress  the  urethra  into  a  mere  slit  or  chink,  may  elongate  it  so 
that  the  prostatic  portion  measures  three  or  four  inches,  or  may  twist  and  distort 
it  so  thr  t  the  most  Hexil)le  instrument  can  only  with  difficulty  be  made  to  traverse 
it.    Tne  tumors  may  be  no  larger  tlian  a  pea  or  may  be  of  the  size  of  a  child's  fist. 

As  the  prostate  grows  certain  changes  in  the  bladder  occur.  The  apex  of 
the  prostate  is  held  in  place  by  the  triangular  ligament.  As  the  gland  enlarges, 
therefore,  it  does  so  in  a  backward  direction,  carrying  with  it  the  neck  of  the 
liladder.  If  the  growth  is  uniform,  the  bladder  simjdy  falls  into  a  pouch  ante- 
riorly between  the  prostate  and  the  pubes,  and  into  another  and  larger  one 
posteriorly,  in  front  of  the  rectum. 

If  the  growth  is  confined  chiefly  to  the  median  lobe,  it  may  act,  as  has 
been  said,  as  a  valve,  and  serves  to  obstruct  the  internal  orifice  very  consider- 
ably (PI.  XXI,  Fig.  2). 

In  cases  of  sudden  obstruction  without  much  antecedent  irritation  the  blad- 
der is  apt  to  undergo  dilatation  and  atony  :  if  the  obstruction  is  of  slow  develop- 
ment and  has  been  accompanied,  as  it  often  is,  by  congestion  of  the  vesical 
neck,  hypertrophy  of  the  muscular  walls  takes  place :  they  thicken,  and  the 
bladder  contracts,  and-  may  become  pouched  or  sacculated,  as  in  the  presence 
of  any  other  obstructive  cause. 

McGill  classifies  tlie  various  forms  of  the  intravesical  growth — tliat  which 
produces  urinary  symptoms — into  (1)  a  projecting  middle  lobe,  pedunculated 
or  sessile ;  (2)  an  overgrowth  of  the  middle  lobe  and  of  the  two  lateral  lobes, 
forming  three  distinct  intravesical  projections  (Plate  XXII) ;  (3)  enlargement 
of  the  lateral  lobes  only  ;  (4)  a  uniform  collar-like  projection  encircling  the  ori- 
fice of  the  urethra.  It  is  only  in  about  50  per  cent,  of  cases  of  hypertrophied 
prostate  that  urinary  troubles  manifest  themselves.  In  the  others,  the  growth 
not  belonging  to  one  of  the  above  varieties,  there  is  but  little  interference  with 
the  functions  of  the  bladder. 

Symptoms. — Often  the  earliest  symptom  of  prostatic  disease  is  the 
increased  frequency  of  urination,  most  marked  at  night.  This  may  precede 
anv  enlargement  appreciable  through  the  rectum  or  recognizable  during  cathe- 
terism.  It  arises  from  the  congestion  of  the  plexus  of  large  veins  at  the  neck 
of  the  bladder,  the  return  circulation  through  which  is  interfered  Avith  by  the 
prostatic  overgroAvth.  To  this  general  congestion  of  the  region  of  the  prostate 
may  also  be  attributed  the  unusual  and  occasionally  unnatural  sexual  desires 
of  old  men.  A  patient  with  prostatic  hypertrophy  may  not  notice  much  increase 
in  the  frequency  of  micturition  during  the  day,  but  at  night  he  Avill  be  com- 
pelled to  get  up  more  and  more  often  as  the  obstruction  increases  and  as  the 
walls  of  the  bladder  gradually  become  less  able  to  overcome  it.  After  a  time 
a  more  or  less  considerable  quantity  of  urine  is  always  retained  within  the 
bladder,  and  the  patient  is  able  only  to  pass  that  w^hich  is  in  excess.  This 
retained  or  "  residual  "  urine  may  remain  stationary  in  amount,  but  more  fre- 
quently will  gradually  increase  until  in  some  cases,  in  which  both  the  hyper- 
trophy of  the  prostate  and  the  atony  of  the  bladder  are  marked,  only  an  ounce 
or  two  can  be  evacuate<l  spontaneously,  although  catheterism  will  show  that  the 
bladder  contains  possibly  a  pint  or  more. 

From  the  same  cause  arises  the  characteristic  enfeeblement  of  the  stream, 
w^hich,  instead  of  being  projected  away  from  the  body,  will  drop  perpendicularly 
toward  the  feet  of  the  patient. 


942  .l^V   AMr.h'K'AX    TKXT-IK )()K    O/'   sriiCEUY. 

Those  symptoms  contimie  for  :iii  imlcfiiiitc  |»(.'rio(l.  ami  in  some  cases, 
after  reaching  a  certain  intensity,  fail  to  increiuse  in  severity,  especially  if  l)y 
aseptic  catheterism  the  residual  urine  is  periodically  withdrawn.  In  others, 
however,  a  subacute  prostate-cystitis  supervenes,  either  froTu  infection  throii<rh 
the  urethra  or  by  means  of  the  catheter,  and  then  tlie  symptoms  felt  are  most 
distressinir.  The  desire  to  urinate  is  nearly  constant,  and  the  act  is  accompa- 
nied with  burning  ])ain  and  tenesmus  :  it  may  be  ff)llowed  each  time  l)y  a  sliglit 
hemorrhage;  rest  at  night  is  interfered  with  ;  the  general  strength  fails  from 
the  continual  suflering ;  the  urine  becomes  fetid,  animoniacal.  and  reduce<l  in 
quantity;  pyelo-nephritis  develops;  general  sepsis  occurs;  and  the  patient 
dies  uremic  and  comatose. 

Diagnosis. — In  determining  the  existence  ami  the  degree  of  'prostatic 
enlargement  a  systematic  course  should  be  followed.  The  patient  should 
always  lie  recumbent,  with  the  knees  drawn  up  and  separated.  The  rectal 
examination  may  conveniently  l)e  made  first.  The  under  surface  of  the  gland 
is  gently  palpated,  the  outlines  recognized,  the  degree  of  projection  into  the 
rectum  and  tlie  longitudinal  enlargement  estimated.  It  may  be  found  regular, 
rounded,  and  uniforndy  increased  in  size,  or  it  may  be  nodulated  and  uneven. 
It  will  usually  be  enlarged  in  both  directions,  so  that  the  lateral  borders  are 
approximated  to  the  pubic  and  ischiatic  rami,  and  the  finger  fails  to  reacb  the 
base  or  upper  limit  of  the  gland.  Ordinarily  it  is  insensitive,  but  occasionally 
there  is  tenderness  on  pressure. 

After  completing  this  examination,  the  patient,  who  should  previously  have 
urinated,  is  catheterized.  It  will  be  found  that  there  is  a  greater  or  lesser 
amount  of  residual  urine :  tliat  the  shaft  of  the  instrument  enters  the  urethra 
to  an  unusual  depth  ;  and  that  the  handle  must  be  depressed  between  the  thighs 
more  than  ordinarily  before  the  point  of  the  catheter  can  be  made  to  enter  the 
bladder.  Sometimes  an  instrument  of  the  usual  length  and  curve  will  not 
reach  the  bladder  at  all ;  and  this  explains  the  occasional  failure  of  attempts 
at  catheterism  for  retention  due  to  enlarged  prostate. 

The  symptoms  due  to  acute  proHtatitia  have  already  been  detailerl,  and, 
together  with  the  history  of  urethral  infection,  will  serve  to  differentiate  the 
two  conditions.     The  age  of  the  patient  may  also  serve  to  exclude  hypertrophy. 

Malignant  disease  may  be  suspected  if  hemorrhage  is  a  predominant  symp- 
tom and  if  the  growth  is  especially  irregular  in  shape  and  uniform  in  consistence. 

Tulierch  of  the  ])rostate  is  almost  always  associated  with  tuberculosis  of 
some  other  portion  of  the  genito-urinary  tract.  By  collecting  the  urine  for 
twenty-four  hours,  permitting  it  to  settle,  and  carefully  examining  the  sediment 
the  presence  of  bacilli  can  usually  be  demonstrated. 

Treatment. — In  most  cases  of  prostatic  enlargement  the  best  two  guides 
to  the  surgeon  are  afforded  by  the  degree  of  disturbance  at  night  and  the 
amount  of  residual  urine.  If  the  patient  sleeps  well,  is  obliged  to  empty  the 
bladder  only  once  or  twice  between  evening  and  morning,  and  has  but  one  or 
two  ounces  of  clear  residual  urine,  the  treatment  should  be  hygienic  and 
general,  and  local  interference  should  be  avoided.  Great  care  should  be  taken 
to  avoid  chilling  of  the  surface  ;  the  diet  should  be  light  and  digestible  ;  alcohol 
should  be  used  not  at  all  or  in  great  moderation  ;  malt  liquors  and  champagne 
should  be  interdicted  ;  the  bladder  should  be  emptied  at  regular  intervals  ; 
constipation  and  straining  at  stool  should  be  especially  avoided.  If.  however, 
the  patient  rises  three  or  four  or  more  times  at  night  to  urinate,  and  if  the 
residual  urine  amounts  to  several  ounces,  systematic  catheterism  should  begin 
at  once.  The  evils  of  delay  are  greater  than  those  associated  with  the  use  of 
the  instrument.     The  amount  of  residual  urine  will  usually  increase,  as  will 


dioxiTo-riMXAKN'  i)isi:.\si<:s. 


I>LATK   XXII. 


General  Enlargement  of  the  Prustate  (White  and  Wood).  The  divided  surfiiees  of  the  supra-uretliral 
portion  and  the  large  median  lobe  sliow  well.  Catheterization  was  possible  in  this  case  only  with  a 
metal  prostatic  catheter,  the  point  of  which  invariably  turned  to  the  patient's  left  on  entering  the  blad- 
der; profuse  bleeding  always  followed  the  introduction  of  the  instrument.  A,  point  in  middle  lobe 
against  which  the  catheter  impinged  and  from  wliich  tlie  hemorrhage  came  ;  B,  verumontanum. 


sri!(ii:in'  or  the  aKxiro-rniXAin'  tract.         9t;3 

the  vesical  atony,  the  risks  ot"  renal  cvunjjlications  are  greater.  an<l  Avlien, 
finally,  the  use  ot"  the  eathetcr  hcconies  iiii|»('rative.  tliere  is  far  greater  danger 
than  if  it  hud  heen  begun  earlier. 

The  fretiueney  with  uhieh  tlie  catheter  slutuld  he  used  is  ))ro|)ortionate 
to  the  (juantity  of  residual  urine  and  the  urgency  of  the  symptoms.  As  a 
rule,  where  the  urine  does  not  exceed  three  fluidounces  in  amount  and  is  not 
turhid  or  bad-smelling,  tlie  use  of  the  instrument  at  bedtime  will  be  sufficient. 
If,  however,  the  urine  is  ammoniacal,  or  if  it  is  of  larger  amount,  or  if  the 
patient  urinates  with  some  pain  and  greater  frecpiency,  it  may  be  well  to 
cathererize  two.  three,  or  even  four  times  daily.  Experience  and  familiarity 
with  the  special  needs  of  each  particular  case  must  decide  this  question.  No 
drugs  have  the  slightest  effect  upon  the  hypertrophy  itself,  but  those  which 
render  the  urine  aseptic  will  be  found  valuable  adjuvants  in  these  as  in  nearly 
all  other  surgical  diseases  of  the  genito-urinary  tract.  It  may  be  necessary  to 
combine  Avith  them  in  certain  cases  the  bromides,  belladonna,  or  small  doses  of 
opiates,  but  tliese  should  always  l)e  regarded  as  necessary  evils,  to  be  used  only 
in  exceptional  cases  or  in  times  of  emergency,  and  to  be  thrown  aside  as  soon  as 
they  can  be  dispensed  with. 

There  are  cases,  however,  in  which  catheterism  fails  to  meet  the  indications. 
Either  in  spite  of  it  or  because  of  it  the  symptoms  increase  in  severity,  the 
general  condition  beconjes  more  alarming,  and  it  is  apparent  that  the  patient 
will  die  exhausted  if  further  relief  is  not  given  ;  or  the  same  condition  may 
arise  in  cases  of  complete  retention  of  urine  with  cystitis  and  with  extremely 
difficult  or  painful  catheterism.  Under  these  circumstances  treatment  may 
still  continue  to  be  palliative,  and  may  consist  in  opening  the  bladder  through 
the  perineum  by  means  of  an  incision  like  that  for  median  lithotomy. 

Occasionally  it  will  seem  wise  to  make  drainage  by  means  of  a  supra- 
pubic puncture,  and  Hunter  McGuire  and  others  have  shown  that  it  is  pos- 
sible to  do  this  by  establishing  a  small,  permanent  fistulous  opening  running 
obliquely  upward,  and  to  retain  considerable  power  over  the  urine.  The 
suprapubic  incision  has  the  advantage  also  of  permitting,  better  than  that 
through  the  perineum,  the  thorough  exploration  of  the  bladder  and  prostate, 
and,  if  necessary,  the  employment  of  more  radical  methods. 

Prostatectomij. — In  selecting  an  operation  for  the  more  permanent  relief 
of  the  condition  it  is  Avell  to  remember  that  the  severity  of  the  symptoms  in 
any  case  has  no  definite  relation  to  the  extent  of  the  enlargement  as  felt 
through  the  rectum,  but  depends  rather  upon  the  presence  and  the  extent  of 
one  or  the  other  of  the  varieties  of  intravesical  growths  described  on  p.  941. 

Such  a  growth  having  been  diagnosticated,  it  may  be  approached  and 
removed  in  one  of  three  ways  (Treves) :  1.  By  perineal  incision.  The  perineum 
and  bladder  are  opened  as  in  median  lithotomy  (p.  873):  the  projection  is 
recognized  with  the  fingers  and  enucleated  with  the  help  of  a  curette  or  seized 
by  a  pair  of  forceps  and  twisted  or  torn  away.  Watson  has  shown  that  in 
two-thirds  of  prostatic  cases  appropriate  for  radical  treatment  the  intravesical 
growth  lies  at  a  distance  of  three  inches  or  less  from  the  perineum,  and  that 
therefore  any  one  possessing  an  index-finger  of  the  length  of  three  inches  may 
be  able  to  attack  them  successfully.  This,  however,  leaves  one-third  of  all 
such  cases  which  cannot  be  reached  after  the  operation  has  begun — a  weighty 
objection  to  this  treatment.  In  a  number  of  instances  pedunculated  growths 
or  projecting  portions  of  lateral  lobes  have  been  seized  and  removed  during 
the  performance  of  perineal  lithotomy.  But  these  were  accidents,  and  in  most 
of  them  the  removal  was  incomplete  so  far  as  its  effects  upon  the  obstructive 
symptoms  were  concerned. 


944  jy  A.vr:ni('AX  TExr-nooK  or^ surgery. 

2.  By  suprapubic  incision.  In  this  operation  the  bladder  is  readied  and 
opened  just  as  in  a  suprapubic  lithotomy-  McGill  has  enumerated  as  follows 
the  special  points  of  technique  :  (1)  The  (juantity  of  water  thrown  into  the  rec- 
tal bag  should  be  smaller  than  usual,  rarely  more  than  from  six  to  ten  ounces. 
{'2)  Preliminary  irrigation  of  the  bladder  should  be  continued  until  the  fluid 
returns  perfectly  clear.  (3)  The  (juantity  of  fluid  left  in  the  bladder  varies 
from  ten  to  twenty  ounces.  (4)  In  cases  where  contraction  of  the  bladder  is 
combined  with  Iiypertrophy  of  the  walls  the  operation  is  contraindicated.  (5) 
A  catheter  left  in  the  bladder  until  the  latter  is  opened  facilitates  the  opera- 
tion. (6)  The  linea  -alba  is  opened  by  an  incision  directly  upon  the  symphy- 
sis, and  afterward  divided  upward  u))on  a  director.  (7)  Before  beginning 
the  removal  of  the  prostate  the  Idadder  must  be  secured  by  passing  a  suture 
through  each  lip  of  the  wound  and  stitching  it  to  the  wound  in  the  abdominal 
wall.  A  third  suture  between  the  lower  angle  of  the  vesical  wound  and  that 
of  the  abdominal  Avound  is  thought  to  aid  in  preventing  urinary  extravasation 
into  the  pre-vesical  space.  (8)  In  the  case  of  a  pedunculated  middle  lobe  the 
pedicle  may  be  divided  with  curved  scissors.  A  sessile  middle  lobe  may  require 
in  addition  some  avulsion  by  forceps.  The  collar  ])rojection  should  be  divided 
into  two  lateral  halves  by  passing  one  blade  of  a  pair  of  scissors  into  the  ure- 
thral orifice  and  cutting  the  portion  above  it,  repeating  the  procedure  for  the 
lower  segment,  and  then  enucleating  with  the  scissors  and  fingers.  (9)  When- 
ever possible,  enucleation  with  the  finger  should  be  preferred  to  cutting  with 
sharp  instruments,  the  mucous  membrane  over  the  ])rojecting  portion  having 
first  been  divided  Avith  scissors.  (10)  Hemorrhage  should  be  arrested  by  irri- 
gation with  very  hot  (almost  scalding)  water.  (11)  The  operator  should  ascer- 
tain that  the  urethra  is  entirely  patent  at  the  end  of  the  operation,  by  inserting 
the  forefinger  as  far  as  the  first  joint  into  the  canal.  (12)  A  large  drainage- 
tube  should  be  left  in  the  bladder  for  forty-eight  hours.  The  wound  should 
be  united  above  the  tube  by  a  deep  and  a  supei'ficial  row  of  sutures.  (13) 
Irrigation  with  boric  solution  may  be  required  as  part  of  the  after-treatment. 

5lcGill  has  removed  portions  of  the  prostate  weighing  in  one  case  seven 
ounces  and  in  another  two  and  a  quarter  ounces.  White  of  Philadelphia 
removed  in  one  case  a  mass  Aveighing  three  ounces. 

In  any  case  where,  after  a  suprapubic  prostatectomy,  the  urethral  canal  is 
not  ordinarily  patent,  the  operation  may  be  supplemented  by  median  perineal 
urethrotomy,  by  means  of  which  growths  in  the  prostatic  urethra  or  in  the 
suburethral  prostate  can  be  dealt  witii. 

The  results  of  experience  thus  far  seem  to  show  that  the  operation  of 
prostatectomy  is  justifiable  in  some  cases  of  hypertrophied  prostate  in  which 
catheterism  is  difficult  or  impossible  or  excessively  painful,  and  in  which  a 
high  grade  of  cystitis  has  developed  and  septicemia  or  uremia  is  imminent. 
The  prognosis  is  unfavorable  in  proportion  to  the  duration  of  the  obstructive 
symptoms  and  the  size  of  the  mass  which  it  is  necessary  to  remove  to  secure 
patency  of  the  urethra,  and  is,  of  course,  much  influenced  by  the  condition  of 
the  kidneys. 

Double  Castration  for  Hypertrophy  of  the  Prostate. —  White's 
Operation. — In  June,  iJ^U-j,  White,  as  the  result  of  researches  begun  a  year 
previously,  suggested  in  a  paper  before  the  American  Surgical  Association 
that  castration  might  produce  atrophy  of  the  enlarged  prostate,  and  might 
thus  be  a  valuable  method  of  treatment.  His  theory  had  resulted  from  a  con- 
sideration of  the  apparent  analogy  between  the  uterine  and  prostatic  fibro- 
myomata,  but  was  further  based  upon  a  series  of  experiments  on  dogs  (which 
showed  rapid  atrophy  of  the  prostate  folloAving  castration),  on  some  physiolog- 


SURQEEY    OF    THE    GEXJTO-URINARY    TRACT.  945 

ical  observations  of"  John  Hunter  on  the  lower  animals  (corroborated  by 
Griffiths),  iiiid  on  some  sciittored  cases  in  surgical  literature  showing  a  shrink- 
ing of  the  prostate  after  castration  for  various  causes,  and  strengthening  the 
opinion  previously  formed.  Since  the  publication  of  his  paper  many  cases 
have  been  reported,  the  large  majority  having  been  extremely  successful.  It 
is  too  soon  yet  to  speak  with  authority  as  to  the  precise  limitations  or  the  exact 
risks  of  the  operation.  It  may  be  said  with  much  confidence,  however,  that 
in  a  considerable  proportion  of  all  cases  of  enlarged  prostate  castration  will  be 
followed  by  a  rapid  diminution  in  the  size  of  the  gland,  and  a  coincident  dis- 
appearance of  many — sometimes  of  all — the  obstructive  symptoms.  More- 
over, with  the  ability  completely  to  empty  itself  the  bladder  has  in  a  number 
of  cases  regained  a  healthy  state  of  the  mucosa,  previously  the  subject  of 
infective  inflammation,  and  with  the  return  of  normal  micturition  all  the  symp- 
toms of  confirmed  cystitis  have  disappeared.  Sir  Joseph  Lister  has  noted  the 
fact  that  the  rapidity  with  which  relief  has  followed  this  operation  has  in 
many  of  the  reported  cases  been  as  remarkable  as  the  degree  of  improvement 
itself. 

Griffiths,  who  eighteen  days  after  double  castration  examined  the  enlarged 
prostate  of  a  patient  who  died  of  popliteal  thrombosis  and  gangrene,  has 
shown  that  changes  were  then  taking  place  which  were  obviously  preliminary 
to  "the  conversion  of-  the  prostate  into  a  small,  firm,  fibrous  mass  containing 
only  remnants  of  the  tubules  and  but  few  traces  of  its  muscular  fibers."  Kirby 
has  found  the  beginning  of  these  changes  in  the  prostate  of  a  patient  castrated 
during  an  advanced  stage  of  uremia,  and  who  died  within  three  days.  Other 
reports  of  similar  character  have  been  published.  Moullin  says  :  "  Removal 
of  the  testes  is  followed  in  a  large  proportion  of  cases,  if  not  in  all,  by  complete 
and  rapid  absorption  of  the  enlarged  prostate.  This  has  now  been  proved  con- 
clusively." The  operation  thus  rests  now  upon  a  firm  clinical  and  pathologi- 
cal basis,  and  has  certainly  passed  the  theoretical  stage.  Experiments  con- 
ducted by  White  with  the  aid  of  Kirby  and  Wood  seem  to  show — a,  that 
unilateral  castration  will  be  followed  by  a  certain  degree  of  prostatic  atrophy 
on  the  corresponding  side,  but  that  it  is  not  certain  that  this  will  be  either 
prompt  enough  or  complete  enough  to  be  curative  in  prostatic  cases ;  b,  that 
ligation  of  the  cord  is  followed  by  prostatic  atrophy,  but  usually  only  when 
the  testicles  have  first  become  functionless  themselves,  and  that  this  atrophy 
is  also  slow  and  somewhat  uncertain  ;  c,  that  ligation  of  the  vas  alone  has 
little  eff"ect  on  the  testicle,  but  causes  a  decrease  in  the  size  and  Aveight  of 
the  prostate ;  c?,  that  ligation  of  the  nervous  and  vascular  constituents  of  the 
cord  separately  influences  the  prostate  only  by  first  producing  disorganization 
of  the  testicles,  and  that  this  result  is  neither  prompt  nor  certain. 

At  present,  therefore,  double  castration  seems  to  be  the  operation  which 
comes  into  direct  comparison  with  the  various  forms  of  prostatectomy,  and  it 
may  safely  be  said  that  it  is  likely  in  properly  selected  cases  to  have  a  lower 
mortality,  is  far  easier  of  performance,  requires  a  much  shorter  period  of 
anesthesia,  and  Avhen  fully  successful  secures  a  return  to  a  condition  more 
closely  resembling  the  normal  than  any  of  the  other  operations  looking  toward 
a  radical  cure  of  the  hypertrophied  prostate. 

The  operation  must  be  regarded  as  still  on  trial  so  far  as  accurate  choice 
of  cases  and  precise  prognosis  are  concerned,  but  the  conclusions  of  Feziwick, 
after  an  experience  of  nine  cases,  are,  with  some  modifications,  accepted  by 
White  after  a  careful  analysis  of  all  reported  cases,  now  numbering  more 
than  four  hundred.  They  are  as  follows:  1.  There  is  no  doubt  that  shrink- 
age of  the  prostatic  tissue  in  many  of  the  forms  of  senile  enlarged  prostate 

60 


94G  AN  A3IERICAN    TEXT-BOOK    OF  SUliUERY. 

ensues  u})on  double  castration.  Further  experience  must,  however,  decide  as 
to  whether  every  Ibrni  of  prostatic  growth  is  thus  affected.  2.  It  is  certain 
that  escape  from  catheter-life  after  castration  depends  largely  upon  the  health 
of  the  vesical  muscle.  The  grade  of  the  atony,  therefore,  should  be  most  care- 
fully estimated  before  any  hopes  of  relief  from  catheterization  are  held  out. 
To  promise  a  confirmed  catheter  case  that  orchectomy  will  do  away  with  the 
instrument  may  merely  bring  discredit  on  the  operation  and  disappointment 
to  the  patient.  Even  after  prostatectomy  we  are  unable  to  promise  such  relief 
if  the  muscle  is  hopelessly  atonic,  and  we  cannot  do  so  after  castration.  3. 
It  is  possible  that  castration,  by  diminishing  the  prostatic  and  vesical  con- 
gestion and  removing  the  obstruction  to  urination  will  enable  the  more  healthy 
tissues  to  overcome  the  microbic  infection  of  the  inflamed  senile  prostate  if 
such  infection  be  present,  or  to  prevent  it  if  not  yet  established,  and  thus 
remove  a  constant  menace  to  the  integrity  of  the  kidneys,  for  it  will  con- 
trol  the  most  prolific  source  of  ascending  pyelitis. 

It  appears  that  while  double  castration  is  likely  to  have  a  wide  range  of  use- 
fulness, the  exact  limitations  of  Avhich  must  be  determined  by  longer  experience, 
it  is  now  safe  to  say  that  it  Avill  prove  of  value  in  the  following  conditions : 

1,  in  reducing  bulky  overgroAvth  of  the  prostate :  it  may  be  found  that  the 
small,  tough,  fibrous  median  or  lateral  vesical  outgrowths  will  be  better  removed 
by  suprapubic  prostatectomy  ;  2,  in  controlling  the  distress  and  danger  of  an 
inflamed  senile  enlarged  prostate ;  3,  in  lessening  the  frequency  or  difiiculty 
of  introducing  the  catheter  in  advanced  or  confirmed  catheter-life;  4,  in  avoid- 
ing the  mechanical  difficulty  of  crushing  a  post-prostatic  or  a  post-trigonal 
stone,  by  levelling  the  base  of  the  bladder,  thus  rendering  the  operation  of 
litholapaxy  feasible  in  a  condition  in  which  before  it  was  impracticable ; 
5,  in  reducing  chronic  cystitis  and  recurrent  phosphatic  calculus  in  cases  of 
confirmed  catheter-life. 

Jacobson  of  London  has  summarized  his  viewg  on  the  subject  as  follows : 
"  The  cases  in  which,  in  my  opinion,  the  operation  is  most  called  for  fall  into 
two  groups :  (a)  The  more  urgent,  where  (1)  previous  appropriate  treatment, 
cai-efully  carried  out,  has  failed ;  (2)  where  there  have  been  one  or  more 
attacks  of  retention  ;  or  (3)  where  hemorrhage  has  taken  place — in  either 
case  the  peril  of  cystitis,  too  often  fatal  here,  is  enormously  increased  ;  (4) 
where  there  is  inability  to  micturate,  or  where  this  is  painful  or  frequent ; 
(5)  where  the  passage  of  the  catheter  is  increasingly  difficult,  with  the  risks 
of  hemorrhage,  formation  of  false  passages,  etc. ;  (6)  where  the  prostate  is 
soft  and  elastic,  not  densely  hard  and  fibrous — in  such  cases  marked  relief 
may  be  expected.  Of  course,  the  greater  the  power  of  voluntary  micturition 
which  remains,  the  more  natural  the  urine  as  to  urea,  specific  gravity,  albu- 
min, and  sugar,  the  greater  the  rallying  power  of  the  patient,  and  the  clearer 
the  mind,  the  better  the  prognosis.  (6)  Less  urgent  cases.  Here  the  opera- 
tion is  prospective  and  preventive.  The  patient  is  younger,  the  power  of 
voluntary  micturition  is  still  good,  there  is  no  cystitis;  but  palliative  treat- 
ment fails  to  relieve  the  frequent  disturbance  at  night,  and  hematuria  has 
begun  to  occur  at  intei'vals.  Here  the  surgeon  is  abundantly  justified  in 
advising  the  operation  as  a  preventive  of  worse  things  which  are  certain  to 
come.  The  operation  will  not  be  often  accepted  here,  but  it  is  in  such  cases 
that  it  will  give  the  best  results. 

''As  to  the  amount  of  relief  which  we  can  promise  our  patients,  Ave  shall 
de  well  to  be  cautious  while  hoj)eful.  deciding  each  case  by  itself  very  care- 
fully, especially  as  regards  these  two  factors:  {a)  The  amount  of  voluntary 
mictunition  and  control  which  this  operation  will  restore  must  largely  depend 


SURG  Ell  V   OF   THE    GEmTO-URINARY   TRACT.  947 

upon  the  condition  of  the  bhulder,  how  far  long-standing  cystitis  or  habitual 
use  of  the  catheter  has  damaged  its  walls,  replacing  the  muscular  with 
fibrous  tissue,  and  converting  it  into  an  inelastic  thick-walled  sac.  (f))  The 
state  of  the  prostate.  The  more  vascular,  the  softer,  the  more  rich  in  gland- 
ular tissue  this  is,  the  more  decided  will  be  the  shrinking  that  follows  castra- 
tion. On  the  other  hand,  the  denser  and  more  fibrous  tlie  gland,  the  longer 
delayed  certainly,  and,  perhaps,  the  less  marked  will  be  the  benefit." 
PiiOSTATiTis  may  be  acute  or  chronic,  follicular  or  parenchymatous. 
Acute  Follicular  Prostatitis  is  usually  a  complication  of  gonorrhea,  and  has 
already  been  described.  (See  pp.  900,  917.)  It  may  occur  as  a,  complication 
of  stricture.  The  mucous  membrane  and  the  follicles  which  empty  upon  its 
surface  are  chiefly  affected.  If  abscesses  occur,  they  are  small,  are  apt  to  be 
numerous,  and  almost  invariably  empty  spontaneously  into  the  urethra. 

Chronic  Follicular  Prostatitis  is  often  a  sequel  of  an  acute  attack.  It 
sometimes  follows  an  attack  of  gonorrhea  in  which  there  has  been  no  evidence 
of  acute  inflammation  of  the  gland.  Its  symptoms,  course,  and  treatment 
have  been  described  in  connection  with  the  subject  of  chronic  urethral  dis- 
charges.   (See  pp.  907,  918.) 

Parenchymatous  Prostatitis. — In  this  form  the  inflammation  affects  the 
whole  substance  of  the  gland,  after  causing  great  disorganization.  It  may 
result  from — «,  traumatism;  b,  tubercle;  or,  c,  gout.  a.  Injuries  of  the  pros- 
tate are  chiefly  those  inflicted  during  the  various  operations  for  stone  or  during 
operations  upon  the  urethra  or  bladder  ;  occasionally  the  use  of  a  large  instru- 
ment, especially  in  patients  broken  down  in  health  or  with  a  cystitis  Avith  fetid 
and  ammoniacal  urine  or  with  pyelo-nephritis,  will  bring  about  this  form  of 
prostatitis.  It  is  ushered  in  by  a  chill,  with  deep-seated  perineal  pain,  and 
swelling  recognized  by  rectal  examination.  It  is  usually  suppurative  in  such 
cases,  but  if  the  symptoms  are  marked  by  the  presence  of  vesical  or  renal 
disease,  or,  especially,  if  there  is  already  distinct  enlargement  of  the  prostate, 
the  character  of  the  trouble  may  escape  detection  until  it  is  far  advanced. 
The  pus  may  escape  through  the  capsule  of  the  gland,  penetrating  the  recto- 
vesical fascia  and  setting  up  a  fatal  pelvic  cellulitis,  or  it  may  point  in  the 
perineum  or  even  in  the  groin. 

Free  evacuation  by  means  of  a  median  perineal  incision  is  ahvays  indicated 
when  the  diagnosis  is  assured,  and  such  an  incision  should  be  made  for  pur- 
poses of  exploration  when  deep-seated  parenchymatous  suppurative  prostatitis 
is  strongly  suspected.  This  is  markedly  in  contrast  with  the  follicular  variety 
(gonorrheal  prostatitis),  in  which  operation  is  scarcely  ever  required. 

b.  Tubercular  prostatitis  is  very  rare  as  a  primary  affection.  It  occurs  in 
the  course  of  tubercular  disease  of  the  bladder  or  kidneys ;  occasionally,  but 
more  rarely,  as  a  sequel  of  tuberculosis  of  the  testicle.  Its  symptoms  in  the 
early  stages  are  those  of  a  high  grade  of  chronic  prostatitis  or  often  closely 
resemble  those  of  vesical  calculus,  hematuria  after  urination  and  pain  at  the 
end  of  the  penis  being  often  present.  Later,  the  urine  becomes  filled  with  the 
debris  of  the  caseating  masses,  and  tubercle  bacilli  may  be  found  if  the  sedi- 
ment from  a  considerable  quantity  of  urine  be  collected  and  examined. 

The  cystoscope  might  show  the  existence  of  ulceration  at  or  near  the  neck 
of  the  bladder. 

The  prognosis  is  very  unfavorable. 

Treatment. — The  general  hygienic  measures  appropriate  for  tuberculosis 
anywhere  are  applicable  here,  but  have  less  than  their  usual  effect.  The  local 
use  of  emulsions  or  of  suppositories  of  iodoform  has  been  recommended,  but  the 
bladder  and  urethra  will  not  tolerate  them  of  sufficient  strength  to  be  of  much 


f)48  AN  AMERICAN   TEXT-HOOK    OF  SURGERY. 

service.  The  direct  application  to  the  ulcerated  region  of  silver  nitrate  (from 
1  to  5  per  cent.,  or  stronger  if  it  is  well  borne)  is  sometimes  of  much  tempo- 
rary benefit.  If  there  .are  no  deposits  elsewhere,  and  there  is  reason  to  believe 
that  the  prostatitis  is  ])rimary,  and  especially  if  the  kidneys  are  thout^ht  to  be 
sound,  perineal  or  suprapubic  prostatotomy,  and  curetting  and  cauterization 
of  the  aft'ected  surfaces,  would  seem  best  to  fulfil  all  the  indications,  but  are 
rarely  applicable  under  these  limitations.  They  may  become  justifiable  as  paU 
liative  measures  for  the  relief  of  hemorrhage,  pain,  and  vesical  tenesmus,  but 
then  a  simple  perineal  cystotomy  would  probably  be  almost  equally  beneficial. 

c.  Grout jf  Prostatitis  is  an  irritative  and  congestive  rather  than  an  inflam- 
matory condition  of  the  gland,  found  in  men  at  or  beyond  middle  life  who  are 
lithemic,  who  have  been  high  livers,  and  who  habitually  indulge  to  excess  in 
malt  liquors  or  sweet  sparkling  wines.  The  uric,  or  sometimes  the  oxalic, 
diathesis  Avill  be  found  to  coexist.  The  symptoms  are  those  of  prostato-ves- 
ical  irritation.  The  disease  never  runs  on  to  suppuration,  and  is  rarely 
serious,  but  is  very  apt  to  recur  if  the  original  errors  of  diet  or  habits  of  life 
are  resumed. 

The  treatment  is  that  indicated  by  the  condition  of  the  urine.  It  should 
be  largely  hygienic. 

Prostatic  Calculi. — The  prostate,  like  other  glandular  structures,  is 
occasionally  occupied  by  concretions  consisting  of  inspissated  secretions. 
These  are  often  small  and  numerous  at  first,  but  later  become  coated  Avith 
secondary  phosphatic  deposits,  and  in  some  cases  have  been  agglutinated  by 
mucous  and  fibrinous  exudates  so  as  to  convert  the  whole  prostate  into  one  cal- 
culous mass.  They  give  rise  tc  symptoms  very  difficult  to  differentiate  from 
those  of  vesical  calculus.  It  will  be  observed  in  cases  of  doubt  that  the  stone 
remains  fixed,  never  changing  its  position  with  the  different  movements  of  the 
body,  as  does  a  stone  in  the  bladder.  It  may  sometimes  be  felt  between  the 
finger  in  the  rectum  and  a  sound  in  the  urethra.  If  movable,  the  introduction 
of  a  large  sound  will  often  displace  it  and  push  it  back  into  the  bladder. 
When  small  and  multiple,  such  calculi  may  often  be  seized  by  urethral  forceps 
and  extracted.  White  has  thus  removed  from  the  prostatic  sinus  ten  calculi 
weighing  altogether  two  hundred  and  thirty  grains.  If  larger  and  fixed,  a 
median  perineal  incision  is  the  best  method  for  their  extraction. 

Malignant  Disease  of  the  Prostate. — Both  carcinoma  and  sarcoma 
afiect  the  prostate.  The  encephaloid  variety  of  the  former  is  more  common. 
When  the  disease  develops  in  a  prostate  already  hypertrophied,  the  diagnosis 
is  very  difficult.  Originating  in  a  prostate  previously  unchanged,  it  may  be 
recod^nized  by  the  rapidity  of  the  growth,  the  frequency  and  severity  of  the 
hemorrhage,  the  associated  cachexia,  etc.  Extension  beyond  the  capsule  of  the 
gland  and  involvement  of  neighboring  parts,  as  the  rectum  and  the  vcsiculse 
seminales,  sometimes  take  place,  and  may  be  discovered  by  digital  exploration. 

Treatment  is  of  but  little  avail.  Suprapubic  or  perineal  cystotomy  for 
drainage  is  sometimes  indicated.  A  pedunculated  growth  might  be  twisted  off 
through  either  incision,  and  obstructive  symptoms  temporarily  relieved.  Death 
usually  occurs  from  exhaustion  or  from  secondary  deposits  in  other  viscera. 


SURGERY   OF   THE    GENITO- URINARY   TRACT.  949 


PART  v.— DISEASES  OF  THE  TESTICLES. 

Congenital  Deformities. — Occasionally  both  testicles  are  entirely  want- 
ing (cryptorchidisin) ;  more  coumionly  one  is  lackinj^  (monorcliidisin).  Supernu- 
merary testicles  have  been  reported,  but  are  probably  instances  of  detachment 
of  the  globus  major  from  the  body  of  the  epididymis  (Agnew). 

Retained  Testicle  (undescended  testicle)  is  much  more  frequent.  It  is 
usually  unilateral,  though  occasionally  both  testicles  fail  to  reach  the  scrotum. 
The  organ  may  be  arrested  during  its  descent  within  the  abdomen  beloAv  the 
kidney,  in  the  inguinal  canal,  or  just  outside  of  the  external  abdominal  ring. 
In  rare  cases  the  testicle  has  been  found  in  the  perineum.  If  both  testicles 
are  retained,  the  suspicion  may  arise  that  the  individual  is  a  cryptorchid,  and 
a  microscopical  examination  of  the  fluid  ejaculated  during  a  sexual  orgasm 
may  be  necessary   to  decide  the   question. 

A  retained  testicle,  especially  if  it  is  situated  in  the  inguinal  canal,  is  liable 
to  inflammatory  attacks  and  even  to  malio-nant  chano;e. 

Treatment. — Various  operations  have  been  devised  for  placing  and  retain- 
ing such  an  organ  in  the  scrotum ;  but  while  they  are  frequently  fol- 
lowed by  temporary  improvement,  they  are  apt  to  be  finally  disappoint- 
ing. If  the  retained  testicle  gives  rise  to  much  trouble,  and  if  the  other 
testicle  is  present  and  is  sound,  castration  is  often  the  most  satisfactory 
treatment. 

Inflammation  of  the  Testicle. — Under  this  head  are  usually  de- 
scribed both  epididymitis  and  orchitis,  which  may  exist  either  separately  or 
conjointly. 

Acute  Epididymitis  is  usually  gonorrheal  in  its  origin,  though  more  rarely 
it  may  follow  perineal  lithotomy,  an  injury  to  the  perineum,  lithotrity,  cathe- 
terization, etc. 

The  symptoms  and  treatment  have  been  sufiiciently  described  in  the 
article  on  Gonorrhea.     (See  pp.  883,  900.) 

Acute  Orchitis  may  I'esult  from  the  extension  of  an  epididymitis,  but  this 
is  uncommon.  It  is  usually  caused  by  traumatism  :  metastasis  in  mumps  may 
give  rise  to  a  very  acute  orchitis. 

When  acutely  inflamed  the  testicle  swells  rapidly,  but  retains  its  normal  oval 
form.  The  pain  is  dull  and  nauseating,  radiates  toward  the  groin,  hips,  and 
loins,  and  is  markedly  lessened  by  support  to  the  testicle.  Acute  hydrocele 
is  not  so  common  an  accompaniment  as  in  cases  of  epididymitis.  The  exudate, 
which  during  the  acute  stage  occupies  the  connective- tissue  spaces  between  the 
seminiferous  tubes,  may  break  down,  and  suppuration  may  follow  in  persons 
already  in  poor  health  and  with  feeble  resistant  powers.  Infection  in  these 
cases  probably  occurs  through  the  blood  rather  than  through  the  urethra  and 
vas  deferens.  More  commonly  reabsorption  takes  place,  but  the  gland  is  apt 
to  be  left  softened  or  atrophied  and  predisposed  to  subsequent  attacks. 

Bilateral  orchitis  may  result  in  impotence  as  a  result  of  these  atrophic 
changes  in  the  secreting  structure  of  the  glands  themselves,  while  bilateral 
epididymitis,  in  consequence  of  its  obstructive  sequelae,  is  far  more  apt  to 
cause  sterility. 

Treatment. — The  patient  should  be  put  to  bed,  the  scrotum  elevated,  and 
iced  lead-water  and  laudanum  applied.  If  the  cold  is  of  itself  a  cause  of  suf- 
fering, hot  fomentations  of  the  same  lotion  will  often  give  relief.  Laxatives 
and  febrifuges  should  be  given,  and  during  the  height  of  the  inflammation 
enough  morphia  hypodermatically  to  control  the  acute  pain.  Aconite  and 
bromide  of  potassium  in  appropriate  doses  will  be  found  of  great  use.     Punc- 


1)50  .1-V  A}ri:L'i(AX  Ti:xr-no<>k'  or  srii(; i:i:y. 

ture  of  the  tunica  vaginalis,  and  even  j)unctuiv  or  incision  of  tlie  tunica  albu- 
ginea,  has  been  rcconmiended  in  cases  in  which  the  tension  and  swelling  are 
very  great.  The  former  is  harmless,  but  usualh'  needless.  The  latter  is  rarely 
if  ever  justifiable.  If  the  orchitis  is  of  the  rheumatic  or  gouty  variety,  the 
salicylates  and  iodide  of  potassium,  with  lithia-water  and  a  restricted  diet,  are 
indicated. 

Chronic  Orchitis  rarely  follows  an  acute  attack,  but  is  more  eonniioidy  the 
result  of  some  constitutional  infection.  When  it  results  from  local  causes  it  is 
characterized  by  a  slow  enlargement  of  the  gland,  with  only  moderate  pain 
and  with  a  loss  of  the  testicular  sensibility.  If  it  continues  for  any  length  of 
time,  atrophy  of  the  gland  is  sure  to  result.  Frequently  the  inflammatory 
exudate  li(iuefies,  the  skin  ulcerates,  infection  occurs,  and  the  organ  is  riddled 
with  sinuses  or  disappears  almost  completely. 

The  treatment  should  consist  in  careful  regulation  of  the  general  health, 
the  administration  of  tonics  with  alteratives,  and  the  local  use  of  eciuable  pres- 
sure by  strapping,  gentle  at  first,  firm  later  if  it  is  well  borne.  An  ointment 
of  mercury,  belladonna,  and  iodine,  or  one  containing  iodoform,  often  seems  to 
be  useful.     Castration  will  be  required  if  there  are  several  suppurating  foci. 

Tubercular  Orchitis  usually  occurs  in  patients  between  the  ages  of  twenty 
and  forty.  There  is  often  a  family  history  of  tubercular  disease.  The 
epididymis  is  apt  to  be  first  involved.  The  disease  is  frequently  bilateral. 
It  is  insidious  in  its  origin,  giving  rise  to  little  or  no  pain,  but  beginning  as 
a  hard,  irregular  enlargement  at  the  lower  and  posterior  aspect  of  the  gland, 
gradually  increasing,  and  sometimes  extending  along  the  vas  deferens.  Later 
the  whole  gland  is  involved  and  undergoes  caseous  degeneration.  The  skin  be- 
comes  adherent,  sinuses  form,  and  purulent  infection  follows.  Secondary  tuber- 
cular deposits  in  the  seminal  vesicles  or  in  more  remote  regions  are  often 
found. 

Treatment. — If  the  diagnosis  is  reasonably  clear  or  if  multiple  sinuses 
have  formed,  and  if  the  disease  is  unilateral,  castration  is  clearly  indicated, 
both  to  secure  local  health  and,  even  more  urgently,  to  avoid  general  dissem- 
ination of  tubercle.  If  both  glands  are  affected,  however,  the  consequences  of 
castration  are  so  unpleasant  that  palliation  and  symptomatic  treatment  should 
be  persevered  in  until  there  is  unmistakable  evidence  of  the  complete  destruc- 
tion of  the  organ.  Sinuses  should  be  enlarged  and  curetted,  abscesses  should 
be  opened  promptly,  ulcers  should  be  treated  with  nitrate  of  silver  and  dressed 
antiseptically.  and  every  attention  should  be  paid  to  the  general  health  and 
strength  of  the  patient. 

Syphilitic  Orchitis  (syphilitic  sarcocele)  also  begins  painlessly,  but,  as  a 
rule,  in  the  body  of  the  gland ;  like  tubercular  orchitis,  it  is  apt  to  be  bilateral. 
It  causes  a  dense,  irregular,  knotty  induration,  but  not  much  increase  in  size. 
These  phenomena,  together  with  the  history  and  the  results  of  specific  treat- 
ment, generally  render  its  recognition  easy.  (For  the  differential  diagnosis 
from  tubercular  orchitis  and  from  carcinoma  of  the  testis  see  p.  169.) 

Malignant  Diseases  of  the  Testicles. — Carcinoma  of  tjie  Testis 
usually  assumes  the  soft  or  encephaloid  form.  It  is  an  exception  to  the  rule 
that  carcinomata  develop  most  frequently  after  middle  age.  Of  67  cases  col- 
lected at  random,  51  were  in  persons  under  forty,  and  24  appeared  before  the 
age  of  thirty.  The  disease  is  usually  unilateral,  and  begins  in  the  form  of 
one  or  more  small  nodules  occupying  the  body  of  the  gland  and  soon  enlarging 
so  as  to  involve  the  epididymis.  The  swelling  is  at  first  smooth  and  uniform, 
but  as  soon  as  the  tunica  albuginea  breaks  down  it  becomes  irregular,  with 
areas  which  are  soft  and  fluctuating,  and  grows  with  increased  rapidity.     The 


sri;(!i:in'  ov  the  aENiTO-vniNAiiY  tract.         i»5l 

veins  of  the  scrotum  are  greatly  enlarged ;  the  ^Vm  hecoines  adherent  and  ulcer- 
ates; the  crroAYth  reaches  a  large  size  and  is  sometimes  enormous;  fungous  pro- 
trusions, insisting  of  granulations,  and  of  sloughs  of  the  connective  tissue  and 
even  of  portions  of  the  glan.l,  make  their  a])pcarance  and  hleed  upon  the  least 
touch  •  the  cord  is  thickene.l.  and  the  inguinal  and  pelvic  glands  are  involved. 
The  <n-ner:il  health  soon  fails,  the  patient  hecomes  cachectic  and  emaciated,  and 
deatl'?  usually  results  in  from  one  to  two  years  after  the  first  appearance  of  the 

growth.  T       4. 

Scirrhus  of  the  testicle  is  very  rare,  and  presents  no  features  peculiar  to 

the  locality.  „         .     .,  ,       ,  ,.   •  • 

Sarcoma  of  the  testicle  is  found  in  all  its  forms.  Several  subdivisions 
have  been  made  of  certain  of  these  sarcomatous  growths,  and  have  somewhat 
unnecessarilv  complicated  the  study  of  the  pathology  of  the  testis. 

The  so-called  Cystic  Tes^tide,  the  "hydrated  testicle"  of  Sir  Astley  Cooper, 
is  probablv  almost  always  an  early  stage  of  sarcoma.  It  is  of  variable 
duration,  Imt  is  often  slow  in  its  development  and  is  attended  with  a  gradual, 
painle^^  uniform  enlargement  of  the  whole  gland,  which  retains  its  oval  shape, 
is  smooth  and  elastic  to  the  touch,  and  often  fluctuates.  It  may  reach  an  im- 
mense size.  It  resembles  hydrocele  or  hematocele  in  form  and  general  appear- 
ance, but  is  heavier  than  the  former,  is  more  ovoidal,  and  is  opaque.  Jrom 
hematocele  the  diagnosis  may  be  more  difficult,  and  sometimes  it  can  be  made 
in  the  later  stages  of  cystic  disease  only  by  recognition  of  the  enlarged  veins 
over  the  surface  of  the  scrotum  and  by  the  general  cachexia.  In  the  earlier 
stacres  the  introduction  of  a  trocar  will  in  either  case  often  be  followed  by 
bleedincT,  but  in  hematocele  the  blood  will  be  in  greater  quantity,  and  will  be 
darker  and  altered  in  appearance.  In  those  cases  in  which  the  contents  of 
an  old  hematocele  have  undergone  partial  organization,  leaving  areas  contain- 
ing fluid  blood,  the  diagnosis  may  be  practically  impossible,  but  it  is  less  im- 
portant, as  in  both  cases  castration  is  indicated. 

Enclmidroma  of  the  Testicle  has  been  described  as  a  benign  growth,  but  it 
is  probable  that  it  is  almost  invariably  a  form  of  sarcomatous  disease.  In  some 
cases  it  grows  very  slowly,  and  may  then  be  recognized  by  its  great  weight 
and  density,  and  by  the  absence  of  pain  and  of  involvement  of  the  skm  or  of 
neif-hborincT  tissues.  Even  then,  however,  it  is  extremely  apt  to  take  on  ma- 
lignant chSnge,  while  in  the  more  rapidly  growing  form  it  is  found  from  the 
outset  in  combination  with  cystic  and  sarcomatous  disease. 

Jacobson  in  this  connection  has  appropriately  called  attention  to  the  close 
relations  of  cartilage  to  the  other  tissues  of  the  connective-tissue  type,  and  says 
that  when  it  is  remembered  how  narrow  is  the  dividmg-lme  between  these 
tissues  and  the  sarcomata,  especially  when,  as  a  result  of  continued  irritataon, 
the  former  tend  to  recur  to  their  embryonic  form,  it  may  well  be  doubted  it  an 
enchondroma  of  the  testicle  ever  really  deserves  the  term  "  innocent." 

Sarcoma  proper  may  be  of  the  round-celled  variety,  in  which  case  it  is  met 
with  in  an  unmixed  form,  grows  rapidly,  reaches  a  large  size,  and  is  soon  fol- 
lowed bv  secondary  deposits  having  all  the  characteristics  of  extreme  malig- 
nancy. "^  Spindle-celled  sarcomata  are  more  frequently  associated  with  other 
structures  of  the  connective-tissue  group— viz.  cartilaginous,  myxomatous,  and 
adipose  tissue— run  a  slower  course,  and  are  more  difficult  of  recognition,  but 
sooner  or  later  develop  the  usual  phenomena  of  this  form  of  malignant  growth. 
Diagnosis  of  Malignant  Disease  of  the  Testis.— In  their  early 
stages  both  carcinomata  and  sarcomata  are  liable  to  be  mistaken  for  enlarge- 
ments due  to  chronic  orchitis,  as  at  this  time  they  both  have  an  oval  shape, 
a  smooth  surface,  and  are  somewhat  indurated.     Later,  as  the  growths  soften, 


952  AN  AMERICAN    TEXT-BOOK    OE  SURGERY. 

and  especially  when,  as  is  often  the  case,  there  is  fluid  in  the  tunica  vaginalis, 
they  may  simulate  an  old  hydrocele  with  a  thickened,  opaque  tunic  or  a  hema- 
tocele w'ith  thickened  walls.  The  following  points  may  be  enumerated  as  of 
chief  diagnostic  value  (Jacobson):  (1)  continuously  progressing  solid  enlarge- 
ment without  inllammation;  (2)  unc((ual  resistance  of  the  swelling  at  diflCcrent 
parts;  (3)  entire  absence  of  translucency ;  (4)  tendency  to  become  adherent; 
(5)  increasing  aches  or  painfulness;  ((J)  enlargement  of  the  cord  and,  a  fortiori, 
of  the  lumbar  glands.  In  doubtful  cases  additional  information  should  be  at 
once  sought  for  by  an  antiseptic  tapping  or  exploratory  incision.  The  latter 
is  preferable,  as  it  gives  more  certain  information,  and  is  the  best  treatment  in 
those  liematoceles  which  are  liable  to  be  mistaken  for  malignant  disease.  Punc- 
ture of  a  malignant  growth  usually  gives  vent  to  blood-stained  fluid  which  is 
not  large  in  amount,  or  to  sero-mucous  fluid  which  is  not  blood-stained.  On 
puncture  of  a  hematocele  there  usually  escapes  either  grumous  altered  blood 
or  fluid  blood,  which  flows  for  some  time,  producing  a  distinct  alteration  in  the 
size  of  the  SAvelling. 

Castration. — The  most  recent  review  of  the  results  of  operation  in  ma- 
lignant disease  of  the  testicles  is  that  of  Butlin.  In  99  cases  collected  by 
him  there  were  4  deaths  from  causes  directly  connected  with  the  operation. 
Many  of  the  patients  were  lost  sight  of,  but  there  were  5  cases  of  sarcoma  well 
at  the  end  of  from  twenty  months  to  two  years,  and  2  cases  of  carcinomata 
without  recurrence  at  the  end  of  forty-two  months  and  one  hundred  and  eight 
months  respectively.  Mr.  Butlin's  conclusions  as  to  this  important  subject 
ai'e  that  castration  for  malignant  disease  is  an  o]ieration  Avhich  may  be  per- 
formed with  very  small  danger  to  life.  The  operation,  whether  for  sarcoma  or 
for  carcinoma,  cannot  be  said  to  be  attended  with  large  success,  so  far  as  com- 
plete cure  of  the  patient  is  concerned,  but  there  is  a  great  lack  of  information 
on  this  subject.  There  is,  however,  evidence  that  it  may  be  attended  with 
permanent  success,  and  there  is  still  further  evidence  that  the  operation  may 
be  an  excellent  palliative  measure  even  if  it  fails  in  its  primary  object,  cure. 
There  is  comparatively  little  likelihood  of  recurrence  in  situ  unless  the  cord  is 
thickened  or  the  scrotum  adherent  at  the  time  of  the  castration.  There  is  no 
prospect  of  success  for  operations  for  recurrent  disease  unless  the  recurrence  is 
in  the  scrotum.  Castration  may  be  performed  for  malignant  disease  of  both 
testes,  if  not  with  a  reasonable  prospect  of  permanent  cure,  yet  certainly  with 
hope  of  temporary  relief,  and  also  with  the  hope  of  temporary  relief  in  cases 
of  malignant  disease  in  children. 

The  operation  is  performed  as  follows :  The  hair  of  the  pubes,  scrotum, 
and  perineum  having  been  shaved  and  these  regions  repeatedly  washed  and 
disinfected,  and  the  possible  jjresence  of  hernia  in  the  scrotum  or  in  the  canal 
being  kept  in  mind,  the  skin  of  the  scrotum  should  be  steadied  by  the  thumb 
and  fingers  of  the  left  hand  of  the  operator  Avhile  an  incision  is  made  from  a 
point  just  below  the  external  abdominal  ring  to  the  bottom  of  the  scrotum. 
This  is  gradually  deepened,  layer  by  layer,  the  tunic  being  recognized,  when 
it  is  reached,  by  its  immobility.  The  testis  and  tumor  may  sometimes  be 
removed  with  the  tunic  by  simply  shelling  out  the  mass  from  the  scrotal  tis- 
sues with  the  fingers,  aided  here  and  there  by  touches  of  the  knife.  Usually, 
however,  it  will  be  necessary  to  lay  open  the  tunic  either  for  ])ur{)oses  of  diag- 
nosis, to  lessen  the  bulk  of  the  swelling,  or  because  the  tunic  itself  has  con- 
tracted inflammatory  adhesions  to  the  surrounding  parts  or  has  become  incor- 
porated with  them  during  the  progress  of  the  disease.  After  the  tumor  is 
freed  from  all  attachments  except  that  to  the  cord,  traction  is  made  upon 
it  so  as  to  elongate  the  latter,  which  is  then  isolated  by  the  finger.     It  may 


SURGERY   OF    THE   GENI TO- URINARY   TRACT.  953 

then  be  secured  by  a  clamp,  divided  below  it,  and  the  vessels  secured  sepa- 
rately, or  it  may  be  encircled  with  a  stout  chromicized  catgut  ligature  or  a 
fine  strong  silk  thread,  and  then  divided,  the  ends  of  the  catgut  or  silk  being 
cut  short  and  the  cord  allowed  to  retract  into  the  canal  after  inspection  of 
the  cut  surface  has  shown  that  there  is  no  hemorrhage.  A  small  drainage- 
tube  may  be  carried  up  to  the  stump  of  the  cord  and  left  in  place  for  a  day  or 
two.  All  hemorrhage,  even  oozing  from  minute  vessels,  should  be  arrested  by 
ligature  before  the  wound  is  closed.  Otherwise  very  troublesome  bleeding 
may  occur.  During  suturing  the  inversion  of  the  edges  of  the  wound  by 
the'  dartos  should  be  guarded  against.  The  scrotum  should  be  moderately 
elevated  and  well  supported  by  the  antiseptic  dressing.  Special  care  should 
be  exercised  to  prevent  infection  from  urine  or  feces. 

Sterility,  or  incapacity  to  fecundate  the  female,  may  depend  on  some 
defect  in  the  spermatic  fluid,  such  as  alisence  or  enfeeblement  of  the  sperma- 
tozoa. I'll  is  may  result  permanently  from  disease,  as  any  of  the  forms  qf 
orchitis,  atrophy  of  the  testicles,  neoplasms,  etc.,  or  temporarily  from  sexual 
excess  or  the  general  feebleness  following  an  exhausting  illness.  It  may  also 
be  caused  by  the  various  forms  of  impotence,  with  the  accompanying  inability 
to  deposit  the  semen  within  the  vagina,  or  it  may  result  from  obstruction  of 
the  excretory  ducts  of  the  testicle,  as  in  double  epididymitis,  tumor  of  the 
seminal  vesicles  or  prostate,  stricture  of  the  urethra,  etc.  The  diagnosis  can 
best  be  made  by  microscopical  examination  of  recently-ejaculated  semen.  If 
live  spermatozoa  are  found  and  if  the  individual  has  no  form  of  impotence, 
sterility  may  be  excluded. 

Impotence,  or  inability  properly  to  perform  the  sexual  act,  may  arise 
from  absence  of  the  penis,  malformation  or  diminutive  size  of  that  organ,  or 
disease  or  injury  producing  changes  in  portions  of  the  erectile  tissue  and  pre- 
venting their  participation  in  the  act  of  erection,  thus  leaving  part  of  the  penis 
flaccid.  Various  diseases  and  injuries  of  the  cerebro-spinal  axis,  and  especially 
of  the  lumbar  cord,  are  accompanied  or  followed  by  loss  of  potency.  Urethral 
stricture,  especially  when  deep-seated  and  associated  with  hyperesthesia  of  the 
prostatic  region,  often  causes  a  certain  degree  of  impotence  by  inducing  pre- 
mature ejaculation,  in  many  cases  the  erection  subsiding  before  an  entrance  can 
be  effected.  Oxaluria  is  not  infrequently  a  cause  of  very  persistent  and  com- 
plete impotence,  which,  however,  disappears  rapidly  under  appropriate  diet  and 
drugs.  The  treatment  of  all  these  forms  should  be  directed  to  the  removal  of 
the  underlying  condition. 

Pseudo-impotence  is  a  form  of  sexual  disability  Avhich  has  its  origin  in  the 
imagination  or  in  the  fear  of  the  patient.  It  is  very  common  among  young 
men  who  have  been  unaccustomed  to  sexual  indulgence  and  who  have  failed 
at  their  first  attempt,  owing  to  nervousness,  want  of  confidence,  or  possibly  a 
genuine  distaste  for  the  female.  This  sometimes  happens  during  the  early 
period  of  married  life,  and  gives  rise  to  intense  anxiety  and  distress  on  the 
part  of  the  husband.  As  a  rule,  all  that  is  needed  is  a  few  words  of  advice 
and  encouragement,  with  the  injunction  to  refrain  from  repeated  attempts  while 
mentally  perturbed.  A  placebo  may  be  given,  and  these  measures  with  time 
will  always  work  a  cure. 

Spermatorrhea  is  a  condition  in  which  there  is  escape  or  oozing  of 
semen,  instead  of  erection  or  pleasurable  sensation.  In  the  sense  of  a  con- 
stant flow  of  semen  it  is  extremely  rare.  When  observed  intermittently  in 
vigorous  men  who  have  suddenly  become  continent,  it  may  almost  be  regarded 
as  physiological.'  It  is  not  infrequently  associated  with  chronic  posterior 
urethritis  or  with  strictures  of  large  calibre. 


954  ^l.V   AMKlilCAX    TEXT- HOOK    OF  SL'llGEltY. 

In  bad  cases  it  is  accompanied  by  a  very  marked  form  of  imjiotence  Avith 
loss  of  both  desire  and  ])o\ver  of  erection.  A  microscopic  examination  of 
tlie  discharge  is  often  necessarA'  to  distinguish  it  from  catarrhal  contlitions 
of  the  uretliral  tract.  The  treatment  varies  with  the  cause:  but  the  pa- 
tients will  usually  be  morbid  and  difficult  to  manage.  Their  hygiene  must 
be  rigidly  attended  to  :  locally,  no  two  things  do  so  much  good,  even  wiien 
they  are  used  empirically,  as  tlie  instillation  of  weak  silver  solutions  into 
the  posterior  uri'tiira  and  prostatic  sinus  and  tlic  use  of  the  ccdd  steel 
sound. 

Varicocele. — The  veins  of  the  spermatic  cord  may  be  divided  into  two 
sets,  an  anterior,  running  with  the  spermatic  artery  and  called  the  pampiniform 
plexus,  and  a  posterior,  smaller  set  accompanying  the  deferential  artery  and 
surrounding  the  vas  deferens.  The  veins  m  the  left  cord  are  said  to  be  always 
larger  than  those  of  the  right  (Spencer).  The  arteries  of  the  cord  are  the 
spermatic,  lying  in  front  of  the  vas,  the  deferential,  which  runs  w  ith  it,  and  the 
cremasteric,  which  is  more  superficial. 

Varicocele  is  usually  an  enlargement  of  the  veins  of  the  pampiniform 
plexus  only,  but  occasionally  all  the  veins  of  the  cord  are  involved.  The 
testicle  on  the  affected  side  is  apt  to  be  smaller  and  softer  than  its  fellow,  and 
the  dartos  structure  is  usually  flabby  and  relaxed. 

The  condition  occurs  chiefly  in  young  unmarried  adults,  and  so  rarely 
develops  before  puberty  or  after  middle  age  that  it  is  evident  that  it  has 
some  relation  to  the  sexual  function,  being  apparently  favored  by  a  lack  of  its 
normal  exercise.  The  mechanical  conditions  of  the  spermatic  veins,  their  great 
length,  their  tortuous  course,  and  the  absence  of  support  from  firm  under- 
lying or  surrounding  muscles,  are  said  to  predispose  to  varicocele ;  but  if  these 
were  very  important  factors  it  would  be  much  more  common  on  the  right  side 
than  it  is.  Sir  Astley  Cooper,  Agnew^  Marshall  (who  examined  30,000 
recruits),  and  others  state  that  they  have  never  seen  a  well-marked  case  on 
the  right  side.  The  entry  of  the  left  spermatic  vein  into  the  corresponding 
renal  vein  at  a  right  angle  instead  of  at  the  acute  angle  at  which  the  right 
spermatic  vein  joins  the  vena  cava,  its  passage  behind  tlie  sigmoid  flexure, 
and  its  greater  length,  bave  all  been  regarded  as  explaining  the  great  pre- 
ponderance of  left-sided  varicocele,  and  probably  all  share  in  bringing  it 
about. 

Exciting  causes  are  found  in  whatever  determines  an  increased  amount  of 
blood  to  the  testicles,  as  heavy  lifting,  straining  during  defecation  or  urination, 
excessive  sexual  indulgence,  etc. 

Symptoms. — The  disease  is  easily  recognized.  The  scrotum  on  the 
affected  side  is  filled  with  a  tortuous  mass  of  veins,  giving  a  peculiar  worm- 
like feel  to  the  touch.  Their  convolutions  are  often  visible  through  the  skin. 
The  scrotum  is  elongated  and  dusky  or  purplish  in  color.  There  is  not  much 
pain,  but  occasionally  a  dull  ache  extending  along  the  cord  and  into  the  loins 
is  experienced.  Patients  with  varicocele  are  apt  to  be  depressed  and  melan- 
choly. They  are  often  the  subjects  of  pseudo-impotence,  and  if  they  have 
once  failed  in  an  attempt  at  sexual  intercourse,  if  they  have  masturbated  when 
younger,  and  especially  if  in  addition  there  is  a  noticeable  diminution  in  the 
size  of  the  testicle  on  the  affected  side,  they  become  sexual  hypochondriacs  of 
the  most  pronounced  type.  Occasionally,  but  rarely,  genuine  atrophy  of  the 
testes  results  from  the  interference  with  the  circulation  produced  by  the  en- 
larged veins,  but,  as  the  other  gland  is  usually  normal,  neither  impotence  nor 
sterility  is  threatened. 

The   disease  can  scarcely  be  mistaken  for   any  other  condition,  and  the 


srn(;i:nY  or  the  aEyiro-rinxAHV  Thwrr. 


9r,5 


directions  often  given  for  its  diagnosis  fnuii  scroliil  licniia  or  congenital  liydro- 
eele  seem  umieces.sarv. 

Treatment. — The  ]ialliatii)n  of  a  case  <»f  vaiicorck-  may  be  attempted  by 
means  of  eold  doudies,  regidation  of  the  bowels,  avoidance  of  all  exciting 
causes,  the  use  of  a  firm,  well-iitting  suspensory  bandage,  etc.,  but  little  or  no 
effect  upon  the  already  existing  enlargement  need  be  exjtected. 

The  radical  cure  may  be  indicated  either  by  actual  pain  and  disability,  by 
progressive  atrophy  of  the  testicle,  or  by  the  mental  condition  of  the  patient. 

Excision  of  the  affected  veins  is  the  operation  which  is  most  satisfactory. 
The  usual  ])reliiiiinary  shaving  and  cleansing  of  the  region  should  be  done,  after 
uliieli.  while  an  assistant  makes  the  tissue  tense  Ijy  drawing  the  testicles  and  scro- 
tum downward,  an  incision  al)out  two  inches  in  length  is  made  over  the  most 
prominent  part  of  the  varicocele.  The  veins  are  exposed,  but  are  not  sepa- 
rated from  the  fascia  surrounding  them  and  holding  them  together.  The 
vas  with  its  venous  plexus  is  recognized  and  avoided.  An  aneurysm  needle 
threaded  with  catgut  is  then  passed  under  the  veins  at  the  upper  end  of  the 

Fig.  374. 


w 


k 


Hydrocele  (original). 


incision  and  again  at  the  lower  end.  The  ligatures  are  tied,  and  in  each 
instance  left  with  one  long  end.  The  intermediate  portion  of  the  veins  is 
then  cut  out  Avith  the  scissors,  and  the  stumps  are  brought  into  apposition 
and  held  by  tying  the  ligature  ends  together.  This  raises  the  testis  to  a 
higher  level  and  results  in  shortening  the  scrotum  on  that  side.  The  results 
have  been  excellent  in  large  numbers  of  cases. 

Hydrocele. — Hydrocele  is  a  condition  in  which  there  is  an  abnormal  quan- 
tity of  fluid  in  the  cavity  of  the  tunica  vaginalis  testis  (Fig.  374).  It  occurs 
with  about  equal  frequency  on  both  sides,  and  is  usually  unilateral.  The  acute 
form  of  hydrocele  accompanies  some  varieties  of  orchitis  and  many  cases  of 
epididvmitis,  and  occasionally  follows  traumatism.  Sometimes  the  cavity  of 
the  tunic  is  divided  into  tw^o  portions  by  the  adhesion  of  its  walls,  in  which 
case  the  hydrocele  is  said  to  be  bilocular.  The  causes  of  hydrocele,  exclusive 
of  traumatism,  are  not  often  very  easily  traced.  It  has  been  attributed  to 
violent  muscular  efforts,  to  straining,  etc.,  and  is  certainly  favored  by  relax- 
ation of  the  scrotum  due  to  long-continued  high  temperature.  Hydrocele  is 
therefore  more  frequent  in  tropical  climates  than  elsewhere. 

The  fluid  of  a  hydrocele  is  almost  identical  in  composition  with  the  serum 


966  A.y  .1 . 1/ /•;/.' /r.LV    Ti:XT-li()<)k'    OF  sritGERY. 

of  the  blood.  In  the  majority  of  eases  it  is  transpurent  and  <jf  a  straw  or 
amber  color.  Occasionally,  especially  in  traumatic  hydroceles  and  in  those 
which  are  secondary  to  disease  of  the  tunic,  the  fluid  is  dark-colored  and 
opaque,  owing  to  the  presence  of  the  coloring  matter  of  the  blood-corpus- 
cles which  it  contains.  In  old  cases  the  tunic  is  often  iiiucli  thickened,  and 
this  thickening  may  of  itself  render  the  hydrocele  incapable  <jf  transmitting 

In  encifsted  hydrocele  the  fluid  is  contained  in  the  sac  between  the  epi- 
didymis and  the  tunic  or  between  the  tunica  vaginalis  and  the  tunica  albu- 
•rinea.  In  coiuienitaJ  hydrocele  the  continuity  between  the  cavity  of  the  tunica 
vaginalis  and  that  of  the  peritoneum  still  exists,  so  that  the  serum  from  the 
al)domen  is  free  to  pass  downward  along  the  track  of  the  cord,  and  thus 
produces  a  hydrocele.  Infantile  hydrocele  may  be  of  either  of  the  above 
varieties. 

Symptoms. — The  swelling  in  hydrocele  begins  at  the  low^er  portion  of 
the  scrotum,  and  is  slow  in  developing :  it  is  slightly  pyriform,  smooth,  tense, 
and  fluctuating ;  it  is  elastic  on  pressure,  which  does  not  alter  the  size  of  the 
swelling ;  it  fluctuates  distinctly,  is  dull  on  percussion,  and  is  not  accompa- 
nied by  pain,  redness,  or  other  alteration  in  the  skin.  A  peculiarity  of 
hydrocele  worthy  of  attention  is  that  the  tumor- instead  of  hanging  downward 
between  the  thighs,  as  in  hernia,  projects  forward  from  the  body,  and,  if  pressed 
back,  springs  again  to  its  original  position  when  released.  The  most  charac- 
teristic symptom  of  hydrocele  is  its  translucency.  This  should  be  elicited  by 
examining  the  patient  in  a  dark  room  while  a  candle  is  held  close  to  one  side 
of  the  scrotum,  which  is  made  tense  by  the  hand  of  the  surgeon,  the  other 
being  placed  in  contact  with  the  anterior  margin  of  the  swelling,  so  as  to  inter- 
cept the  rays  of  light.  In  ordinary  hydroceles  the  translucency  is  easily 
recognized.  In  those  which  contain  an  opaque  or  bloody  fluid  it  cannot,  of 
course,  be  found,  and  the  use  of  an  aspirating  needle  may  be  required  to  estab- 
lish the  diagnosis.  The  test  by  transmitted  light  should  always  be  em])loyed 
in  cases  of  supposed  hydrocele,  to  exclude  the  possibility  of  a  coexistent  hernia 
and  to  fix  the  position  of  the  testis,  which  will  generally  be  found  posteriorly 
just  below  the  middle  of  the  scrotum.  Attention  to  the  features  of  the  condi- 
tion which  have  just  been  described  will  usually  render  the  diagnosis  easy,  but 
in  rare  instances  it  is  possible  to  be  mistaken,  as  in  cases  of  irreducible  omental 
hernia  with  redema  of  the  scrotum  and  the  subjacent  tissues. 

Treatment. — The  treatment  of  hydrocele  may  be  palliative  or  radical. 
Palliative  treatment  consists  in  occasional  tappings  when  the  tunic  becomes 
fully  distended.  The  patient  should  lie  upon  his  back  in  a  semi-recumbent 
position  ;  the  skin  of  the  scrotum  should  be  thoroughly  disinfected  and  made 
tense  by  the  left  hand  of  the  surgeon,  who  with  the  other  plunges  a  small 
trocar  into  the  anterior  part  of  the  sac  in  a  direction  upward  and  inward, 
avoiding  any  large  superficial  vein  which  may  be  apparent.  The  dej)th  to 
which  the  trocar  is  plunged  should  be  limited  by  keeping  the  thumb  or  finger- 
nail in  contact  with  the  canula  at  the  distance  of  an  inch  and  a  half  or  two 
inches  from  the  point  of  the  instrument  (Fig.  375).  By  observing  this 
precaution  and  by  inserting  the  trocar  in  the  proper  direction  all  danger  of 
wounding  the  testicle  is  easily  avoided,  especially  if  its  position  has  been 
previously  and  accurately  determined  by  the  light  test.  The  sac  having 
been  emptied,  the  canula  is  withdrawn,  and  the  little  opening  immediately 
closed  by  a  pledget  of  bichloride  cotton  held  in  place  by  iodoform  and 
collodion. 

The  radical  treatment  of  hvdrocele  mav  be  either  by   injection  or  by 


sunoEJ!)'  or  Tin-:  <n:xrn)-URiNAiiv  travt. 


957 


!"i<i.  .S7'j. 


^H 


Tapping  a  Hydrocele;  testicle  in  usual 
position:  //</,  cavity  of  hydrocele ;  NH, 
epididymis;  i/o,  testicle  (Tillmanns). 


Operation.  In  the  former  case  tlic  lliiiil  is  withdrawn  as  above  described. 
After  the  sac  is  emptied  a  (piaiitity  of  tlie  undiluted  offieinal  tincture 
of  iodine  proportionate  to  the  size  of  the  sac, 
and  varvino;  from  one  to  five  or  six  drams,  is 
thrown  tlirouirli  tlic  caiuda  into  the  sac  and 
allowed  to  remain  lli(>re.  To  prevent  the 
escape  of  any  portion  of  the  iodine,  it  is  well 
to  withdraw  the  syringe  and  canula  together. 
The  li(iuid  is  diftused  over  the  entire  surface 
of  the  memhi-ane  by  lifting  and  gently  rub- 
bing the  scrotum.  The  canula  ])uncture  is 
closed  with  cotton  and  collodion,  the  scrotum 
is  elevated,  and  if  it  becomes  very  swollen  and 
sensitive  is  covered  with  dilute  lead-water  and 
laudanum.  In  the  course  of  twenty-four 
or  thirty-six  hours  the  swelling  will  have 
reached  its  original  size  or  even  passed  be- 
yond it.  After  tills  it  begins  to  subside, 
and  at  the  end  of  three  or  four  weeks  will,  in 
successful  cases,  have  disappeared  entirely. 
The  cause  of  failure  in  this  simple  ope- 
ration is  usually  a  neglect  to  use  a  suf- 
ficient (juantity  of  iodine,  or  a  failure  to 
empty  the  sac  of  the  hydrocele,  so  that  the 
iodine  which  is  injected  is  at  once  diluted 
by  the  remaining  fluid  and  does  not  set  up  an  adequate  degree  of  inflammatory 
action.  Sometimes,  too,  even  when  these  precautions  have  been  observed,  a 
considerable  quantity  of  the  iodine  already  injected  is  lost  at  the  moment  of 
taking  the  syringe  out  of  the  canula.  The  great  majority  of  all  cases  of 
uncomplicated  hydrocele  are  curable  by  this  method  when  properly  performed, 
but  if  the  tunica  vaginalis  be  much  thickened,  injection  however  performed, 
must  fail,  owing  to  the  impossibility  of  absolute  collapse  of  the  sac. 

In  congenital  hydrocele  in  adults  the  method  of  injection  may  be  danger- 
ous on  account  of  the  communication  of  the  sac  with  the  peritoneal  cavity. 
It  would  probably  be  better  always  to  employ  one  of  the  methods  yet  to  be 
described.  Carbolic  acid  may  be  used  in  place  of  iodine,  and  is  preferred  by 
some  surgeons.  From  ten  to  thirty  drops  of  the  pure  acid,  liquefied  with  the 
least  possible  amount  of  water,  are  injected,  or  a  dram  of  the  5  per  cent. 
solution  in  glycerin  of  the  crystallized  acid  may  be  used. 

Treatment  hy  Incision. — By  this  method  a  vertical  incision  from  one  and 
a  half  to  two  inches  in  length  is  made  through  the  disinfected  tissues  of  the 
scrotum  and  along  the  anterior  and  low^er  portion  of  the  sw^elling,  and  into  the 
tunica  vaginalis.  The  margins  of  the  tunic  are  then  stitched  to  the  edges  of 
the  skin-Avound  by  a  few  catgut  sutures,  and  a  large  drainage-tube  is  introduced 
into  the  sac.  The  wound  is  dressed  antiseptically  and  is  washed  out  daily. 
The  drainage  is  shortened  at  intervals,  and  the  sutures  may  be  removed  before 
the  end  of  the  first  week.  Instead  of  using  a  tube,  the  cavity  of  the  hydro- 
cele may  be  packed  with  iodoform  gauze. 

Excision  of  the  parietal  layer  of  the  tunic  has  been  re-introduced  by  Von 
Bergmann,  and  consists  in  dissecting  it  out  from  the  tissues  of  the  scrotum 
and  cutting  ofi"  portions,  leaving  sufficient  to  serve  as  a  normal  covering  for 
the  testicle.  A  drainage-tube  is  inserted  and  the  edges  of  the  external 
'••ound  are  sutured.     This  method  is  more  severe  than  those  just  described. 


fi58  A.\  .i.i//;///r.i.v   ri:xT-Jiouh'  c/'  sri^'aEiiv. 

Iiiit  may  Ix;  rcMjuired  in  c;i.sc.>  of  inveterate  liy<lroccle  in  Avliich  all  other 
methods  fail. 

Indieations  for  the  selection  of  one  or  the  other  of  the  other  two  methods 
are  as  folloAvs :  In  the  great  majority  of  simple  cases  in  which  no  previous 
operation  has  been  tried  the  absence  of  a  cutting  operation  or  of  an  open 
wound,  the  fact  that  no  anesthetic  is  required,  and  the  comparatively  sliort 
convalescence,  together  with  the  extremely  favorable  results,  render  the  treat- 
ment l)y  iodine  injection  the  method  of  choice. 

The  antiseptic  incision  should  be  selected  {<i)  in  cases  of  previous  failure 
with  iodine:  (//)  where  the  sac  is  very  large  or  has  very  thick  walls;  {<■)  where, 
on  account  of  ill-health  or  premature  age,  the  risk  of  inflammation  after  iodine 
injection  is  especially  to  be  dreaded;  {d)  in  cases  of  congenital  hydrocele, 
when  a  careful  incision  w  ith  antiseptic  precautions  will  be  safer  than  any  other 
method  if  the  pressure  of  a  truss  for  the  obliteration  of  the  peritoneal  com- 
munication cannot  be  persevered  in  ;  {e)  where  the  surgeon  is  desirous  of 
exploring  the  sac  of  the  tunica  vaginalis,  as  in  cases  where  enlargement  of  the 
testis  of  a  doubtful  nature  coexists  with  hydrocele,  and  does  not  yield  to  ordi- 
nary treatment ;  (/)  where  two  hydroceles  coexist — e.  g.  vaginal  and  encysted 
hydroceles ;  ((/)  in  some  cases  of  hydrocele  complicated  with'  hernia — e.  g. 
where  the  bowel  is  irreducible,  and  where,  especially  in  uniiealthy  patients, 
there  is  a  risk  of  the  inflammation  set  up  by  the  iodine  extending  to  the  her- 
nial sac  (Jacobson). 

Hematocele. — Hematocele  is  a  collection  of  blood  in  the  tunica  vaginalis. 
It  is  usually  due  to  injury,  but  may  be  the  result  of  disease  aifecting  the  inner 
surface  of  the  membrane.  It  sometimes  follows  violent  straining  efforts,  and 
now  and  then  is  a  se(|uel  of  the  treatment  of  hydrocele  by  tapping.  It  consti- 
tutes an  ovoidal  or  globular  tumor,  witli  its  largest  circumference  below,  non- 
fluctuating,  opaque,  heavy,  quite  solid,  and  resistant  to  pressure.  If  these 
symptoms  are  all  present,  the  diagnosis  is  usually  easy.  In  old  cases  the 
thickening  of  the  tissues  is  so  great,  and  the  density  of  the  contents  of  the 
tunic  is  such,  that  the  swelling  resembles  a  solid  tumor,  and  its  true  character 
can  sometimes  be  recognized  only  by  means  of  an  exploratory  incision. 

Treatment. — In  acute  traumatic  cases  the  scrotum  shotdd  be  elevated 
and  wrapped  in  iced  lead-water  and  laudanum.  After  the  swelling  has  become 
stationary  or  has  begun  to  subside,  absorption  of  the  blood  may  be  favored  by 
gentle  and  uniform  compression,  either  by  means  of  a  narrow  elastic  bandage 
or  by  strapping  with  adhesive  plaster.  If,  in  spite  of  these  means,  a  hemato- 
cele is  very  large,  is  increasing  in  size,  and  is  accompanied  by  heat,  pain,  and 
oedema  of  the  scrotum,  it  is  well  to  make  a  longitudinal  incision  into  the  sac, 
evacuate  its  contents,  irrigate  the  cavity,  pack  it  with  iodoform  gauze,  and 
dress  it  antiseptically.  If  at  this  time  disease  of  the  testicle  itself  is  discov- 
ered, or  if  there  is  a  marked  amount  of  inflammatory  change  in  the  tunic, 
accompanied  by  great  pain  and  irritation,  castration,  with  removal  of  the  sac, 
is  the  most  satisfactory  treatment. 

DISEASES  OF   THE  SPERMATIC  CORD. 

The  cord  is  subject  to  a  variety  of  growths,  the  most  common  of  which, 
however,  are  the  lipomata.  These  may  be  single  or  multiple.  They  are 
usually  harmless  and  require  no  surgical  treatment.  Primary  malignant 
growths  of  the  cord  are  exceedingly  rare,  although  malignant  disease  is  often 
found  to  be  secondary  to  similar  disease  of  the  testicle. 

Diffused  Hydrocele  of  the  Cord. — The  most  important  pathological 


,Si'R(JERy    or    THE    GKNlTO-URlNAltY    TRACT.  959 

conditions  of  the  spermatic  cord  are  found  in  the  various  forms  o-t  hydrocele. 
As  the  testicle  descends  from  the  loins  to  the  scrotum  it  carries  with  it  a 
double  layer  of  peritoneum,  and  this  makes  a  serous  sac  extending  from  the 
internal  ring  of  the  abdomen  to  the  scrotum,  one  layer  lying  in  contact  with 
the  cord  and  the  tunica  albuginea,  and  the  other  with  the  inner  surface  of  the 
cremaster  muscle  and  the  scrotum.  The  space  between  that  portion  of  these 
two  layers  which  surrounds  the  testicle  constitutes  the  tunica  vaginalis  testis. 
Usually,  above  the  external  ring  the  space  between  the  two  layers  is  oblite- 
rated and  they  invest  the  cord  as  a  single  membrane.  If  they  remain  sepa- 
rate between  the  internal  and  external  rings,  and  if  serum  accumulates  between 
them,  an  elongated  swelling  forms,  extending  from  a  little  distance  above  the 
testicle  to  the  internal  ring,  cylindrical  while  the  patient  is  lying  down,  but 
becoming  pyriform  when  ho  is  standing  up.  The  swelling  is  soft  and  iluctu- 
ates :  it  may  be  made  to  appear  below  the  external  ring  by  pressure  over  the 
course  of  the  canal,  and  will  disappear  when  that  pressure  is  removed.  It  is 
occasionally  translucent  by  transmitted  light.  It  is  most  likely  to  be  mistaken 
for  an  irreducible  omental  hernia,  as  when  it  is  tense  there  is  a  very  perceptible 
impulse  on  coughing,  and  as  the  sac  of  such  a  hernia  may  contain  a  fluid  which 
resembles  that  of  hydrocele.  It  may  be  treated  by  iodine  injection  or  by  the 
introduction  of  the  seton. 

A  similar  condition,  in  which  the  two  layers  of  the  tunic  investing  the  cord 
have  remained  open  at  one  or  more  places  and  are  blended  together  at  others, 
gives  rise  to  Encysted  Hydrocele  of  the  Cord,  which  is  somewhat  different 
in  shape  from  the  form  just  described,  but  otherwise  has  the  same  characteris- 
tics. Very  rarely,  the  funicular  process  of  the  peritoneum  contracts  and  becomes 
adherent  to  the  cord  at  the  external  ring,  but  remains  open  above,  communi- 
cating with  the  general  peritoneal  cavity.  If  this  upper  opening  is  large,  it  is 
possible  to  have  a  hernia  and  a  hydrocele  coexistent,  but  usually  the  funicular 
process  adheres  to  the  cord  with  sufficient  closeness  at  the  internal  ring  to  per- 
mit only  of  the  entrance  and  exit  of  fluid.  When  the  patient  stands  erect  the 
symptoms  of  this  form  of  hydrocele  are  those  of  diffused  hydrocele  of  the  cord, 
but  when  he  assumes  the  recumbent  posture  the  tumor  disappears,  on  account 
of  its  reducibility ;  and,  as  it  often  has  a  distinct  impulse  on  coughing,  this 
swelling  is  likely  to  be  mistaken  for  hernia.  It,  however,  disappears  more 
slowly  than  the  latter  affection  and  without  the  characteristic  gurgle,  is  slower 
in  reappearing,  and  is  often  translucent.  It  should  be  treated  by  the  applica- 
tion of  a  truss,  which,  especially  in  young  persons,  will  often  be  followed  by 
the  closure  of  the  peritoneal  prolongation  at  the  internal  ring. 

In  congenital  hydrocele  in  children^  and,  indeed,  in  all  forms  of  hydrocele 
in  infants,  the  treatment  by  the  use  of  the  seton  is  extremely  satisfactory. 
The  sac  is  punctured  by  a  sharp  tenotome,  and  a  needle  threaded  with  aseptic 
silk  is  passed  along  the  blade  of  the  instrument  and  brought  out  through  the 
skin  of  the  scrotum.  The  silk  is  loosely  tied ;  the  contents  of  the  sac  drain 
away  by  the  side  of  the  thread,  which  soon  sets  up  sufificient  adhesive  inflam- 
mation to  obliterate  the  cavity  of  the  sac;  it  should  be  removed  in  two  or 
three  days,  and  should  be  covered  in  during  its  retention  by  an  antiseptic 
dressing. 

DISEASES  OF  THE  SCROTUM. 

(Edema  of  the  scrotum  deserves  mention,  as  it  is  sometimes  mistaken  for 
hydrocele.  It  may  follow  any  acute  inflammation  of  the  parts  or  any  trauma- 
tism, but  is  oftener  produced  by  the  conditions  which  cause  oedema  of  the  lower 
extremities,  such  as  cardiac  and   renal  diseases.     It  is  an  almost  invariable 


9G0  ^l.V    AMl'JRICAN    TKXT-llOOK    OF  SURGERY. 

symptom  of  extravasation  of  urine  superficial  to  Colles'  fascia,  in  wliicli  case 
it  soon  extends  to  the  subcutaneous  tissue  of  the  penis  and  prepuce,  and  often 
to  that  of  the  abdomen.  It  may  usually  be  easily  recognized  by  tiie  pitting 
on  pressure,  the  semi-transparent,  glazed,  and  sliiniiig  appearance  of  the  skin, 
the  disappearance  of  the  normal  scrotal  folds,  tlie  doughy  feel,  and  tlie  uniform 
character  of  the  swelling,  "which  is  almost  always  bilateral. 

No  special  treatment  is  necessary  except  in  cases  where  it  arises  from 
retained  pus  or  urine,  or  where  the  tension  is  so  great  that  the  vitality  of  the 
skin  is  threatened.  Under  these  circumstances  free  incisions  extending  well 
into  the  subcutaneous  tissues  should  be  employed. 

Elephantiasis  of  the  Scrotum  is  a  disease  which  is  accompanied  by  an 
enormous  hypertrophy  of  the  subcutaneous  connective  tissue,  due  probably  to 
a  chronic  inflammatory  condition  of  the  lymph-vessels,  which,  in  its  turn,  may 
be  produced  by  the  presence  in  tlie  blood  of  the  filaria  sanguinis  hominis. 
(See  p.  472.)  ' 

Epithelioma  of  the  Scrotum,  known  as  chimney-sweep's  cancer,  is  a 
disease  which  has  the  characteristics  of  epithelioma  elsewhere,  beginning  as  a 
little  warty  growth,  usually  at  the  lower  part  of  the  scrotum,  often  covered  Avith 
a  peculiar  crust,  ulcerating,  and  gradually  extending  until  all  the  superficial 
tissues  are  involved.  Later,  the  inguinal  glands  are  infected,  and  the  patient 
dies  as  in  otlier  forms  of  carcinoma.  It  is  exceedingly  rare  in  this  country, 
and  its  comparative  frequency  at  one  time  in  Great  Britain  was  supposed  to 
be  due  to  the  soft  coal  which  was  so  commonly  used  there,  the  soot  or  particles 
of  which,  accumulating  in  the  flexures  of  the  scrotum  of  an  uncleanly  person, 
were  thought  to  give  rise  to  persistent  irritation,  which  later  determined  the 
cancerous  growth.     The  treatment  is  by  early  and  thorough  excision. 

PART  VI.— DISEASES  AND  INJURIES  OF  THE  PENIS. 

Hypospadias. — This  is  a  congenital  deficiency  in  the  lower  wall  of  the 
urethra,  which  may  terminate  at  the  perineo-scrotal  junction  or  at  any  point 
anterior  to  it.  The  varieties  of  hypospadias  are  described  in  accordance  with 
the  degree  of  arrest  of  development  which  has  occurred.  If  this  has  been 
extreme,  the  anterior  orifice  of  the  urethra  may  even  lie  in  the  perineum,  the 
two  halves  of  the  scrotum  remaining  ununited,  and  often  consisting  of  two 
separate  pouches,  which-  arc  empty  when  the  testicles  have  failed  to  descend, 
and  Avhich  therefore  resemble  strongly  the  external  genitalia  of  the  female. 
In  these  cases  the  penis  is  atrophied  and  is  closely  applied  to  the  fissure  in  the 
scrotum.  In  the  penoscrotal  variety  the  opening  is  at  the  junction  of  the 
anterior  fold  of  the  scrotum  with  the  inferior  surface  of  the  penis,  and  the 
latter  is  apt  to  be  somewhat  better  developed,  although  still  strongly  curved 
downward,  owing  to  its  being  much  shorter  on  its  inferior  than  on  its  upper 
surface.  In  the  penile  variety  of  hypospadias  the  urethral  opening  may  be 
at  any  point  on  the  lower  surface  of  the  penis  between  the  peno-scrotal  junc- 
tion and  the  corona  glandis.  In  the  so-called  balanic  hypospadias  the  opening 
of  the  urethra  is  situated  on  the  under  surface  of  the  glans ;  the  fraenum  is 
absent.  There  is  often  a  little  groove  at  the  anterior  extremity  of  the  glans 
which  resembles  the  normal  meatus,  but  which  usually  ends  in  a  blind  j)ouch. 
When  this  disease  is  situated  far  back,  the  patient  is  usually  sterile,  though 
not  necessarily  impotent  if  the  organ  is  well  developed.  Often,  however, 
it  is  so  rudimentary  or  so  markedly  curved  upon  itself  that  intercourse  is 
impossible.  The  glandular  forms  of  hypospadias  are  of  no  physiological 
importance. 


SURGERY    OF    THE    (i  KXITO-Uli  IXA  liV    TRACT. 


961 


The  operation  which  has  been  most  successful  in  the  relief  of  this  condition 
is  that  Avhich  has  been  formulated  by  Duplay,  and  is  performed  in  three  stages: 


Fig.  376. 


A  B 

Duplay's  Operation  for  Hypospadias  (Duplay  and  Reclus). 


Fig.  377. 


(1)  The  penis  is  straightened  by  incising  transversely  the  ridge  which  unites 
the  glans  to  the  hypospadic  opening,  and  cnrrying  this  incision  as  deep  as  is 
necessary  to  obtain  complete  straightening  of  the  penis. 
A  considerable  delay  should  follow  this  step,  often  as 
much  as  three  or  four  months  if  the  incurvation  has 
been  considerable. 

(2)  The  next  step  should  consist  in  the  restoration 
of  the  meatus  and  the  formation  of  a  new  urethral 
canal  from  the  extremity  of  the  glans  to  the  neighbor- 
hood of  the  hypospadic  opening,  Avhich  should  be  left 
untouched  to  give  exit  to  the  urine.  The  meatus  is 
formed  simply  by  freshening  the  two  lips  or  by  deep- 
ening the  latter  by  means  of  incision,  and  then  uniting 
the  lips  over  a  small  gum  catheter.  The  remainder  of 
the  canal  is  formed  by  making  on  each  side  of  the 
])enis  and  on  its  lower  surfoce  a  longitudinal  incision  extending  from  the  base 
of  the  glans  to  near  the  hypospadic  opening  (Fig.  376,  A,  ah,  a'h').  The 
internal  lip  of  this  incision  is  dissected  up  slightly,  while  the  external  is  dis- 
sected freely,  so  as  to  make  a  large  flap,  taken  from  the  skin  of  the  lateral 
parts  of  the  penis.  These  flaps  are  then  united  by  quilled  sutures  of  silver 
wire  or  silk,  perforated  shot  being  employed  to  fasten  them,  or  the  wire  or 
silk  may  be  passed  through  small  perforated  leaden  plates  or  tubes  (Fig.  376, 
B).  These  flaps  are  united  over  the  catheter,  which  will  thus  have  a  cuta- 
neous covering  at  its  upper  and  lateral  aspect  and  a  linear  granulating  surface 

Gl 


Transverse  Section  of  the 
Penis  after  Operation :  S, 
the  new  urethra  (Duplay 
and  Reclus). 


0G2  AN   AMU  HI  CAN    TKXT-nooK    OF   SURUKliV. 

bcnoatli  it  (Fi<;.  377).  Diiplay  asserts  that  no  contraction  of  the  canal  results 
fron)  the  cicatrix  thus  fornied. 

(8)  The  third  stage  consists  in  the  freshening  of  the  fistulous  opening  which 
is  left,  and  the  union  of  its  edges  over  the  retained  catheter  by  means  of  the 
same  form  of  suture. 

In  the  second  stage  several  operations  may  he  rcfpiired  to  secure  a  com- 
plete urethra.  An  operation  based  on  that  of  Wood  of  London,  in  which  a 
transverse  incision  is  made  in  the  ledundant  ])r('j)uce  close  to  the  coronal 
groove  in  the  dorsum,  the  glans  slipped  through  the  opening  thus  made,  the 
prepuce  brought  down.  s|)lit,  and  stitched  to  raw  surfaces  made  by  dissecting 
up  lateral  penile  flaps,  has  recently  been  revived  by  White,  who  re|)orts  satis- 
factory results. 

Epispadias  is  an  absence  of  the  vipper  wall  of  the  urethra,  and  is  much 
rarer  than  hypospadias.  It  is  often  associated  with  exstrophy  of  the  bladder. 
It  may  be  extensive,  in  which  case  the  opening  of  the  urethra  is  close  to  the 
pubes,  or  there  may  be  a  congenital  absence  of  the  pubic  symphysis.  An  ope- 
ration similar  to  that  just  described  is  employed  for  its  cure,  but  is  often  more 
troublesome  and  less  successful  than  that  used  for  hypospadias. 

Wounds  of  the  Penis  are  of  no  special  importance  unless  they  involve 
the  urethra  or  extend  deeply  into  the  spongy  or  cavernous  bodies.  They  should 
be  treated  on  the  general  principles  which  apply  to  the  treatment  of  all  wounds, 
but  will  require  in  addition,  in  the  majority  of  cases,  the  introduction  and 
retention  of  a  metal  catheter  in  order  to  give  a  point  of  support  for  sutures 
or  dressings.     Hemorrhage  is  sometimes  very  obstinate. 

When  the  urethra  has  been  divided,  immediate  sutures,  extending  to  the 
submucous  tissue,  and  a  retained  catheter  should  be  employed. 

Fracture  of  the  Penis  has  been  known  to  occur  during  coition,  and 
consists  in  laceration  of  the  corpora  cavernosa,  followed  by  extensive  extrav- 
asation of  blood  into  the  erectile  tissue.  It  has  also  occurred  from  injury 
inflicted  accidentally  or  maliciously,  but  always  when  the  organ  was  in  a 
state  of  firm  erection.  Hemorrhage  must  be  arrested  as  soon  as  possil)le  by 
enveloping  the  penis  in  cold  clotlis  and  tightly  bandaging  it.  If  the  disten- 
tion from  the  escape  of  blood  into  the  spongy  tissue  is  so  great  as  to  imperil 
the  vitality  of  the  tissues  or  of  the  organ,  one  or  more  incisions  should  be 
made  for  the  escape  of  blood.  An  annoying  sequel  of  the  accident  is  the 
tendency  to  lateral  or  upward  or  dow^nward  curvature  during  erection.  This 
is  sometimes  so  marked  as  greatly  to  interfere  with  coitus,  and  even  to  render 
the  patient  permanently  impotent. 

Phimosis  is  a  condition  in  which  the  prepuce  is  unnaturally  elongated, 
and  at  the  same  time  its  orifice  is  contracted  so  that  it  is  difficult  or  impos- 
sible to  uncover  the  glans.  It  is  generally  congenital,  although  occasionally 
acquired  as  the  result  of  masturbation  at  a  very  early  age.  It  is  of  more  than 
local  importance,  as  in  the  young  it  keeps  up  a  continual  irritation  which  often 
leads  to  masturbation  or  to  vesical  irritability.  It  frequently  interferes  with 
the  full  growth  and  development  of  the  organ.  The  balanitis  and  balano- 
posthitis  to  which  it  gives  rise  are  sometimes  followed  by  grave  nervous  symp- 
toms— chorea,  epilepsy,  and  other  diseases  of  a  similar  character.  It  also 
favors  greatly  the  contraction  of  venereal  disease. 

The  operation  of  circumcision  is  indicated  in  every  case  in  which  the  above 
condition  exists.  No  child  is  too  young  for  its  performance,  and  most  adults 
with  hypertrophied  foreskins  with  small  orifices  would  be  benefited  by  the 
operation.  In  preparing  for  its  performance  the  two  layers  of  the  prepuce 
should  be  carefully  washed  with  soap  and  water,  and  disinfected  and  rendered 


SURGERY    OF   THE    G EX/TO- URINARY   TRACT.  963 

aseptic  in  the  usual  manner.     The  prepuce  is  then  drawn  forward,  so  that  it  can 
be  grasped  in  front  of  the  anterior  extremity  of  the  ghms  by  a  pair  of  forceps 
the  bhides  of  whicli  are  long  enough  to  extend  on  either  side  beyond  its  edges. 
These  may  be  self-retaining  or  may  be  entrusted  to  an  assistant.'    The  operator 
then  seizes  the  projeeting  portion  of  the  prepuce  and  removes  it  by  means  of  a 
sharp  bistoury,  cutting  along  the  anterior  edge  of  the  forceps.     These  being  re- 
moved, it  will  be  found  that  while  the  skin  retracts  to  or  behind  the  corona  the 
ghins  is  still  covered  by  the  hood-like  mucous  membrane.      This  should  now  be 
divided  in  the  median  line  up  to  the  dorsum  of  the  glans  near  the  corona,  and 
then  should  be  trimmed  oft"  at  a  distance  of  a  sixteenth  to  an  eighth  of  an  inch 
from  the  point  of  reilection,  following  the  curve  of  the  coronal  edge,  and  either 
going  through  the  frjBnum  or  leaving  it  untouched,  according  to  the  amount  of 
hypertrophy  present  at  that  point.     It  should  be  remembered  that  the  chief 
cause  of  the  not  infrequent  failure  of  young  o])erators  permanently  to  uncover 
the  glans  penis  by  this  operation  is  their  neglect  to  cut  this  fold  sufficiently 
short.     When  it  is  left  long  enough  to  come  forward  in  front  of  the  meatus,  it 
brings  with  it  the  elastic  and  extensile  skin:  the  cicatrix  forms  in  that  position, 
and  the  phimosis  for  which  the  operation  was  performed  recurs.     By  leaving 
the  strip  of  mucous  membrane  no  broader  than  an  eighth  of  an  inch  this 
accident  may  always   be  prevented.      If  the  frenal  artery  is  cut  during  the 
operation,  it  should  be  ligated  with  fine  catgut.     Torsion  is  not  always  reliable. 
The  edges  of  the  skin  and  mucous  membrane  should  be  brought  into  appo- 
sition by  a  few  interrupted  sutures,  and  the  line  of  incision  dressed  wuth  some 
unirritating  antiseptic.      Some  operators  prefer  an  entirely  dry  dressing,  and 
Palmer  of  Louisville  describes  as  follow^s  a  method  by  which  he  has  had^dmi- 
rable  results :  After  stitching,  a  piece  of  dry  aseptic  gauze,  four  inches  long 
and  half  an  inch  wide,  covered  with  iodoform  and  boric  acid  and  spread  on  a 
clean  towel,  is  laid  under  the  frsenum,  brought  up  around  the  cut,  right  and  left, 
to  the  dorsum,  and  trimmed  Avith  scissors.     Over  this  a  strip  of  absorbent  cotton 
three-quarters  of  an  inch  wide,  then  a  Maltese  cross  of  dry  gauze,  with  a 
central  hole  for  the  meatus,  and  then  a  similar  cross  of  rubber  tissue,  are 
applied,  and  the  whole  bandaged  snugly  in  place.     A  waist-belt,  a  jock-strap, 
and  a  bunch  of  cotton  to  cover  the  glans,  Avell  dusted  with  boric  acid,  com- 
plete a  dressing  that  permits  the  subject  to  go  to  work  at  once  at  any  ordinary 
vocation.     If  the  patient  will  retract  the  dressing  on  urinating  and  use  a  little 
absorbent  cotton  to  receive  the  final  drops,  this  original  dressing  mav  be  left 
on  five  days.     When  the  stitches  are  removed  the  parts  should  be  dusted  with 
boric  acid,  a  loose  pledget  of  cotton  wrapped  around  them,  and  the  patient 
discharged. 

Occasionally,  owing  to  oozing  of  blood,  it  may  be  found  necessary  to  make 
additional  pressure.  In  such  a  case  an  extra  one-inch  roller  may  be  applied 
over  the  dressing,  to  be  removed  some  hours  later  without  disturbing  the  dress- 
ing proper. 

Inflammation  of  the  Penis  is  usually  the  result  of  extension  either  from 
a  severe  infective  urethritis  or  from  a  phagedenic  chancre  or  chancroid. 

Gangrene  of  the  Penis  is  almost  always  the  result  either  of  mechanical 
obstruction,  as  where,  either  for  mischief  or  for  purposes  of  sexual  excitement, 
foreiirn  bodies  have  been  tied  around  the  organ,  or  of  phagedena.  It  occasion- 
ally follows  unrelieved  cases  of  paraphimosis. 

Epithelioma  of  the  penis  and  of  the  foreskin  has  the  usual  characteristics 
of  this  disease  elsewhere.  It  is  favored  by  the  presence  of  a  long  or  contracted 
prepuce  and  by  accumulations  of  smegma,  by  concretions  or  calculi,  or  by  any 
other  source  of  local  irritation.     If  it  is  confined  to  the  foreskin  and  is  reco.y- 


964  AX   A.VFRrf'AX    TKXT-JIOOK    OF  Sr^RGKRY. 

nized  early,  circumcision  is  sufficient  treatment.  But  if,  as  is  more  commonly 
the  case,  it  has  already  extended  to  the  glans,  nothing  short  of  amputation  of 
the  penis  will  be  of  any  value,  and  it  is  better  in  these  cases  to  sacrifice  the 
larger  portion  of  the  organ. 

The  operation  is  a  simple  one :  the  hemorrhage  may  be  controlled  by  the 
grasp  of  the  thumb  and  finger  of  an  assistant  close  to  the  pubes  or  by  sur- 
rounding the  root  of  the  organ  with  a  narrow  rubber  cord ;  and  a  circular 
stroke  of  the  knife  at  a  point  well  behind  the  uppermost  limit  of  the  disease 
is  sufficient  for  the  removal  of  the  organ.  The  vessels  may  be  tied  separately ; 
the  mucous  membrane  can  be  brought  forward  and  stitched  to  the  skin,  or,  if 
the  operation  is  modified  and  the  corpus  spongiosum  containing  the  urethra  is 
left  somewhat  longer  than  the  rest  of  the  stump — the  better  plan — the  urethra 
may  be  slit  up  with  scissors,  and  the  lower  wall  attached  by  a  suture  to  the 
skin  of  the  under  surface  of  the  penis,  while  the  cut  edges  of  the  upper  wall 
are  sutured  to  the  corpora  cavernosa.  The  retained  catheter  will  be  required: 
an  antiseptic  dressing,  preferably  of  iodoform,  should  be  applied  around  it,  and 
if  there  occurs  any  moistening  of  the  parts  with  urine,  they  should  be  irrigated 
and  dusted  afresh  with  iodoform  daily.  The  method  of  section  by  the  ecraseur 
is  not  to  be  recommended. 

Amputation  of  the  entire  penis  is  sometimes  required  for  malignant  dis- 
ease.  The  operation  is  as  follows  (Treves) :  The  patient  having  been  placed 
in  the  lithotomy  position,  the  skin  of  the  scrotum  is  incised  along  the  whole 
length  of  the  raphe.  With  the  finger  and  the  liandle  of  the  scalpel  the  halves 
of  the  scrotum  are  then  separated  down  to  the  corpus  spongiosum.  A  full-sized 
metal  catheter  is  now  passed  as  far  as  the  triangular  ligament,  and  the  knife 
is  inserted  transversely  between  the  corpora  cavernosa  and  the  corpus  spongi- 
osum. The  catheter  having  been  withdrawn,  the  urethra  is  cut  across.  The 
deep  end  of  the  urethra  is  then  detached  from  the  penis  back  to  the  triangular 
ligament.  An  incision  is  next  made  round  the  root  of  the  penis  continuous 
with  that  in  the  median  line  ;  the  suspensory  ligament  is  divided,  and  the  penis 
separated  except  at  the  attachment  of  the  crura.  The  knife  is  now  laid  aside, 
and  with  a  stout  periosteal  elevator  or  rugine  each  crus  is  detached  from  the 
pubic  arch.  This  step  of  the  operation  involves  some  time,  on  account  of  the 
very  firm  union  of  the  parts  to  be  separated.  Four  arteries — the  two  arteries 
of  the  corpora  cavernosa  and  the  two  dorsal  arteries — require  ligature.  The 
corpus  spongiosum  is  slit  up  for  about  half  an  inch,  and  the  edges  of  the  cut 
are  stitched  to  the  back  part  of  the  incision  in  the  scrotum.  The  scrotal 
incision  is  closed  by  sutures,  and  a  drainage-tube  is  so  placed  in  the  deep 
part  of  the  wound  that  its  ends  can  be  brought  out  in  front  and  behind. 
No  catheter  is  retained  in  the  urethra. 


SURGERY    OF    THE   FEMALE    GEXERATIVK    ORGANS.     965 


CHAPTER    VIII. 


SURGERY  OF  THE  FEMALE  GENERATIVE  ORGANS. 

Anatomical  Memoranda. — Certain  anatomical  data  are  important  to  be 
borne  in  mind  by  the  surgeon  in  the  investigation  and  operative  treatment  of 
the  generative  organs  of  the  female. 

The  peritoneum  which  invests  the  uterus  descends  in  front  only  far  enough 
to  cover  the  upper  three-fourths  of  its  surface  (Fig.  378).     Being  reflected 

Fig.  37S. 


Diagrammatic  Sagittal  Section  of  the  Female  Pelvis:  U,  uterus;  R,  rectum:  S,  symphysis  :  P,  perineal  body ; 
B  is  beneath  bladder.    This  is  the  position  of  the  uterus  when  the  bladder  is  alniost  empty  (Skene). 

thence  upon  the  posterior  wall  of  the  bladder,  usually  at  about  the  level  of  the 
OS  uteri  internum,  the  lower  segment  of  the  uterus,  anteriorly,  is  left  in  close 
relation  to  the  base  of  the  bladder,  being  separated  from  it  only  by  a  thin 
layer  of  loose  connective  tissue.  Along  the  posterior  surface  of  the  uterus  the 
peritoneum  descends  somewhat  below  the  level  of  the  vaginal  insertion  before 
it  is  reflected  backward  upon  the  rectum.  The  layers  of  the  peritoneum  which 
extend  laterally  from  the  uterus  to  the  sides  of  the  pelvis,  constituting  the 
broad  ligaments,  enfold  the  Fallopian  tubes,  the  ovaries,  the  parovarium,  and 
the  round  ligaments,  together  with  the  cellular  tissue,  lymphatics,  nerves,  and 
some  muscular  fiber.  When  tension  is  made  upon  the  round  ligaments  from 
without  so  as  to  draw  them  out  through  the  internal  abdominal  ring,  as  in 


imC) 


AX   AMERICAN    TEXT-HOOK    OF   SrUOEUY. 


Fig. 


operations  to  shorten  them,  their  closely-attached  ])eritoncal  covering  is  drawn 
out  with  them  to  some  extent,  and  rec^uires  to  be  carelully  detached  and  re- 
flected in  order  to  make  possible  the  extraction  of  the  required  amount  of 
the  ligament. 

The  ovaries  project  upon  tlie  posterior  surface  of  the  broad  ligaments,  and 
the  fiTnbriated  extremities  of  the  tubes  droop  posteriorly  toward  the  ovaries. 
To  this  anatomical  relation  is  due  the  fact  that  in  inllanimatory  affections  of 
the  ovaries  and  tubes  these  organs  tend  to  sink  into  and  become  adherent  in 
the  posterior  cul-de-sac,  where  they  must  be  sought  by  the  finger  of  the  sur- 
geon for  the  purpose  of  enucleation.  The  two  layers  of  the  broad  ligaments 
are  loosely  joined  by  connective  tissue.  They  are  easily  separated  to  an 
indefinite  extent  by  hemorrhagic  or  inflammator}^  effusions  or  by  the  develop- 
ment of  new  growths.  The  ovarian  artery  courses  along  the  upper  border  of 
the  outer  part  of  the  broad  ligament.  If  traction  is  made  upon  the  ovary  so 
as  to  make  tense  and  prominent  the  part  of  the  ligament  extending  from  the 
ovary  to  the  lateral  pelvic  Avail,  the  artery  may  be  easily  identified,  and  pre- 
liminary ligation  or  compression  of  it  may  be  readily  done. 

The  uterine  artery,  leaving  the  lateral  pelvic  wall  at  a  point  just  above  the 
ischial  spine,  reaches  the  vaginal  wall   at  the  level  of  the  os  externum,  and 

thence  runs  upward  toward  the 
uterus  (Fig.  379).  Opposite  the 
junction  of  the  vagina  and  uterus 
it  gives  off  a  good-sized  branch, 
which  with  its  fellow  of  the  op- 
posite side  encircles  the  cervix. 
Thence  it  runs  tortuously  up  the 
side  of  the  uterus  between  the 
folds  of  the  broad  ligament,  giv- 
ing off"  frequent  branches  to  the 
uterus,  and  finally  inosculates  with 
the  ovarian  artery  above.  Pre- 
liminary ligature  of  this  artery 
may  be  readily  done  from  the 
vagina  by  pulling  the  cervix  down 
toward  the  vulva,  and  then  pass- 
ing a  ligature  by  means  of  a  well- 
curved  needle  introduced  deeply 
at  the  side  of  the  cervix  through 
the  lateral  vaginal  pouch.  The 
needle,  having  described  a  curve 
through  the  tissues,  is  brought  out 
a  short  distance  behind  its  point 
of  entrance.  The  ligature  which 
thus     introduced     will     have 


379. 


IS 


Relations  of  TTreters  and  Uterine  Arteries  to  the  Cervix 
V,  uteni ;  C,  cervix  ;  la,  vagina;  Vt,  ureter ;  A  U,  uter 
inc  arteries  (Pozzi). 


passed  around  the  artery,  and 
when  firmly  drawn  and  tied  will 
have  closed  it.  The  uterine  artery 
may  also  be  tied  from  above  within  the  pelvis,  Avhen  the  pelvic  organs  have 
been  exposed  by  abdominal  section,  by  drawing  the  uterus  to  the  side  opposite 
to  that  upon  which  the  ligature  is  to  be  applied,  and  then  carrying  a  curved 
needle,  armed  with  a  ligature,  through  the  attachment  of  the  broad  ligament 
to  the  uterus,  so  as  just  to  engage  the  substance  of  tlie  uterus  ;  then,  having 
penetrated  both  layers  of  the  broad  ligament,  it  should  be  carried  back,  per- 


SURGERY    OF    riJK    FEMAJ.E    G  EXE  RATI  VE    ORGANS.     9G7 

forating  the  ligament  again  at  a  point  about  three-eighths  of  an  inch  to  the 
outside  of  the  first  perforation.  The  artery  Avill  be  embraced  by  this  loop, 
which  may  then  be  tied. 

The  ureters  in  their  course  toward  the  base  of  the  bladder  approach  later- 
ally to  within  about  half  an  inch  of  the  uterus  at  the  level  of  the  os  internum. 
They  preserve  about  this  distance  from  the  cervix  as  they  pass  onward  to  the 
bladder,  the  opening  of  the  ureter  into  the  bladder  being  about  half  an  inch 
anterior  to  the  cervico-vaginal  junction  (Fig.  879).  The  lower  outlet  of  the 
pelvis  is  closed  in  by  a  diaphragm  of  muscular  and  fascial  tissue,  the  fibers  of 
which,  having  their  origin  from  the  lateral  bony  points,  blend  in  the  middle 
line,  where  they  converge  to  the  outlets  of  the  rectum  and  the  vagina.  By 
the  integrity  and  tonicity  of  the  various  parts  of  this  complex  diaphragm  the 
pelvic  viscera  are  held  in  place.  Additional  support  is  received  from  the  peri- 
toneal reflections  that  envelop  the  pelvic  viscera,  and  from  the  fibrous  strands 
and  connective-tissue  substance  that  bind  them  together. 

By  the  extensibility,  the  contractility,  and  the  mobility  of  its  different 
supports  the  widely-varying  degrees  of  distention  and  of  contraction  which 
the  functions  of  the  pelvic  organs  normally  require  are  made  possible.  This 
peculiarity  of  structure  makes  it  possible  for  the  uterus  to  be  drawn  down  to 
the  vaginal  outlet  for  examination  and  for  operative  attack,  and  facilitates 
the  introduction  of  specula  and  of  the  finger  for  purposes  of  exploration. 
By  the  rupture  or  over-distention  of  important  portions  of  this  diaphragm 
the  pelvic  organs, 'deprived  of  their  proper  support,  tend  to  sink  down  perma- 
nently from  their  proper  positions  and  to  protrude  in  varying  degrees  through 
the  outlets  below. 

METHODS   OF  INVESTIGATION. 

Diagnostic  investigations  of  the  generative  organs  of  the  female  include 
examination  by  inspection,  palpation,  percussion,  and  exploratory  puncture. 

The  bladder  should  always  be  evacuated,  preferably  by  a  catheter. 
When  distended  with  urine,  it  has  been  mistaken  for  an  abdominal  tumor. 
(See  Fig.  345.) 

Inspection. — Inspection  includes  the  careful  observation  of  the  hypogas- 
trium  and  the  pudenda,  and  the  exposure  of  the  cavity  of  the  vagina  and  the 
surface  of  the  vaginal  portion  of  the  cervix  uteri  by  proper  specula.  Micro- 
scopic investigations  may  properly  be  classed  as  methods  of  inspection. 

Inspection  of  the  hypogastrium  requires  the  supine  position ;  of  the  pudenda, 
the  same  posture  with  "the  knees  drawn  up  and  the  thighs  abducted.  For  intra- 
vaginal  inspection  a  retractor  for  the  perineum  is  required ;  for  instance,  the 
well-known  retractor  of  Sims.  The  patient,  having  been  placed  upon  a  table 
of  proper  height,  is  made  to  lie  upon  her  left  side,  the  left  arm  behind  the  back, 
the  thorax  fully  prone  upon  the  table,  the  right  knee  fully  flexed  and  brought 
up  as  far  as  possible  under  the  body,  while  the  left  knee  and  leg  are  carried  up 
about  half  the  distance.  The  pelvis  is  now  brought  to  the  edge  of  the  table, 
the  retractor  inserted  into  the  vagina,  and  the  perineum  strongly  drawn  back. 
The  vagina  is  distended  by  the  air  which  is  thus  admitted,  and  by  properly 
varying  the  depth  to  which  the  retractor  is  inserted  and  the  direction  in  which 
traction  is  made,  together  with  elevation  of  the  right  labium  and  natis  by  the 
hand  of  an  assistant,  the  entire  vagina  and  the  vaginal  portion  of  the  cervix 
uteri  may  be  brought  into  view.  Inspection  may  be  still  further  facilitated  by 
elevating  the  anterior  wall  of  the  vagina  by  a  suitable  rod  or  speculum  and  by 
drawing  down  the  uterus  with  a  tenaculum. 

Palpation. — By  the  touch  may  be  ascertained  the  rigidity  of  overlying 
parts;  the  sensitiveness  of  the  organs;  their  position,  size,  shape,  and  den- 


968 


.l.V    AAfL'h'/CAX    TKXr-liOOk'    OF   sriidHh'Y. 


sity  ;  tlicir  iii()l)ility  and  tlit-ir  relations  to  other  oi'^ans  :  tlie  presence  of  adhe- 
sions, infiltrations,  exudations,  and  tumors  ;  the  character  and  extent  of  tumors 
and  other  abnormal  masses. 

For  the  purpose  of  palpation  that  position  should  be  secured  which  will 
relax  as  much  as  possil)le  the  nmscular  and  fascial  coverings  that  hide  the  parts 
to  be  palpated.  As  a  rule,  the  suj)ine  position,  with  the  knees  drawn  up  on  a 
firm  table  of  j)roper  lieiji^ht,  is  the  most  favorable,  (jreat  differences  exist  in  the 
comi)leteness  with  which  palpati(»n  may  be  done  uj)on  dif!'erent  individuals,  owinj^ 
to  the  varying  degrees  of  rigidity  and  sensitiveness  of  tissues  and  of  accumu- 
lations of  adipose  tissue.  The  more  relaxed  and  thin  the  tissues,  the  more 
facile  the  palpation.  The  induction  of  relaxation  by  complete  anesthesia  is 
often  recjuisite  to  make  satisfactory  palpation  possi))le. 

Large  pelvic  tumors  are  readily  detected  and  much  valua])le  information 
about  them  is  to  be  gained  by  simple  hypogastric  palpation.  'J'heir  size,  their 
mobility,  wlietlier  solid  or  fluid,  their  shape,  the  readiness  with  which  the 
abdominal  wall  can  be  made  to  glide  over  them,  may  be  ascertained  with  con- 
siderable accuracy.  The  vaginal  touch  in  such  cases  may  supplement  the 
hypogastric,  and  is  especially  valuable  in  determining  the  relations  of  the 
tumor  to  the  uterus  and  the  character  of  the  deeper  portion  of  the  tumor. 

Palpation  of  the  ovaries,  tubes,  and  uterus  should  always  be  done  by  the 
combination  of  hypogastric  pressure  with  the  vaginal  or  rectal  touch — bimanual 


Fig.  380. 


Bimanual  ralpation  (Pozzi). 

palpation.  The  external  hand  should  be  placed  above  over  the  nonnal  site  of 
the  organ  to  be  examined,  and  deep,  firm  pressure  should  be  exerted  in  the 
direction  of  the  tip  of  the  vaginal  or  rectal  finger,  so  as  to  push  the  organ 
down  toward  it  and  prevent  its  escape.  The  finger  which  is  in  the  vagina 
should  at  the  same  time  press  upward  into  the  pelvis  as  far  as  possible.  In 
this  way  in  favorable  cases  the  organ  can  be  balanced  between  the  tAvo  forces 
and  its  examination  satisfactorily  effected  (Fig.  380).  Rectal  examination 
may  be  made  more  complete  and  satisfactory  by  simultaneously  drawing  down 
the  uterus  toward  the  vulva  by  a  tenaculum  in  the  hands  of  an  assistant. 
The  uterine  sound  is  available  as  a  means  of  ascertaining  the  depth  and  direc- 


SUliClKRY   OF    rill':    FEMM.E    (iKNKIiATIVK    OlidANS.     969 

tion  of  the  uterine  canal.  It  is  practically  a  lengthened  finger,  and  its  use  is 
one  form  of  jjalpation.     It  is  rarely  needed. 

Pereu^min. — The  relative  dulness  or  resonan(;e  ovci-  the  hypogastric  region 
gives  valuahle  infoniiation  as  to  the  |)resence  and  location  of  inflated  intestine 
and  of  solid  or  lluid  tiniioi\s.  It  is  chietlv  valuahle  in  distinLrnishin<£  ascitic 
fluid  from  cysts. 

Exploratory  Puncture. — Information  as  to  the  composition  of  an  ohscure 
swelling  deep  in  the  pelvis  may  be  obtained  by  the  use  of  a  small  trocar  and 
aspirating  syringe.  Its  results  cannot  always  be  considered  as  certain,  for  a 
swelling  may  be  fluid  at  one  part  and  solid  at  another,  and  the  exploring  ti-()car 
may  not  reach  the  fluid  part,  and  so  conclusions  ))ased  upon  the  results  of  its 
insertion  mav  be  erroneous.  Danf^er  of  woundin<i:  other  orj'ans  or  vessels  or 
■of  introducing  or  disseminating  infection  attends  its  use,  so  that  it  should  rarely 
be  resorted  to,  especially  as  the  information  sought  to  be  gained  by  it  can  gene- 
rally be  obtained  by  other  means.  Whenever  it  is  resorted  to  it  should  be 
with  the  most  careful  antiseptic  precautions. 

SURGERY  OF  THE  VULVA. 

Injuries  of  the  Vulva  are  likely  to  be  attended  with  special  symptoms 
from  the  rupture  of  some  branch  of  the  rich  venous  plexus  with  which  it  is 
supplied.  Penetrating  wounds  may  occasion  copious  hemorrhage ;  contusions 
may  produce  extensive  infiltrations  of  blood.  These  are  to  be  treated  on  the 
general  surgical  lines  described  in  the  chapter  devoted  to  Wounds  in  general. 
The  more  distinct  blood-masses,  hcematoma  vulvce  or  pudendal  hematocele,  as 
a  rule  disappear  in  time  under  simple  rest  and  gentle  pressure.  When  the 
€ff"usion  is  so  large  as  to  cause  decided  pressure  eff"ects.  or  when  the  distended 
tissues  threaten  spontaneously  to  give  way,  it  is  better,  with  proper  antiseptic 
precautions,  to  lay  the  whole  mass  freely  open  by  the  knife,  turn  out  the  clots, 
ligate  or  clamp  any  bleeding  points,  and  allow  the  wound  to  granulate. 

Inflammations  of  the  Vulva. — The  muco-cutaneous  covering  of  the 
vulva  may  be  provoked  to  inflammation  by  the  presence  within  its  folds  of 
irritating  foreign  matter,  of  decomposing  secretions,  or  of  acrid  discharges  ;  by 
undue  friction  ;  and  by  the  extension  of  inflannnation  of  parts  adjacent  to  it. 
The  inflammation  may  be  diffuse  and  superficial,  may  extend  to  the  deeper 
layers  of  tissue,  or  may  be  limited  to  the  muciparous  or  sebaceous  follicles. 
Diabetic  subjects  are  prone  to  the  development  of  an  aggravated  eczema  of 
the  vulva,  due  to  the  irritation  of  fermenting  saccharine  urine  which  is  per- 
mitted to  moisten  the  parts.  By  the  infection  of  abrasions  or  wounds  phleg- 
monous suppurative  inflammation  may  develop.  Gangrenous  inflammation  of 
the  vulva — noma — occasionally  occurs  in  persons  whose  resisting  power  has 
been  undermined  by  exhausting  disease  or  constitutional  cachexige.  It  has 
most  frequently  occurred  in  badly-nourished  children  as  a  sequel  to  one  of  the 
eruptive  diseases.  The  ulcerations  and  eruptions  (mucous  patches)  seated  upon 
the  vulva,  due  to  venereal  infection,  have  been  treated  in  the  chapter  devoted 
to  Syphilis. 

Symptoms. — The  parts  are  tender  and  congested,  and  more  or  less  tume- 
fied and  covered  with  muco-purulent  secretion.  Raw  patches  due  to  exfolia- 
tion of  epithelium  may  be  present.  Pruritus  is  apt  to  be  a  source  of  com- 
plaint. In  the  follicular  variety  minute  red  papular  elevations  may  stud  the 
surface  of  the  part.  These  are  the  congested  orifices  of  the  aff"ected  follicles, 
and  give  exit  to  an  altered  and  increased  mucous  or  sebaceous  secretion. 
Inflammation  of  the  gland  of  Bartholin  will  declare  itself  by  the  appearance 


970  AN  AMERICAN    TEXT-BOOK    OE  SURGERY. 

of  a  painful  tense  oval  swelling  Ioav  down  upon  the  inner  aspect  of  tlie  vulva 
at  the  entrance  of  the  vagina.     In  the  phlegmonous  forins  of  vulvitis  increased 
local  swelling  and  pain  and  more  marked  constitutional  reaction  are  present 
Suppuration  and  gangrene  are  indicated  by  their  usual  signs. 

Treatment. — The  milder  forms  of  vulvitis  need  little  more  tlian  rest,  the 
removal  of  the  exciting  cause,  and  cleanliness.  The  parts  ma}'  be  irrigated 
with  a  warm  solution  of  l)orax  or  boric  acid,  and  the  labia  kept  separated 
by  a  fold  of  soft  absorbent  fabric,  as  absorbent  gauze,  saturated  Avith  oxide-of- 
zinc  cream,  the  latter  being  simply  enough  oxide  of  zinc  stirred  up  in  water 
to  form  a  creamy  fluid,  which  may  be  extemporaneously  prepared  as  often 
as  needed.  Solutions  of  permanganate  of  potassium,  sulphate  of  zinc,  alum, 
nitrate  of  silver,  and  otlier  mildly  antiseptic  and  astringent  substances  may 
also  be  used  to  advantage  for  purposes  of  irrigation.  When  tlie  inflammation 
is  more  acute  and  painful,  warm  fomentations  of  lead  and  opium  (lie},  plumbi 
subacetat.,  ,lij  ;  tinct.  opii,  f§j  ;  aquae,  Oij)  are  to  be  used  until  the  acute 
symptoms  subside.  Deep  suppuration  requires  treatment  by  early  incision, 
as  in  other  parts  of  the  body.  Gangrene  should  be  attacked  locally  by  the 
free  use  of  the  actual  cautery  or  of  tlie  knife,  followed  by  a  saturated  solution 
of  chloride  of  zinc,  so  as  to  destroy  the  local  infective  poison,  with  subsequent 
continuous  antisepsis  of  the  parts  by  iodoform  tampons,  while  every  possible 
means  to  stimulate  the  general  strength  of  the  patient  should  be  employed. 

Pruritus. — The  annoying  itching  which  attends  the  various  forms  of 
vulvitis  may  require  special  treatment  for  its  relief  while  the  measures  required 
for  the  cure  of  the  conditions  that  cause  it  are  being  carried  on.  The  vulvar 
surfaces  must  be  protected  as  far  as  possible  from  the  contact  of  all  irritating 
discharge.  The  antiseptic  washes  used  for  the  relief  of  the  vulvitis  may  suffice 
for  this.  Keeping  the  vulva  well  smeared  with  a  bland  ointment,  as  ungt. 
zinci  oxidi,  will  give  relief.  The  use  of  a  solution  of  corrosive  sublimate  in 
emulsion  of  bitter  almonds  (1  :  500)  Avill  give  the  combined  antiseptic  and  anti- 
pruritic eifects  of  the  mercurial  and  of  hydrocyanic  acid.  It  may  be  employed 
twice  daily.  In  diabetic  cases  the  fermentation  of  the  urine  may  be  kept  in 
check  by  the  free  use  of  a  3  per  cent,  solution  of  hyposulphite  of  soda  or  of 
chloral.  In  senile  pruritus  pudendi,  in  which  there  is  atrophy  of  the  nerve- 
terminals,  rather  than  inflammatory  irritation,  peppermint-water  Avill  sometimes 
afford  relief — five  drops  of  oil  of  peppermint  shaken  up  thoroughly  in  a  pint  of 
hot  Avater  to  Avhich  a  teaspoonful  of  borax  has  been  added.  The  parts  should 
be  bathed  freely  Avith  this  lotion.  An  8  per  cent,  solution  of  cocaine  pencilled 
over  the  parts  Avill  also  sometimes  afford  relief.  In  inveterate  cases  that  have 
resisted  other  treatment  relief  may  possibly  be  obtained  by  pencilling  the  entire 
affected  surface  Avith  a  mixture  containing  equal  parts  of  carbolic  acid  and  tinc- 
ture of  iodine.  A  superficial  eschar  is  produced,  Avith  permanent  change  in  the 
sensitiveness  of  the  nerve-endings.  Certain  cases  resist  all  treatment  and  re(juire 
the  constant  use  of  opiates  to  relieve  the  suffering  Avhich  the  affection  entails. 

Tuberculosis  Vulv^. — The  labia  are  occasionally  the  seat  of  local  tuber- 
cular infection.  The  disease  in  its  advanced  ulcerative  stages  has  been  termed 
lupus  vulvae,  and  by  the  French  esthiomene.  The  local  infection  first  mani- 
fests itself  by  the  formation  of  superficial  tubercles,  Avhich  coalesce.  The  moist- 
ure and  Avarmth  of  the  parts  favor  early  necrosis.  The  resulting  ulcer  grad- 
ually extends  peripherally,  surrounded  by  a  zone  of  infiltrate<l  infected  tissue. 
The  edges  of  the  ulcer  are  thin,  purple,  and  undermined,  and  its  base  is  irreg- 
ular and  eroded,  secreting  a  scanty,  thin,  puriform  discharge.  Cicatrization  is 
frequently  present  at  one  part  while  the  ulcer  is  extending  at  other  points. 
The  extent  of  the  infiltration  and  the  destruction  of  tissue  may  vary  greatly: 


SURGERY    or    THE    E EM  ALE    GENERATIVE    ORGANS.      971 

in  some  instances  the  inflammatory  and  tubercular  infiltration  of  the  parts  is 
sufficient  to  occasion  great  increase  in  their  volume;  in  others,  a  predominating 
ulcerative  action,  involving  especially  the  skin  and  adjacent  connective  tissue, 
may  produce  extensive  dissections  about  the  vagina,  bladder,  and  rectum. 
Erosion  of  blood-vessels  may  provoke  repeated  hemorrhages.  The  affection 
is  most  freciueiit  in  the  young,  and  is  likely  to  be  accompanied  with  tuber- 
culosis of  other  portions  of  the  body.  Recurrence  after  apparent  healing  is 
frequent. 

Diagnosis. — The  affection  is  to  be  distinguished  from  epithelioma  and 
from  syphilitic  ulceration  :  differentiation  is  not  ahvays  easy,  but  may  usually 
be  made  by  attention  to  the  following  points:  1.  The  age  of  the  patient:  the 
tubercular  ulcer  is  most  common  in  early  life,  epithelioma  in  later  life.  2.  The 
history  :  antecedent  syphilis  ;  tuberculosis  in  other  parts  of  the  body.  3.  The 
appearance  of  the  ulcer :  the  epithelioma  exudes  a  more  abundant  fetid  secre- 
tion ;  its  surface  is  mammillated,  its  edges  are  heaped  up,  and  its  base  is  more 
extensively  and  deeply  infiltrated.  The  syphilitic  ulcer  is  crateriform,  with 
sharply-cut  edges,  in  marked  contradistinction  to  the  flat,  superficial  eroded 
tubercular  ulcer  with  its  undermined  edges.  4.  The  effects  of  treatment :  anti- 
syphilitic  treatment  causes  speedy  improvement  in  the  syphilitic  ulcer ;  is  with- 
out benefit  in  the  other  forms.  5.  Bacteriological  tests :  the  detection  of  the 
bacilli  of  tuberculosis-  by  adequate  tests  suffices  to  establish  the  diagnosis. 

Treatment. — Constitutionally,  measures  calculated  to  improve  the  general 
health  which  are  of  proved  value  in  dealing  with  tuberculosis  in  any  part  of 
the  body  are  to  be  vigorously  resorted  to.  Locally,  thorough  curetting  of  the 
base  and  borders  of  the  ulcer  should  be  done,  scraping  away  all  the  somewhat 
soft  and  degenerated  tissue  which  may  be  present,  and  which  will  readily  yield  to 
the  curette.  The  remaining  surfaces  should  then  be  cauterized  with  the  thermo- 
cautery or  with  a  saturated  solution  of  chloride  of  zinc.  Tampons  of  iodoform 
gauze  or  dressings  of  Peruvian  balsam  should  be  used  in  the  after-treatment 
till  full  cicatrization  is  accomplished. 

Tumors  of  the  Vulva. — The  labia  may  become  the  seat  of  any  of  the 
growths,  benign  or  malignant,  to  which  similar  tissue  in  other  parts  of  the 
body  is  subject.  Out  of  10,290  neoplasms  in  females  recently  analyzed  by  W. 
R.  Williams,  420  had  their  initial  seat  in  the  external  genitals,  including  the 
vagina.  Of  these,  158  were  epitheliomata ;  3  were  sarcomata  ;  17  were  fibro- 
mata ;  1  was  a  lipoma ;  167  were  non-venereal  papillomata,  of  which  148  were 
urethral  caruncles  ;  and  74  were  cystomata. 

Papillomatous  Growths  sometimes  display  much  luxuriance,  Avhich  is 
favored  by  the  warmth,  moisture,  and  friction  of  the  parts.  They  should  be 
excised  if  pedunculated  ;  destroyed  by  caustic  if  broadly  sessile.  Small  vas- 
cular papillomata  at  the  entrance  of  the  urethra — urethral  caruncles — are 
common.  They  appear  as  bright-red,  fleshy  growths  of  small  size,  and  are 
often  the  source  of  much  annoyance  from  smarting  during  urination  and  from 
bleeding.  They  may  be  destroyed  by  cauterization  or  by  excision,  great  care 
being  given  to  the  absolute  arrest  of  the  bleeding. 

Malignant  Disease  of  the  Vulva  tends  to  rapid  extension  and  early 
involvement  of  the  adjacent  lymphatic  glands.  Excision  to  be  of  any  avail 
must  be  done  early  and  with  care  to  excise  a  wide  area  of  the  apparently 
uninvolved  tissues. 

Dermoid  and  Sebaceous  Cysts  are  met  with,  but  the  most  common  cys- 
tic tumor  of  the  vulva  is  a  retention-cyst  of  the  glands  of  Bartholin, 
which  presents  itself  as  an  ovoid,  tense,  elastic,  painless  tumor  low  down  at  the 
vulvo-vaginal  junction.     It  may  demand  no  treatment,  but  if  its  size  becomes 


972  AN   AMERICAX    TEXT-BOOK    OF  SURGERY. 

inconvenient  it  should  be  dissected  out.  If  it  becomes  inflamed,  it  should  be 
freely  laid  open  and  its  sac  dissected  out. 

Lymphcrdema,  or  Elephantiasis,  occurs  in  the  vulva  next  in  frequency 
to  elephantiasis  of  the  leg  and  foot.  Extirpation  with  the  knife  is  the  only 
remedy  of  any  value. 

YARirosE  VEINS  of  the  vulva  are  frequently  met  with.  They  may  arise 
spontaneously,  or  may  be  due  to  the  pressure  of  a  pregnant  uterus  or  of  a 
pelvic  turaorupon  the  venous  trunks  into  which  the  vulvar  veins  empty,  or  to 
occlusion  of  the  latter.  In  the  latter  cases  rest  in  the  recumbent  posture  and 
gentle  support  by  a  properly-adjusted  compress  is  the  most  that  can  be  done 
by  way  of  palliation.  In  other  cases  ligation  and  excision  of  the  varicose 
vessels  are  re(juired. 

Adherent  Labia. — Adhesion  of  the  opposite  surfaces  of  the  labia  minora 
is  not  uncommon  in  infants  as  the  result  of  slight  vulvitis  from  defective  clean- 
liness. The  adhesions  are  usually  not  very  firm,  and  give  way  to  traction. 
If  necessary,  the  knife  may  be  used  to  accomplish  their  separation.  The  parts 
should  be  kept  separated  by  a  suitable  compress  until  the  abraded  surfaces  of 
the  labia  become  healed. 

More  dense  and  extensive  adhesions  of  the  labia  in  later  life  may  result 
from  ulcerative  inflammation  of  these  parts  and  their  blending  together  in  the 
subsequent  cicatrization.      Such  adhesions  require  the  knife. 

SUEGERY   OF  THE   PERINEUM. 

Rupture  of  the  Perineum  may  be  occasioned  by  accidental  traumatism, 
but  is  commonly  the  result  of  over-distention  of  the  perineal  body  during 
childbirth.  Every  degree  of  laceration  may  result  from  this  latter  cause, 
from  slight  tears  of  the  fourchette  to  extensive  rents  involving  the  sphincter  ani 
and  a  portion  of  the  recto-vaginal  septum.  If  the  rent  does  not  involve  the 
sphincter  ani,  it  is  termed  an  incomplete  rupture  ;  if  the  sphincter  is  involved, 
the  rupture  is  said  to  be  complete.  In  other  and  not  infrequent  instances 
subcutaneous  rupture  of  the  muscular  tissue  and  fasciie  of  the  perineum  takes 
place,  producing  relaxation  of  the  pelvic  floor  and  loss  of  perineal  support, 
although  the  skin  and  mucous  surfaces  remain  intact.  Such  injuries  may  be 
termed  concealed  ruptures. 

The  chief  disabilities  determined  by  tears  of  the  perineum  depend  upon 
the  greater  or  less  loss  of  the  muscular  support  to  the  pelvic  viscera  which 
results.  The  injury,  as  a  whole,  is  a  combination  in  varying  amounts  of 
separation,  paresis,  and  atrophy,  the  eff'ects  of  over-distention  and  bruising  as 
well  as  of  laceration,  so  that  often  the  apparent  tear  gives  little  clue  to  the 
extent  of  the  real  loss  of  support. 

The  symptoms  are,  first,  a  sense  of  Aveakness  and  of  dragging  down  of 
the  pelvic  organs  from  the  sagging  down  of  the  pelvic  floor  and  the  resulting 
undue  stretching  of  the  remaining  supports ;  and,  secondly,  actual  prolapse  in 
varvinjr  degree  of  the  vajrina,  bringino;  with  it  the  anterior  wall  of  the  rectum, 
reetocele,  and  the  base  of  the  bladder,  ci/stocele,  and  ultnnately  the  uterus, 
procidentia  uteri.  These  conditions  of  relaxation  and  prolapse  are  often  greatly 
aggravated  by  the  imprudence  of  patients  in  leaving  their  beds  within  a  few 
days  after  delivery,  before  full  involution  of  the  uterus  has  taken  place  and 
before  the  overstretched  and  semi-])aralyzed  tissues  of  the  pelvic  floor  have  had 
time  to  regain  their  tone.  Rupture  of  the  sfthincter  ani  adds  to  the  above 
symptoms  those  of  incontinence  of  feces  and  of  flatus. 

Treatment. — Immediate  suture  of  a  perineal  rent  for  the  purpose  of  secur- 


SURGERY    OF    THE   FEMALE    GENERATIVE    ORGANS.     973 

ing  primary  union  if  possible  should  always  be  done.  These  tears  are  lacerated 
and  infected  Avounds,  and  are  to  be  nianajied  in  accordance  with  the  general 
principles  governing  the  treatment  of  such  wounds.  Special  care  should  be 
taken  so  to  place  the  sutures  that  perfect  coajitation  of  the  inuscular  elements 
of  the  perineum  shall  be  secured.  A  strip  of  iodoform  or  oxide-of-zinc  gauze 
should  be  laid  in  the  vagina,  protruding  from  the  vulva,  to  act  as  a  drain  for 
the  vagina,  preventing  accumulation  of  the  lochia  within  it,  and  an  abundant 
absorbent  compress  sliould  cover  the  perineum  and  vulva,  and  be  changed  as 
often  as  saturated.  The  bowels  should  be  kept  loose,  and  the  bladder  relieved 
by  catheter  during  the  first  week.  The  sutures  should  remain  in  situ  for  ten 
days,  but  should  be  removed  at  any  time  if  evidences  of  deep  suppuration 
demand  the  abandonment  of  the  attempt  at  primary  union.  The  usual  ten 
days'  recumbency  observed  after  childbirth  should  be  prolonged  to  at  least 
twenty-one. 

I^erineoplasti/. — Plastic  operations  for  restoration  of  the  perineal  body  are 
required  when  primary  suture  has  failed  or  been  omitted.  They  should  not  be 
undertaken  until  from  six  to  twelve  months  after  the  original  injury,  and  a 
time  should  be  chosen  when  both  the  local  and  the  constitutional  conditions  of 
the  patient  are  good.  In  the  complete  variety  relaxation  of  the  contracted 
sphincter  should  first  be  secured  by  distending  it  twice  daily  for  a  Aveek  or 
more  before  the  operation  by  inserting  a  finger  into  the  anus  and  pressing 
the  parts  firmly  back  toward  the  coccyx  for  five  minutes  at  a  time. 

As  an  essential  preliminary  in  all  cases  the  bowels  should  have  been  thor- 
oughly cleaned  out  by  a  course  of  laxatives,  and  the  rectum  finally  Avashed  out 
by  copious  enemata  before  the  operation.  An  hour  before  the  operation  a  sup- 
pository containing  a  grain  of  opium  should  be  placed  in  the  rectum.  The 
vagina  and  the  vulva  should  have  been  subjected  to  repeated  boro-salicylic  or 
hydro-naphthol  douches  for  some  days,  and  the  parts  about  the  field  of  ope- 
ration should  be  shaved  and  Avell  scrubbed  immediately  before  beginning  the 
operation. 

The  instruments  required  are  few  and  simple,  including  a  sharp  bistoury, 
scissors  curved  on  the  flat,  two  pairs  of  mouse-toothed  forceps  and  one  of  dis- 
secting forceps,  a  dozen  hemostatic  forceps,  a  needle  forceps,  two  or  more  large 
full-curved  needles,  preferably  Hagedorn's  pattern,  as  many  small  curved 
needles,  and  a  pair  of  suitable  retractors  for  holding  back  the  labia.  Silk 
thread,  sterilized  by  boiling  or  steam  shortly  before  using,  is  to  be  preferred 
for  sutures — a  coarser  thread  for  the  deep  sutures,  a  finer  one  for  superficial. 
Catgut  is  to  be  used  for  ligatures,  and  occasionally  will  be  best  for  sutures. 
The  patient  should  be  put  in  the  lithotomy  position,  with  the  pelvis  elevated 
on  a  hard  pillow.  Should  operations  upon  the  cervix  uteri  or  upon  the  ante- 
rior vaginal  wall  be  required,  they  may  be  done  at  the  same  sitting  before 
beginning  with  the  perineum. 

The  operative  procedures  will  vary  according  as  the  laceration  is  of  the 
incomplete  or  the  complete  variety.  The  concealed  variety  are  to  be  made  into 
the  incomplete  by  transfixion  Avith  the  bistoury  and  incision  as  the  first  step  of 
the  operation.  Much  scope  to  the  ingenuity  and  judgment  of  the  surgeon  Avill 
be  given  in  the  effort  to  meet  the  varying  conditions  of  different  cases,  while 
he  keeps  in  vicAv  the  primary  indication  of  bringing  together  and  securing 
the  reunion  of  the  divided  and  separated  muscular  elements  of  the  perineum. 
These  have  retracted  on  each  side  toAvard  the  pubic  rami,  and  a  careful  in- 
spection of  the  parts  when  the  labia  are  held  asunder  will  usually  discover 
some  lateral  depresssion  in  the  borders  of  the  cicatrized  laceration  indicating 
the  site  of  these  muscular  stumps.     A  more  marked  dimpling  on  each  side  of 


974 


^.V   AMFJUCAX    Ti:X'r-r,(i()K    OF   SI' lid  EH  V. 


tlio  anus  shows  jdaiuly  tlio  sites  of  the  retracted  ends  of  tlie  sphincter  ani  wlien 
the  laceration  is  a  complete  one.  Whatever  incisions  are  made  must  l>e  planned 
so  as  fully  to  denude  these  points,  and  the  sutures  must  be  placed  so  as  to  bring 
and  hold  them  in  apposition  till  reunion  has  occurred.  This  may  usually  be 
best  done  in  the  following  manner: 

I.  Incomplete  Laceration. — The  labia  being  held  apart,  the  sur- 
geon, having  noted  the  beginning  of  the  cicatricial  tissue  on  each  side  at 
the  base  of  the  nym])lue,  makes  an  incision  through  the  skin  along  the  outer 
edge  of  the  cicatri.x,  from  one  to  the  other  of  these  points  (Fig.  8M1).  The 
vaginal  end  of  this  incision  is  now  seized  at  its  middle  by  a  pair  of  forceps, 
which  retains  its  hold  upon  it  until  the  close  of  the  ojieration,  lifting  it  uj)  and 
holding  it  out  of  the  way  as  the  work  progresses.     With  the  scissors  the  surgeon 


Fig.  381. 


Fig.  382. 


Line  of  Incision  in  Perineoplasty  (Pozzi). 


Perineoplasty,  the  Vaginal  Flap  raised  (Pozzi). 


now  works  his  way  in  between  the  rectum  and  the  vagina  for  about  an  inch  and 
a  half  below  and  well  into  the  base  of  the  labia  on  each  side.  As  the  vajjinal 
flap  is  raised  up  without  removing  any  tissue,  a  broad  and  extensive  area  of 
denudation  is  formed  (Fig.  882).  The  splitting  of  the  tissues  should  be  car- 
ried deeply  into  the  lateral  sulci,  so  as  to  expose  the  retracted  muscular  stumps. 
At  this  ])oint  there  is  likely  to  be  free  bleeding,  for  the  control  of  which  pres- 
sure forceps,  hot-water  tampons,  ligatures,  and  the  after-pressure  of  the  deep 
sutures  will  suffice.  Caution  will  often  be  re(juired  in  the  course  of  tlie  dis- 
section to  avoid  opening  into  the  rectum,  but  care  to  keep  the  dissection  along 
the  plane  of  the  loose  submucous  tissue  between  the  vagina  and  rectum  will 
prevent  such  an  accident. 

Bleeding  having  been  arrested,  the  sutures  are  to  be  placed.  The  deep 
sutures  are  first  in  order.  Beginning  at  the  lower  angle  of  the  denudation,  a 
large  strong  needle,  armed  with  a  strong  coarse  thread,  is  introduced  clo.se  to 
the  margin  of  the  incision,  passed  outward  deeply  into  the  tissues,  and  made  to 
sweep  around  so  as  to  emerge  in  the  center  of  the  wound  in  its  depth  between  the 
vagina  and  the  rectum,  care  being  exercised  not  to  penetrate  into  the  rectum. 


SURGERY    OF    THE    FEMALE    (iFNERATIVE    ORG  ASS.     975 


Having  been  brought  out  at  tliis  point,  it  is  again  inserted  at  the  same  point 
anil  passed  on  through  the  tissues  of  the  opposite  side,  being  thrust  in  deeply 
at  the  side,  so  as  to  grasp  an  abun(Uint  thiekness  of  tissue  in  its  loop,  emerging 
tiirough  tlie  skin  close  to  the  border  of  the  incision  at  a  point  opposite  to  where 
it  was  introduced  on  the  other  side.  A  second,  third,  and  possibly  a  fourth  sim- 
ilar suture  are  then  introduced  in  like  manner,  proceeding  from  l^elow  upward, 
until  sufficient  have  been  placed  evenly  and  firmly  to  close  the  wound.  While 
these  sutures  are  being  introduced,  the  tissues  in  the  lateral  sulci,  which  natu- 
rally tend  to  retract,  should  be  seized  with  the  mouse-toothed  forceps  and  drawn 
strongly  into  the  wound,  so  that  the  sutures  shall  obtain  a  deep  grasp  upon 
them.  The  sutures  are  now  tied  seriatim,  havino-  been  drawn  sufficiently  tij^ht 
to  bring  the  parts  into  coaptation.  If  they  have  been  introduced  in  the  way 
described,  the  deeper  parts  will  be  fully  and  easily  brought  from  each  side 
into  contact,  and  a  firm,  competent  perineal  body  will  be  restored.  The  ends 
of  each  suture  should  be  cut  off  an  inch  or  tw'o  from  the  knot,  in  order  that 
the  suture  may  be  easily  found  when  it  is  desired  to  remove  it  later,  for,  as  a 
rule,  the  knot  itself  will  have  become  somewhat  imbedded  in  the  skin.  After 
the  tying  of  the  deep  sutures,  as  many  points  of  superficial  sutures  may  be 
placed  as  may  seem  to  be  required  fully  to 
coaptate  the  superficial  portions  of  the  edges 
of  the  wound.  The  fold  at  the  entrance  to 
the  vagina  made  by  the  lifting  of  the  center 
of  the  flap,  if  too  redundant,  may  be  retrenched 
to  any  degree  and  the  edges  sutured  (Fig.  388). 

The  sutures  having  been  applied,  the  parts 
should  be  well  dredged  with  powdered  oxide 
of  zinc.  Increased  comfort  will  be  given  the 
patient  by  the  pressure  of  a  soft  absorbent  pad 
against  the  perineum,  but  it  is  not  essential. 

In  the  after-treatment  especial  care  is  to  be 
taken  to  guard  the  wound  from  the  urine.  The 
patient  should  turn  over  upon  her  face  to  uri- 
nate, and  the  parts  should  be  Avell  douched  with 
the  boro-salicylic  solution  after  each  urination. 
If  the  patient  is  unable  to  urinate  in  this  way, 
a  catheter  must  be  used,  with  every  precaution 
to  avoid  infection  of  the  bladder  and  conse- 
quent cystitis.  The  sutures  should  remain  in 
place  for  at  least  ten  days.  If  they  are  not 
causing  much  irritation,  they  should  be  left  in 
some  days  longer.  The  patient  should  be  kept 
in  the  reclining  position  for  three  weeks,  and 
not  allowed  upon  her  feet  until  four  weeks  have  elapsed. 

II.  Complete  Laceration. — If  the  rent  extends  up  into  the  recto-vag- 
inal septum  for  any  distance,  it  is  best  to  secure  its  repair  down  to  the  level  of 
the  sphincter  as  a  separate  operation,  reserving  the  repair  of  the  latter  and  of 
the  perineum  until  a  later  period. 

The  operation  upon  the  recto-vaginal  rent  is  to  be  conducted  as  follows : 
The  edges  and  apex  of  the  rent  should  first  be  split  by  a  bistoury  to  the 
depth  of  about  three-eighths  of  an  inch.  Two  rows  of  sutures  are  required, 
rectal  and  vaginal.  Beginning  within  the  rectum  at  the  apex  of  the  rent, 
fine  silk  sutures,  at  intervals  of  about  three-sixteenths  of  an  inch,  are  intro- 
duced w^ith  a  small  well-curved  needle,  so  that  each  shall  come  out  at  the  bot- 


Perineoplasty,  condition  after  Suturing 
(Pozzi). 


076  AN  AMERICAN    TENT-BOOK    OF  SURGERY. 

torn  of  the  s])lit  tliat  has  been  made,  thus  embracing  only  tlie  rectal  half  of 
the  denudation.  These  should  then  be  tied  in  the  order  in  wliich  they  were 
introduced.  A  similar  series  of  sutures,  preferably  of  catgut,  should  now  be 
inserted  along  the  vaginal  line  of  the  wound,  each  being  tied  as  it  is  inserted. 
In  this  way  a  broad  surface  of  apposition  is  secured.  In  the  after-treatment  a 
loose  movement  of  the  bowels  should  })e  secured  daily  and  the  ordinary  atten- 
tion to  cleanliness  of  the  parts  should  be  maintained.  Further  operation  may 
be  delayed  until  after  a  period  of  at  least  six  weeks,  when  the  procedures 
are  the  same  as  are  now  to  be  described  for  the  ordinary  complete  lacer- 
ation. 

The  first  steps  are  the  same  as  those  that  have  been  described  for  repair  of 
the  incomplete  form.  Then  the  lateral  incisions  are  to  be  prolonged  backward 
along  the  side  of  the  anus  sufficiently  far  fully  to  expose  the  retracted  stumps 
of  the  sphincter  ani.  A  first  set  of  sutures  must  now  be  introduced  to  bring 
together  the  denuded  fibers  of  the  sphincter.  The  location  of  the  stump  of  the 
muscle  on  each  side  having  been  identified,  the  needle  should  be  passed  through 
it  so  as  to  grasp  its  substance :  the  deepest  suture  should  be  placed  first,  being 
entered  well  back  by  the  side  of  the  anus  and  directed  forward  toward  the 
perineum,  emerging  in  the  middle  line,  there  to  be  reintroduced  and  carried 
back  on  the  other  side  in  the  reverse  direction  till  it  shall  emerge  on  the 
other  side  of  the  anus  at  a  point  symmetrical  with  that  Avhere  it  originally 
entered.  Three  such  sutures  should  be  introduced.  The  remaining  sutures, 
for  the  perineum  proper,  should  be  introduced  as  in  the  incomplete  variety. 
The  parts  are  now  brought  into  apposition  and  the  sutures  tied  in  tiie  order  of 
their  introduction.  The  dressings  and  the  after-treatment  are  the  same  as 
above  described. 

Not  a  few  surgeons  prefer,  however,  to  remedy  the  entire  defect  at  a  single 
operation. 

SURGERY   OF   THE   VAGINA. 

Malformations  of  the  Vagina  may  be  congenital  or  acquired.  The 
former  are  vices  of  development,  the  latter  the  results  of  sloughing,  adhesion, 
and  cicatricial  contraction.  A  median  longitudinal  septum  occasionally  divides 
the  canal  more  or  less  completely  into  two,  owing  to  the  imperfect  coalescence 
of  the  ducts  of  Miiller  of  the  embryo.  The  hymen  may  be  imperforate.  The 
vagina  may  be  rudimentary  or  altogether  absent ;  in  which  case  there  is  usually 
imperfect  development  or  total  absence  of  the  uterus  and  ovaries.  These  con- 
ditions call  for  surgical  treatment  only  after  puberty  in  those  cases  in  which  the 
presence  of  the  developed  uterus  has  established  menstruation  and  vaginal  mal- 
formation, or  in  which  atresia  causes  retention  of  the  menstrual  fluid.  'J'he  opera- 
tive procedures  required  may  vary  from  a  simple  puncture  of  a  distendcil  hymen 
to  a  long  and  difficult  dissection  between  the  bladder  and  the  rectum  through 
the  connective  tissue  that  has  replaced  the  vagina.  The  practical  difficulties 
which  attend  efforts  to  keep  open  a  long  channel  that  has  been  estal)lished  by 
such  a  dissection  are  very  great,  so  that  in  the  cases  where  two  or  more  inches 
of  the  vagina  are  occluded  the  surgeon  Avould  be  justified  in  removing  the 
uterus  through  a  suprapubic  abdominal  incision  rather  than  in  attempting  to 
overcome  the  vaginal  atresia.  The  evacuation  of  a  (juantity  of  retained 
vnenstrual  fluid  is  attended  with  sjiecial  danger  from  septic  infection.  'J'o 
guard  against  this,  every  possible  antisejitic  precaution  should  be  observed. 
The  incisions  should  be  free,  the  cavity  should  be  thoroughly  emptied  and 
irrigated  with   an  antiseptic  solution,   a  fold  of  iodoform  gauze  should  be 


SURGERY    OF    TlIK    FEMALE    dENERATIVE    ORGANS.     977 

placed  in  tlio  vai:^ina  extending  from  tlie  cavity  of  tlie  uterus  to  the  vulva  to 
act  as  a  drain,  and  an  abundant  absorbent  dressing  should  be  jdaced  over  the 
vulva,  to  be  changed  as  oi'ten  as  it  is  saturated  by  the  discharges.  The  irri- 
gations may  be  re})eated  daily  until  the  distended  parts  have  contracted  to 
their  normal  dimensions. 

Vaginismus. — This  term  is  applied  to  a  spasmodic  contraction  of  the  mus- 
cles of  the  vaginal  opening  upon  any  attempt  at  coitus,  which  renders  marriage 
unfruitful.  The  introduction  of  the  finger  for  a  vaginal  examination  may  pro- 
duce the  same  effect. 

Its  cause  is  sometimes  the  sensitive  remains  of  the  hymen,  which,  though 
they  appear  to  be  normal,  yet  often  contain  enlarged  nerve-filaments :  some- 
times there  is  erosion  at  the  entrance  of  the  vagina,  and  sometimes  the  affec- 
tion is  apparently  entirely  nervous  in  origin. 

The  treatment  may  with  advantage  be  at  first  the  application  of  a  5  or 
10  per  cent,  solution  of  cocaine  a  few  minutes  before  coitus.  Whatever  the 
cause,  this  will  often  allay  the  pain  and  irritation  and  permit  intercourse.  If 
this  does  not  succeed,  a  careful  examination  should  be  made,  and  if  ulceration 
is  found  it  should  be  treated  with  nitrate  of  silver  or  other  suitable  application. 
If  sensitive  remains  of  the  hymen  are  present,  they  may  be  excised.  The 
mere  stretching  of  the  vaginal  orifice  will  often  effect  a  cure.  After  excision 
or  stretching  the  vagina  should  be  methodically  dilated  for  some  time,  until 
painless  intercourse  is  possible. 

Injuries. — Lacerated  wounds  of  the  vagina  have  occurred  as  the  result 
of  a  first  coitus :  they  are  not  infrequent  in  connection  with  ruptures  of  the 
cervix  uteri  or  of  the  perineum.  They  may  occur  in  the  course  of  operative 
procedures  upon  the  uterus.  The  hemorrhage  is  likely  to  be  abundant. 
The  treatment  of  such  wounds  should  be  in  accordance  with  general  surgical 
principles,  and  should  never  be  attempted  without  first  fully  exposing  the 
wounded  point.  Removal  of  clots  and  free  admission  of  air  to  the  vagina 
will  often  secure  hemostasis. 

The  injuries  of  the  vagina  which  most  engage  the  efforts  of  the  surgeon 
are  those  in  which  penetrations  of  the  bladder  or  rectum  are  present  and 
degenerate  into  permanent  fistulas.  The  most  common  cause  of  such  fistulte 
is  sloughing  from  the  prolonged  pressure  of  the  foetal  head  during  a  difficult 
labor.  The  resulting  opening  into  the  adjacent  viscus  may  vary  greatly  in 
its  size,  form,  and  location.  In  rare  instances  the  cavity  of  the  uterus  is 
invaded.  The  two  forms  of  fistula  most  commonly  met  with  are  the  vesico- 
vaginal and  the  recto-vaginal. 

VESICO-VAGINAL  FISTULA. 

These  fistulse  range  in  size  from  minute  openings,  recognizable  with  diffi- 
culty, to  those  where  much  of  the  septum  is  lost  and  the  anterior  wall  of  the 
bladder  prolapses  into  the  vagina.  Cicatricial  contractions  of  the  vagina  are 
frequent  complications. 

The  symptoms  are  those  of  incontinence  of  urine,  the  external  genitals 
being  continually  bathed  and  irritated  by  the  urine. 

The  diagnosis  is  usually  at  once  determined  by  inspection  after  the 
anterior  vaginal  wall  has  been  brought  into  view.  Confirmation  may  be  had 
by  the  use  of  a  sound  or  probe  if  needful,  and,  in  cases  Avhere  the  orifice  is 
minute  or  hidden  by  a  cicatricial  fold,  by  the  injection  of  colored  fluids  into 
the  bladder. 

62 


978 


AX    AMFJUCAX    TEXT-llOOK    OF  SURGEllY. 


The  prognosis  is  usually  ^ood  if"  the  case  is  ainciiahk'  to  i»la>tic  (iiicration 
for  its  closuro. 

The  treatment,  cxecjit  in  cases  of  verv  ininiitt'  fistuhv,  is  hy  jdastic  fipera- 
tion.  When  the  openiiii!;  is  very  small,  it8  closure  may  ))ossil)ly  he  effected 
by  touching  it  with  a  cautery  point  and  thus  exciting  adhesive  inllammation. 
During  the  after-treatment  of  such  a  case  the  bladder  should  be  kej)t  drained 
of  urine  by  a  permanent  catheter.     In  every  case  operation  should  be  deferred 


Vesico-vaglnal  Fistukt  exposed,  edges  of  fistula  being  pared  (Simon). 

till  the  general  health  of  the  patient  is  well  established  and  the  local  con- 
ditions ai-e  favorable  for  repair.  All  local  inflammation  must  have  been 
subdued  and  excoriations  healed.  Cicatricial  contractions  of  the  vagina 
must  have  been  overcome  by  division  or  dilatation.  The  functions  of  the 
bowels  and  of  the  kidneys  must  have  been  brought  into  a  state  of  healthy 
activity. 

The  fistula  may  best  be  exposed  by  putting  the  patient  in  an  exaggerated 
lithotomy  position,  the  pelvis  being  raised  upon  a  firm  cushion  and  the  vagina 
widely  opened  by  the  use  of  suitable  retractors,  laterally,  superiorly,  and  infe- 
riorly.     The  uterus  is  now  to  be  drawn  down  by  a  tenaculum  so  as  to  make 


siic(ii:ny  nr  the  femaij-:  (;exi:r.\tive  ohgans.    utd 

the  fistula  still  more  acfc.s.siblo.  The  edges  of  the  fistula  are  now  freelv  and 
evenly  pared  by  knife  or  scissors,  the  strip  to  he  renioveil  being  held' by  a 
toothed  tissue  forceps  or  tenaculum,  bevelling  the  edges  niaiidv  at  the  experise 
of  the  vaginal  portion,  but  taking  care  to  remove  all  cicatricial  tissue  and  to 
extend  the  removal  of  tissue  at  the  points  which  arc  to  be  at  the  ends  of  the 
suture  line,  so  that  there  shall  be  no  puckering  when  the  sutures  are  tied. 
AVhen  tl)e  tissues  are  thin  and  it  is  important  to  avoid  the  removal  of  tissue, 
the  edges  of  the  fistula  may  be  split  instead  of  pared,  and  thus  a  sufficient  raw 
surface  for  coaptation  secured.  The  rather  free  bleeding  which  follows  these 
incisions  will  be  controlled  by  the  sutures  when  api)lied,and  need  not  delay, 
their  immediate  ajiplication.  For  the  sutures  fine  silk  is  the  best-  material.' 
For  the  needles  the  liat,  i)artly-curved  needles  of  llagedorn  are  to  be  prefen-ed. 
A  needle  forceps  adapted  to  them  will  be  required.  The  sutures  should  be 
introduced,  beginning  at  the  most  distant  point,  the  needle  entering  near  the 
vaginal  edge  of  the  incision,  sweeping  outward  into  the  tissues,  so  al  to  bring 
within  the  suture  loop  an  abundant  portion  of  the  thickness  of  the  tissue^ 
finally  emerging  at  the  depth  of  the  wound  just  below  the  vesical  mucous  mem- 
brane, to  be  then  entered  at  a  corresponding  point  at  the  opposite  side  of  the 
wound,  and  carried  through  its  edge  in  a  reverse  direction  into  the  vagina. 
The  sutures  should  be  introduced  at  intervals  of  about  three-sixteenths  of  an 
inch,  and  care  should  be  taken  to  have  the  two  sides  of  the  fistula  penetrated 
by  the  sutures  at  corresponding  points  to  ensure  accuracy  in  the  subsequent 
adjustment.  If  necessary  to  relieve  tension — for  no  tension  must  be  permitted 
on  the  suture  line — relaxing  sutures  may  be  inserted  a  little  farther  from 
the  wound-edges,  and  carried  either  below  the  vesical  mucous  membrane  or 
through  it  into  the  bladder  if  need  be.  When  all  the  sutures  are  in  place, 
the  bladder  should  be  irrigated  with  a  warm  antiseptic  lotion  to  remove 
any  blood-clot  that  may  have  accumulated  within  it.  The  sutures  are  then 
tied.  A  few  accessory  points  of  suture  finally  may  appear  needful  to  secure 
perfect  apposition.  A  small  tampon  of  gauze  "impregnated  with  oxide  of  zinc 
should  be  left  in  the  vao-ina. 

For  ten  days  the  patient  should  remain  in  bed,  being  allowed  to  assume 
any  position  she  may  prefer.  For  the  first  forty-eight  hours  the  urine  should 
be  removed  by  catheter  every  four  hours,  and  after  that  spontaneous  micturi- 
tion may  be  allowed  as  often  as  the  patient  desires.  On  the  third  day  the 
tampons  may  be  removed  and  subsequent  daily  vaginal  douches  instituted.  On 
the  eighth  day  the  sutures  may  be  removed.  Vesical  tenesmus,  if  present,  is 
to  be  relieved  by  morphia  and  hyoscyamus.  After  the  tenth  day  the  patient 
may  gradually  resume  her  wonted  duties.  Daily  free  evacuations  of  the  bowels 
should  be  secured  from  the  first.  Should  only  partial  success  be  secured  by  a 
first  effort,  repetitions  of  the  operations  should  be  made  at  a  later  date  till  final 
closure  is  secured. 

For  the  partial  relief  of  aggravated  cases,  in  which  the  loss  of  substance  is 
too  great  for  any  plastic  operation  for  the  closure  of  the  opening  into  the 
bladder,  closure  of  the  vagina  has  been  practised.  In  some  instances  this 
procedure  has,  however,  entailed  such  serious  disorders  from  urinary  retention 
and  decomposition  in  the  unnatural  reservoir  that  the  vagina  has  had  to 
be  reopened.  In  other  instances  a  portion  of  the  recto-vaginal  septum  has 
been  removed,  so  as  to  make  the  rectum  a  receptacle  for  the  urine  and  men- 
strual secretions  after  the  urethra  and  vagina  have  been  closed  up,  and  com- 
fort has  thus  been  secured.  Should  these  devices  prove  fruitless  or  inad- 
visable, the  ureters  may  be  detached  from  the  bladder  and  implanted  into 


980  A\  J. 1/ /•;/.' /r.LV  TKA'T- /!()() h'  OF  sri!(;i:iiv. 

the    V((.tiiiii,   :is   h;is    hccii   done   witli   success   in   cases  of"   exstropliv  of   the 
bhidtler. 

Kkcto-Yacuxal  Fistula. — The  metliods  of  exposino;  and  treating  these 
fi^tuhv  are  in  <:eneral  siinihir  to  those  Just  detailed.  If  the  fistula  is  lii^^h  up, 
the  sphincter  ani  should  be  paralyzed  by  thorough  stretching  before  the  ope- 
ration is  begun,  and  the  movements  of  the  bowels  be  restrained  by  opiates  for 
the  first  week  thereafter.  If  the  fistula  is  near  the  anus,  the  ti.ssues  of  the 
perineum  and  anus  should  be  divided  into  the  fistula,  and  then  the  repair  con- 
ducted as  described  for  complete  lacerations  of  the  perineum. 

INFLAMMATIONS  OF  THE   VAGINA. 

The  vaginal  mucous  membrane  may  be  provoked  to  inflammation  by  the 
presence  of  irritating  foreign  bodies,  by  the  use  of  irritative  injections  or  appli- 
cations, by  the  contact  of  irritating  secretions,  by  the  irritation  of  excessive 
coition,  and  by  infection  with  the  gonorrheal  poison.  The  inflammation 
provoked  by  the  latter  cause  is  not  distinguishable  from  that  due  to  other 
causes,  except  possibly  under  the  microscope  by  the  detection  of  the  gonococci 
in  the  discharge.  Vaginitis  may  be  acute,  subacute,  or  chronic.  It  is  usually 
attended  with  more  or  less  vulvitis.  The  gonorrheal  form  is  prone  to  extend 
to  the  endometrium  and  thence  to  the  Fallopian  tubes,  provoking  ultimately 
pyosalpinx  and  often  pelvic  peritonitis. 

The  symptoms  of  vaginitis  depend  on  the  acuteness  and  intensity  of  the 
attack.  Local  lieat  and  pain,  with  some  tumefaction,  and  altered  secretion — 
scanty  at  first,  but  soon  becoming  copious  and  muco-purulent  in  character — 
are  the  chief  symptoms.  Inspection  of  the  vaginal  mucous  membrane  shows 
that  it  is  congested  and  bathed  in  muco-pus,  often  with  patches  of  excoriation. 
In  the  more  intense  forms  an  ulcerative  process  may  become  established,  with 
subsequent  cicatricial  contractions  and  adhesions.  In  the  mildest  cases  nothing 
may  be  complained  of  but  the  altered  and  excessive  discharge  or  leucorrhea. 
Every  degree  of  severity  betAveen  the  two  extremes  may  occur.  Its  natural 
tendency  is  toward  cure,  but  in  many  instances  the  persistence  of  cau.sative 
influences  prolongs  it  indefinitely.  In  some  cases  a  granular  condition  of  the 
mucous  membrane  is  produced,  constituting  a  very  intractable  and  painful  state. 
The  flowing  of  acrid  discharges  over  the  parts  at  the  outlet  of  the  canal  often 
produces  excoriations  and  fissures  at  this  point,  which  make  coitus  very  pain 
iul,  even  impossible. 

Treatment. — During  the  acute  stage  of  an  attack,  rest  in  bed.  saline  ape- 
rients, and  fre(iuent  hot  hip-baths  are  indicated.  The  vagina  should  be  washed 
out  several  times  daily  with  a  copious  hot,  mildly  antiseptic  douche,  as  of  borax, 
one  dram  to  water  one  quart,  or  of  licjuor  jdunibi  subacetatis,  half  a  fluid- 
ounce  to  water  one  quart.  As  soon  Jis  the  symptoms  have  moderated  somewhat 
the  cure  will  be  expedited  by  keeping  the  walls  of  the  vagina  separated  by  a 
fold  of  lint  or  gauze  soaked  in  oxide-of-zinc  cream.  This  should  be  carried 
well  up  to  the  posterior  fornix  through  a  speculum  and  protrude  between  the 
labia.  It  should  be  removed  at  the  end  of  twenty-four  hours,  the  vagina 
douched,  and  the  medicated  lint  again  inserted.  This  treatment  should  be  per- 
severed in  until  the  cessation  of  the  symptoms  indicates  that  the  disease  has 
subsided.  An  occasional  douche  should  be  persisted  in  for  a  time  thereafter, 
to  prevent  recurrences.  In  the  more  chronic  forms,  if  the  use  of  the  zinc 
tampons  is  impracticable,  recourse  may  be  had  to  douches  of  sulphate  of  zinc, 
one  dram  to  the  quart  of  hot  water  once  or  twice  daily.  In  the  more  invete- 
rate forms  inspection  will  show  certain  parts  which  are  especially  affected  to 


srRf;i:nv  or  riii-:  femat.e  (ikmiumivi:  ouaAXS.    osi 

■wbicli  direct  applications  of  nitrate  of"  silver  or  carbolic  acid  may  be  needful. 
In  all  cases,  as  far  as  possil)le,  tlie  cxcitin<2;  cause  sbould  be  removed.  Coitus 
is  to  be  forbidden. 

If  fissurfs  ))ersist  or  are  indicated  by  pain  wlicn  efforts  to  dilate  tbe  canal 
are  made,  tbey  sbould  be  sou^bt  for,  and  treated  by  distention  and  cauteriza- 
tion to  their  deepest  point  witb  stick  nitrate  of  silver.  Sucb  applications 
sbould  be  made  once  a  week  till  a  cure  is  effected,  tbe  parts  meanwbile  being 
kept  protected  by  smearing  them  with  oxide-of-zinc  cerate. 

TUMORS   OF  THE   VAGINA. 

Solid  gi'owths  are  of  rare  occuiTence.  Cases  of  lipoma  and  sarcoma  have 
been  recorded,  but  are  of  extreme  rarity.  Myoma  in  tbe  vafrinal  wall  has  been 
occasionally  observed,  (\ircinoma  is  rare  as  a  primary  disease,  tboujrh  frequent 
by  extension  from  the  cervix  uteri.  Cysts  are  of  more  frequent  occurrence. 
They  may  develop  from  persistent  embryonic  canal-ducts  of  Muller  or  canal 
of  Gartner ;  from  dilated  lymph-ducts ;  or  more  commonly  from  closed  and 
distended  mucous  follicles. 

Excision  of  all  these  growths  should  be  done  when  practicable.  In  cases 
of  cysts,  if  the  cyst-wall  cannot  be  easily  excised  in  toto,  the  portion  left  should 
be  freely  cauterized  to  destroy  its  secreting  surface  and  excite  adhesive  inHam- 
tion  thereof. 

FOREIGX    BODIES   IN   THE   VAGINA. 

The  vagina  has  been  made  the  receptacle  of  many  foreign  substances,  which 
become  the  subjects  of  surgical  care  through  the  inflammation  and  ulceration 
which  are  excited  by  them.  Their  presence  is  detected  in  the  course  of  the 
explorations  required  for  ascertaining  the  cause  of  the  symptoms.  They  are 
to  be  removed,  and  the  inflammation,  ulcerations,  or  fistulae  produced  by  them 
treated  on  the  lines  already  laid  down. 

PROLAPSE  OF  THE  VAGINA. 

As  the  result  of  injuries  to  the  perineum  and  loss  of  support  from  the  pelvic 
floor,  an  eversion  of  the  vagina  to  some  extent  is  common.  As  the  posterior 
wall  rolls  out  it  brings  with  it  the  anterior  wall  of  the  rectum,  and  produces 
a  swelling  of  varying  size  upon  tbe  floor  of  the  introitus,  to  which  the  term  rec- 
tocele  is  applied.  Similarly,  the  anterior  vaginal  wall  in  its  eversion  brings 
with  it  the  base  of  the  bladder,  constituting  a  cystocele.  Both  of  these 
conditions  entail  more  or  less  functional  disturbance  of  the  organ  involved. 
Diminution  of  the  expulsive  power  of  the  lower  part  of  the  rectum  attends 
rectocele.  Pouchinor  of  the  floor  of  the  bladder,  with  retention  and  decom- 
position  of  urine  and  cystitis,  is  the  result  of  cystocele.  For  their  relief  it 
is  of  prime  importance  that  the  pelvic  floor  be  restored  by  perineoplasty.  At 
the  same  time,  the  following  special  plastic  operations  may  be  done  upon  the 
walls  of  the  vagina  if  the  extent  of  the  relaxation  and  prolapse  seems  to  call 
for  them. 

Anterior  and  Posterior  Elytrorrhaphy. — These  operations  consist  in 
the  removal  of  longitudinal  strips  of  the  vaginal  mucous  membrane  of  varying 
length  and  width,  and  closing  the  gaps  thus  made  by  sutures,  so  as  to  narrow 
or  to  reef  in  the  relaxed  membrane.  The  anterior  wall  of  the  vagina  most 
frequently  calls  for  this  retrenchment,  which  is  a  most  valuable  accessory  to 
the  other  measures  instituted  for  renewing  the  supports  of  prolapsing  pelvic 
organs.     The  denudation  in  anterior  elytrorrhaphy  should  be  quite  free,  should 


082 


A.X    AMi:h'I(AX    TKXr-l'.OUK    OF   SLlidKnY. 


extend  from  Lalf  an  inch  behind  the  raeatus  urinarins  cxt^rnns  backward 
nearly  to  the  cervix  uteri,  and  sliould  lie  trianguhir,  or  rather  arrow-shajie<i.  in 
form,  Avith  tlie  base  of  the  trianjrle  or  arrow  just  in  front  of  the  cervix.  The 
elytrorrhaphy  sliouhl  be  done  before  the  perineophisty  is  proceeded  with,  and 
after  any  operation  on  the  cervix  that  may  have  been*re(juired.  The  piece  to 
be  removed  should  first  be  marked  out  with  the  point  of  the  scalpel,  and  then 
with  the  tissue  forceps  and  scissors  the  entire  piece  should  be  dissected  away, 
beginning  behind  and  working  forward,  care  being  taken   not  to  wound  the 


Fig.  386. 


Cervix  Uteri. 

Shape  of  Flap  to  be  Removed  in  Anterior 
Elytrorrhaphy  (original). 


First  Step  in  SuturiniEr  the  Wound  of  Anterior 
Elytrorrhaphy  (original). 


bladder.  In  Fig.  385  the  lines  A  B  D  C  A  indicate  the  shape  and  relations 
of  the  denudation  recommended.  The  application  of  the  sutures  is  to  be 
made  first  to  the  barbs  of  the  arrow,  B  F  being  sutured  to  B  D,  and  C  E  to 
CD,  the  sides  of  the  lozenge  DA  (Fig.  386)  then  remaining  to  be  sutured. 
Silk  is  the  best  material  for  these  sutures.  They  are  to  be  removed  in  eight 
or  ten  days. 

SURGEKY   OF  THE   UTERUS. 

Hypertrophy  of  the  Cervix. — A  true  overgrowth  of  the  cervical  por- 
tion of  the  uterus,  unaccompanied  by  inflammation,  due  to  an  as  yet  unex- 
plained error  in  nutrition,  occasionally  occurs.  The  tissues  of  the  cervix  are 
apparently  normal  in  their  character.     The  overgrowth  assumes  the  character 


suRaKRv  or  Tin-:  femali-:  (n:xi:iiATi\'i':  oiuians.    983 

of"  an  eloii^^ation  whit-li  may  fill  the  va<i;iiia.  even   to  the  extent  of  protruding 
from  the  vulva  (Fi^.  oST).      It  is  an  att'ection  occurring  more  freriuently  in 


Fio.  387. 


Fig.  388. 


Hypertrophy  of  the  ("ervix  Uteri  (Skene). 

the  unmarried.  It  entails  obstructive  dysmenorrhea  by  the  angulation  or 
bending  of  the  uterine  canal  which  it  produces ;  it  is  a  source  of  sterility  after 
marriasre ;  it  irritates  the  vagina  and  is  a  cause  of  much  local 
discomfort. 

The  diagnosis  is  readily  established  by  careful  bimanual 
examination,  which  will  show  the  body  of  the  uterus  to  be  in  its 
proper  place  and  of  uoi*mal  size,  while  the  finger  in  the  vagina 
will  trace  the  reflexion  of  its  mucous  membrane  to  the  cervix 
at  its  normal  distance  from  the  introitus,  notwithstanding  that 
the  elongated  cervix  fills  the  vagina. 

The  treatment  is  by  amputation.  The  annexed  figure, 
388,  shows  the  lines  of  incision  adapted  to  obtain  the  best 
resulting  stump  (Skene).  Subsequent  shrinking  is  to  be  ex- 
pected, for  which  reason  the  stump  should  be  made  a  little 
longer  than  the  normal  cervix. 

Wounds  of  the  Uterus. — Lacerations  of  the  cervix  uteri 
are  a  frequent  complication  of  childbirth.  If  they  are  exten- 
sive and  are  recognized  at  the  time,  immediate  sutures  should  be 
applied.  If  neglected,  they  heal  by  granulation,  leaving  often 
permanent  Assuring  of  the  cervix,  in  many  cases  accompanied 
with  marked  hyperplasia  and  eversion  and  erosion  of  the  mucous  membrane 
of  the  cervical  canal,  a  chronic  inflammatory  condition  of  the  whole  endo- 
metrium, and  subinvolution. 


Diagram  of  the 
Pieces  re- 
moved in  Am- 
putation of 
H  y  p  e  r  t  r  0- 
phied  Cervix 
(Skene). 


1)84 


A.\    AM  ERICA  y    rilXT-nOOK    OF   SLRtlKltY 


Fig.  389. 


Bilateral  Laceration  of  Cervix  Uteri  of  Moderate 
Degree  (original). 


In  manv  instances  these  healed  fissures  jrivo  rise  to  no  synij)tonis,  when 
they  shouM  be  let  alone.  More  fre(|uently  the  constant  e.\j)Osiii('  of"  the 
everted  cervical  mucosa  to  vaginal  infections  and  irritations  serves  to  per- 
petuate and  aggravate  the  co- 
existent metritis  and  endome- 
tritis, and  re))air  of  the  lacer- 
ation hy  a])|)i-oj)riate  jdastic 
o|»erati()n  is  necessary  as  a 
part  of  the  ti'eatment  re(|uired 
for  curing  the  chronic  uterine 
inflainniation. 

The  operation  for  hin-r- 
afcii  crrrir  is  best  done  while 
the  patient  is  in  the  dorsal 
])osition,  as  for  vaginal  fis- 
tula. (See  Fig.  4()»j.)  The 
perineum  being  retracted  and 
the  labia  being  separated  on 
either  side,  the  cervix  is 
brought  down  to  the  intro- 
itus  by  a  tenaculum,  and 
held  by  a  stout  thread  passed 
through  each  lip  for  the  more 
convenient  control  of  the 
parts.  With  an  ordinary 
scalpel  the  cicatricial  tissue  at  the  apex  of  the  fissure  is  now  thoroughly 
divided ;  along  the  limits  of  the  mucous  lining  of  the  canal  a  second 
incision  is  carried,  and  the  flaps  thus  marked  out  are  dissected  away,  giving 
broad  raw  surfaces  for  coaptation.  If  the  fissure  is  bilateral,  both  sides  should 
be  thus  freshened  before  any  sutures  are  introduced.  Pretty  free  bleeding 
may  be  expected  from  these  incisions,  but  it  will  be  fully  controlled  by  the 
tying  of  the  sutures.  Silkworm  gut  or  stout  silk  thread  is  the  best  material 
for  the  sutures,  and  a  strong,  well-curved  Ilagedorn  needle  of  small  size  answers 
well  for  the;r  introduction,  a  suitable  needle-holder  being  essential.  The 
number  of  these  sutures  and  the  method  of  their  introduction  are  governed 
by  the  general  principles  applicable  to  all  plastic  work.  The  sutures  should 
be  left  in  situ  for  ten  days,  during  which  time  the  patient  should  remain 
recumbent. 

Punctured  Wounds  of  the  Uterus  assume  ini])ortance  when  they  are 
the  subjects  of  septic  infection,  as  when  inflicted  by  unskilful  attempts  at  pro- 
ducing abortion.  Septic  inflammation  of  the  substance  of  the  womb  and  of 
the  peritoneum  may  follow,  with  the  gravest  consequences.  The  treatment 
indicated  is,  first,  full  dilatation  of  the  cervical  canal ;  then  thorough  curetting 
and  repeated  antiseptic  irrigations  of  the  uterine  cavity,  aided  by  continuous 
drainage  by  a  mesh  of  iodoform  gauze  placed  within  the  uterine  cavity  and 
protruding  into  the  vagina.  The  extension  of  the  infection  to  the  Fallopian 
tubes  and  to  the  pelvic  peritoneum  may  call  for  abdominal  section,  ablation  of 
appendages,  and  intra-peritoneal  irrigations  and  drainage. 

Rupture  of  the  Uterus,  when  occurring  as  a  complication  of  difficult 
childbirth,  presents  a  lacerated  wound  of  the  body  of  the  uterus,  l)eginning 
usually  in  tlie  lower  segment  of  the  uterus  and  extending  to  a  variable  degree 
both  longitudinally  and  transversely  from  the  point  of  beginning.  The 
symptoms  of  the  accident  include  shock,  heiiio!  rhage,  cessation  of  the  ute- 


SURGJ'JRV    OF    Tin-:    FKMALI':    (SKXEUATIVK    OUdANS.      985 

vine  contractions,  and  in  most  cases   escape  of  the  (a-tiis  tliroii^'li   the  rent 
into  the  abiloniinal  cavity. 

The  treatment  shoukl  be  by  abdoiniiial  section,  ))recede(l,  if"  need  be,  by- 
intravenous  infusion  of  a  (|uart  or  more  of  a  (i :  1000  saline  sohition  to  combat 
the  eftects  of  hemorrhai^e  and  shock  ;  the  removal  of  the  f(ctus  and  blood-clots 
from  the  ])eritoneal  cavity:  the  brin<;ing  of  the  uterus  out  throujih  the  abdom- 
inal wound,  and  the  arrest  of  hemorrhage  by  an  elastic  cord  drawn  about  the 
cervix  ;  the  cleansing  and  suturing  of  the  rent  in  the  uterus  after  the  manner 
advised  in  Cesarean  section,  or,  if  the  condition  of  the  lacerated  tissues  is  such 
as  to  render  their  subsecjuent  kind  healing  uncertain,  the  total  ablation  of  the 
uterus,  with  vaginal  drainage,  as  ])ractise(|  after  vaginal  li vsterectoniy. 

Incision  of  the  Uterus  for  Removal  of  Foetus. — Cesarean  Section. 
— The  necessity  for  incising  tlie  uterus  for  the  delivery  of  a  child  that  cannot 
be  delivered  alive  by  other  methods  having  been  determined  by  the  rules  of 
obstetrics,  the  operation  is  performed  as  follows  : 

Preliminanj  Preparation. — Every  possible  antiseptic  detail  in  the  cleans- 
ing and  disinfection  of  the  patient's  abdominal  surface  and  of  the  vagina  is  to 
be  carried  out,  as  in  all  cases  of  abdominal  section.  In  all  the  steps  of  the 
operation  the  most  rigorous  precautions  against  sepsis  are  to  be  observed. 

Tlie  Operation. — The  patient  having  been  placed  upon  a  proper  table, 
preferably  a  short  one,  with  her  knees  at  its  edge  and  her  feet  supported  on 
a  chair  to  facilitate  access  to  the  vagina,  and  having  been  anesthetized,  an 
incision  is  made  through  the  abdominal  wall  in  the  median  line  over  the  most 
prominent  part  of  the  tumor,  beginning  about  three  inches  above  the  pubes 
and  extending  upward  above  the  umbilicus,  being  in  all  from  five  to  six 
inches  in  length.  As  the  abdomen  is  opened  the  uterus  projects  into  the  open- 
ing :  an  assistant  now  presses  the  abdominal  walls  on  each  side  of  the  incision 
down  against  the  uterus,  thus  retracting  the  wound-edges  and  pressing  the  ute- 
rus still  more  prominently  into  the  wound-opening.  At  the  upper  end  of  the 
incision  a  limited  vertical  incision  is  at  once  made  into  the  presenting  wall  of 
the  uterus :  if  it  does  not  quite  perforate  the  uterine  wall,  the  finger  may  be 
used  to  complete  the  perforation.  Then,  the  finger  being  pushed  along  as  a 
director,  the  uterine  incision  is  to  be  lengthened  downward  to  the  full  extent  of 
the  primary  incision,  using  preferably  an  angular  scissors  for  the  purpose.  The 
amniotic  sac  pouts  into  the  wound,  and  is  next  to  be  equally  freely  divided, 
unless,  as  may  have  happened,  it  has  been  already  opened  and  divided  with  the 
uterine  wall.  If  the  placenta  should  lie  in  the  line  of  the  incision,  the  fingers 
should  be  insinuated  between  it  and  the  uterine  wall  until  its  margin  is  reached, 
when  the  membranes  are  to  be  ruptured  as  before.  The  hand  of  the  operator 
now,  plunging  into  the  uterine  cavity,  seeks  the  head  of  the  child  if  it  is  acces- 
sible, or  otherwise  the  feet,  and  quickly  extracts  it.  If  the  head  has  previously 
become  impacted  in  the  pelvis,  it  should  be  pushed  up  by  the  hand  of  an  assist- 
ant in  the  vagina.  The  umbilical  cord,  having  been  double  clamped  by  forceps, 
is  cut  between  them,  and  the  liberated  child  turned  over  to  a  nurse. 

Bleeding  from  the  uterine  incision,  if  free,  should  be  controlled  by  direct 
compression  or  by  compression  of  the  neck  of  the  uterus  by  the  hand  of  an 
assistant.  If  spontaneous  contraction  of  the  uterus  does  not  take  place,  a 
hypodermatic  injection  of  ergotine  (gr.  ij)  should  be  given.  The  placenta 
and  membranes  should  now  be  withdrawn  from  the  uterus.  If  not  already 
detached,  the  placenta  should  be  grasped  by  the  hand  and  lifted  away  by 
compression  from  circumference  to  center. 

The  empty  and  contracted  uterus  may  now  be  lifted  out  of  the  abdominal 
cavity,  resting  upon  hot,  wet  towels  that  are  placed  beneath  it  and  over  the 


98G  J.V    AM /•:/>•/<  AX    TKXT-noOk'    OF   SURGERY. 

alxloiuiiial  wound  to  facilitate  the  ap|)lieation  of  the  sutures.  Or  it  may  be 
sutured  in  i<lta  if  the  conditions  favor  ready  access  to  tlie  wound  in  it. 

Tlie  suturin<r  must  be  done  Avitli  jTreat  care,  for  upon  this  detail,  more  tiian 
on  any  other,  dej)ends  the  after-course  of  the  case.  Two  layers  of  sutures  are 
•required,  a  deep  and  a  superficial.  Silk  is  the  most  reliable  material  to  use  for 
sutures.  The  deep  sutures  are  first  placed.  A  well-curved  needle  is  intro- 
duced about  a  quarter-inch  from  the  wound-edge,  made  to  sweep  outward  into 
the  substance  of  the  uterus,  and  then  brought  out  near  to,  but  not  through, 
the  mucosa.  The  number  of  these  should  be  from  two  to  three  to  the  inch. 
Care  is  to  be  taken  that  no  suture  shall  penetrate  into  the  uterine  cavity.  The 
sutures  are  to  be  tied  firmly,  but  not  so  tightly  as  to  strangulate  the  tissues. 
For  the  purpose  of  making  the  approximation  still  more  perfect,  if  any  defect 
apjiears  anywhere  along  the  line  a  number  of  accessory  sutures  may  be  applied 
betAveen  the  primary  deep  sutures  wherever  the  need  may  appear.  These  may 
include  only  about  one-fourth  the  thickness  of  the  uterine  Avail. 

A  second  superficial  set  of  sutures  is  finally  to  be  introduced,  in  number 
about  two  to  each  deep  suture,  and  of  fine  silk.  A  strip  of  the  peritoneum 
with  a  thin  layer  of  muscular  tissue,  beginning  just  to  the  outer  side  of  the  line 
of  the  primary  sutures,  is  transfixed  Avith  a  fine  needle,  Avhich  is  carried  across 
to  the  other  side  of  the  Avound-line.  Avhere  it  again  picks  up  the  peritoneum  as 
at  the  beginning.  By  tying  these  sutures  the  peritoneum  is  aj»proximated  over 
the  whole  Avound-line  and  the  primary  sutures  are  covered  in.  The  peritoneal 
cavity  is  noAv  to  be  cleaned  by  irrigation  and  sponging,  the  uterus  replaced, 
the  omentum  drawn  doAvn  over  it,  and  the  abdominal  incision  closed  in  the  ordi- 
nary manner.  If  at  the  time  of  the  operation  the  uterus  be  found  to  be  already 
the  subject  of  septic  infection,  it  should  be  extirpated  in  toto.  This  is  to  be 
done  according  to  the  technique  for  abdominal  hysterectomy  for  other  conditions. 

The  after-treatment  of  Cesarean  section  does  not  differ  from  that  required 
after  abdominal  section  in  general. 

SymiJhyseotomy. — The  necessity  of  resorting  to  Cesarean  section  for  de- 
livery of  a  foetus  in  cases  of  contracted  pelves  may  be  avoided  in  certain  cases 
by  a  section  of  the  interpubic  articulation  at  the  symphysis  and  temporarily 
drawing  apart  the  pubic  bones.  It  is  practicable  to  carry  such  separation  to 
a  distance  of  about  three  inches  (seven  centimeters)  without  serious  injury  to 
the  sacro-iliac  articulation.  AVhen  the  obstetrician  has  determined  that  the 
space  gained  by  such  an  amount  of  separation  will  enable  the  head  of  the 
foetus  to  pass,  symphyseotomy  should  be  done. 

The  technique  of  the  operation  is  as  folloAvs  :  The  pubes  having  been 
shaved  and  cleansed,  a  sufficiently  free  incision  is  made  in  the  middle  line 
through  the  soft  parts  doAvn  to  the  bone,  to  expose  the  articulation.  This  in- 
cision should  terminate  below  or  a  little  above  the  clitoris.  The  Avound-edges 
having  been  retracted,  the  glistening  fibers  of  the  symphyseal  ligaments  are 
clearly  exposed  by  further  light  touches  of  the  knife.  By  drawing  upon  the 
clitoris  the  filaments  of  its  suspensory  ligament  are  made  prominent,  and  by 
a  transverse  cut  these  are  severed  and  the  subpubic  space  exposed.  By  push- 
ing a  finger  or  a  blunt  instrument  like  a  periosteal  elevator  betAveen  the  recti 
muscles  above,  the  soft  tissues  can  noAv  be  pressed  back  from  the  posterior  sur- 
face of  the  symphysis  and  guarded  from  injury,  Avhile  with  an  ordinary  scalpel 
the  joint  is  divided  from  before  backAvard.  Much  separation  of  the  joint  is 
still  prevented  by  the  dense  fibers  of  the  triangular  ligament  or  deep  perineal 
fascia.  Rupture  of  this  fiiscia,  if  it  is  caused  by  the  uncontrolled  crowding 
doAvn  of  the  foetal  head  from  strong  uterine  contractions,  may  tear  through  the 
venous  plexuses  about  the  neck  of  the  bladder,  and  even  lacerate  the  urethra 


SCRdKnv    OF    THE   r  EM  ALE    (iEXEnATlVK    OJiOANS.     987 

and  vuiiina.  Profuse  liciuon-lia'ri',  witli  (lifliciilty  controlled  by  tampons  and 
by  mass  ligatures,  is  the  immediate  result  of  such  an  accident,  and  sepsis  and 
fistuhc  the  later.  Fatal  results  have  eventuated  from  these  causes.  To  pre- 
vent these  a  systematic  division  of  the  deej)  fascia  from  the  arch  of  the  pubis 
on  either  side  should  be  made  at  once  after  dividing  the  symphysis.  A  blunt- 
pointed  bistoury  by  closely  hugging  the  bone  on  each  side  can  readily  and 
s<ifely  accomplish  this.  The  full  separation  possible  of  the  bones  at  the  sym- 
physis should  be  made,  and  tlie  gaping  Avound  tem))orarily  tamponed  ^vith  iodo- 
form gauze,  after  \vhich  the  delivery  of  the  child  should  be  immediately  ef- 
fected. After  delivery  has  been  accomplished  the  external  wound  should  be 
sutured,  except  at  its  lower  angle,  in  which  a  small  strip  of  iodoform  gauze  as 
a  drain  should  be  kept  for  the  first  forty-eight  hours.  The  bones  should  be 
approximated  and  supported  by  a  broad  adhesive  bandage  encircling  the  pelvis. 
The  patient  should  be  kept  recumbent  for  about  four  weeks. 

Inflammations  of  the  Uterus. — The  mucous  lining  of  the  uterus,  the 
endometrium,  is  the  chieffseat  of  inflammatory  conditions  affecting  the  uterus. 
The  submucous  tissues  share  to  a  greater  or  less  extent  in  the  superficial  i'nflam- 
matory  disturbances  of  the  mucosa,  and  in  certain  acute  affections  complicating 
the  puerperal  state  a  spreading  septic  lym])hangitis  and  phlebitis  are  excited, 
which  cause  the  whole  substance  of  the  uterine  Avails  to  become  acutely  inflamed, 
often  with  a  fatal  result. 

Endometritis  may  be  confined  to  the  cervix  or  may  involve  the  corpo- 
real endometrium  as  well.  Cervical  endometritis  is  the  most  frequent  variety. 
The  inflammation  may  be  acute  or  chronic.  In  the  acute  form  th-e  mucous 
membrane  is  congested  and  SAvollen  :  an  abundant,  viscid,  rauco-purulent  secre- 
tion is  poured  out  upon  its  surfiice  {Jencorrhea).  The  submucous  tissues  are 
congested  and  infiltrated  with  inflammatory  exudates  in  a  varying  degree,  de- 
pendent upon  the  severity  of  the  superficial  inflammation.  According  to  the 
extent  of  the  endometrium  invaded,  there  will  be  swelling  of  the  cervix  only 
or  of  the  whole  organ.  The  inflammation  not  infrequently  extends  along  the 
Fallopian  tubes  and  may  involve  the  pelvic  peritoneum.  More  frecjuently  the 
affection  is  of  gradual  development  and  assumes  a  subacute  form,  with  tendency 
to  chronicity  from  the  beginning.  In  the  clironie  form  the  mucous  membrane  is 
swollen  and  pulpy,  oedematous,  passively  congested,  prone  to  fungoid  vegeta- 
tions, easily  provoked  to  bleed.  The  leucorrheal  discharge  is  abundant  and 
acrid.  The  orifices  of  the  mucous  follicles  of  the  cervix  (glands  of  Naboth) 
frequently  become  occluded,  with  formation  of  small  retention-cysts  as  the 
result.  The  os  uteri  is  tumid,  the  cervix  swollen,  and,  if  the  body  of  the 
uterus  is  involved,  the  whole  organ  is  enlarged,  with  an  increase  in  the  depth 
of  its  cavity.  Where  lacerations  of  the  cervix  permit  it,  the  SAvollen  cervical 
flaps  become  everted,  with  erosion  of  their  epithelial  covering.  As  the  result 
of  long-existing  congestion,  proliferation  of  submucous  connective  tissue  takes 
place,  with  subsequent  contraction,  atrophy  of  glandular  elements,  and  sclero- 
sis. When  the  corporeal  endometrium  is  more  especially  affected  the  cervical 
appearances  described  will  be  absent. 

Etiology. — A  predisposition  to  endometritis  may  arise  from  a  multitude  of 
causes,  constitutional  and  local,  which  diminish  the  resisting  power  of  the  tis- 
sues of  the  organ,  interfere  with  its  nutrition,  and  conduce  to  local  blood-stasis. 
Bad  hygiene,  overwork,  improper  clothing,  uterine  displacements,  suppressed 
menstruation,  excessive  coitus,  abortions,  subinvolution  after  parturition,  and 
cervical  lacerations  are  among  the  predisposing  causes  that  should  be  especially 
mentioned.    The  exciting  cause  is  always  infection  with  pathogenic  micro-organ- 


988  AN   AMEIilcAX    Ti:xr-IU)()K    OF   SC lid F.Ii  Y. 

isms.  These  may  be  derived  from  the  vagina  or  cervix,  the  cavities  of  wliich 
ahvavs  contain  pyojienic  cocci  in  abundance,  tlioufrh  of  little  virulence  :  or  they 
niav  be  introduced  from  without  by  tiie  finger  of  the  surgeon  or  accoucheur, 
a  sound,  a  pessary,  or  other  instrument,  or  the  finger  of  the  patient  herself. 
The  puerjicral  uterus  presents  conditions  especially  favorable  to  the  full 
activity  of  pathogenic  micro-organisms,  mf)st  of  all  when  organic  d(^bris  is 
retained  within  the  uterine  cavity  or  when  unhealed  lacerations  of  its  sub- 
stance are  present 

The  infection  may  be  of  gonorrheal  origin,  in  which  case,  after  the  subsi- 
dence of  the  acute  vaginal  symi)toms,  the  infection  may  persist  in  the  cervical 
follicles  indefinitely,  occasioning  only  slight  symptoms  until  reawakened  into 
activity  by  some  of  the  conditions  named  as  jiredisposing,  especially  abortion, 
parturition,  and  traumatism.  Gonorrheal  endometritis  is  prone  to  extend  into 
the  Fallopian  tubes  and  induce  an  inveterate  salpingitis. 

The  symptoms  of  endometritis  comprise  dull  pelvic  pain  and  tenderness ; 
aching,  referred  to  the  sacral  and  lower  lumbar  regions  ;  a  sense  of  dragging 
within  the  pelvis;  more  or  less  profuse  leucorrhea.  Menstruation  is  painful  or 
in  the  more  chronic  conditions  is  unduly  frequent  and  prolonged :  the  bladder 
is  irritable;  the  bowels  are  torpid;  inspection  reveals  a  viscid  discharge  issu- 
ing from  the  os  externum  ;  the  cervix  is  tumid  and  congested ;  and  epithelial 
erosions,  granular  degenerations,  and  cystic  enlargements,  if  present,  are 
detected  at  a  glance.  If  the  endometritis  involves  the  body,  the  sound  or 
bimanual  examination  shows  an  enlargement  of  the  organ,  and  the  endome- 
trium is  tender  and  bleeds  easily  when  touched  with  an  instrument.  In  gene- 
ral, the  digestion  is  deranged,  and  the  nervous  system  especially  is  the  subject 
of  multiform  disturbances.  In  many  cases  a  condition  of  chronic  invalidism 
is  establishe<l.  In  the  more  acute  cases  the  attack  may  be  ushered  in  with 
rigors  and  fever,  and  may  be  attended  with  all  the  recognized  signs  of  local 
septic  inflammation. 

The  prognosis  must  depend  upon  the  extent  of  tissue  involvetl.  the  pre- 
vious duration  of  the  affection,  and  the  complications  present,  together  with  the 
constitutional  conditions  of  the  patient.  To  these  must  be  added  the  ability 
and  willingness  of  the  patient  to  submit  to  the  treatment  refjuired.  The  disease 
is  sometimes  rebellious  to  treatment,  but.  as  a  rule,  may  be  expected  to  yield  to 
intelligent  and  thorough  measures.  A  disposition  to  relapses  characterizes  the 
affection,  due  to  the  lingering  of  infective  material  in  the  glandular  recesses  of 
the  endometrium  and  to  the  frequent  repetition  of  the  exciting  cau.ses. 

Treatment. — Minute  inquiry  must  be  made  into  the  existence  of  predis- 
posing ami  the  continuance  of  exciting  causes,  and  especial  care  must  be  given 
to  their  removal.  Acute  attacks  require  absolute  rest  in  bed.  the  free  use  of 
saline  cathartics  and  warm  enemata,  hot  fomentations  to  the  hypogastrium.  and 
the  administration  of  a  copious  hot  vaginal  douche  twice  daily,  continued  for 
thirty  minutes  at  a  time,  the  patient  being  recumbent. 

In  subacute  and  chronic  conditions  constitutional  treatment  a.ssumes  import- 
ance. Anemia  and  neurasthenia  must  be  combated  :  constipation  must  be 
guarded  against.  The  local  treatment  requires  the  correction  of  malpositions, 
the  restoration  of  support  to  the  organ,  and  the  avoi<lance  of  the  irritation  of 
sexual  congress.  Frequent  periods  of  rest  in  the  recumbent  position  are 
important.  Hot  vaginal  douches,  as  described  above,  may  be  continued.  In 
the  intervals  between  the  douches,  or  as  a  substitute  for  them  in  part,  may  be 
u.^sed  wool  or  cotton  tampons  saturated  with  glycerin  and  tannin  Oj-f.?j). 
Of  the  highest  value  in  treating  persistent  endometritis  is  the  thorough  scrap- 
ing away  of  the  altered  superficial  layers  of  the  mucosa  (curetting),  followed 


siRdKin'  or  Till-:  female  aE^EU.\'riVE  organs.    98D 

1)V  c'(|u;illv  tlmroiiixli  disiiil'cct ioii  of"  tlic  rciii:iiiiiii<;  |i(irti(m  iiiid  ;i<li'(|uate  drain- 
a^e  tlioreatU-r. 

(Jin'cff<((/<'  of  the  ciKluiiictriitiii  slioiild  always  Ix'  <fiiaiilcd  l)_v  lull  aiitiso[)tic 
precautions.  I*roliiiiiiiary  scnibbiMjj:;  and  antiseptic  irrigations  of  the  vulva 
and  the  vagina  should  he  thoroughly  made.  Anesthesia  is  often  re(|uired. 
The  dorsal  position  is  to  he  chosen,  the  cervix  expose*!,  seized  with  the  vol- 
sella.  and  drawn  down  to  the  introitus.  Preliminary  dilatation  of  the  cervi- 
cal canal  is  usually  necessary.  A  sharp  uterine  curette  is  to  be  selected,  and 
after  the  direction  and  depth  of  the  uterine  canal  have  been  ascertained  witli 
a  sound,  is  introduce<l  to  the  bottom  of  the  cavity,  and  with  firm  repeated 
strokes  is  drawn  over  the  whole  endometrium  until  the  superficial  layer  of  the 
entire  mucosa  has  been  removed.  The  curette  is  then  withdrawn  and  the 
interior  of  the  uterus  is  thoroughly  irrigated  with  a  hot  antiseptic  solution. 
A  10  per  cent,  emulsion  of  iodoform  is  now  freely  injected  into  the  uterine 
cavity  through  a  glass  catheter  introduced  to  its  fundus.  The  vaginal  sur- 
face of  the  cervix  and  the  adjacent  vaginal  mucosa  should  be  plentifully 
sprinkled  witli  oxide  of  zinc  powder.  Recumbency  in  bed  for  one  week 
sliould  follow.  Should  free  bleeding  from  the  endometrium  persist,  the  cavity 
of  the  uterus  should  be  packed  Avith  iodoform  gauze,  which  packing  should 
be  removed  on  the  fourth  day  afterward. 

Lacerations  of  the  cervix  should  be  repaired  as  soon  as  the  congestion  of 
the  cervix  is  relieved';  mucous  polypi  should  be  scraped  or  twisted  off:  if  the 
cervix  has  become  hypertrophied  or  remains  persistently  enlarged  by  passive 
congestion  and  oedema,  a  portion  of  it  should  be  removed  with  the  knife,  as 
already  described  for  Amputation  of  the  Cervix. 


DISPLACEMENTS    OF    THE    UTERUS. 

Normally  the  uterus  lies  in  the  pelvic  cavity  in  a  position  of  slight  ante- 
flexion, suspended  among  the  other  viscera  of  the  lesser  pelvis, by  the  uniform 
pressure  of  which  on  all  sides  it  is  maintained  in  position.  The  direction  of 
its  longitudinal  axis  varies,  however,  through  a  considerable  arc,  according  to 
the  position  of  the  body  and  the  relative  fulness  of  the  bladder  and  the  rectum. 
Displacements  to  a  degree  that  call  for  surgical  intervention  may  occur  for- 
ward— anteversion  and  anteflexion  ;  backward — retroversion  and  retroflexion  ; 
and  downward — prolapse  and  procidentia.  The  symptoms  which  arise  in  cases 
of  displacement  are  not  due  to  the  mere  change  of  axis  or  place  of  the  organ, 
but  are  due  to  the  tension  upon  the  ligaments,  the  dragging  upon  adjacent 
organs,  and  the  nervous  and  circulatory  reactions  from  coincident  congestions 
of  the  uterus  and  adnexa.  Considerable  displacement,  in  the  absence  of 
these  complications,  may  therefore  exist  without  causing  any  symptoms  or 
disability. 

Anteversion  and  Anteflexion. — Mere  anteversion,  a  position  in  which  the 
uterus  is  inclined  forward  to  an  undue  degree,  causes  no  symptoms  and  calls  for 
no  treatment.  When  it  is  due  to  subinvolution  and  chronic  endometritis  the 
symptoms  present  are  due  to  these  conditions,  and  may  be  relieved  by  appro- 
priate treatment.  When  it  is  a  part  of  a  more  extended  inflammation,  and  the 
uterus  is  bound  down  by  adhesions,  the  malposition  of  the  uterus  is  a  relatively 
minor  incident  in  the  complex  conditions  present,  and  does  not  in  itself  con- 
stitute an  important  indication  for  treatment. 

In  nntf'ficxion  the  uterus  is  bent  forward  u))on  itself,  the  angle  of  flexion 
being  usually  at  the  junction  of  the  body  and  the  cervix.    (See  Fig.  391.) 


990 


AX  .1.1/ /•;/.' /r.Lv  TNXT-iiooK  or  scuaKin' 


Such  a  flexion  may  ho  duo  either  to  defective  deveh)|)niciit  of  the  tissue  of  the 
anterior  wall  of  the  uterus  durin*:;  the  period  of  devel()i)inental  aetivitv  at 
puhert}^  or  it  may  be  the  result  of  later  inllammatory  conditions  of  the  uterus 
and  adnexa  l)y  means  of  -which  the  cervi.x  becomes  h.xed  by  adhesions  or  the 
utero-saeral  bands  arc  shortened,  while  the  swollen  fundus  is  toppled  over  for- 
ward, and  is  not  infrequently  fixed  by  adhesions  to  the  anterior  pelvic  wall. 

Stenosis  of  the  uterine  cavity  at  the  point  of  bendin<f — the  os  internum — 
is  the  immediate  effect  of  the  flexion.     The  retention  of  secretions  and  the 


Fig.  .390. 


Normal  I'ositiou  of  the  Uterus  (original). 

altered  circulatory  and  nutritive  conditions  that  follow  in  turn  induce  a 
chronic  inflammatory  state  of  the  endometrium.  Dysmenorrhea,  and  in  the 
married  sterility,  result. 

The  symptoms  are  chiefly  those  of  dysmenorrhea.  Pain,  referable  to 
the  uterus,  precedes  the  ap])earance  of  each  menstrual  flux.  It  is  paroxysmal 
in  character,  varies  much  in  its  intensity,  but  is  usually  in  proportion  to  the 
acuteness  of  the  flexion.  As  the  flow  becomes  established  the  pain  is  relieved. 
The  attendant  endometritis  produces  its  own  special  symptoms,  while  it  also 
aggravates  the  stenosis.  In  some  cases  a  considerable  degree  of  anteflexion 
fails  to  produce  any  symptom. 

Diagnosis. — The  globular  mass  of  the  fundus,  pressing  forward  upon  the 
bladder,  is  at  once  felt  by  the  examining  finger  when  pressed  uj)  in  front  of 
the  cervix,  and  its  continuity  with  the  cervix  and  the  angle  at  their  junction 
can  readily  be  made  out.  B}^  combined  manipulation,  aided,  if  need  be,  by  a 
finger  introduced  into  the  rectum,  the  whole  contour  of  the  organ  may  be 
ascertained.  Some  uncertainty  may  arise  when  the  cervix  is  long  and  is 
directed  into  the  vagina,  as  if  belonging  to  a  retroverted  uterus,  and  also  when 
a  fibroid  seated  in  the  anterior  wall  of  the  uterus  causes  the  anterior  sur- 
face to  simulate  that  of  an  acute  flexion.    A  sound  introduced  into  the  uterine 


SUBGJ'JRV    or    Till:    rilMALE    GENERATIVE    ORGANS.      ll!)l 

canal  uilKk'toriniMc  the  dia<,'iiosi.s  by  doinoiistrating  the  real  direction  of  the 
canal.  To  facilitate  the  introduction  of  the  sound,  the  cervix,  after  having 
been  exposed,  should  be  drawn  downward  and  backward  }>y  a  volsellum  for^ 
ceps,  and  the  sound  should  be  well  curved. 

The  treatment  consists,  first,  in  the  straiH;litening  of  the  organ  by 
manipulation  as  just  described;  secondly,  in  the  dilatation  of  the  canal^  either 
by  a  uterine  dilator  or  by  the  introduction  of  sounds  of  successive  graduated 
sizes  ;  thirdly,  in  the  curetting  of  the  altered  endometrium.  These  procedures 
are  to  be  accompanied  with  abundant  antiseptic  irrigations  of  the  uterine  and 

Fig.  391. 


uterus  Anteflexed  (original). 

vaginal  cavities  and  adequate  disinfection  of  all  instruments  and  appliances. 
Whenever  the  tendency  to  recurrence  of  the  flexion  is  marked,  resort  may  be 
had,  fourthly,  to  the  introduction  of  a  stem-pessary  of  suitable  length,  which 
may  be  Avorn  for  two  or  more  months.  An  essential  requisite  of  this  pessary 
is  that  it  shall  not  interfere  with  the  ready  drainage  of  the  uterine  cavity. 
The  wire  pessary  of  Outerbridge  is  recommended  for  this  reason. 

If,  as  is  often  the  case,  the  projection  of  the  anterior  lip  of  the  cervix  into 
the  vagina  is  abnormally  slight,  it  should  be  let  down  into  the  vagina  by 
making  a  free  transverse  incision  through  the  vaginal  mucous  membrane  at  its 
point  of  reflexion  upon  the  cervix.  By  pulling  the  cervix  backward  this 
transverse  incision  is  converted  into  a  longitudinal  one  by  the  approximation 
of  its  lateral  angles,  Avhich  should  be  secured  by  sutures.  If  there  is  an 
excessive  projection  of  the  posterior  lip,  it  may  be  shortened  and  the  canal 
made  straighter  by  taking  out  a  transverse  wedge  from  its  posterior  surface 
and  suturing  the  raw  surfaces.  If  the  vaginal  portion  of  the  cervix,  as  a 
whole,  is  long  and  conical,  a  portion  should  be  amputated. 


J)W2 


,I.V    AMKinCAX    TKXT-IIOOK    OF   SriiCKUY. 


lietrovcrsion  and  Ii<'tr()Jh'.n'on. — When  tlie  fiiiulus  of  tlie  uterus  habitu- 
ally points  toward  the  sacrum  a  rctrovcmwn  of  the  organ  exists.  The  degree 
to  which  such  tilting  backward  extends  may  vary  much.  It  is  usually  asso- 
ciated with  some  prolapse.  In  the  great  majority  of  cases  which  })resent 
symptoms  the  uterus  becomes  also  bent  upon  itself  backward,  constituting  the 
condition  of  retrojlexion. 

Backward  displacements  of  the  uterus  occur  more  commonly  in  women  who 
have  borne  children,  being  sequelae  of  accidents  complicating  childbirth  ;  and 
as  a  result  the  uterine  supports  are  relaxed,  the  swollen  uterus,  becoming  more 
or  less  prolapsed,  is  forced  backward  by  the  pressure  of  the  abdominal  organs, 
and  by  the  same  process  is  flexed  upon  itself  after  the  further  descent  of  the 


Fig.  392. 


Uterus  Retroverted  and  Retrollexed  (-original). 

cervix  is  arrested.  In  nulliparous  women  it  is  also  met  with.  As  predisposing 
causes  may  be  enumerated  any  condition  that  induces  laxncss  of  the  uterine 
supports,  such  as  general  aneinia,  debility  from  illness  or  fatigue,  or  natural 
flabbiness  of  muscular  or  fibrous  tissue  ;  improper  posture  in  standing  or  sitting, 
in  which  the  pelvis  is  held  in  a  position  of  lessened  oblicjuity  by  an  undue  pro- 
jection forward  of  the  symphysis,  and  the  weight  of  the  abdominal  viscera, 
that  should  be  supported  by  the  lower  abdominal  wall  and  the  pubic  arch,  is 
directed  into  the  pelvis  upon  the  fundus  and  the  anterior  surface  of  the  uterus; 
habitual  tight  constriction  of  the  abdomen,  whereby  intrapelvic  pressure  is  in- 
creased :  increased  weight  of  the  organ,  as  during  menstruation  or  as  the 
result  of  endometritis  w  myomatous  tumors. 

The  immediate  cause  of  a  retroversion  is  intrapelvic  pressure.  This  is 
usually  gradual  in  producing  its  effect,  but  occasionally  produces  acute  symp- 
toms during  great  strain,  as  in  lifting  or  coughing  or  by  a  fall.  Pelvic  tumors 
may  crowd  the  uterus  backward. 


SURGERY    OF   Till:    FEMALE    (IFXFUATIVI:    ORGANS.     993 

Backward  displacements  that  cause  symptoms  have  usually  advanced  to  the 
extent  of  flexion,  and  as  rule  arc  complicated  with  chronic  eiuloinetritis  and 
uterine  hyperplasia,  most  extensive  in  the  cervical  portion.  In  many  cases 
these  inflanimatory  conditions  antedate  the  displacement,  and  have  contributed 
to  it,  but  after  the  displacement  has  developed  they  are  perpetuated  and  aggra- 
vated by  it ;  when  previously  absent  they  are  produced  by  it.  Not  infre- 
quently an  intercurrent  pelvic  peritonitis  produces  adhesions  which  bind  the 
uterus  in  its  malposition. 

Symptoms. — The  complex  of  symptoms  which  attend  endometritis  and 
relaxation  of  the  pelvic  floor  (see  pp.  972  and  98S)  indicate  the  presence  of 
those  conditions.  Dysmenorrhea  and  menorrhagia  are  common.  The  pelvic 
discomfort  is  aggravated  by  walking  or  standing,  and  is  often  sufficient  to 
greatly  restrict  the  following  of  any  occupation  or  the  enjoyment  of  any  exer- 
cise. Pressure  upon  the  rectum  renders  defecation  difficult,  often  painful,  and 
fosters  the  development  of  hemorrhoids.  Backache,  referred  to  the  middle  of 
the  sacrum,  is  the  rule.  Sterility  is  common.  Cases  vary  much  in  the  degree 
to  which  particular  symptoms  are  present. 

The  diagnosis  is  made  by  vaginal  touch.  The  cervix  is  felt  lower  than 
normal  in  the  vagina  and  pointing  somewhat  forward.  If  retroversion  only  is 
present,  the  posterior  surfiice  of  the  uterus  is  palpated  by  the  tip  of  the  finger 
pressed  into  the  posterior  fornix  ;  if  flexion  exists,  the  rounded  fundus  is  like- 
wise detected,  and  the  angle  of  the  junction  of  the  body  with  the  cervix  ap- 
preciated. The  diagnosis  may  be  confirmed  by  the  uterine  sound  and  by 
rectal  palpation.  Endometritis  and  other  inflammatory  complications  declare 
themselves  by  their  own  special  symptoms.  Adhesions  are  detected  by  the 
resistance  that  is  met  with  to  attempts  at  the  reposition  of  the  organ.  Peri- 
metric bands  and  masses  of  exudate  can  sometimes  be  felt  by  the  examining 
finger.  A  small  fibroid  jutting  out  from  the  posterior  wall  of  the  uterus,  an 
enlarged  ovary  prolapsed  into  the  cul-de-sac  of  Douglas,  or  masses  of  inflam- 
matory exudate  behind  the  uterus  may  be  mistaken  for  a  retroflexed  fundus, 
with  which,  indeed,  they  may  coexist.  By  careful  and  thorough  palpation  of 
all  the  pelvic  contents  the  distinction  may  be  made. 

Treatment. — Complicating  inflammatory  conditions,  if  present,  demand 
first  attention.  The  details  of  the  treatment  of  such  conditions  are  given  else- 
where. In  particular,  inflammation  of  the  appendages  and  of  the  pelvic  peri- 
toneum should  be  relieved  before  any  forcible  attempts  at  reposition  of  the 
uterus  are  made.  But  if  the  uterus  is  freely  movable,  though  swollen  from 
endometritis,  it  may  be  replaced  at  once  and  supported  by  tampons  charged 
with  boro-glyceride  or  ichthyol  and  glycerin  (12  per  cent,  mixtures),  applied 
also  for  their  primary  depletive  and  antiseptic  action. 

Keposition  of  a  retrodisplaced  uterus,  if  it  is  jwt  bound  down  by  adhesions, 
may  be  readily  effected  in  many  cases  by  introducing  a  properly-curved  uterine 
sound  in::  ;.e  uterine  canal,  with  its  concavity  toward  the  sacrum,  and  then 
slowly  sweeping  its  handle  around  an  arc  of  180°  until  its  concavity  looks  for- 
ward. Then,  by  depressing  the  handle  against  the  perineum,  the  uterus  is 
brought  into  anteversion.  This  maneuver  should  be  done  while  the  patient  is 
in  the  latero-prone  position.  It  is  then  aided  by  the  force  of  gravity,  which 
will  also  serve  to  retain  the  uterus  in  its  restored  position  until  suitable  means 
for  its  retention  may  be  applied.  This  procedure  should  be  done  with  the 
greatest  gentleness,  and  if  the  uterus  does  not  readily  follow  the  sound,  the 
procedure  should  at  once  be  abandoned.  Special  repositors  have  been  devised 
to  accomplish  the  same  end.  They  are  sounds  so  constructed  that  the  portion 
introduced  into  the  uterine  cavity  is  a  lever  that  by  mechanism  may  be  moved 

63 


9i*4  Ai\    AMKRIi'AX    TEXT-IK >(JK    OF  srii<;i:in\ 

so  as  to  lift  up  tlie  uterus  and  throw  it  over  into  anteversion.  Tlie  same  result 
can  be  obtained  by  placing  the  patient  in  the  knee-chest  position  and  then  re- 
tracting the  perineum.  The  vagina  is  ballooned  out  by  the  atmospheric  pres- 
sure ;  the  intestines  gravitate  away  from  the  pelvis,  and  the  uterus,  freed  from 
pressure,  topples  over  forward.  If  the  uterus  is  im})acted  so  as  not  to  obey 
the  force  of  gravity,  it  may  be  loosened  by  drawing  the  cervix  downward  and 
backward  with  a  tenaculum,  and  pushing  against  the  fundus  witii  a  sponge 
pressed  up  in  the  posterior  fornix  by  forceps. 

As  a  preliminary  to  these  operations  the  clothing  of  the  patient  must  be 
loosened  about  the  waist. 

In  patients  with  lax  and  thin  abdominal  walls  the  reposition  may  be 
effected  l)y  conjoined  manipulation  :  the  uterus  is  first  lifted  u{)  by  two  fingers 
in  the  rectum  or  vagina,  and  then  the  fingers  of  the  other  hand,  pressing  the 
abdominal  wall  deeply  into  the  pelvis,  insinuate  their  tips  behind  the  fundus 
of  the  uterus  and  tip  it  forward. 

When  the  uterus  is  jixed  in  retroposition  by  adJwsions  little  success  will 
result  from  attempts  at  repositing  it  by  the  means  above  mentioned.  If  the 
adhesion  is  limited  to  the  anterior  wall  of  the  rectum,  the  rectal  wall  may  be 
temporarily  pulled  forward  with  the  uterus,  but  as  soon  as  the  repositing  force 
is  withdrawn  the  displacement  recurs.  Delicate  adhesions  may  be  ruptured, 
but  eftbrts  to  rupture  any  adhesions  within  the  pelvis  by  force  applied  from 
■without  involve  possibilities  of  rupture  of  intestine  or  blood-vessels.  Such 
blind  efforts  should  therefore  never  be  made.  Adhesions  are  best  overcome 
by  the  fingers  introduced  into  the  pelvic  cavity  through  an  incision  in  the 
anterior  abdominal  wall.  The  gravity  of  this  procedure  will  depend  upon  the 
extent  and  density  of  the  adhesions  and  the  character  of  the  organs  involved. 
Such  adhesions  may  range  from  the  presence  of  a  few  slender  fibrous  filaments, 
readily  ruptured,  through  every  stage  up  to  the  very  solid  fusion  of  the  uterus 
in  a  mass  of  appendages  and  exudates.  When  adhesions  are  extensive  or 
dense  they  should  be  separately  dealt  with  under  the  guidance  of  the  eye  after 
full  exposure  of  the  pelvic  cavity  through  a  free  incision  of  the  abdominal  wall, 
with  the  pelvis  elevated  so  as  to  secure  gravitation  of  the  boAvels  out  of  the 
pelvis  toward  the  diaphragm.  A  uterus  thus  adherent  is  usually  associated 
with  conditions  of  the  appendages  that  call  for  the  ablation  of  the  latter. 
Great  care  is  often  required  to  avoid  wounding  the  intestine  or  bladder.  After 
full  enucleation  has  been  secured  the  uterus  may  present  extensive  denuded 
areas  on  its  surface  that  will  invite  fresh  intestinal  adhesions.  A  uterus 
thus  extensively  denuded,  and  by  the  removal  of  its  appendages  made  func- 
tionally useless,  may  very  properly  be  also  entirely  ablated. 

Retention  of  the  reposited  uteriis  in  its  proper  position  may  recjuire  means 
of  widely  differing  character.  When  there  are  no  adhesions  ;  when  no  tender 
prolapsed  ovary  makes  pressure  behind  the  uterus  intolerable  ;  when  no  in- 
flammatory conditions  of  the  vagina,  uterus,  or  adnexa  are  present ;  when  the 
pelvic  floor  is  intact  and  the  tonicity  of  the  uterine  supports  is  sufficient  to 
prevent  any  marked  degree  of  prolapse  ;  when  the  retro-displacement  has  been 
the  result  of  the  relaxation  caused  by  temporary  anemia  or  by  increased  intra- 
pelvic  pressure  caused  by  improper  dress  or  habitual  positions  of  the  body, 
which  conditions  may  be  remedied, — the  reposited  uterus  may  be  kept  in  its 
usual  position  by  a  properly-adapted,  closed,  double-lever  pessary.  (See  Figs. 
8i>8  ami  304.)  Such  a  pessary  acts  by  making  tense  the  natural  supports  of 
the  uterus,  especially  the  utero-sacral  ligaments.  If  it  is,  as  it  should  be, 
somewhat  conical,  with  the  larger  end  lying  behind  the  cervix,  the  contraction 
of  the  vaginal  wall  upon  it  tends  to  crowd  it  upward,  and  thus  to  prevent  the 


SURGERY    OF    Till':    FEMALE    GENERATIVF    ORGANS.      ;)!)5 


uterus  IVoni  descending,  while  the  cervix  is  forced  backward.  It  should  never 
make  undue  pressure  at  any  point,  and  its  presence  in  the  vagina  should  not  be 
appreciated  by  the  patient  exce{)t  by  the  comfort  experienced  from  it.  It  should 
be  adapted  to  the  oajiacity  of  the  vagina  in  which  it  is  to  be  placed.  Its  length 
should  correspond  to  the  distance  from  the  j)osterior  fornix  to  the  upper  end  of 
the  uretlira  ;  its  width,  to  the  transverse  diameter  of  the  vagina  measured 
across  the  cervix.  The  depth  of  the  posterior  fornix  should  be  the  measure 
of  the  posterior  curve.  Hard  rubber  is  the  best  material  from  which  a  pessary 
should  be  made.  Immersion  for  a  short  time  in  boiling  water  will  soften  such 
a  pessary  so  that  its  shape  may  be  readily  altered  as  required.     A  temporary 


Fig.  393. 


Fig.  395. 


Closed  Double-lever  I'essary. 
Fig.  394. 


Pessary,  side  view. 


Pessary  in  Position  (redrawn  from  Skene). 


substitute  for  a  pessary  may  be  improvised  by  adjusting  pledgets  of  cotton  or 
lamb's  wool  in  the  vagina  so  as  to  distend  the  posterior  fornix  and  the  canal. 
Such  tampons  should  be  rendered  antiseptic  by  charging  them  with  oxide  of 
zinc  or  boro-glyceride  and  glycerin.  They  may  be  left  in  situ  as  long  as  a 
week  without  becoming  oifensive. 

When  a  pessary  is  to  be  introduced,  the  patient  should  be  in  the  latero- 
prone  position  ;  the  uterus  should  first  be  reposited ;  the  pessary,  after  being 
oiled,  is  seized  by  its  narrower  end,  turned  on  its  edge,  introduced  into  the 
introitus,  and,  by  pressing  the  perineum  strongly  back,  is  pushed  on  into  the 
vagina.  Here  it  is  turned  so  that  its  broader  end  is  transverse.  Usually  the 
posterior  bar  comes  in  front  of  the  cervix  at  first,  and  it  is  necessary  that  the 
index  finger  be  introduced  to  depress  it  and  guide  it  past  the  cervix  into  the 
posterior  vaginal  fornix.  The  removal  of  the  pessary  is  accomplished  by 
grasping  its  lower  end  between  the  thumb  and  finger  and  steadily  withdrawing 
it,  pushing  the  perineum  strongly  backward  with  it  as  it  emerges.  As  long 
as  a  pessary  is  in  use  the  vagina  should  be  douched  with  borax  and  hot  water 
daily.  Should  irritation  or  local  tenderness  in  the  vagina  be  caused  by  it,  it 
should  be  withdrawn.  It  is  either  imperfectly  shaped  for  the  case  or  further 
treatment  to  relieve  local  inflammatory  conditions  is  required.  A  properly- 
fitted  pessary  may  be  left  in  the  vagina  for  periods  of  two  or  three  months  at 
a  time.  Should  its  prolonged  use  be  required,  it  should  be  removed  at  inter- 
vals of  at  least  three  months,  and  not  be  replaced  for  some  days,  preferably  a 
week. 

From  the  limitations  enumerated  at  the  beginning  of  this  section  it  is 
plain  that  in  a  very  large  proportion  of  cases  of  retro-displacement  of  the 


99G  ^.V   AMKIUCAX    TEXr-lK^OK    OF   SVRUFAlY. 

uterus  pessaries  Avill  either  be  inefficient  or  undesirable  for  maintaining  the 
organ  in  its  proper  phice  after  it  has  been  reposited.  They  are  ahvajs  to  be 
regarded  as  temporary  palliative  agents  to  be  dispensed  with  as  soon  as  possi- 
ble ;  that  is,  as  soon  as  the  natural  tonicity  of  the  uterine  supports  has  been 
so  regained  that  the  uterus  is  held  by  them  in  normal  position. 

Sagging  of  the  pelvic  floor,  which  is  a  frecjuent  complication,  should  in  all 
cases  be  remedied  by  the  appropriate  surgical  procedures,  perineorrhaphy  and 
colporrhaphy.  Certain  cases  in  which  pessaries  could  not  be  used  before  the 
restoration  of  the  pelvic  floor  may  then  be  employed.  But,  inasmuch  as 
much  uncertainty  must  always  exist  in  this  respect,  it  is  preferable  that  cases 
Avhich  have  to  be  submitted  to  operations  upon  the  pelvic  floor  should  at  the 
same  time  be  given  the  benefit  of  some  additional  measure  to  make  more 
secure  the  retention  of  the  uterus  in  anteposition.  Many  operative  procedures 
have  been  devised  for  this  end.  Among  these  two  are  especially  to  be  recom- 
mended as  practical  and  efficient — viz.  first,  shortening  of  the  round  liga- 
ments ;  and,  second,  suturing  of  the  posterior  surface  of  the  fundus  of  the 
uterus  to  the  anterior  abdominal  wall. 

Shortening  of  the  Round  Ligaments. — The  proper  function  of  the 
round  ligaments,  to  preserve  the  fundus  of  the  uterus  in  slight  anteversion,  and 
thus  indirectly  to  aid  in  supporting  the  uterus  in  its  normal  position  in  the  pel- 
vis, depends  upon  the  tonicity  of  its  fibro-muscular  structure.  When  from  any 
cause  the  uterus  is  chronically  retroverted,  and  especially  through  lacerations 
or  over-distention  of  the  pelvic  floor,  the  uterus  is  also  prolapsed,  the  tissue  of 
the  round  ligaments  is  prevented  from  contracting  to  its  normal  length,  and  a 
condition  of  permanent  elongation  is  induced  which  entirely  destroys  its  func- 
tion as  a  uterine  support  or  guy.  The  retention  of  the  uterus  in  its  normal 
position  after  the  employment  of  other  means  required  to  restore  the  pelvic 
floor  and  overcome  subinvolution  and  endometritis  will  be  much  more  certainly 
ensured  by  so  shortening  the  round  ligaments  that  they  again  make  sufficient 
traction  on  the  fundus  of  the  uterus  to  bring  it  well  up  toward  the  symphysis 
pubis.      This  is  practicable  only  in  cases  free  from  adhesions. 

The  credit  of  establishing  this  procedure  as  a  proper  resource  in  suitable 
cases  is  to  be  given  to  Mr.  Alexander  of  Liverpool,  with  whose  name  the  ope- 
ration is  often  associated. 

Technique  of  the  Operation. — The  field  of  operation  should  be  cleansed 
with  the  same  care  that  has  been  directed  in  connection  with  abdominal  sec- 
tions, and  rigorous  antiseptic  precautions  should  be  observed  in  all  particulars. 
The  location  of  the  internal  abdominal  ring  having  been  identified  (at  a  point 
midway  between  the  anterior  superior  spine  of  the  ilium  and  the  spine  of  the 
pubes  and  half  an  inch  above  Poupart's  ligament),  a  two-inch  incision  through 
skin  and  superficial  fascia,  parallel  with  Poupart's  ligament,  should  be  made 
over  the  internal  ring,  about  one-third  of  it  being  to  the  outer  side  of  the  ring, 
^  and  the  other  tAvo-thirds  running  along  the  line  of  the  inguinal  canal.  The 
aponeurosis  of  the  external  oblique  muscle  being  exposed,  and  the  diverging 
fibers  of  the  roof  of  the  inguinal  canal  being  identified,  the  inguinal  canal  is 
freely  opened,  so  as  to  expose  the  internal  ring.  The  overhanging  fibers  of  the 
internal  oblique  muscle  are  to  be  diawn  upward,  so  that  the  tissues  emerging 
through  the  ring  may  be  clearly  identified.  A  little  teasing  of  the  connective 
tissue  that  binds  together  the  parts  will  soon  make  plain  the  outlines  and  the 
structure  of  the  round  ligament  as  it  runs  forward  along  the  floor  of  the  canal. 
As  soon  as  it  is  identified  it  should  be  isolated,  and  with  gentle  traction  drawn 
out  from  the  pelvis  :  as  this  is  done  the  connective-tissue  fibers  that  invest  it 
and  hold  it  will  have  to  be  carefully  strippetl  from  it  by  suitable  forceps  :  as 


SURGERY    OF    THE    FEMALE    GENERATIVE    ORGANS.     097 

the  cord  is  further  drawn  out,  it  will  S(jon  become  apparent  that  a  cuft'  of  peri- 
toneum is  being  stripped  back  from  it.  A  little  inadvertence  may  easily  tear 
this  peritoneal  investment  and  the  peritoneal  cavity  be  opened — an  accident, 
however,  wliieh  has  no  serious  significance.  The  pulling  out  of  the  ligament 
is  thus  continued  until  it  no  longer  emerges  with  any  freedom  through  the 
ring  ;  from  two  to  three  inches  of  the  ligament  may  easily  be  drawn  out ;  the 
uterus,  meanwhile,  should  be  lifted  up  from  below  by  the  finger  of  an  assist- 
ant in  the  varjina  to  facilitate  the  running;  of  the  ligament  and  to  determine 
when  the  control  over  the  uterus  by  the  ligament  has  been  regained. 

A  strand  of  gauze  is  now  passed  under  the  loop  of  the  portion  of  the  liga- 
ment that  has  been  brought  out,  and  a  temporary  antiseptic  tamponade  and 
covering  of  the  wound  applied,  while  the  ligament  of  the  other  side  is  in  the 
same  manner  found  and  drawn  out. 

Beginning  with  the  second  ligament,  suture  of  the  ligaments  is  next  to  be 
done.  Silkworm  gut  is  the  best  suture  material  to  be  used.  AVhile  the  liga- 
ment is  strongly  drawn  out  a  needle  is  passed  through  the  integument,  and 
each  layer  of  the  wound-edge  in  turn,  down  to  the  border  of  the  internal  ring 
which  it  pierces,  and  then,  transfixing  the  ligament,  is  made  to  pass  out  on  the 
other  side  in  the  same  way.  Similar  sutures  are  passed  at  intervals  of  about 
one-third  of  an  inch  along  the  course  of  the  inguinal  canal  until  the  apposition 
of  the  deep  wound  is  secured  and  the  fixation  of  the  ligament  is  accomplished. 
The  slack  of  the  ligament  is  tucked  up  under  the  aponeui'osis  of  the  external 
oblique  muscle  at  the  inner  end  of  the  wound.  A  few  strands  of  silkworm 
gut  may  be  introduced  at  the  outer  angle  of  the  wound  down  to  the  internal 
ring  for  drainage,  and  enough  points  of  superficial  suture  applied  to  bring  the 
wound-edges  fully  together.  A  proper  protective  and  absorbent  dressing  is  to 
be  applied.  Primary  union  is  to  be  expected.  The  patient  should  remain 
recumbent  for  four  weeks.  The  sutures  may  be  removed  at  the  end  of  two 
weeks.  The  uterus  should  be  supported  by  a  lever  pessary  or  tamponade  of 
the  vagina  for  some  months. 

Hysteropexy,orSuturingof  the  Posterior Surfaceof  the  Fundusto 
the  Anterior  Abdominal  Wall. — Whenever  the  abdominal  cavity  has  already 
been  opened  for  the  separation  of  adhesions  or  for  dealing  with  diseased  appen- 
dages, to  antevert  the  uterus  and  suture  it  to  the  anterior  abdominal  wall  is  a 
natural  step  when  a  retroversion  has  previously  existed.  The  anteposition  and 
the  security  from  prolapse  obtained  by  such  suturing  seems  more  absolute  and 
more  certainly  reliable  than  even  that  obtained  from  shortening  the  round 
ligaments  ;  for  which  reason  surgeons  Avho  are  able  to  so  control  their  operative 
conditions  as  to  avoid  all  dangers  of  sepsis  are  warranted  in  opening  the  abdom- 
inal cavity  for  the  special  purpose  of  thus  securing  the  uterus.  The  time 
occupied  for  this  operation  and  the  amount  of  operative  traumatism  inflicted 
are  very  much  less  than  in  the  operation  for  shortening  the  round  ligaments : 
for  this  reason,  especially  in  feeble  patients  and  in  those  in  whom  for  any 
reason  prolonged  anesthesia  is  to  be  avoided,  utero-ventral  suture  would  be 
preferred.  The  adhesions  which  result  from  this  procedure  gradually  elongate, 
so  as  to  give  considerable  play  to  the  uterus,  but  not  sufficient  to  permit  of  its 
retroversion.  Experience  has  shown  also  that  the  dilatation  of  the  bladder 
with  urine  is  not  embarrassed.  Subsequent  pregnancy  may  pursue  a  normal 
course. 

Technique  of  the  Operation. — The  preliminary  preparations  should  be 
those  prescribed  for  an  abdominal  section  for  any  other  purpose.  In  all  the 
steps  of  the  operation  rigid  asepsis  must  be  observed.  A  general  anesthetic 
is  required.     A  three-inch  incision  should  be  made  in  the  middle  line  of  the 


998 


AN  A3IERICAN    TEXT-BOOK    OF  SURGERY. 


abdomen,  beginning  just  above  the  symphysis.  Through  this  incision  two 
fingers  are  introduced,  which  lift  up  the  fundus  of  the  uterus  and  bring  it  into 
view  while  the  sides  of  the  incision  are  held  apart  by  retractors.  As  soon  as 
the  fundus  is  exposed  it  is  seized  at  its  middle  by  vulsellum  forceps,  lifted 
up  and  drawn  forward  against  the  symphysis.  By  these  maneuvers  the 
uterus  is  anteverted  and  the  posterior  surface  of  the  fundus  is  made  to  present 
in  the  lower  part  of  the  abdominal  incision,  and  the  insertion  of  the  sutures 
required  is  made  easy  and  safe.  The  sutures  may  be  of  silk  or  of  silkworm 
gut,  preferably  the  latter.  Three  should  be  inserted  at  intervals  of  one-third 
of  an  inch.  A  slightly  curved  needle,  grasped  by  a  needle-holder,  is  desirable. 
The  lowest  suture  should  be  introduced  first,  the  point  of  introduction  being 
about  an  inch  below  the  fundus  where  grasped  by  the  vulsellum.  The  needle, 
armed  with  a  strand  of  gut,  is  carried  transversely  through  tlie  uterine  tissue, 
penetrating  to  the  depth  of  an  eighth  of  an  inch,  and  emerging  about  three- 
quarters  of  an  inch  from  its  point  of  entrance.  The  two  other  sutures  are  in- 
troduced in  the  same  manner,  the  last  and  highest  passing  underneath  the 

Fig.  396. 


Position  of  Uterus  after  Suture  of  the  Posterior  Surface  of  the  Fundus  to  the  Anterior  Abdominal  Wall 

(utero-ventral  suture ;  original). 

prongs  of  the  vulsellum.  The  free  ends  of  the  sutures  on  either  side  are 
then  each  in  turn  threaded  into  a  curved  needle,  and  are  passed  through 
the  parietal  peritoneum  at  a  distance  from  the  edge  of  the  incision  in  it 
equal  to  one-half  the  width  of  the  included  uterine  area.  A  portion  of 
the  rectus  muscle  and  of  the  aponeurotic  fibrous  sheath  of  the"  rectus  is 
also  penetrated  by  this  needle.  When  the  three  sutures  have  thus  been 
passed  on  the  two  sides,  they  are  to  be  tied,  the  one  nearest  the  symphysis 
first,  and  the  others  in  the  reversed  order  to  that  in  which  they  were 
introduced.  The  ends  of  the  sutures  are  then  cut  off  close,  and  the  su- 
tures buried  by  the  subsequent  closure  of  the  superficial  portion  of  the 
wound.  In  this  manner  the  lower  part  of  the  peritoneal  opening  is 
closed,  and  a  broad  and  even  apposition  of  the  serous  surfaces  of  the 
uterus   and   parietes   secured.      Any   slight   bleeding   which    may   have   oc- 


SURGEin'    OF    THE    FEMALE    OENERATIVF    ORGANS.      999 

curved  from  the  pricks  of  the  uterus  is  at  once  arrested  by  pressure  when 
the  sutures  are  tied.  The  cul-de-sac  of  Douglas  should  be  sponged  out, 
and  the  entire  wound  then  sutured  as  in  any  other  abdominal  section. 
No  tampon  or  pessary  in  the  vagina  is  required.  The  after-care  is  the 
same  as  in  other  simple  abdominal  sections.  As  a  rule,  the  convalescence 
is  smooth.  The  buried  sutures  create  no  irritation.  In  a  small  proportion 
of  cases  they  may  after  a  time  excite  a  local  irritation  and  the  development 
of  a  sinus,  for  the  cure  of  Avhich  the  suture  will  have  to  be  exposed  and 
removed. 

Prolapse  and  Procidentia. — Any  descent  of  the  uterus  below  its  normal 
position  in  the  pelvis  is  a  prolapse.  The  association  of  the  lesser  degrees  of  pro- 
lapse Avith  retroversion  has  already  been  considered.  When  the  prolapse  becomes 
so  aggravated  that  the  cervix  tends  to  protrude  at  the  vulva,  or  the  uterus  by 
eversion  of  the  vagina  escapes  in  toto  from  the  pelvic  cavity  (^procidentia),  the 
displacement  assumes  characters  of  its  own  requiring  separate  consideration. 
To  the  same  causes  which  unite  to  produce  the  lesser  degrees  of  prolapse  and 
retroversion  are  due  the  more  extreme  degrees.  A  more  marked  weakening 
of  the  pelvic  floor,  a  greater  relaxation  of  the  uterine  ligaments,  an  increased 
or  longer-continued  abdominal  pressure,  suffice  to  urge  farther  downward  the 
sinking  uterus,  until  it  finally  presents  habitually  at  the  introitus,  or  by  an 
eversion  of  the  vagina  presents  as  a  tumor  between  the  thighs.     Usually  pro- 


FiG.  397. 


Complete  Prolapse  of  the  Uterus,  with  Eversion  of  Vagina  (original). 

lapse  of  the  vagina  precedes  that  of  the  uterus  ;  the  anterior  vaginal  wall 
gives  way  most  easily  and  brings  with  it  the  floor  of  the  bladder. 

In  less  degree,  but  with  much  frequency,  the  posterior  wall  rolls  out,  car- 


J  000 


Ai\    J.i//;/.'/r.LV     TllXr-llOOK    OF   sriiCEliY. 


rvin<,'  with  it  tlie  anterior  wall  of  the  rectum  (rectocele;  see  p.  972).  An 
apparent  prolapse  may  be  due  to  hypertrophic  elonfjation  of  the  cervix  (Fig. 
387,  p.  983).  Some  hypertrophy  of  the  cervix,  often  considerable,  attends 
real  prolapse,  and  is  the  result  of  hyperplasia  due  to  congestion  and  to  the 
dragging  of  the  cervical  attachments.  Endometritis  is  always  present.  The 
prolapse<l  mucous  surfaces  are  thickened  and  tougiiencd,  often  excoriated  and 
ulcerated. 

The  severity  of  the   subjective   symptoms    produced    is    not   necessarily 
gauged  by  the  amount  of  prolapse  present.      The   lesser  degrees  are  most 

Fig.  :W8 


Uterus  Prolapsed ;  Complete  Eversion  of  Vagina;  extreme  dragging  downward  of  bladder  (original). 


frequently  attended  by  pain  and  invalidism  ;  in  the  more  severe  types  the 
complaint  is  more  from  the  mechanical  inconveniences  of  the  tender  tumor 
hanging  from  the  vulva. 

Treatment. — Palliation  may  be  secured  by  the  pressure  of  a  perineal  pad 
attached  to  an  abdominal  bandage.  The  uterus  having  been  pushed  back 
into  place,  a  rubber  ball  may  be  introduced  into  the  vagina  and  kept  in  place 
by  the  perineal  pad ;  or  a  shalloAV  cup,  supported  upon  a  stem  bent  to  follow 
the  curve  of  the  vagina,  may  be  made  to  support  the  uterus,  the  stem  being 
held  in  place  by  a  perineal  band.  Such  supports  are  at  best  inefficient  and 
obnoxious,  and  should  be  advised  only  when  the  patient  positively  refuses 
operative  relief. 


SURGERY  or  rill-:  i  emalI'I  GKNKHArn'i-:  organs,  looi 


Via.  399. 


To  relieve  prolapsus  perniaiieiitly  resort  must  be  made  to  a  eombination  of 
whatever  procedures  are  required  to  restore  the  integrity  and  tone  of  the 
pelvic  floor  and  of  the  uterine  supports,  and  in  the  most  aggravated  cases  to 
reinforce  these  natural  su|)ports  hy  additional  sources  of  support.  As  a  pre- 
liminary the  size  and  weight  of  the  uterus  itself  will  first  re(juire  operative 
interference.  The  degenerated  and  chronically  inflamed  endometrium  should 
be  curetted  and  treated;  the  enlarged  cervix  will  often  re((uirc  amputation,or 
lacerations  call  for  plastic  repair  ;  the  thickened  and  relaxed  vaginal  walls 
should  be  retrenched  by  excising  longitudinal  strips  from  them  ;  to  the  opera- 
tion on  the  anterior  wall  (described  on  p.  972j,  for  cystocele,  being  added  the 
excision  of  ovoid  strips  from  the  lateral  walls,  if  need  be.  Tlie  retrenched 
vagina  may  be  still  more  reinforced  and  its  eversion  prevented  by  a  scries  of 
circular  submucous  ligatures  inserted  in  the  following  manner  (method  of 
Freund) :  The  vagina  being  everted  and  the  cervix  uteri  protruding,  a  well- 
curved  needle,  armed  with  a  strand  of  silk- 
worm gut,  is  inserted  through  the  vaginal 
mucosa,  at  a  point  about  an  inch  and  a  half 
from  the  vagino-cervical  junction,  and  is  car- 
ried circularly  about  the  vagina  in  the  sub- 
raucous  tissue  as  far  as  the  needle  will  con- 
veniently go ;  the  needle  then  is  brought  out 
through  the  mucous  ?;urface  ;  after  some  inches 
of  the  thread  have  been  drawn  out  the  needle 
is  re-entered  in  the  same  opening  through 
which  it  emerged,  and  made  to  traverse  again 
the  submucous  tissue  farther  around  the  vagina, 
is  brought  out,  reinserted,  and  again  passed  on 
until  it  has  made  the  complete  circuit  of  the 
vagina,  and  finally  emerges  at  the  needle-open- 
ing first  made.  A  second  encircling  suture  is 
placed  in  the  same  manner  about  an  inch  and  a 
quarter  away  from  the  first,  and  a  third  at  about  the  same  distance  again  away 
from  the  second.  The  uterus  is  now  pushed  up,  carrying  with  it  the  vagina. 
As  the  vaginal  walls  infold  and  the  line  of  the  first  applied  suture  is  turned  in, 
the  tAvo  ends  of  the  thread  are  draAvn  out  firmly  until  the  lumen  of  the  vagina  is 
narrowed  so  as  to  barely  admit  the  tip  of  the  finger.  A  knot  is  now  tied,  and 
made  to  bury  itself  in  the  submucous  tissue  by  cutting  the  ends  short  and 
pushing  the  knot  through  the  needle-opening  out  of  sight.  As  the  reposition 
of  the  uterus  is  continued  by  the  pressure  of  the  finger,  the  second  and  third 
sutures  each  are  in  turn  treated  in  the  same  manner.  The  number  of  such 
encircling  sutures  may  vary  with  the  exigencies  of  the  particular  case.  They 
act  by  interposing  a  mechanical  barrier  to  the  eversion  of  the  vagina,  and  are 
of  special  value  during  the  early  months  after  the  operation,  until  the  natural 
tonicity  of  the  parts  has  been  regained.  They  may  also,  by  their  irritation, 
provoke  inflammatory  deposits  along  their  course,  which  may  act  as  perma- 
nent sources  of  vaginal  constriction.  They  should  be  reserved  for  cases  which 
have  passed  the  childbearing  age.  If  at  any  time  they  ulcerate  through  into 
the  vagina  at  any  point,  they  are  easily  removed. 

The  relaxed  and  lacerated  perineum  will  require  perineoplasty.  These 
measures  should  be  still  further  supplemented  by  shortening  the  round  liga- 
ments or  by  anterior  utero-ventral  suture.  If,  despite  the  combination  of 
these  measures,  the  prolapse  recur,  it  would  be  justifiable  to  remove  the  uterus 
as  a  part  of  an  extensive  plastic  operation. 


Showing  Method  of  introducing  Circu- 
lar Submucous  Sutures  in  the  Vagina 
for  relief  of  Prolapse  (Freund). 


1 002 


.l.V   AMinUCAy    TEXT-BOOK    OF   SlHUERY 


Inversion    of  Uterus ; 
angles  of   inflection 


INVERSION    OF    THE    FTERUS. 

The  uterus  may  become  turned  inside  out  as  the  result  of  a  force  dragging 
down  upon  the  fundus  while  the  cervix  is  relaxed  and  dilated.  Such  inver- 
sion, which  may  be  partial  or  complete,  is  a  very  rare  accident.  It  has  taken 
place  most  fre(^uently  as  a  coinjjlication  of  cliildbirth  ;  in  other  instances  a 
polypoid  growth,  attached  to  the  fundus,  but  driven  down  by  the  uterine 
contractions,  has  dragged  with  it  the  fundus. 

The  uterus  when  completely  inverted  forms  a  pear-shaped  body  distending 

the  vagina  ;  it  may  be    associ- 
V\(--  -l*^'**-  ated   with    j)ro]apse    to    such   a 

/ --^n/t  degree  that  it  projects  through 

the  vulva  as  an  external  tumor. 
The  mucous  membrane,  tumid 
and  congested,  bleeds  easily. 
In  long-standing  cases  it  may 
by  atrophy  and  cicatrization  lose 
much  of  its  peculiar  glandular 
structure. 

Tlie  symptom  most  prom- 
inent is  hemorrhage.  When 
the  inversion  is  sudden  and 
complicates  childbirth,  this 
hemorrhage  is  severe,  at  times 
uncontrollable  and  fotal.  In 
the  more  chronic  conditions 
every  degree  of  metrorrhagia 
may  be  present.  The  symptoms 
of  endometritis  and  prolapse  will  be  added,  according  to  the  degree  of  each 
which  may  be  present. 

Diagnosis. — Vaginal  examination  reveals  the  tumor  filling  the  vagina. 
By  deep  palpation  of  the  pelvic  cavity  by  the  rectum,  or  from  the  abdominal 
surfiice  in  thin  subjects,  may  be  made  out  the  funnel-shaped  depression  formed 
by  the  inverted  peritoneal  surfiice  of  the  uterus,  into  which  the  Fallopian 
tubes,  the  round  ligaments,  and  in  some  cases  the  ovaries,  are  drawn.  (See 
Fig.  400.) 

Treatment. — In  recent  cases  reposition  may  be  effected  by  a  process  of 
taxis,  the  patient  being  anesthetized.  The  manipulations  must  be  conducted 
80  as  to  produce  dilatation  of  the  cervical  ring  and  pressure  upward  of  the 
inverted  mass.  These  manipulations  should  not  be  persisted  in  for  more  than 
an  hour  at  a  time.  In  the  event  of  failure,  and  from  the  first  in  more  chronic 
cases,  some  form  of  continuous  elastic  pressure  must  be  devised.  This  will 
consist  of  a  suitable  hard-rubber  sliallow  cup  to  embrace  the  presenting  portion 
of  the  tumor,  to  which  a  strong  stem  is  attached  that  protrudes  from  the 
vagina  externally.  To  this  elastic  tapes  are  attached  that  lead  in  front  and 
behind  to  an  abdominal  bandage  above.  By  means  of  these  elastic  bands  the 
requisite  elastic  pressure  is  exerted.  Anesthesia  is  not  required  while  such  an 
apparatus  is  in  use.  The  process  of  replacement  is  slow  in  its  progress,  and 
may  require  the  pressure  to  be  kept  up  for  as  long  as  forty-eight  hours.  In 
the  event  of  failure  to  reduce  the  inversion  after  a  forty-eight  hours"  trial  of 
elastic  pressure,  it  would  be  justifiable  to  open  the  abdomen  above  the  pubis 
and  dilate  instrumentally  the  contracted  cervical  ring  from  above,  while  pres- 
sure is  made  from  below  on  the  vaginal  tumor.      In  the  event  of  final  fail- 


a,  vagina;    b.   fundus    uteri;   c,  c, 

c,  c,  d,  d.  extent    of  uninverted 

cervix  ;  e,  vaginal  wall ;  /,  the  peritoneal  cul-de-sac  of 
the  inverted  uterus  ;  g,  g,  Fallopian  tubes  passing  down 
into  the  inverted  uterus ;  h,  h,  ovaries ;  i,  i,  broad  liga- 
ments ;  k,  k,  round  ligaments  (Crosse). 


iiUIi(n:ilV    OF    TllK   FEMALE    GENERATIVE    ORGANS.    lOO.'i 

urc  to  aet'oni])lish  reposition   Ity  tliis  means  the  total   exeision  of  the   uterus 
shouhl  be  (h>ne. 


TUMORS  OF  THE  UTERUS. 

FrRRO-MYOMATA. — Tumors  composed  of  tlie  unstriped  muscular  fibers  and 
of  the  connective  tissue  normal  to  the  uterus  are  frcfjuently  developed  in  the 
walls  of  the  uterus.  The  relative  proportion  of  muscular  and  fibrous  tissue 
varies  greatly :  to  those  tumors  in  which  the  former  preponderates  the  term 
myomata  is  applied  ;  to  the  latter,  fibromata.  The  class  is  best  designated  by 
the  compound  term  fihro-wyoinata. 

The  number  of  such  tumors  which  may  develop  in  a  single  uterus  is 
variable :  often  the  growths  are  multiple,  in  some  cases  occurring  in  large 
numbers,    in    others    singly.       They 

may  attain  great  size,  and  are  liable  ^^^^-  ^'^l- 

to  degenerative  changes.  According 
to  the  location  of  these  tumors  a 
clinical  subdivision  of  them  is  estab- 
lished. Those  which  are  near  the 
external  surface  of  the  uterus  tend 
to  protrude  under  the  peritoneum, 
and  in  that  case  form  the  subserous 
variety ;  those  which  are  more  cen- 
trally located  in  the  wall  of  the 
uterus  are  interstitial  or  intramural 
growths ;  those  which  grow  toward 
the  cavity  of  the  uterus  form  the 
submucous  group.     (See  Fig.  401.) 

The  tumor-mass  is  usually  differ- 
entiated from  the  surrounding  uterine 
tissue  by  a  layer  of  loose  connective 
tissue  that  forms  a  kind  of  capsule 
to  it  and  facilitates  its  enucleation. 
When  the  tumors  protrude  from  a 
free  surface,  their  position  tends  to 
luxuriant  development,  and  as  the 
growth  proceeds  the  bond  of  connec- 
tion with  the  uterus  becomes  rela- 
tively smaller,  forming  a  distinct  pedicle.  A  tumor  floating  in  the  peritoneal 
cavity  is  apt  to  provoke  irritation  of  the  serous  surfaces  with  which  it  comes 
in  contact,  and  to  contract  adhesions  with  them  as  a  consequence.  Such  adhe- 
sions are  most  frequent  with  the  omentum  and  the  intestines.  Tumors  orig- 
inating in  the  tissues  of  the  cervix  may  push  outward  between  the  layers  of 
the  broad  ligament  or  may  protrude  into  the  vagina.  A  general  hypertrophy 
of  the  whole  uterus  to  some  degree  always  attends  the  development  of  these 
growths.  The  endometrium  becomes  hyperplastic  and  swollen,  and  is  prone  to 
inflammatory  changes  with  consequent  menorrhagia.  Fibro-myomatous  growths 
belong  to  the  period  of  functional  activity  of  the  uterus.  Their  natural  tend- 
ency is  to  grow  as  long  as  menstrual  life  continues,  while  their  presence  tends 
to  delay  the  natural  menopause.  After  the  menstrual  climacteric  has  been 
passed  they  tend  to  undergo  involution  and  atrophy,  but  in  exceptional  instances 
their  growth  remains  unchecked. 

Fibro-myomata  occasionally  share  in  the  process  of  involution  following 
an  intercurrent  pregnancy,  and  thus  disappear.     Defective  nutrition,  due  to 


Fibro-myomata  Uteri  (diagrammatic),  showing  (1> 
submucous,  ('_')  intramural,  and  (3)  subserous 
growths  (origiualj. 


1U04  A.y  AMJ'JJiJCAA'    TKXT-JKJOK    OF  SURGERY. 

elongation  or  torsion  of  the  pedicle  or  other  interference  with  the  hlood-supply, 
may  arrest  growth  or  induce  atrophy.  In  this  shrinking  a  process  of  calcifi- 
cation sometimes  occurs.  Defective  nutrition  of  an  overgrown  myoma  may 
induce  liquefaction  of  the  growth  at  points  in  its  interior,  leading  to  the  forma- 
tion of  spaces  filled  with  fluid,  cyHtic.  degeneration.,  or  to  the  permeation  of  a 
portion  of  it  with  serous  or  mucoid  fluid,  (edematous  or  'iiiijxo)natous  degenera- 
tion. Occasionally  an  enormous  development  of  blood-vessels  and  blood-spaces 
takes  place,  angio/natous  degeneration.  Such  a  change  may  also  involve  more 
particularly  the  lymph-vessels  and  lymph-spaces,  constituting  a  lymphangio- 
matous  degeneration.  A  fibro-myoma  may  become  the  seat  of  pyogenic  infec- 
tion, with  abscess-formation.  Sloughing  is  a  not  infrequent  occurrence  in  sub- 
mucous growths  as  the  result  of  injury  and  infection,  in  which  case  spontaneous 
elimination  may  occur,  or  if  the  necrotic  masses  ai"e  retained  the  phenomena 
of  septic  absorption  in  a  high  degree  result. 

The  symptoms  caused  by  fibro-myomata  are  variable  and  multiform, 
being  dependent  upon  the  location  and  size  of  the  growth,  the  changes  pro- 
duced in  the  uterus,  and  the  complications  that  may  arise.  Interstitial  and  sub- 
serous growths  may  attain  considerable  development  without  provoking  especial 
symptoms.  Submucous  growths,  however  small,  determine  at  once  marked 
hemorrhages,  uterine  discharges,  and  the  whole  complex  of  symptoms  attend- 
ing chronic  endometritis.  The  tendency  to  hemorrhage  and  the  consequent 
anemia  are  always  marked  accompaniments  of  this  class.  Menstruation  is 
usually  painful  as  well  as  profuse,  and  the  protrusion  of  these  polypoid  growths 
into  the  uterine  cavity  is  sufficient  to  occasion  strong  expulsive  pains  in  the 
organ.  Growths  imbedded  within  the  pelvis,  even  though  not  very  large,  may 
give  rise  to  much  suffering  from  pressure  upon  adjacent  organs — e.  g.  the 
bladder,  the  ureters,  the  rectum,  the  nerves,  and  the  blood-vessels.  Growths 
which  have  ascended  into  the  general  abdominal  cavity  cause  annoyance  chiefly 
by  their  weight,  unless  they  have  attained  great  size,  Avhen  renal,  hepatic,  and 
cardiac  lesions  may  result.  The  presence  of  adhesions  may  give  rise  to  pain- 
ful traction  symptoms. 

The  diagnosis  of  fibro-myomata  is  to  be  established  by  bimanual  palpa- 
tion, by  which  the  changes  in  the  form  and  size  of  the  uterus  are  appreciated. 
If  a  distinct  tumor  is  visibly  pushing  forward  the  abdominal  wall,  or  upon 
pressure  may  be  felt  within  the  pelvis,  such  manipulations  and  counter-pressure 
are  to  be  made  as  may  be  required  to  determine  whether  or  not  the  tumor 
springs  from  the  substance  of  the  uterus.  When  the  abdominal  Avails  are 
thin,  and  the  case  is  otherwise  also  favorable  for  examination,  the  relations  and 
shape  of  the  tumor  in  the  pelvis  may  be  mapped  out  with  much  distinctness, 
especially  under  general  anesthesia.  In  less  favorable  cases  uncertainty  may 
arise  as  to  whether  a  given  mass  is  an  outgroAvth  from  the  uterus,  or  is  distinct 
from  it,  but  closely  attached  to  it.  The  depth  and  course  of  the  uterine  canal 
give  important  evidence  in  settling  this  question,  for  it  is  always  elongated  and 
often  tortuous  in  cases  of  fibro-myoma.  Careful  palpation,  both  rectal  and 
vaginal,  will  usually  enable  the  surgeon  to  detect  the  outlines  and  estim.ate  the 
volume  of  the  uterus,  and  thus  aid  in  differentiating  tumors  of  tubal  or  ovarian 
origin  from  those  belonging  to  the  uterus.  (See  the  sections  on  Tubal  and 
Ovarian  Diseases.)  Even  small  nodules  on  the  serous  surface  of  the  uterus 
may  be  felt  by  the  finger:  small  interstitial  growths  may  be  difl'icnlt  or  even 
impossible  to  recognize,  but  may  be  inferred  from  the  coni])lexus  of  sym])toms, 
especially  if  the  uterine  canal  is  elongated  and  tortuous.  In  some  cases  of 
interstitial  growth  in  their  earlier  course  it  may  be  diflUcult  to  differentiate  the 
condition  from  pregnancy,  but  continued  observation  cannot  fail  in  due  time  to 


SURi^ERV    OF    THE   FEMALE    GENERATIVE    ORGANS.   1005 

develop  the  distinj^uishing  cliamcteristics  of  the  latter  eondition.  Small  sub- 
mueous  growths  are  to  be  detected  by  the  sound,  and  even  more  ccrtairdy  by 
the  curette  in  the  course  of  the  curettage  to  which  the  organ  will  be  naturally 
subjected  for  the  relief  of  the  persistent  endometritic  symptoms  present.  Pro- 
truding polypoid  masses  are  detected  by  the  finger  or  exposed  by  the  speculum. 

Tlie  prognosis  of  Fibro-myomata,  as  far  as  regards  direct  danger  to 
life,  is  in  general  favorable.  Only  a  small  proportion  of  such  growths  deter- 
mine sym])toms  of  sulFicient  gravity  to  bring  them  to  the  attention  of  the  sur- 
geon. Of  these,  the  most  atrophy  and  cease  to  become  sources  of  suffering 
after  the  menopause ;  in  rare  instances  of  the  submucous  variety  spontaneous 
expulsion  into  the  uterine  cavity  or  gradual  breaking  down  by  sloughing  and 
escape  through  the  vagina  have  occurred.  In  other  instances,  however,  the 
growth  is  so  rapid  or  so  uninterrupted  even  by  the  menopause  as  to  entail 
serious  risks  to  life  from  the  com})ression  of  other  organs,  from  its  interference 
with  the  normal  processes  of  life,  from  the  pains  and  disabilities  it  entails,  or 
from  the  profound  anemia  caused  by  persistent  and  profuse  hemorrhages. 
When  comparatively  young  women  become  the  subjects  of  troublesome  fibro- 
myomata,  the  case  assumes  a  serious  aspect,  for  many  years  of  invalidism  and 
of  exposure  to  intercurrent  complications  are  probable  before  the  favorable 
influence  of  the  menopause  can  be  expected.  The  occurrence  of  cystic  degen- 
erations destroys  the  hope  of  later  disappearance  by  involution ;  the  occur- 
rence of  septic  infection  with  suppurative  and  gangrenous  processes  immedi- 
ately threatens  life.  Growths  springing  from  the  cervical  portion  and  extending 
between  the  layers  of  the  broad  ligament  occasion  early  and  severe  symptoms 
from  pressure  upon  adjacent  pelvic  viscera.  Submucous  growths  have  a 
special  danger  from  the  hemorrhages  which  they  induce.  Sarcomatous  degen- 
eration of  fibro-myomata  has  been  reported  in  a  number  of  instances.  It 
must  be  acknowledged,  therefore,  that  the  prognosis  of  a  growing  fibro- 
myoma  is  always  a  serious  one.  Such  a  growth  possesses  possibilities  of  death, 
through  the  exhaustion  consequent  upon  a  complexus  of  sufferings;  through 
renal,  cardiac,  or  digestive  disturbances  ;  through  the  prolonged  anemia  and 
consequent  general  nutritive  failure  and  lessened  power  to  withstand  inter- 
current maladies ;  through  thromboses  originating  in  the  sluggish  current 
of  dilated  blood-spaces  in  vascular  growths ;  or,  finally,  through  septic  or  ma- 
lignant changes  in  the  tumor  itself.  Further  than  this,  in  a  large  proportion 
of  cases  in  which  life  is  not  directly  threatened  the  presence  of  these  growths 
very  greatly  restricts  the  usefulness  of  the  patient,  prevents  her  from  gaining 
a  livelihood,  and  entails  upon  her  a  prolonged  condition  of  invalidism. 

Treatment  is  called  for  only  in  cases  in  which  troublesome  symptoms 
have  arisen  or  are  impending,  and  must  be  directed  to  the  relief  of  symptoms, 
the  arrest  and  retrogression  of  the  growth,  if  possible,  and,  lastly,  the  removal 
of  the  tumor  by  operative  measures. 

Hemori'liage  is  to  be  combated  by  rest  in  the  recumbent  posture  during  the 
menstrual  periods ;  by  the  administration  of  ergot  and  opium  or  cannabis  indica 
in  full  doses  ;  and  by  thorough  curettage  of  the  endometrium,  followed  by 
gauze  packing,  or  by  the  caustic  action  of  a  galvanic  electrode  introduced 
into  the  uterine  cavity,  through  which  an  electric  current  of  sufficient  power 
is  passed.  In  the  event  of  these  measures  failing,  the  removal  of  the  Fal- 
lopian tubes  and  ovaries  will  induce  an  artificial  menopause,  and  thus  put  a. 
stop  to  the  bleeding  with  rare  exceptions. 

Arrest  of  growth  and  retrogression  of  tumor  may  be  secured  in  some  cases — 
1.  Bg  prolonged  administration  of  ergot.  This  may  best  be  given  hypoder- 
matically,  from  1  to  2  grains  of  purified  ergotin  in  an  antiseptic  solution  (1  jiart 


lUOG  JiV    AMi:ilI('AX    TKXT-noOK    OF  SURUEnV. 

of  or^otin  to  10  parts  of  the  monstrmini)  being  used  for  each  injection  twice 
ilailv.  If  no  iniprovenuMit  is  niaiiitV'st  after  two  inoiitlis'  continuanee  of  such 
injections,  they  nniy  be  abandoned.  Tiie  best  efteots  of  ergot  may  be  expected 
when  the  tumors  arc  of  recent  devehi])nient.  are  soft,  and  liave  caused  only 
moderate  symptoms. 

2.  Bii  Eh'ctroli/slH. — A  current  of  from  75  to  2;")0  milliamj)eres'  strength 
when  j>assed  tlirough  the  substance  of  a  fibro-myoma,  if  continued  for  a  suf- 
ficient length  of  time  or  repeated  often  enough,  has  been  demonstrated  to  be 
capable  of  inducing  in  some  instances  rapid  retrogression  of  the  tumor.  Sub- 
mucous and  interstitial  growths  of  moderate  size  are  the  ones  most  likely  to  be 
benefited  by  electrolysis.  If  possible,  the  uterine  electrode  should  be  intro- 
duced into  the  cavity  of  the  uterus,  and  each  introduction  should  lie  preceded 
by  thorough  disinfection  of  the  uterine  and  vaginal  cavities  and  of  the  electrode 
itself.  When  the  introduction  of  the  electrode  into  the  uterine  canal  is  imprac- 
ticable, and  the  growth  is  readily  accessible  through  the  vaginal  wall,  a  spear- 
pointed  electrode  nuiy  be  thrust  directly  through  the  vaginal  wall  into  the 
substance  of  the  growth,  the  most  scrupulous  antiseptic  precautions  being  used. 
The  abdominal  electrode  should  cover  a  broad  surface  and  be  closely  in  contact 
with  the  skin  over  its  whole  extent.  Experience  has  shown  that  the  usefulness 
of  electrolysis  for  the  dispersion  of  uterine  fibro-myomata  is  much  restricted, 
since  it  not  only  fails  favorably  to  influence  a  large  proportion  of  such  growths, 
but  also  introduces  risks  of  provoking  septic  and  gangrenous  complications,  of 
causing  peritoneal  irritation  and  consequent  adhesions,  and  in  some  cases  of 
postponing  needed  operative  interference,  which  has  to  be  resorted  to  ultimately 
under  much  less  favorable  conditions  for  success  than  would  have  been  pres- 
ent earliei". 

3.  Bji  Removal  of  the  Fallopian  Tubes  and  the  Ovaries,  thus  inducing  arti- 
ficially the  menopause.  The  reported  results  of  this  procedure  in  suitable 
cases  are  very  uniform  in  their  success.  The  largest  number  of  cases  reported 
by  one  surgeon  is  that  of  Tait,  who  in  1891  reported  271  operations  of  the 
kind  for  myomata.  Of  these,  6  (2.2  per  cent.)  died  as  the  result  of  the  opera- 
tion ;  in  8  no  favorable  efteet  resulted,  the  patients  having  subsequently  to 
undergo  hysterectomy  or  having  died;  in  the  remaining  257  cases  complete 
relief  ensued,  the  troublesome  symptoms  ceased  entirely,  and  the  tumor  either 
disappeared  or  ceased  to  grow.  The  reported  results  of  other  surgeons  are 
equally  favorable  as  regards  the  ultimate  effects  upon  the  tumor  and  the  hem- 
orrhages, but  the  rate  of  mortality  has  been  greater. 

Resort  to  the  removal  of  the  tubes  and  ovaries  is  indicated  in  all  cases  in 
which  growths  or  hemorrhages  persist  despite  treatment,  and  in  which  the  tech- 
nical difficulties  and  dangers  are  less  than  would  attend  hysterectomy.  Early 
operation  is  more  especially  indicated  when  the  patients  are  comparatively 
young.  In  cases  of  very  large  tumors  removal  of  the  appendages  is  contra- 
indicated  on  account  of  danger  of  inducing  oedema  and  necrosis  of  the  growth. 
(For  the  technique  of  the  operation  see  the  sections  on  Diseases  of  the  Tubes 
and  Ovaries.) 

Removal  of  Fibro-myomata  by  Operative  Measures. — Extirpatioyi 
through  the  i^agina  is  feasible  for  groAvths  occupying  the  vaginal  portion  of 
the  cervix,  for  polypoid  growths  springing  from  the  body  of  the  uterus  and 
protruding  into  the  uterine  cavity,  and  for  moderate-sized  submucous  growths 
which  are  being  pressed  into  the  cavity  by  violent  uterine  contractions.  Dila- 
tation of  the  cervix  and  bilateral  division  of  it  up  to  the  vaginal  junction  may 
be  done  when  required  to  give  sufficient  access  to  the  growth.  The  pedicles  of 
small  polypoid  growths  may  be  twisted  and  cut  with  scissors.     Irrigations  with 


SURGERY    OF    Till-:   FEMALE    (iEXEHATIVE    ()I{(JAXS.    1007 

hot  water  and  taiii]i()iia(lc  with  iodol'onii  ^aiize  will  siiilico  to  contiol  the  laiiior- 
rha«;e,  or,  if  not,  a  suitalde  clamp  forci'j)S  jiiay  be  left  ap])lied  to  the  .stump  for 
a  few  hours,  Lar«fe  polypoid  growths  which  fill  up  the  vagina  require  a  pre- 
liminary process  of  diminution  by  piecemeal  excision  until  their  volume  is 
Bufficiently  reduced  to  make  it  ))()ssible  to  reach  their  ])edicles  for  final  division. 

iSubmucous  fibroids  of  nn^derate  size,  not  larger  than  a  foetal  head,  which 
are  being  expressed  into  the  uterine  cavity  are  susceptible  of  removal  through 
the  vagina  if  the  latter  is  roomy  or  distensible.  The  capsule  is  first  split  freely 
with  the  knife  and  peeled  back  to  each  side,  while  the  tumor,  held  and  drawn 
upon  by  suitable  hooked  forceps,  is  worked  out  by  blunt-edged,  spoon-shaped 
enucleators,  assisted  by  the  scissors  as  required.  The  work  is  usually  tedious 
and  laborious  :  attempts  of  this  kind  should  be  restricted  to  small  growths  or 
to  moderately  large  ones  which  have  become  spontaneously  pressed  down  by 
uterine  contractions  against  the  internal  os  uteri,  with  some  dilatation  of  the 
cervical  canal.  Care  is  to  be  taken  to  guard  against  hemorrhage,  shock, 
peritonitis,  and  septicemia,  which  have  been  the  chief  causes  of  the  mortality 
attending  these  operations. 

Extirpation  through  Abdominal  Incision. — Tumors  which  have  persisted 
in  growing  despite  the  intelligent  use  of  the  measures  already  described,  and 
are  accompanied  w'ith  symptoms  that  threaten  the  existence  of  the  patient, 
or  which  seriously  compromise  the  usefulness  or  the  happiness  of  life,  and 
which  are  not  accessible  through  the  vagina,  may  be  reached  and  extir- 
pated through  suitable  incision  in  the  abdominal  wall.  The  character  of  the 
operation  will  vary  according  as  the  tumor  (a)  projects  freely  into  the  peri- 
toneal cavity  and  is  attached  to  the  uterus  by  a  distinct  pedicle ;  {J>)  is  sessile 
upon  the  peritoneal  surface  of  the  uterus,  or,  if  imbedded  in  the  wall  of  the 
uterus,  lies  near  the  peritoneal  surface  and  can  be  enucleated  without  opening 
the  cavity  of  the  uterus  ;  (c)  embraces  so  much  of  the  substance  of  the  uterus, 
and  has  deformed  it  to  such  an  extent,  that  the  removal  of  the  tumor  requires 
the  removal  of  the  uterus  at  the  same  time  ;  {d)  when  in  addition  to  the  latter 
condition  the  tumor  has  developed  low  down  beneath  the  parietal  peritoneum 
or  into  the  folds  of  the  broad  ligament. 

In  varieties  (a)  and  (h),  after  the  abdomen  has  been  opened  and  the  tumor 
and  uterus  exposed,  the  tumor  is  to  be  removed  with  the  knife  as  if  it  were 
upon  any  other  part  of  the  body,  the  character  of  the  incisions  being  deter- 
mined by  the  principles  applicable  to  growths  in  general.  Growths  imbedded 
in  the  uterine  wall  are  readily  enucleated  as  soon  as  they  have  been  freely 
exposed  by  incision  of  the  overlying  tissue.  Bleeding,  which  usually  is  not 
great,  is  to  be  controlled  by  ligatures  to  bleeding  points  and  by  the  pressure 
of  the  sutures  ;  ligatures  in  mass  may  be  required.  In  cases  of  large  pedun- 
culated growths  the  pedicle  may  be  yjrovisionally  secured  with  an  elastic  liga- 
ture, or  by  transfixion  with  a  double  ligature,  or  by  strong  compression  forceps, 
while  the  tumor  is  cut  away.  Apposition  and  suture  of  the  wound-surfaces  are 
to  be  effected  by  fine  silk  passed  deeply  so  as  to  bring  the  surfaces  fully  into 
contact.  When  all  bleeding  has  been  fully  staunched  and  the  wound  well 
sutured,  the  uterus  is  allowed  to  resume  its  place  in  the  pelvis,  the  abdominal 
cavity  is  cleansed  from  blood,  and  the  incision  in  the  abdominal  wall  is 
closed.  These  steps  constitute  the  procedure  of  myomectomy.  In  varieties 
(c)  and  {d)  a  portion  or  the  whole  of  the  uterus  is  removed  with  the  tumor,  and 
the  operation  becomes  one  of  supravaginal  j^^rtial  hysterectomy  or  of  total 
hysterectomy,  as  the  case  may  be.  For  the  purpose  of  gaining  the  required 
access  to  these  tumors,  which  are  usually  large  and  often  complicated  by  adhe- 
sions, the  abdominal  incision  should  be  made  free  at  the  outset  or  should  be 


1008 


^i.v  .\Mi:in<  A.\   Ti:xT-ii(K>K  or  sri:(;i:i;y 


enlar<£e(l  at  once  if  the  nece.ssarv  iuaiii|)ulation.s  are  found  to  l)c  lianijierod  Vjy 
the  restricted  length  of  the  priiuarv  incision.  Care  must  be  taken  at  the 
lower  angle  of  the  cut  not  to  wound  the  bladder,  which  is  often  carried  up 
much  beyond  its  usual  location  upon  the  anterior  face  of  the  tumor.  Adhe- 
sions must  be  systematically  searched  for,  and  sej)arated  as  they  are  ex])Osed, 
especial  care  bein;;  taken  to  control  hemoi'rhage  from  them,  if  they  are  vas- 
cular, by  doul)l('  li<^ature  both  upon  the  side  of  the  tumor  and  upon  that  of 

the  surfaces  to  which  it  is  adherent. 
Ki(i.  402.  Finally,  the  hand  is  able  to  slij)  under- 

neath the  tumor,  to  dislodge  it  from 
its  bed,  and  to  bring  it  out  through 
the  abdominal  incision.  The  further 
manipulations  within  the  pelvis  will 
be  much  facilitated  by  the  elevation 
of  the  pelvis,  as  shown  in  Fig.  402, 
the  position  being  known  as  Tren- 
delenburg's position. 

After  the  disengagement  and  de- 
livery of  the  tumor  immediate  atten- 
tion should  be  given  to  its  relations 
to  the  bladder,  which  often  will  be 
found  extensively  attached  to  its  an- 
terior face.  If  so,  it  must  be  care- 
fully detached  well  down  to  the  neck 
of  the  uterus. 

The  relations  of  the  broad  liga- 
ment and  the  appendages  to  the  tumor 
next  require  attention.  If  the  tumor 
has  developed  laterally  between  the  folds  of  the  broad  ligament  upon  one  or  both 
sides,  suitable  incisions  of  these  folds  must  be  made  to  admit  of  the  enucleation  of 
the  tumor.  This  will  be  facilitated  by  preliminary  ligation  of  the  ovarian  artery. 
The  denuded  surfaces  of  the  broad  ligament  left  after  enucleation  or  detachment 
of  the  tumor  should  be  brought  into  apposition,  and  complete  hemostasis  secured 
by  a  row  of  sutures  running  from  its  upper  free  border  down  to  the  cervix  uteri. 
Where  the  broad  ligament,  though  carried  up  on  the  tumor,  still  presents  appre- 
ciable normal  folds,  these  are  to  be  treated  as  lateral  pedicles  by  tying  them  off 
with  successive  double  ligatures  in  mass,  applied  on  the  sides  next  the  pelvis  and 
the  tumor  respectively,  between  which  they  are  severed.  Clamp  forceps  may  be 
substituted  provisionally  for  the  ligatures,  especially  upon  the  side  next  the 
tumor,  often  Avith  advantage  in  the  saving  of  time.  When  the  tumor  has  devel- 
oped mainly  in  the  fundus  in  such  a  manner  that  the  broad  ligaments  have  not 
become  involved  with  it,  they  demand  no  special  attention  from  the  surgeon, 
except  in  cases  of  total  extirpation,  in  connection  with  which  procedure  they  will 
again  be  referred  to.  In  other  cases  they  become  engaged,  to  a  greater  or  less 
degree,  in  the  constrictor  which  is  thrown  around  that  portion  of  the  uterus 
which  is  to  constitute  the  pedicle,  by  the  division  of  which  the  tumor  is  finally 
completely  detached  and  removed,  together  with  the  tubes  and  ovaries. 

By  the  means  now  described  the  isolation  of  the  tumor  will  have  been 
accomplished,  and  only  a  somewhat  narrow  ma.ss  of  uterine  tissue  will  remain 
to  be  divided,  which  will  be  drawn  up  to  the  abdominal  wound.  This,  the 
pedicle,  will  usually  be  composed  of  the  cervical  portion  of  the  uterus.  Its 
treatment  is  a  vital  point  in  the  operation,  and  may  be  conducted  in  various  ways. 
The  pedirlf  is  at  once  to  be  strongly  constricted.     This  may  most  quickly 


Trendelenburg's  Position :  elevation  of  the  pelvis 
for  facilitating  intrapelvic  manipulations. 


SURGERY    OF    Till':    FEMALE    (iENERATIVK    ORGAXS.    1009 

be  tlone  by  an  t'lastic  cord,  usin^  tor  the  |iiir|»oso  strong  rubber  tubing  or 
solid  cord  of  about  one-quarter  inch  (0  mm.)  diameter,  which,  -while  strongly 
stretche<l,  is  passed  two  or  three  times  around  the  part  and  its  crossed  ends 
secured  by  tying  them  with  silk  or  by  compressing  them  together  with  a 
strong  clamp  forceps.  Just  above  the  ligature  two  large  pins  should  be 
thrust  through  the  pedicle,  in  order  to  prevent  slipping  of  the  ligature  when 
the  tumor  is  cut  away.  If  the  pedicle  is  very  thick,  it  may  be  transfixed  by 
the  elastic  cord  and  ligated  in  two  parts.  Care  must  be  taken  in  applying 
this  ligature  that  neither  bladder  nor  intestine  is  caught  in  its  bite.  A  differ- 
ent but  very  efficient  method  of  constriction  may  be  found  in  the  use  of  a  wire 
constrictor  with  a  sliding  bar  forced  down  by  screw  pressure.  The  pedicle  is 
embraced  by  the  two  arms  of  a  strong  copper  wire  loop;  the  bar,  pierced  at 
each  end  to  receive  these  arms,  is  slid  along  them  down  to  the  pedicle,  and 
then  by  a  screw  attachment  is  powerfully  pressed  against  it.  Any  amount  of 
constriction  can  thus  be  applied :  the  positiveness  and  certainty  of  the  con- 
stricting force  have  made  this  device  a  favorite  with  many  operators.  When 
it  is  used,  after  suitable  constriction  has  been  effected  the  bar  is  secured  in 
position  by  a  small  set-screw,  the  main  screwing  apparatus  is  detached,  and 
the  wire  is  left  in  place,  resting  on  the  surface  of  the  abdomen,  until  the 
strangulated  mass  shall  slough  off  and  set  it  free. 

The  pedicle  having  been  constricted,  the  tumor  is  cut  away  at  a  sufficient 
distance  above  the  constrictor  to  ensure  against  its  slipping  off.  The  toilet  of 
the  peritoneal  cavity  is  noAv  to  be  made,  wnth  close  examination  to  discover  any 
bleeding  points.  Should  much  blood-clot  or  fluid  have  accumulated  in  the 
peritoneal  cavity,  it  should  be  freely  Avashed  out  with  warm  water,  110°  F.,  or 
preferably  with  a  normal  salt  solution  (6  :  1000)  poured  into  it.  The  sponges  and 
instruments  should  have  been  counted  and  their  number  written  down  before 
the  operation,  and  they  should  be  now  recounted  to  ascertain  that  none  have 
been  left  in  the  abdomen.  The  cavity  having  then  been  carefully  dried,  the 
abdominal  Avound  is  to  be  closed.  At  the  loAver  angle  of  the  wound  the  pedi- 
cle is  first  to  be  fixed  by  carefully  suturing  with  catgut  the  adjacent  edges  of 
the  parietal  peritoneum  to  the  peritoneal  surfaces  of  the  pedicle  just  below  the 
constrictor ;  then  the  remaining  Avounded  peritoneal  surfaces  are  to  be  sutured, 
followed  by  suture  of  the  remaining  abdominal  planes.  The  superficial  sutures 
are  not  inserted  for  a  little  distance  from  the  pedicle,  but  the  parts  are  allowed 
to  gape  a  little  to  receive  the  disinfecting  tampon  with  which  it  is  best  to  sur- 
round the  pedicle  while  sloughing.  Upon  the  cut  surface  of  the  pedicle  is  now 
placed  a  thin  pledget  of  cotton  squeezed  out  of  a  saturated  solution  of  chloride 
of  zinc  ;  the  gutter  about  the  pedicle  is  freely  dusted  with  a  drying  and  antisep- 
tic powder  (as  tannin  three  parts  and  salicylic  acid  one  part)  and  packed  with 
sterilized  cotton.  An  abundant  sterilized  absorbent  dressing  is  placed  over  all, 
and  may  remain  undisturbed  for  a  Aveek  or  more.  Subsequent  dressings  will 
be  made  as  required  to  meet  the  needs  for  cleansing  and  antisepsis  which  the 
necrotic  stump  may  present.  During  the  second  or  third  Aveek  the  separation 
of  the  pedicle  slough  may  be  expected :  when  all  necrotic  tissue  has  cleared 
away,  a  deeply-depressed  granulating  surface  will  be  left,  Avhich  will  rapidly 
shrink  and  heal. 

The  delay,  annoyance,  and  possible  danger  of  infection  from  the  sloughing 
stump  Avhen  treated  in  the  AA'ay  described  may  be  avoided  by  hollowing  out  the 
cut  surface  of  the  pedicle  Avith  the  knife,  cauterizing  well  the  accessible  por- 
tion of  the  cervical  canal  Avith  the  thermo-cautery,  and  scAving  together  the 
opposite  walls  of  the  cup-shaped  cut  surface  of  the  stump  by,  first,  a  series  of 
sunken  catgut  sutures  to  close  the  deeper  parts,  and  then  by  a  row  of  silver 

64 


1010  .l.Y    AMKIUCAS    TEXT- HOOK    OF  Sillii  III:  Y. 

sutures  to  close  the  more  sujjerficiiil  parts;  the  ends  of  tlie  silver  sutures  are 
to  be  left  long,  so  that  they  may  l)e  brought  out  through  the  lower  angle  of  the 
abdominal  wound,  there  to  be  fastened  to  a  transverse  bar  or  simply  grasped  in 
the  bite  of  a  long-nosed  clamp  forceps  laid  across  the  abdomen,  by  which  the 
stump  of  the  pedicle  may  be  held  up  in  contact  with  the  anterior  abdominal 
wall.  The  suturing  of  the  pedicle  stump  is  to  be  done  Avhile  the  elastic  con- 
Btrictor  is  still  in  place;  then  the  uterine  arteries  are  to  be  ligated  below 
the  constrictor  by  a  silk  suture  passed  deeply  into  the  lateral  surface  of 
the  cervix  on  each  side  and  lirmly  tied ;  the  rubber  constricting  cord  is  now 
removed ;  any  oozing  of  blood  from  between  the  lips  of  the  stump-wound  is 
to  be  controlled  by  tlie  introduction  of  additional  sutures  so  placed  as  to  com- 
press the  sources  "of  oozing  when  tied  tightly  on  its  free  margin.  The  toilet 
of  the  peritoneal  cavity  is  now  to  be  made,  as  already  described,  the  perito- 
neum of  the  stump  united  on  all  sides  by  catgut  sutures  to  the  parietal  peri- 
toneum, and  the  abdominal  Avound  above  closed  in  the  usual  manner,  except 
at  its  lower  portion,  where  it  is  allowed  to  gape  to  expose  the  suture-line  of 
the  attached  pedicle  stump.  The  silver  suspensory  sutures  project  through  the 
raping  wound  here,  and  are  to  be  secured  to  a  transverse  support,  as  already 
mentioned.  Care  should  be  taken  in  the  original  application  of  these  wire 
sutures  to  tAvist  them  all  in  one  direction,  and  to  give  to  all  a  certain  recorded 
number  of  turns  in  order  to  facilitate  their  later  removal  Avhen  the  points  of 
twisting  will  have  become  concealed  at  the  bottom  of  a  retracted  granulating 
pit.  The  suspension  of  \)a(i  pedicle  stump  having  been  effected,  a  tampon  of 
iodoform  or  oxide-of-zinc  gauze  is  gently  crowded  between  the  wires  and  the 
adjacent  wound-edges ;  the  general  wound-line  above  is  treated  as  usual,  and 
over  all  an  abundant  sterilized  protective  dressing  applied  (Kelly).  By  this 
method  the  pedicle  incision  is  for  a  time  kept  extra-peritoneal,  and  hemorrhage 
or  infection  from  it  can  be  readily  observed  and  treated.  If  no  such  compli- 
cation occurs,  the  primary  dressing  may  be  left  in  place  for  a  week,  and  by  the 
tenth  day  the  suspensory  sutures  may  be  removed  and  the  unclosed  portion  of 
the  abdominal  wound  be  brought  together  by  secondary  sutures  or  allowed  to 
heal  by  granulation.  In  some  cases  enough  of  the  peritoneum  will  have  been 
detached  to  allow  of  its  inversion  and  suture.  The  pedicle  is  then  dropped  into 
the  abdomen.  The  canal  should  have  been  disinfected  by  the  Paquelin  cautery, 
and  will  serve  for  drainage. 

Total  Hysterectomy. — Rather  than  leave  any  portion  of  the  cervix  behind, 
whether  treated  as  a  pedicle  fixed  in  the  abdominal  wound  or  as  a  stump 
covered  over  by  peritoneum  and  dropped  back  into  the  pelvis,  it  is  better  to 
excise  it  totally  whenever  practicable.  Usually  this  can  be  done  quite  as 
readily  and  speedily  as  the  partial  excision.  In  every  case  the  preliminary 
disinfection  of  the  vagina  and  of  the  cervical  canal  should  be  made  prepara- 
tory to  total  excision.  For  this  purpose  the  patient,  after  anesthetization, 
should  be  placed  in  the  lithotomy  position,  the  pudenda  and  the  vagina 
thoroughly  scrubbed  with  soft  soap  smeared  upon  a  sponge  on  a  handle,  the 
cervix  curetted  and  swabbed  out  with  a  solution  of  chlori(le  of  zinc,  1:10, 
and  tamponed  with  iodoform  gauze  ;  copious  antiseptic  irrigations  of  the  vagina 
and  pudenda  should  follow:  then  the  cervix  should  be  detached  from  the 
vagina  by  an  incision  at  the  cervico-vaginal  junction,  which  should  be  deep- 
ened anteriorly  suflRciently  to  detach  the  bladder  from  the  cervix,  and  pos- 
teriorly sufficiently  to  strip  up  the  posterior  peritoneal  covering  from  the  cervix 
to  an  equal  distance,  or  to  open  into  the  cul-de-sac  of  Douglas.  The  spaces 
thus  opened  uj)  should  be  packed  with  sterilized  gauze,  and  the  vagina  l)elov- 
should  also  be  tightly  stuffed  with  the  same  material  to  arrest  the  iienioi 


ow 


SUBGEHV    OF    THE   FEMALE    GENERATIVE    ORGANS.   1011 

rliago.  The  i):itifiit  should  tlien  be  phiced  in  tlie  usual  dorsal  position  and 
the  abdouiiual  incision  made.  After  the  peritoneal  cavity  has  been  opened  the 
pelvis  should  be  elevated  into  the  position  of  Trendelenburg,  and  the  remainder 
of  the  operation  conducted  with  the  patient  in  that  position.  The  tumor 
should  now  be  lifted  out  of  the  abdomen  through  the  incision,  which  should 
have  been  made  long  enough  to  admit  of  its  easy  delivery  ;  all  adhesions  are 
dealt  with  as  they  appear  according  to  the  methods  elsewhere  described.  If 
the  ovaries  and  tubes  appear  diseased,  they  should  noAv  first  be  separately  ex- 
tirpated;  if  they  are  healthy,  they  require  no  special  attention.  The  relations 
of  the  bladder  to  the  tumor  are  then  identified,  after  which  an  incision  through 
the  peritoneum  across  the  anterior  face  of  the  uterus  should  be  made  just 
above  the  line  of  the  vesico-uterine  reflexion  ;  this  incision  should  extend 
laterally  on  either  side  to  the  broad  ligament :  this  peritoneal  flap  is  now 
stripped  from  the  uterus  by  blunt  dissection ;  soon  the  cellular  interspace 
between  the  uterus  and  bladder  is  entered,  and  the  ready  separation  of  the 
bladder  from  the  uterus  is  proceeded  with  until  the  wound-space  previously 
made  below  from  the  vagina  is  opened  into.  This  is  made  more  facile  by  the 
way  it  has  been  distended  and  made  prominent  by  the  gauze  packing.  By 
careful  tearing  of  the  connective  tissue  of  the  broad  ligaments  at  either  side 
of  the  cervix,  thus  exposed  from  the  front,  the  uterine  vessels  are  identified  and 
partially  isolated  ;  by  means  of  a  suitable  ligature-carrier  a  catgut  or  silk  liga- 
ture is  passed  around  them  subperitoneally,  and  they  are  tied,  first  on  one  side 
and  then  on  the  other,  close  down  to  the  vaginal  insertion.  Care  must  be 
taken  not  to  include  the  ureters  in  this  ligature.  If  the  precaution  is  observed 
to  keep  close  to  the  cervix  in  passing  the  ligature,  there  is  little  danger  to  the 
ureters,  which  have  been  carried  well  fa-ward  with  the  bladder.  The  greatest 
danger  of  such  an  accident  attaches  to  cases  in  which,  on  account  of  growths 
springing  from  the  cervix  low  down  and  extending  outward  into  the  broad 
ligament,  the  relations  of  the  structures  have  been  changed.  In  such  cases 
especial  caution  must  be  used  in  identifying  and  isolating  the  structures 
about  which  ligatures  are  to  be  tied.  The  broad  ligaments  are  next  tied  off, 
outside  the  ovaries  and  tubes,  by  two  or  more  catgut  or  silk  ligatures  on  either 
side.  The  chief  vessels  supplying  the  uterus  have  thus  been  tied,  and  the 
tumor  and  uterus  may  now  be  removed  in  one  piece  between  the  ligatures  :  as 
the  section  of  the  broad  ligaments  reaches  their  base,  the  tumor  should  be 
carried  forward  upon  the  symphysis  so  as  to  expose  the  posterior  face  of  the 
uterus ;  an  incision  through  the  peritoneum  across  the  posterior  face  of  the 
uterus  at  about  the  juncture  of  the  cervix  and  the  body  is  now  made,  and  a 
posterior  flap  of  peritoneum  bluntly  dissected  down  until  the  posterior  wound- 
cavity  previously  made  from  the  vagina  is  entered.  This  posterior  and  the 
anterior  vaginal  opening  are  now  connected  by  cutting  with  scissors  inside  the 
ligatures  on  the  uterine  vessels,  and  the  whole  mass,  thus  freed,  is  taken  away. 
Nothing  but  the  most  insignificant  bleeding  will  have  attended  any  of  the  steps 
of  the  operation  until  the  final  section  of  the  lateral  connections.  After  the 
last  cut  one  or  two  small  vaginal  branches  will  probably  spurt,  but  are  readily 
caught  by  hemostatic  forceps  and  ligated.  The  pelvic  cavity  should  now  be. 
carefully  sponged  out :  after  an  assistant  has  withdrawn  from  below  the  pre- 
liminary vaginal  packing,  a  fold  of  iodoform  gauze  should  be  passed  from 
above  through  the  superior  opening  of  the  vagina,  so  that  it  may  be  seized  by 
the  assistant  and  drawn  through  until  its  end  protrudes  at  the  vulva,  while  the 
upper  portion  of  this  gauze  is  left  as  a  loose  packing  in  the  wound  made  by 
the  ablation  of  the  uterus.  Over  this  packing  the  peritoneal  flaps  are  drawn 
and  sutured  from  side  to  side,  so  as  to  close  off  from  the  general  peritoneal 


1012  ^.Y   AMKRICAX    TKXT-liOOK    OF  KrinnJiY. 

cavitv  the  entire  wound-Jirea  with  its  lin:ature.s.  Special  care  should  be  taken 
to  cover  with  a  peritoueal  fold  the  stump  of  the  infundibulo-pelvic  ligament 
on  either  side.  When  this  suturing  is  completed,  the  pelvic  cavity  is  seen  to 
be  closed  below  by  a  smooth  peritoneal  diaphragm  which  shuts  off  the  wound- 
cavity,  which  latter  remains  extraperitoneal  and  well  drained  through  the 
vagina  bv  the  iodoform  gauze  previously  inserted.  The  abdominal  wound  is 
now  closed  in  the  usual  manner. 

In  cases  in  which  the  tumor  is  too  bulky  to  be  readily  handled,  as  required 
for  carrying  out  the  technique  as  now  described,  an  elastic  rubber  cord  may 
be  cast  about  tiie  cervix  after  the  anterior  peritoneal  flap  has  been  reflected 
and  the  greater  part  of  the  mass  amputated.  The  remaining  stumj)  may  then 
be  removed  in  the  manner  described  above,  after  disinfecting  the  exposed  cervi- 
cal canal  by  cautery. 

During  the  after-treatment  an  antiseptic  absorbent  pad  at  the  vulva  re- 
ceives the  vaginal  discharges.  At  the  end  of  four  days  the  iodoform-gauze 
drain  may  be  removed  and  the  granulating  cavity  irrigated  with  an  antiseptic 
solution.  A  new  light  packing  of  iodoforai  gauze  is  placed  in  the  vagina.  At 
the  end  of  another  week  this  may  be  removed,  and  no  further  drain  will  be 
required.  A  mildly  antiseptic  douche  should  be  used  daily  as  long  as  there  is 
any  discharge.  During  the  first  four  days  after  operation  the  bladder  should 
be  emptied  by  catheter.  After  the  first  change  of  vaginal  drains  spontaneous 
urination  may  be  allowed.  At  the  end  of  the  third  week  the  patient  may  be 
allowed  to  gel  up,  and  gradually  thereafter  to  go  about. 

GENERAL   CONSIDERATIONS    PERTAINING    TO    ABDOMINAL    SECTIONS   FOR    DIS- 
EASES  OF  THE   FEMALE   GENERATIVE  ORGANS. 

The  Preparation  of  the  Patient. — Especial  care  should  be  given  to 
have  the  bowels  empty.  For  three  days  or  more  beforehand  the  diet  should 
be  of  soft,  easily-digested  food.  On  the  day  before  operation  a  saline  purge 
should  be  given,  supplemented,  if  need  be,  by  a  simple  enema.  During  the 
same  period  a  daily  warm  bath  should  be  given  and  the  skin  of  the  abdomen 
should  be  well  scrubbed  with  soap  and  brush,  especial  care  being  taken  with 
the  umbilicus.  During  the  night  preceding  the  operation  the  abdomen  should 
be  kept  covered  with  gauze  saturated  with  the  boro-salicylic  solution,  this  to 
be  replaced  in  the  morning  Avith  gauze  saturated  with  corrosive-sublimate  solu- 
tion, 1  :  2000,  after  a  final  scrubbing  and  shaving  of  the  pubes.  The  vagina 
should  be  subjected  to  copious  antiseptic  douching  twice  daily,  and  if  total 
hysterectomy  is  contemplated  the  more  thorough  and  vigorous  sterilization 
already  described  should  be  done.  The  patient  should  empty  her  bladder 
voluntarily  before  being  taken  to  the  operating  room  ;  the  use  of  a  catheter  is 
rarelv  required.  The  antiseptic  precautions  which  must  be  observed  as  to  the 
room,  instruments,  etc.  will  be  found  detailed  in  the  chapter  ujion  this  subject. 

The  Position  of  the  Patient. — Large  growths  wliich  have  pushed  up  into 
the  general  abdominal  cavity  and  are  readily  accessible  and  removable  without 
requiring  much  manipulation  in  the  true  pelvis,  and  small  pelvic  masses  which 
are  enucleable  by  the  fingers  alone  without  the  aid  of  the  eye  and  can  readily 
be  brouorht  up  to  and  out  of  a  small  abdominal  wound,  may  be  satisfactorily 
dealt  with  while  the  patient  is  in  the  ordinary  horizontal  dorsal  position. 
When,  however,  any  of  the  steps  of  the  operation  are  embarrassed  by  the  pres- 
ence of  intestinal  coils  or  where  it  is  desirable  to  bring  into  sight  the  recesses 
of  the  pelvis,  the  patient's  pelvis  should  be  raised  sufficiently  to  place  the  trunk 
at  an  incline  of  from  4.5°  to  60°  to  the  horizontal.     (See  Fig.  402.) 

The  Incision  through  the  Abdominal  Wall — The  position  and  length  of  this 


SURGERY  or  tup:  fkmalk  generative  organs.  1013 

must  be  detcniiiiKMl  l)y  tlie  special  case,  and  are  referred  to  in  eonnection  with 
each  condition  treated  of.  In  general,  however,  it  should  be  midway  between 
the  pubes  and  the  umbilicus,  and  as  short  as  is  consistent  with  the  accurate, 
ready,  and  raj)id  performance  of  the  manipulations  re(iuired  for  the  exploration, 
the  separation,  and  the  removal  of  the  tumors.  When  the  growths  arc  cystic 
in  character  and  free  from  adhesions,  an  incision  from  two  to  three  inches  in 
length  will  usually  suffice,  whatever  the  size  of  the  tumor,  the  collapsed  sac  of 
Avhich,  having  been  emptied  by  tapping,  is  readily  drawn  out  of  the  relatively 
small  opening.  The  operator  should  not  permit  himself  to  be  embarrassed  by 
an  unduly  restricted  incision  at  any  time,  but  should  enlarge  it  with  scissors  at 
once  according  to  the  needs  of  the  case. 

Adhesions. — The  search  for  adhesions  is  usually  to  be  reserved  until  in  the 
case  of  cysts  these  have  been  emptied  of  their  contents,  or  in  the  case  of  solid 
growths  these  have  been  freely  exposed  so  that  their  attachments  can  be  readily 
recognized  and  dealt  with.  If  the  adhesions  are  soft  and  recent,  they  are 
easily  separated  by  the  finger-tip  or  sponge.  If  they  are  firm  and  vascular, 
they' should  be  secured  by  double  ligatures  or  clamp  forceps,  and  cut  between 
them.  At  times  the  adhesions  to  intestine  or  bladder  will  be  so  close  and  firm 
as  to  prevent  this  double  ligation ;  in  this  case  a  portion  of  the  wall  of  tlie 
growth  must  be  dissected  away  and  left  attached  to  the  viscus.  If  possible 
the  raw  surface  thus  left  attached  should  be  folded  in  upon  itself  and  sutured 
so  as  to  leave  a  peritoneal  covering  exposed.  Firm  omental  adhesions  are  to 
be  treated  by  tying  the  omentum  in  sections  and  cutting  it  away.  If  intestine 
or  bladder  be  lacerated  in  the  attempts  to  separate  adhesions,  immediate  suture 
of  the  wound  should  be  done,  and  the  Avounded  part,  if  possible,  brought  up  and 
secured  in  juxtaposition  to  the  abdominal  wound,  and  protected  by  a  tampon 
of  iodoform  gauze  for  some  days  until  the  possibility  of  fecal  or  urinary  extrav- 
asation has  passed  aAvay. 

A7'rest  of  Hemorrhage. — The  sources  of  hemorrhage  are  chiefly  three — 
adhesions,  the  pedicle,  and  raw  surfaces  left  by  the  enucleation  of  non-pedun- 
culated  growths.  The  temporary  use  of  clamp  compression  forceps,  to  be 
later  replaced  by  permanent  ligatures  if  necessary,  is  of  the  greatest  value 
in  expediting  the  removal  of  abdominal  growths.  The  elastic  ligature  for 
the  compression  of  thick  pedicle  stumps  has  been  already  described.  Mass 
ligatures  are  often  required,  and  can  be  resorted  to  freely  with  comparative 
impunity  in  consequence  of  the  fact  that  the  tied-off  parts  do  not  necrose,  but 
soon  become  again  vascularized  after  having  been  nourished  for  a  time  through 
imbibition.  Catgut,  as  a  rule,  is  the  best  material  for  ligatures.  Masses  that 
are  too  large  to  be  included  in  a  single  loop  may  be  transfixed  and  tied  in  sec- 
tions, two  or  more  as  the  case  may  require.  Each  succeeding  loop  should  catch 
the  preceding  one.  Membranous  edges  or  folds  may  be  secured  by  a  sort  of 
hemstitch  or  shoemaker's  stitch.  Broad  oozing  surfaces  may  often  be  best 
treated  by  cauterization  with  the  thermo-cautery.  Cases  occur  in  which  none 
of  the  methods  described  avail  fully  to  arrest  bloody  oozing  from  a  deeply- 
placed  raAV  surface.  For  such  conditions  is  reserved  the  use  of  an  antiseptic 
tampon  by  stuffing  the  cavity  Avith  iodoform  gauze.  For  this  purpose  a  pouch 
of  iodoform  gauze  of  suitable  depth  and  capacity  may  be  carried  doAvn  upon 
the  bleeding  surface  and  its  cavity  stuffed  Avith  long  strips  of  sterile  gauze,  the 
ends  projecting  through  the  loAver  end  of  the  abdominal  incision.  (See  Fig. 
403.)  More  positive  compression  may  be  exerted  by  stuffing  successive  layers  of 
a  lono-  strip  of  iodoform  gauze  into  the  cavity,  and  finally  bringing  the  end  of 
the  o-auze  out  through  a  glass  drainage-tube,  the  end  of  Avhich  is  made  to  press 
doAvn  upon  the  tampon  beloAv.     Later,  by  raising  the  tube  somewhat,  the  entire 


1014 


AX   AMKIiJCAX    TEXT- HOOK    OF  SLRiUlUY 


strip  Clin  readily  be  drawn  out  through  it.      Such  a  tampon  shouhl  he  removed 
after  forty-eight  or  seventy-two  hours,  according  to  the  amount  of  oozin". 


Fig.  408. 


Tamponade  of  the  Peritoneal  Cavity  after  Hysterectomy:  a, a,  pouch  or  tube  of  iodoform  gauze  :  A  thread 
fastened  to  center  of  pad  ;  c,  c,  c,  strips  of  iodoform  gauze  (Pozzi). 

If  the  bleeding  is  too  copious  to  be  controlled  by  such  a  tampon,  clamp 
forceps  may  be  applied  and  left  in  situ  for  from  twenty-four  to  forty-eight 
hours,  their  handles  being  brought  together  out  throurrh  tlie  lower  angle  of  the 
abdominal  incision. 

Cleansing  of  the  Peritoneal  Cavity. — All  blood  and  other  fluids  that  have 
escaped  into  the  peritoneal  cavity  should  be  carefully  removed  before  closing 
the  abdominal  wound.  If  there  is  much  such  material  to  be  removed,  washing 
out  of  the  cavity  should  be  resorted  to  by  pouring  into  it,  while  the  relaxed 
parietes  are  held  apart,  several  pitcherfuls  of  warm  salt  solution.  6 :  1000,  and 
110°  F.  in  temperature.  Most  of  this  fluid  at  once  escapes  upon  squeezing 
the  parietes  together ;  the  rest  is  to  be  carefully  sponged  out.  Finally,  the 
utmost  caution  is  to  be  used  not  to  leave  in  any  of  the  recesses  of  the  cavity 
any  sponge  or  instrument,  a  deplorable  accident  which  has  happened  many 
times,  and  to  jruard  airainst  which  it  should  be  the  invariable  rule  to  bejxin  such 
an  operation  with  a  definite  known  number  of  sponges  and  forceps,  all  of  which 
should  be  accounted  for  before  the  incision  is  closed. 

Drainage. — Whenever  the  separation  of  extensive  adhesions  has  left  behind 
surfaces  from  which  considerable  sero-sanguinolent  oozing  is  to  be  expected, 
and  especially  if  any  suspicion  of  possible  infection  of  such  secretions  exists, 
provision  should  be  made  for  drainage.  If  the  question  is  a  doubtful  one,  the 
benefit  of  the  doubt  should  be  given  to  the  drainage-tube,  since  it  can  be 


ISURGERY   OF    Till-:    FEMALE    GENERATIVE    OlidAXS.    1015 

removetl  at  an  early  day  it*  f'niiiKl  siiitcrlliioiis.  In  eases  where  secondary  hera- 
orrha<;e  is  feared  a  drain  sliould  he  eni))loyed  until  the  period  of  reaction  has 
been  fully  established.  "  Folds  of  sterile  gau/e  are  to  be  preferred  for  the 
drainage  of  blood  and  serum  ;  when  the  area  has  been  infected  iodoformized 
gau/.e  is  indicated;  wlien  heniostati(r  tanijionade  has  been  rcijuired  the  gau/.e 
taui|M)n  likewise  acts  as  an  energetic  drain.  One  end  of  the  gauze  is  laid 
upon  the  area  to  Ite  drained,  the  other  is  led  out  through  the  parietal  wound; 
over  this  projecting  end  is  placed  an  abundant  absorbent  dressing,  which  is 
chaniied  as  often  as  it  becomes  saturated  with  discharges.  As  soon  as  the 
discharge  becomes  scanty  the  drain  should  be  removed.  In  favorable  cases 
this  may  be  done  from  the  second  to  the  fourth  day.  If  upon  the  removal 
of  the  drain  the  welling  up  of  retained  secretion  should  show  that  the  drain- 
age had  been  incomplete,  a  rubber  tube  drain  should  be  inserted  to  the  bottom 
of  the  discharging  cavity,  and  its  after-care  conducted  on  the  general  princi- 
ples which  govern  the  use  of  a  drain  in  any  part  of  the  body.  By  many  sur- 
geons glass  tubes  have  been  used  for  abdominal  drainage,  together  with  fre- 
(puMit  careful  aseptic  syringe-suction  to  remove  accumulating  secretion,  or  a 
gau/.e  wick  may  be  introduced  into  the  tube." 

The  Closure  and  Dressin;/  of  the  Abdominal  Wound. — The  first  precau- 
tion is  to  secure  union  of  the  peritoneal  edges:  to  ensure  this,  separate  sew- 
ing of  the  peritoneum  may  be  done  with  a  running  suture  of  catgut.  Many 
surgeons  deem  this  unnecessary.  If  a  pedicle  stump  has  been  brought  out 
at  the  lower  angle  of  the  wound,  the  peritoneal  edges  adjacent  to  it  should  be 
carefully  sewed  around  the  pedicle  below  the  constrictor.  If  at  the  same 
time  a  drainaore-tube  has  been  inserted,  it  should  be  brought  out  an  inch  or 
more  above  the  pedicle  and  the  intervening  space  sutured.  By  many  opera- 
tors all  the  remaining  tissues  along  the  wound-line  are  now  brought  together 
at  once  by  a  series  of  interrupted  sutures,  silk  or  silkworm  gut  being  used  as 
the  material.  A  more  perfect  safeguard  against  subsequent  hernia  will  be 
obtained,  however,  by  separate  suture  with  catgut  of  the  edges  of  the  fibrous 
structure  of  the  linea  alba  or  of  the  sheath  of  the  rectus  muscle,  and  this 
should  be  done  if  the  condition  of  the  patient  will  warrant  the  slight  addi- 
tional delay  which  it  may  cause.  Lastly,  the  superficial  fascia  and  skin  are 
sutured.  If  a  drain  is  used,  one  or  two  silkworm-gut  sutures  should  be  intro- 
duced through  the  whole  thickness  of  the  edges  at  the  place  where  the  wound 
must  gape  to  receive  the  gauze.  These  sutures,  having  been  loosely  tied 
when  introduced,  are  to  be  draAvn  tight  when  the  gauze  is  removed,  so  as  to 
secure,  if  possible,  immediate  union  also  of  that  part  of  the  wound.  If  dur- 
ing the  introduction  of  the  peritoneal  sutures  the  intestines  tend  to  protrude, 
they  should  be  kept  back  by  a  sterile  gauze  pad  placed  over  them  until  the 
sutures  have  been  introducetl,  enough  of  the  last  introduced  sutures  being 
left  momentarily  untied  to  admit  of  the  final  withdrawal  of  the  protecting- 
pad.  The  external  dressing  should  be  sterile,  soft,  and  absorbent,  and  a 
sufficient  mass  of  it  should  be  placed  over  the  wound  to  protect  it  from 
accidental  infection.  The  wound  may  be  still  further  protected  by  a  layer 
of  iodoformized  collodion  (1  :  lo)  painted  thickly  over  it,  or  by  free  dust- 
ing with  a  powder  of  iodoform  and  boric  acid  (1  :  7)  or  with  oxide-of-zinc 
powder.  The  main  dressing  is  to  be  kept  in  place  by  several  broad  strips  of 
adhesive  plaster  or  by  a  suitable  binder. 

After-treatment. — Shock  is  to  be  combated  upon  general  surgical  prin- 
ciples. Severe  pain  must  be  relieved  by  the  hypodermatic  use  of  morphine, 
but  the  use  of  opium  in  any  form  is  to  be  avoided  as  much  as  possible.  Vomit- 
incr,  if  persistent  and  distressing,  is  to  be  alleviated  by  small  frequent  doses 


101  <J  AX    A  mi:  IN  (AX    TEXT- lion  K    OF   SVUCKIiV. 

of  hot  water,  by  an  ounce  of  stron<T  infusion  of  coffee,  or  by  cocaine  in  doses 
of  gr.  \-\  every  two  hours,  and  by  rectal  feeding.  The  vomiting  attendant 
upon  peritonitis,  should  that  condition  develop  after  sume  days,  is  to  be  met 
by  the  relief  of  the  condition  which  ciiuses  it.  Tynij)anites  is  to  be  relieved  bv 
the  introduction  liigh  up  of  a  rectal  tul)c  and  the  occasional  administration  of  a 
turpentine  enema  or  one  containing  half  an  ounce  of  tincture  of  asafetida  and 
twenty  grains  of  bisulphate  of  (jiiinia.  Peritonitis,  if  threatened,  calls  for 
the  ap))lication  of  an  ice-coil  to  the  abdomen  and  for  the  free  use  of  .saline 
purges.  If  uncheckeil  by  these,  the  wound  should  be  reopened,  collections  of 
septic  fluids  sought  for  and  evacuated  by  free  antiseptic  irrigations,  and  thor- 
ougi)  drainage  provided  for.  Hemorrhage  into  the  ]>eritoneal  cavity  may 
occur  from  a  slipped  ligature  or  from  a  vessel  which,  though  not  bleeding  when 
the  wound  was  closed,  has  begun  to  bleed  with  the  establishment  of  reaction. 
Symptoms  of  progressive  anemia  and  shock  beginning  to  show  themselves  a 
few  hours  after  an  operation  indicate  such  bleeding,  and  call,  at  any  risk,  for 
immediate  reopening  of  the  wound,  exploration  of  the  peritoneal  cavity,  and 
arrest  of  the  hemorrhage. 

In  general,  cases  of  abdominal  section  which  escape  any  of  the  complica- 
tions named  demand  simply  the  ordinary  attentions  proper  to  a  person  seriously 
ill.  For  the  first  twenty-four  hours  notliing  should  be  introduced  into  the 
stomach  except  an  occasional  sip  of  hot  Avater.  Thirst,  if  great,  can  be  slaked 
by  enemata  of  hot  water  ;  ice  and  the  drinking  of  cold  water  should  be  avoided. 
As  soon  as  the  nausea  and  vomiting  have  subsided,  the  administration  of  small 
quantities  of  liquid  food  may  be  begun.  Milk  with  lime-water  or  Yichy  water, 
thin  gruels,  beef-juice,  and  such-like  ])reparations,  are  to  be  used.  If  the 
patient  will  take  it,  peptonized  milk  is  best  of  all.  As  the  convalescence  pro- 
gresses, a  gradual  advance  to  a  more  solid  and  varied  dietary  will  be  made 
according  to  the  judgment  of  the  surgeon  in  the  particular  case.  If  the  irri- 
tability of  the  stomach  persists  beyond  the  first  forty-eight  hours,  feeding  by 
the  rectum  should  be  resorted  to  and  continued  until  the  stomach  becomes  able 
to  tolernte  food.  Peptonized  milk,  beef  peptonoids,  eggs  beaten  up  with  salt 
and  milk,  are  recommended  for  rectal  feeding.  The  bladder  should  be  emptied, 
if  possible,  voluntarily,  but  if  at  the  end  of  about  eight  hours  spontaneous 
urination  has  not  occurred,  a  catheter  should  be  used,  every  precaution  being 
taken  against  the  introduction  of  septic  matter  into  the  bladder,  the  intro- 
duction of  the  catheter  being  always  preceded  by  a  cleansing  of  the  external 
meatus  with  an  antiseptic  wash.  The  catheter  should  be  passed  at  intervals 
of  eight  hours  until  the  power  of  normal  urination  is  regained.  The  bowels 
should  be  moved  on  the  third  day  by  an  ordinary  enema  if  they  have  not  been 
spontaneously  evacuated  before. 

Re-dressing  of  the  abdominal  wound  in  an  uncomplicated  case  will  not  be 
required  until  the  end  of  ten  days  or  two  weeks.  At  the  end  of  this  time,  the 
primary  dressing  having  been  removed,  the  wound  will  be  found  firmly  healed 
and  the  sutures  may  be  taken  out.  If  any  stitch-hole  abscesses  should  be  dis- 
covered, they  will  be  treated  on  general  principles ;  otherwise  a  small  protect- 
ive pad  is  simply  laid  over  the  recent  cicatrix  and  suitable  strips  of  adhesive 
plaster  are  applied  to  prevent  any  undue  tension.  During  the  third  week  the 
patient  may  be  allowed  to  sit  up,  and  according  to  the  more  or  less  rapid 
return  of  her  strength  may  thereafter  be  allowed  to  resume  her  usual  life. 
A  protective  abdominal  binder  should  be  worn  for  at  least  six  months 
thereafter. 

Jntestinal  Adhesiotis,  with  consequent  Angulation  ayid  Obstruction,  consti- 
tute a  complication  to  be  feared  whenever  extensive  raw  surfaces  have  to  be  left 


SURGERY   OF    Till-:    FEMALE    GENERATIVE    ORGANS.   1017 

within  tlie  peritoneal  cavity.  It  is  difticiilt  t(»  differentiate  this  accident  from 
general  peritonitis,  both  conditions  declaring  themselves  by  obstinate  vomit- 
ing, constipation,  and  tympanites,  and  tending  to  speedy  death.  In  either 
case  reopening  of  the  wound  and  exploration  are  called  for.  If  angulation  is 
found  to  be  ])resent,  the  adhesions  must  be  broken  up  and  the  intestine  set  free. 
Ke-adhesion  and  renewed  olistruetion  should  be  j)revented  Ijy  the  use  of  saline 
purges  to  provoke  peristalsis.  Martin  suggests  anointing  the  raw  surfaces  that 
are  to  be  left  behind  with  sterilized  olive  oil  as  a  possible  preventive  of  adhe- 
sion. In  any  case,  a  cardinal  rule  is  always  to  draw  over  every  raw  surface 
as  much  of  a'  peritoneal  covering  as  possible  by  sliding  and  suturing  before 
closing  an  abdominal  wound. 

CARCINOMA   OF  THE   UTERUS. 

According  to  the  statistics  of  Williams,  31  per  cent,  of  all  cases  of  carci- 
noma occurring  in  women  have  their  seat  in  the  uterus.  The  cervix  is  the 
region  most  frequently  affected  primarily  ;  the  body  is,  nevertheless,  not  rarely 
the  point  of  origin.  It  is  rare  for  it  to  occur  in  women  under  thirty  years  of 
age.  About  tAvo-thirds  of  all  cases  occur  between  the  ages  of  forty  and  sixty. 
In  addition  to  the  influence  of  age  as  a  predisposing  cause,  there  is  much 
ground  for  assigning  a  marked  influence,  as  contributing  to  its  development, 
to  chronic  inflammatory  conditions  of  the  uterus,  especially  when  combined 
with  neglected  lacerations  of  the  cervix. 

Carcinoma  of  the  Cervix  Uteri  may  present  itself  primarily  either  as 
an  affection  of  the  vaginal  portion  or  of  the  mucous  membrane  of  the  canal,  or 
as  a  nodular  infiltration  of  the  wall  of  the  cervix.  The  first  form,  the  cancroid 
of  some  authors,  may  remain  for  a  long  time  limited  to  the  vaginal  portion. 
Its  further  spread,  as  a  rule,  is  particularly  marked  toward  the  vagina. 

Carcinoma  of  the  Corpus  Uteri  occurs  as  a  primary  disease  more 
rarely  than  that  of  the  cervix.  It  originates  in  the  glandular  structures  of 
the  endometrium,  and  thence  extends  as  a  diffuse  infiltration  with  rapid  dis- 
integration. 

In  all  forms  of  cervical  cancer  the  vagina  is  frequently  invaded  early ; 
extension  upward  to  the  body  of  the  organ  is,  as  a  rule,  slow.  The  vascular 
and  lymphatic  streams  tend  outward  from  the  cervix  along  the  base  of  the 
broad'  ligament  (Fig.  404) :  hence  the  extension  of  the  disease  in  this  direc- 
tion outward  into  the  broad  ligaments  before  the  proper  body  of  the  uterus  is 
involved.  The  inguinal  lymphatic  glands  become  affected  only  after  a  wndely- 
disseminated  pelvic  disease  has  been  created. 

As  the  infiltration  characteristic  of  the  disease  increases,  the  contiguous 
tissues  and  adjacent  organs  become  involved;  the  bladder,  uterus,  or  rec- 
tum (Fig.  405)  may  become  more  or  less  seriously  damaged,  and  the  symp- 
toms referable  to  their  irritation  or  obstruction  be  added  to  those  existing 
previously.  The  early  involvement  of  the  connective  tissue  of  the  broad 
ligaments  thickens  and  shortens  them  and  anchors  the  uterus  firmly,  while  it 
may  cause  compression  of  the  pelvic  vessels,  giving  rise  to  oedema  of  the  lower 
extremities  and  to  pain  along  the  involved  nerve-trunks.  A  more  or  less 
rapid  disintegration  of  the  new  growth  supervenes  early  ;  the  processes  of 
infiltration  and  ulceration  follow  close  upon  each  other :  as  a  result,  the  blad- 
der or  the  rectum,  one  or  both,  may  be  opened  into,  and  one  great  foul  cloaca, 
receiving  urine,  feces,  and  the  debris  and  discharges  from  the  uterus,  be  created. 
A  forerunning  adhesive  inflammation  alone  prevents  the  frequent  opening  of 
the  peritoneal  cavity  also. 


U»18  Ay    AMKliUAy    TEXT-noOK    OF  SLllUKllY. 

TIk'  symptoms  in  its  earlier  staf^es  are  indefinite  and  uncertain.     Card- 


^'..y 


Lymphatic  Vessels  of  the  Uterus:  1,  lymphatics  coming  from  body  and  fundus  of  uterus;  2,  ovary;  3, 
vagina;  4,  Fallopian  tube:  5,  lymphatics  coming  from  neck  of  uterus;  6,  lymphatic  vessels  coming 
from  neck  of  the  womb  and  going  to  the  iliac  glands  ;  7,  lymphatic  vessels  coming  from  the  body  and 
fundus  of  the  uterus  and  going  to  the  lumbar  glands;  8,  anastomosis  uniting  the  vessels  of  the  neck 
and  body  of  the  uterus ;  9,  small  lymphatic  vessel  situated  in  the  round  ligament  and  terminating  in 
the  inguinal  glands;  10,  11,  lymphatic  vessels  of  the  Fallopian  tube  emptying  into  the  great  lym- 
phatics of  the  body  of  the  uterus;  12,  ligament  of  the  ovary  (Pozzi;. 

nomatous  degeneration  of  the  uterus  may  attain  considerable  proportions  with- 
out   provoking    any  noticeable    synip- 
FiG.  405.  toms,  and  may  finally  be  detected  only 

by  accident.  More  frequently  the  oc- 
currence of  vague  pains,  irregular  hem- 
orrhages, and  a  somewhat  ])rofuse  and 
offensive  vaginal  discharge  invites  ex- 
amination as  to  their  cause.  The  ir- 
regular and  easily-provoked  bleeding.s^ 
which  mark  an  invasion  of  carcinoma 
when  it  occurs  at  the  period  of  the 
menopause  are  often  attributed  to  the 
menstrual  irregularities  which  so  fre- 
quently attend  it.  The  occurrence  of 
such  bleedings  at  that  period  of  life, 
therefore,  is  to  be  considered  a  suspi- 
cious circumstance  and  to  call  for  care- 
ful examination.  The  discharges  that 
attend  a  disintegrating  carcinoma  are 
thin,  watery,  and  dirty,  often  acrid 
and  mixed  with  shreddy  debris,  and 
exceedingly  offensive. 
The  diagnosis  declares  itself  at  once  to  the  eye  and  to  the  touch,  upon  exam- 


Cancer  of  both  Lips  of  the  Uterus  (Skene). 


^cuajjjiv  OF  r/n:  fhmalf  (hixfaiative  onaAXs.  ioi9 

ination,  in  cases  that  are  well  advanced  in  their  development,  hut  in  the  earliest 
stages  it  is  impossihle,  except  hy  the  aid  of"  the  inicroscope,  to  difterentiate  the 
disease  from  the  indurations  and  erosions  due  to  ordinary  inflammatory  con- 
ditions. In  all  suspicious  cases  a  small  section  of  the  affected  tissue  should 
be  removed  and  submitted  to  the  examination  of  a  pathologist.  If  the  affected 
part  is  high  up,  and  hence  not  readily  accessible,  scrapings  from  the  deeper 
mucosa  should  I)e  o))tained  Avith  a  sharp  curette  for  similar  examination. 

The  prognosis  is  that  which  attends  like  malignant  disease  elsewhere. 
The  average  prolongation  of  life  when  the  disease  pursues  its  natural  course  is 
from  twelve  to  eighteen  months.  The  younger  the  patient  the  more  rapid  the 
course  of  the  disease.  If  the  disease  is  detected  early  enough  to  admit  of 
the  absolute  removal  of  all  affected  tissue,  j)ermanent  cure  may  be  expected. 
The  early  extension  of  the  disease  outward  along  the  lymphatic  channels  of  the 
deep  pelvis,  which  for  some  time  it  may  be  impossible  to  detect,  makes  the 
prognosis  in  any  given  case  uncertain.  In  estimating  the  proportion  of  cases 
in  which  permanent  relief  is  obtained  by  extirpation,  the  consideration  of  all 
cases  in  which  the  clinical  diagnosis  has  not  been  confirmed  or  established  by 
the  microscopical  findings  as  determined  by  a  competent  pathologist  must  be 
excluded.  This  is  especially  important  in  dealing  with  malignant  disease  of 
the  vaginal  portion,  for  which  simple  inflammatory  conditions  are  often  mistaken. 
The  principles  which  govern  the  prognosis  of  carcinoma  of  the  uterus  are  the 
same  as  obtain  in  other  organs  of  the  body,  modified  by  the  special  anatom- 
ical relations  of  the  uterus.  Cure  is  to  be  expected  only  from  operative  meas- 
ures that  Avill  secure  the  removal  of  a  very  considerable  zone  of  apparently 
healthy  tissue  around  and  beyond  that  Avhich  is  manifestly  diseased.  Since 
carcinoma  of  the  portio  vaginalis  is  usually  detected  at  an  earlier  period  of 
development,  and  naturally  extends  slowly  at  first,  it  will  always  present  the 
largest  proportion  of  cures  of  any  of  the  forms  of  the  disease. 

Treatment. — The  prevention  of  the  development  of  carcinoma  of  the 
uterus  has  a  practical  side  through  the  probable  predisposing  influence  of 
chronic  endometritis,  especially  when  accompanied  with  laceration  and  ero- 
sion of  the  cervix.  The  proper  treatment  and  early  cure  of  such  conditions, 
therefore,  assume  importance  in  the  prophylaxis  of  carcinoma.  The  occur- 
rence of  irregular  hemorrhages  or  the  development  of  leucorrheal  discharges 
in  women  who  are  approaching  or  have  passed  the  menopause  should  be  the 
signal  for  immediate  and  thorough  examination  of  the  uterus.  The  presence 
of  carcinoma  having  been  determined,  its  total  extirpation  is  to  be  done  at 
the  earliest  possible  moment  if  the  disease  appears  to  be  still  sufficiently 
limited  to  afford  ground  for  hope  that  its  removal  is  practicable. 

Carcinoma  of  the  portio  vaginalis,  when  detected  in  its  earliest  stages 
while  vStill  superficial  and  circumscribed  to  a  limited  area,  may  be  attacked 
with  some  hope  of  permanent  cure  by  a  supra-vaginal  excision  of  the  cervix^ 
followed  by  thorough  cauterization  of  the  wound  surfaces  exposed.  The 
usual  preparatory  treatment  is  first  attended  to.  The  cervix  having  been 
draAvn  down  as  much  as  possible,  a  preliminary  ligature  is  first  applied  to 
each  uterine  artery  by  a  curved  needle  armed  Avith  a  stout  thread,  intro- 
duced dee])h^  in  each  lateral  vaginal  fornix ;  the  vaginal  mucous  mem- 
brane is  then  divided  circularly  where  it  is  reflected  upon  the  cervix,  and 
the  submucous  connective  tissue  is  bluntly  dissected  from  the  cervix,  keep- 
ing close  to  the  cervix,  separating  the  bladder  from  it  in  front,  until  the 
end  of  the  internal  os  is  reached  ;  similarly  the  posterior  surface  of  the 
cervix  is  enucleated  to  the  same  height.  Any  accidental  opening  through 
the  peritoneum    into  the  posterior  cul-de-sac   should    be    sutured.     As  the 


1()2(> 


.4^V    AMKIUCAS    TEXT-nOOK    OF  SVIICKRY. 


denudation  is  extended  laterally,  should  any  vessels  sj)out  they  are  ligated  in 
the  wound.  The  denuded  eervix  is  then  split  into  an  anterior  and  a  poste- 
rior half  by  lateral  incisions,  and  each  part  cut  oft"  transversely  at  the  highest 
point  accessible.  The  exposed  stump  is  then  thoroughly  seared  by  a  therrno- 
or  electric-cautery  button,  and  a  light  tampon  of"  iodoform  gauze  ap]»lied. 
The  subse(juent  treatment  is  simple:  the  eschar  separates  in  due  time,  leav- 
ing a  granulating  surface  v  hich  heals  rapidly,  rec^uiring  only  the  use  of  daily 
antiseptic  douches  for  cleansing  purposes.  For  some  time  the  parts  should 
be  carefully  watched,  and  the  appearance  of  any  susj»icious  change  should  be 
met  by  the  [)rompt  removal  of  the  entire  organ. 

Total  extirpation  of  tJie  tifmfx  is  preferred  by  many  surgeons  to  any  jKir- 
tial  removal  in  all  cases  without  reference  to  the  apparent  limitation  of  the 
disease.  AVhen  done  by  the  vaginal  j»ath  alone,  and  in  the  absence  of  infil- 
trations of  the  broad  ligament  to  restrict  the  movability  of  the  uterus,  the 


Fig.  406. 


Showing  method  of  exposing  uterus  preparatory  to  operative  attack  upon  it  tliroURh  tlie  vagina. 

total  extirpation  takes  but  little  more  time,  and  is  attended  with  but  little 
if  any  more  hazard  to  life  than  is  the  partial  operation,  and  has  the  advantage 
of  leaving  no  uterine  tissue  to  become  the  seat  of  recurring  disease. 

Vacfinal  Jfi/sterctonit/. — As  an  immediate  preliminary  to  the  operation 
the  rectum  and  bladder  should  have  been  emptied,  the  pubes  shaved,  and 
thorough  disinfection  of  the  external  genitals  and  thighs  made.  For  the 
operation  the  ])atient  should  be  placed  upon  her  back  with  pelvis  raised  in  an 
exaggerated  lithotomy  position.     (See  Fig.  406.) 

The  labia  and  perineum  having  been  retracted,  the  cervix  is  seized  by  a 
suitable  volsellum  forceps  and  drawn  as  far  down  as  possible;  any  excavation 
in  the  cervix  left  by  the  curetting  and  cauterization  is  first  well  irrigated  with 
sublimate  solution,  1  :  1000,  and  then  filled  with  a  tampon  of  iodoform  gauze, 
and  its  lips  sewed  as  closely  together  as  possible  by  a  continuous  suture.  The 
cervix  is  then  lifted  strongly  forward,  so  as  to  put  the  posterior  vaginal  pouch 


SURGERY    OF    TU F    FIlMALl-]    dE^^FJlATIVE    ORdANS.   1021 

on  tlie  stretch.  A  transverse  incision  is  next  made  just  heliind  the  cervix 
through  the  vaginal  wall,  opening  into  the  sac  of  Douglas.  A  series  of  sutures 
is  then  passed  so  as  to  control  bleeding  from  the  vaginal  vessels  severed  by 
the  cut. 

The  cervix  is  now  drawn  strongly  to  one  side,  and  a  moderately  large 
curved'needle,  armed  with  a  strong  thread,  is  thrust  through  the  lateral  reflec- 
tion of  the  vagina  as  close  as  [)ossible  to  the  uterus,  deeply  into  the  base  of 
the  broad  ligament,  and  after  executing  a  sharp  curve  is  brought  out  again 
about  a  quarter  of  an  inch  from  its  point  of  insertion.  This  manoeuver  may 
be  aided  and  guided  by  the  forefinger  introduced  into  the  posterior  incision 
already  made.  The  cervix  having  been  permitted  to  drop  back  into  its  natural 
position  in  the  middle  line,  this  ligature  is  tightly  tied,  and  thus  the  uterine 
artery  encompassed  by  it  is  ligated.  After  the  same  manoeuver  has  been  exe- 
cuted upon  the  opposite  side,  the.  cervix  is  further  separated  from  the  vagina 
by  prolonging  the  incision  already  made,  laterally,  inside  the  ligatures;  the 
cervix  is  separated  from  the  broad  ligaments  on  each  side  up  to  the  limit  of 
the  tissue  grasped  by  the  lateral  ligature  applied.  If  bleeding  points  present 
themselves,  they  should  be  controlled  by  the  insertion  of  additional  sutures 
from  the  vaginal  surface.  These  hemostatic  sutures,  as,  indeed,  all  ligatures 
applied  throughout  the  course  of  the  operation,  should  be  tied  with  great  firm- 
ness. The  cervix  is  now  drawn  backward  and  downward  so  as  to  expose  the 
anterior  vaginal  pouch  and  put  the  bladder  attachments  upon  the  stretch.  The 
remaining  vaginal  attachment  is  now  divided  by  a  transverse  incision  in  front 
of  the  uterus  and  as  close  to  it  as  possible.  This  incision  should  open  into  the 
cellular  interspace  between  the  uterus  and  the  bladder.  By  the  finger,  aided 
by  scissors  if  necessary,  the  bladder  is  stripped  oif — great  care  being  taken  to 
keep  close  to  the  uterus  in  the  w^ork  of  separation,  lest  the  bladder  be  injured — 
until  the  peritoneum  is  reached.  The  extent  of  tissue  to  be  worked  through 
before  the  peritoneum  is  reached  will  vary  considerably  in  diff'erent  subjects,  but 
the  diminished  sense  of  resistance  communicated  to  the  finger  when  the  peri- 
toneum is  reached  will  suffice  to  indicate  its  presence,  even  though  it  be  not  rec- 
ognizable by  the  eye.  It  may  be  at  once  opened,  or  its  incision  may  be  deferred 
to  a  later  stage  of  the  operation,  whichever  may  seem  the  more  convenient.  The 
cervix  has  now  become  freed  for  some  distance  above  the  vaginal  attachment : 
its  safe  liberation  from  its  broad-ligament  attachments  remains  to  be  accom- 
plished. Having  been  drawn  down  as  much  as  possible,  a  ligature,  by  means 
of  a  strongly  curved  needle  upon  a  suitable  handle  (Deschamps'  needle),  is 
carried  upAvard  close  alongside  the  uterus,  so  as  not  to  encompass  too  great  a 
portion  of  the  lateral  tissues  still  holding  the  uterus ;  the  thread,  having  been 
brought  out  again,  is  securely  tied,  and  the  greater  part  of  the  tissue  grasped 
by  it  is  cut.  By  a  succession  of  ligatures  thus  applied,  taking  care  to  in- 
clude in  each  ligature  a  portion  of  the  tissue  held  by  the  preceding  one,  fol- 
lowed by  successive  snips  of  the  scissors,  the  broad  ligaments  are  gradually 
tied  and  cut  off.  The  application  of  the  higher  ligatures  may  be  facilitated 
by  retroverting  the  uterus  by  the  help  of  a  finger  passed  through  the  poste- 
rior incision  over  its  fundus,  together  with  volsellum  forceps  to  make  trac- 
tion, and  pulling  it  down  as  far  as  possible.  By  this  act  the  upper  part  of 
the  broad  ligament,  twisted  upon  itself,  is  made  readily  accessible.  The 
lateral  attachments  i)eing  all  finally  cut,  the  anterior  peritoneal  reflection,  if 
not  cut  before,  is  now  cut  across  and  the  uterus  entirely  liberated. 

If  at  any  time  in  the  course  of  the  manipulations  the  intestines  tend  to 
protrude  through  the  peritoneal  opening,  which  is  uncommon,  they  should  be 
crowded  back  by  a  sponge,  to  which  a  marked  string  is  attached  to  identify 


102'2  AX   AMERICA  X    TEXT- HOOK    OF   Sf /,'(//: J,' V. 

it  for  siibsei|uent  romoval.  puissed  into  the  pelvic  cavity.  'I'lie  sponirc  tanijion, 
if  one  has  been  inserted,  liaving  been  Avithdrawn,  and  all  bleedin<!;  having 
been  absolntely  controlled  by  ligatures,  sutures,  or  clamp  forceps,  tlie  parts 
should  be  irrigated  with  a  mild  antiseptic  douche,  and  finally  dried  uith 
sjionges  upon  suitable  liolders.  The  vaginal  •wound  mav  be  diminished  in 
extent  by  a  suture  apj)litMl  at  either  lateral  conimissure,  but  this  is  not 
important. 

A  strip  of  iodoform  gauze  is  next  pushed  up  into  the  pelvic  cavity  for 
drainage  purposes,  its  lower  portion  being  coiled  up  in  the  vagina.  A  sepa- 
rate small  piece  of  iodoform  gauze  should  be  stufted  into  the  introitus,  to  be 
frequently  changed  as  retjuired  by  the  exigencies  of  urination.  An  abundant 
.*^oft  absorbent  pad  is  placed  over  the  vulva,  to  be  changed  Avhcnever  saturated 
with  the  discharges. 

The  after-treatment  is  very  simple,  and  is  guided  by  general  principles. 
An  easy  convalescence,  free  from  pain  and  constitutional  disturbance,  is  usual. 
At  the  end  of  the  first  week  tlie  long  gauze  drain  is  AvithdraAvn  and  the  vagina 
gently  irrigated.  After  another  week  the  patient  may  be  allowed  to  sit  up. 
Careful  vaginal  douches  may  be  given  daily  as  required  for  cleanliness.  After 
three  weeks,  Avalking  and  gradual  return  to  ordinary  life  may  be  begun. 

Instead  of  tying  off  the  ])road  ligaments,  as  above  recommended,  it  will 
often  be  found  practicable  and  more  expeditious  to  clamp  the  broad  ligaments 
by  suitable  long-jaAved  clamp  forceps,  which  are  left  hi  situ  protruding  from 
the  vulvar  opening  for  from  forty-eight  to  seventy-two  hours,  when  they  may 
be  gently  loosened  and  removed  without  fear  of  further  hemorrhage.  If  the 
clamps  are  to  be  used,  the  posterior  and  anterior  peritoneal  pouches  are  to  be 
opened  first,  and  through  these  openings  the  blades  of  the  clamps  are  to  be 
adjusted  close  to  the  uterus.  If  the  operation  is  embarrassed  by  rigidity  and 
narrowness  of  the  introitus  or  of  the  vagina,  the  perineum  may  ])e  incised  so 
as  to  obtain  more  room.  The  proper  sutures  to  close  the  incision  are  to  be 
inserted  after  the  uterus  has  l)een  removed. 

Hemorrhage,  sepsis,  ligature  of  a  ureter,  and  wound  of  tlie  bladder  are 
accidents  against  which  the  surgeon  must  be  especially  on  guard.  The  liabil- 
ity of  some  tissue  to  slip  out  from  the  jaws  of  a  clamp  when  a  large  mass  of 
tissue  is  held  in  its  grasp  is  an  important  objection  to  the  use  of  clamps  in 
such  a  manner.  In  the  application  of  ligatures,  also,  too  great  a  mass  of  tissue 
should  not  be  embraced  by  the  loop  of  a  single  ligature,  for  the  same  reason. 
In  any  event,  great  care  should  be  taken  to  see  that  perfect  hemostasis  is  ob- 
tained at  each  step  of  the  operation.  As  to  sepsis,  the  chief  source  of  infec- 
tion is  likely  to  be  the  uterus  itself,  owing  to  defects  in  the  attempts  at  steril- 
izing it.  Special  care  should  be  taken  to  make  this  preliminary  Avork  thor- 
ough. The  ureter  is  liable  to  be  wounded  or  to  be  included  in  the  grasp  of  a 
ligature  or  clamp  if  care  is  not  taken  to  keep  close  to  the  u*:erus  in  all  the 
manipulations  involving  the  base  of  the  broad  ligaments.  When  such  an  acci- 
dent happens,  if  not  fiital,  it  results  in  a  ureteral  fistula.  A  tear  of  the  blad- 
iler  is  also  possible  during  its  separation  from  the  cervix  if  the  operator  is  not 
careful  to  confine  his  dissections  to  the  tissues  close  to  the  uterine  substance. 
If  the  bladder  is  torn,  immediate  suture  of  the  rent  should  be  done,  and  a  soft 
catheter  retained  in  the  bladder  for  five  days. 

Excision  of  Cdi'cinoniatoiis  Uterus  and  Broad  Lijiavwnt  hy  the  Abdominal 
Route. — Cases  originating  in  the  mucous  membrane  of  the  cervical  canal,  or 
presenting  much  infiltration  of  the  cervical  substance,  or  involving  any  por- 
tion of  the  corpus  uteri,  call  for  the  total  extirpation  of  the  uterus,  together 
with  the  lymphatic  vessels  and  glands  of  the  broad  ligaments,  provided  the 


iSU-BGEI^y    or    Tlfb:    female    aENERATIVE    ORGANS.   1023 

iuvolveint'iit  of  iH'i_i;lib()i'ing  organs  and  the  extension  ot"  tlie  infiltration  to 
tlie  pelvic  walls  are  not  manifestly  such  as  to  demonstrate  that  total  removal 
of  the  disease  is  impracticable.  Even  in  the  latter  case  it  has  been  demon- 
strated that  by  removal  of  the  diseased  uterus  and  ligation  of  the  internal 
iliac  arteries  the  further  progress  of  the  disease  may  be  much  tlclayed  and 
a  period  of  from  one  to  two  years  added  to  the  life  of  the  individual.  The 
fiehl  of  justiHable  o[)erative  interference  has  thus  become  much  extended. 
The  development  of  metastatic  foci  in  the  lymph  nodes  of  the  broad  liga- 
ment by  transmission  of  infecting  cells  along  the  lymphatics  takes  place  so 
early  and  for  a  long  period  is  so  difficult  of  detection  by  any  means  of  gross 
examination,  that  it  is  better  to  regard  all  cases  of  uterine  carcinoma  when 
discovered  as  having  already  developed  such  extension,  and  therefore  to 
resort  to  the  widest  possible  removal  of  the  circum-uterine  tissue,  together 
with  removal  of  the  uterus  itself,  as  soon  as  the  diagnosis  is  clearly  estab- 
lished. Such  radical  excision  can  best  be  done  by  an  attack  by  the  com- 
bined vaginal  and  abdominal  routes. 

Ti'cliiii'iue. — Preliminary  thorough  disinfection  of  the  surface  of  the  ab- 
domen, of  the  pudenda,  and  of  the  vagina  is  to  be  done,  followed  by  curet- 
tage of  the  uterus,  cauterization  of  any  broken-down  surface,  stuffing  the 
uterine  canal  Avith  iodoform  ijauze,  and  suturino;  the  external  os,  and  a  final 
<louching  of  the  vagina.  The  ureters  may  now  have  a  catheter  introduced 
into  each,  if  the  operator  chooses,  for  the  purpose  of  facilitating  their  iden- 
tification in  the  later  steps  of  the  operation;  but,  as  a  rule,  this  is  not 
necessary.  Then  the  mucous  membrane  of  the  vagina  is  to  be  separated 
from  the  cervix,  the  bladder  freed,  and  the  posterior  cul-de-sac  opened,  as 
already  described  under  vaginal  hysterectomy.  Finally,  the  spaces  opened 
up  in  front  and  behind  the  cervix  are  stuffed  with  iodoform  gauze  and  the 
field  of  attack  transferred  to  the  abdomen.  The  dorsal  decubitus  with  ele- 
vated pelvis  is  now  required,  and  the  abdomen  is  opened  by  a  median  supra- 
pubic incision  sufficiently  free  to  give  perfect  exposure  of  and  ready  access  to 
the  pelvic  viscera.  A  ligature  is  now  placed  upon  the  upper  part  of  each 
broad  ligament  near  the  pelvic  brim,  and  also  upon  each  round  ligament,  and 
those  structures  divided;  next  the  vesico-uterine  reflexion  of  the  peritoneum 
is  incised  transversely,  and  the  bladder  is  separated  from  the  uterus ;  the  in- 
cision in  the  peritoneum  is  now  prolonged  on  either  side  outward  to  join  those 
previously  made,  and  by  blunt  dissection  along  the  pelvic  wall  the  trunk  of 
the  internal  iliac  artery  is  exposed ;  two  ligatures,  half  an  inch  apart,  are 
applied  to  each  artery  and  the  vessel  severed  between  them.  The  ureter 
should  then  be  identified  under  that  portion  of  the  peritoneum  on  the 
inner  side  of  the  incision  made  for  exposing  the  artery ;  this  is  (juickly  and 
easily  done,  and  the  ureter  should  thereafter  be  kept  in  view  throughout  the 
successive  steps  of  the  dissection,  care  being  taken  that  no  injury  be  in- 
flicted upon  it.  On  each  side  successively  is  now  dissected  out  the  tissue  of 
the  broad  ligament,  with  its  vessels  and  glands,  until  the  primary  vaginal 
incisions  are  opened  into  and  the  uterus  is  freed.  Hemorrhage  is  much 
restrained  by  preliminary  ligation  of  the  internal  iliacs;  but  some  venous 
trunks  on  the  outer  wall  of  the  pelvis,  and  some  arterial  twigs  from  the  ob- 
turator and  the  hemorrhoidal  arteries,  may  require  ligation.  Careful  search 
for  enlarged  glands  is  to  be  made  along  the  pelvic  floor  and  the  outer  wall  of 
the  pelvis,  and  any  found  are  to  be  removed.  All  hemorrhage  having  been 
arrested,  the  vaginal  tampons  are  removed  and  a  new  strip  of  iodoform  gauze 
is  thrust  from  above  down  into  the  vagina,  while  its  upper  portion  is  kept 
loosely  folded  in  the  denuded  area  ;  then  the  edges  of  the  peritoneal  flaps  are 


1024  J.V   AMKRiCAy    TKXT-IKJOK    OF  SLnUKliV. 

brought  togetlier  so  as  to  cover  over  tlie  raw  area  exce])t  at  tlie  inidtUe  of  tho 
suture  line,  wliere  an  opening  sliouM  be  left  into  which  an  end  ot"  the  gauze 
drain  shoubl  be  drawn.  Should  the  ureters  and  the  base  of  the  bladder  be 
involved  in  the  carcinomatous  growth,  it  will  be  necessary  to  excise  all  the 
diseased  tissue,  going  through  sound  tissue  wide  of  the  disease,  and  after- 
ward to  suture  the  bladder  and  reinijdant  the  shortened  uretei's  into  its 
u])|>er  part.  Considerable  time  and  a  iair  degree  of  technical  skill  are  re- 
(juired  for  the  accomplishment  of  the  ojieration  thus  described.  The  result- 
ing shock  is  best  combated  by  intravenous  injection  of* a  saline  solution 
of  three  pints  or  more.  The  after-care  does  not  differ  from  that  already  de- 
scribed for  abdominal  operations  in  general.  The  mortality  attending  the 
removal  of  the  carcinomatous  uterus,  while  necessarily  iniluenced  much  by 
tile  technical  skill  and  exj)erience  of  the  operating  surgeon,  is  dependent 
still  more  upon  the  degree  of  exhaustion  already  caused  by  the  disease,  and 
the  extent  and  duration  of  tlie  oj)erative  steps  required  to  eradicate  outlying 
aff'ected  tissues  in  addition  to  the  uterus  itself.  The  removal  by  the  vagina 
of  a  uterus  still  movable  and  with  disease  limited  to  its  own  structure  entails 
but  little  hazard  to  life  when  done  with  ordinary  care  and  skill.  The  more 
extensive  and  prolonged  the  dissection  retpiired.  as  in  the  procedures  de- 
scril)ed  in  the  last  paragraph,  the  greater  the  immediate  danger  from  shock, 
hemorrhairc.  and  prolonged  anesthesia.      The  immunitv  from  recurrence  de- 

.      *  11*1 

pcnds  upon  the  stage  in  the  development  of  the  primary  growth  at  which 
the  radical  extirpation«is  done:  the  earlier  in  the  history  of  the  growth  and 
the  less  its  apparent  extension  the  greater  the  probability  of  future  immu- 
nity and  the  more  easily  and  quickly  are  the  most  thorough  procedures 
accomplished,  and  the  least  are  the  immediate  dangers  to  life  that  attend 
them. 

The  ultimate  results  obtained  in  efforts  at  extirpation  of  uterine  carci- 
noma do  not  differ  from  those  obtained  by  the  removal  of  similarly  diseased 
organs  in  other  ]iarts  of  the  body. 

Palliative  Treatment  of  Advanced  Cases. — Unfortunately,  a  large 
proportion  of  cases  of  cancer  of  the  uterus  do  not  present  themselves  to  the 
surgeon  until  the  disease  has  extended  beyond  the  limits  of  the  uterus,  espe- 
cially along  the  lymphatics  of  the  pelvic  connective  tissue  in  the  base  of  the 
broad  ligaments.  This  is  indicated  by  the  fixation  of  the  uterus  and  by  the 
indurations  perceptible  to  the  finger  in  the  parametric  tissues.  Disintegration 
of  the  carcinomatous  growth  is  also  more  or  less  advanced,  hemorrhages  are 
frequent,  and  the  discharges  are  copious  and  offensive.  Such  cases  may  be 
temporarily  much  benefited  by  free  curetting  of  the  softening  tissue,  followed 
by  thorough  cauterization,  the  curetting  should  be  done  with  a  sharp  curette, 
and  should  be  radical  in  its  extent.  If  the  bleeding  provoked  by  it  is  not 
quickly  checked  by  irrigations  with  hot  water  and  compression  with  an  iodo- 
form tampon,  hemostasis  may  be  secured  by  deep  sutures  introduced  so  as  to 
encompass  the  bleeding  points.  When  the  bleeding  has  been  stopped  the 
cauterization  is  to  be  done.  For  general  use  chloride  of  zinc  is  the  most  con- 
venient and  efficient  caustic.  The  technique  of  its  use  is  as  follows :  Small 
pledgets  of  absorbent  cotton,  soaked  and  wrung  out  of  a  saturated  solution  of 
zinc  chloride,  are  stuffed  into  the  cavity  left  by  the  curetting  until  it  is  filled 
up.  The  adjacent  surfaces  of  the  vagina  are  smeared  with  an  ointment  of 
bicarbonate  of  sodium  and  petrolatum,  1  :  3,  and  the  vagina  filled  with  a  tam- 
pon of  absorbent  cotton  wrung  out  of  a  saturated  solution  of  Idcarbonate  of 
sodium,  the  latter  provision  being  adopted  to  prevent  cauterization  of  the  vagina. 
On  the  third  day  the  tampon  and  as  much  of  the  caustic  packing  as  w  ill  easily 


SURGERY  or   Tin-:  FEMALE  dENERATlVE  ORGANS.   102o 

come  away  are  to  be  removed.  By  the  fifth  (hiy  all  the  packing  will  have 
been  removed.  Between  the  fifth  and  tentii  days  the  eschar  will  come  away, 
leaving  behind  a  grannlating  surface,  which  will  to  a  large  extent  contract 
and  cicatrize  during  the  subse<iuent  weeks,  while  simple  cleansing  douches  are 
used.  A  notable  amelioration  of  all  symptoms  at  once  occurs,  and  is  main- 
tained until  the  processes  of  infiltration  and  breaking  down  have  again  become 
far  advanced. 

Malkinant  Ai)1:noma  of  the  corporeal  endometrium  is  a  transitional  form 
of  disease  between  simple  inflammatory  hyperf)lasia  of  the  glandular  structures 
of  the  endometrium  and  carcinomatous  degeneration.  It  is  characterized  by 
an  abundant  new  formation  of  glandular  tissue  that  tends  to  infiltrate  the 
deeper  tissues.  It  is  slow  in  its  growth,  possibly  taking  some  years  to  develop 
serious  symptoms :  its  most  prominent  symptom  is  hemorrhage,  which,  if  the 
affection  is  developed  before  the  menopause,  is  a  menorrhagia ;  if  later  in  life, 
is  irregular  in  its  attacks.  If  subjected  to  the  curettings  and  cauterizations 
efficient  against  simple  inflammatory  glandular  hyperplasia,  it  quickly  recurs, 
and  after  a  lapse  of  a  more  or  less  prolonged  period,  from  three  to  five  years, 
develops  into  typical  carcinoma,  with  involvement  of  adjacent  tissues,  metas- 
tasis, and  death. 

The  diagnosis  is  to  be  made  by  comparison  of  the  histological  findings 
from  microscopical  examination  of  deep  scrapings,  with  the  clinical  course. 
The  microscope  shows  the  marked  and  irregular  proliferation  of  the  glands 
with  diminution  of  interglandular  tissue,  and  the  history  of  the  case  is  charac- 
terized by  repeated  recurrence  after  treatment.  Such  an  assemblage  of  con- 
ditions, particularly  if  a  new  development  in  a  woman  who  is  approaching  or 
has  passed  the  menopause,  is  sufficient  to  establish  the  probable  diagnosis  of 
malignant  adenoma  and  to  make  radical  treatment  justifiable. 

The  treatment  is  the  sam^  as  for  true  carcinoma  of  the  body  of  the 
uterus — viz.  total  hysterectomy,  by  the  vagina  if  possible. 

Sarcoma  of  the  Uterus  is  rare :  it  may  occur  at  any  period  from  child- 
hood to  old  age  ;  its  most  frequent  development  has  been  noted  as  a  degenerative 
change  in  fibro-myomata.  Its  symptoms  and  cause  are  not  essentially  different 
from  those  of  other  forms  of  uterine  malignant  disease,  and  its  treatment  is 
the  same. 

THE   fallopian   TUBRS. 

Inflammation  of  the  Fallopian  Tubes,  or  Salpingitis,  is  a  frequent 
condition,  being  secondary  to  inflammatory  conditions  of  the  endometrium. 
Septic  endometritis  and  gonorrheal  endometritis  stand  in  a  direct  causative 
relation  to  nearly  all  cases  of  salpingitis.  Tuberculosis  occasionally  develops 
in  the  Fallopian  tubes  and  determines  its  own  type  of  inflammation.  Cancer 
of  the  uterus,  as  it  disintegrates,  is  accompanied  with  secondary  septic  infec- 
tions that  may  be  propagated  to  the  tubes  and  determine  there  inflammatory 
complications  of  more  immediate  danger  and  suffering  than  the  primary  dis- 
ease. Both  tubes  become  affected  in  about  one-half  the  cases.  When  but 
one  tube  is  diseased,  the  left  tube  is  the  one  most  frequently  affected. 

Pathology. — The  changes  in  the  muco.sa  of  the  tubes  are  those  common 
to  inflamed  mucous  membranes  in  general,  and  depend,  as  to  their  extent, 
upon  the  intensity  and  depth  of  the  inflammation.  The  tissues  of  the  tube 
become  infected,  swollen,  and  succulent ;  the  secretion  is  increased  in 
amount,  and  in  the  more  severe  cases  is  purulent.  The  tube  elongates  and 
becomes  somewhat  convoluted.  The  most  important  changes  are  those  which 
result  from  the  involvement  of  the  peritoneum  in  the  inflammatory  processes. 

65 


102G 


A  A   AMEliKWy    'lEXr-liOOK   OF  SiJiiJJJliY 


Local  peritonitis  may  be  excited  either  by  extension  of  the  infianunation 
throujili  the  wall  of  the  tube  to  its  investing  peritoneinn  or  by  the  escape  of 
infective  secretions  from  the  ojien  abdominal  end  of  the  tube.  Diftuse,  raj)i<lly- 
fatal  ])eritonitis  may  result,  but  in  general  the  peritonitis  remains  localized 
within  the  pelvis,  and  by  its  exudate  cements  together  to  a  varying  degree 
the  pelvic  organs.  In  the  majority  of  cases  the  peritoneal  inflammation  is 
limited  to  the  immediate  neighborhood  of  the  abdominal  end  of  the  tube, 
the  fiml)ri;\}  of  -which  become  agglutinated  and  adherent  to  tlie  ovary  or  other 
adjacent  structure.  The  minute  uterine  orifice  of  the  tube  early  becomes 
blocked  by  infiammatory  swelling  of  the  mucosa,  so  that  the  occlusion  of  the 
abdominal  opening  determines  an  accumulation  of  its  secretions  within  the 
closed  tube  and  its  greater  or  less  distention,  forming  a  convoluted  sausage-like 
bodv  hanginjx  down  bv  the  side  of  the  uterus.     (See  Fiir-  407.) 

Fig.   407. 


Hydrosalpinx  (Hennig). 

If  the  retained  fluid  is  purulent,  the  condition  is  that  known  as  pi/osalpinz  ; 
if  the  secretion  is  mucoid  and  limpid,  possibly  chocolate-colored,  a  hydrosalpinx 
is  present.  A  bloody  effusion  constitutes  hemafosalpiur.  There  is  reason  to 
believe  (Bland  Sutton)  that  nearly  all  cases  of  blood-effusions  into  the  Fallo- 
pian tubes  are  results  of  a  tubal  pregnancy. 

The  ovary  becomes  involved  early  when  the  inflammation  extends  to  the 
peritoneum.  Its  capsule  undergoes  inflammatory  thickening ;  its  follicles  are 
unable  to  discharge  their  contents  and  become  converted  into  cystic  dilatations 
(Fig.  401>) ;  the  suppurative  process  may  extend  to  one  of  these  dilatations, 
and  an  ovarian  abscess  result. 

Pus  enclosed  in  a  Fallopian  tube  is  practically  an  abscess  within  the  cav- 
ity of  the  pelvis,  and  has  often  been  spoken  of  as  pelvic  abscess.  If  the  in- 
fection is  active  and  the  local  conditions  are  favorable,  the  pus  may  continue 
to  accumulate  until  great  distention  of  the  tube  has  been  produced;  mean- 
while, extensive  adhesions  to  adjacent  organs  are  formed,  so  that  the  ultimate 
openinfi'  of  the  abscess  may  be  into  intestine,  vagina,  or  bjaihler.  or  it  may 
find  its  way  to  the  surface  in  the  inguinal  region.  Less  frequently  it  bursts 
into  the  free  peritoneal  cavity.  In  more  favorable  cases  the  obstruction  at  the 
uterine  orifice  may  be  overcome  and  the  tube  discharge  itself  into  the  uterus ; 
in  other  instances  the  active  suppuration  is  arrested,  the  secretion  becomes 
inspissated,   and  a  thickened,   chronically  inflamed  tube,  enclosing  a  limited 


SUBGERV  Of   rill-:   ri:.UMJ:   aKMlHATlVE   OUGANS.    1027 

amount  of  thick  jms,  rt'iiiains.  A  slow  afcmnulatioii  of  serous  lluid  may  take 
place  into  such  a  cavity,  convertinj;  it  into  a  hydrosalpinx. 

Salpiui^itis  may  from  the  outset  l)e  less  severe  in  its  type  than  has  })een 
described,  may  never  determine  peritoneal  comj)lications,  and,  like  any  other 
mucous  catan-Ji.  may  subside  and  leave  no  pei'maiii'iit  daraa<fe  Ix'hirid  it.  The 
swellin<^  of  the  mucous  lining  of  the  tube  leads  to  temporary  obstiuction  of  the 
uterine  orifice,  and  to  the  production  of  the  symptoms  of  tubal  distention  with 
the  increased  mucous  secretion.  Under  treatment  the  iiiHammation  subsides, 
the  orifice  a<xain  becomes  patent,  and  the  retention  is  relieved  by  the  escape 
of  the  secretion  into  the  uterus.      Such  attacks  are  liable  to  recur. 

The  symptoms  of  salpingitis  will  vary  acconlini:;  to  the  acuteness  of 
the  attack,  the  virulence  of  the  infection,  the  involvement  of  the  peritoneum, 
and  the  e.xistence  of  occlusion  and  distention  of  the  tubes.  Acute  suppura- 
tive salpim/itis  is  ushered  in  by  rigors,  fever,  and  pain  in  the  lateral  regions 
of  the  pelvis.  Pressure  into  the  pelvis,  either  from  above  or  from  the  vagina, 
shows  great  tenderness.  Conjoined  mani))ulati()n  makes  evident  to  the  finger 
in  the  vagina  or  the  rectum  the  more  or  less  swollen  tube.  The  involvement 
of  the  peritoneum  is  signalized  by  a  more  diffused  pain  and  tenderness,  with 
some  tympanites.  The  pouring  out  of  exudate  into  the  pelvic  pouch  and  the 
cementincT  t02;ether  of  the  organs  give  to  the  examinin";  finijer  a  sense  of  a 
hard  mass  filling  up  more  or  less  of  the  pelvis,  enveloping  the  uterus  and 
appendages,  and  immobilizing  the  uterus.  The  later  general  symptoms  are 
those  of  chronic  septicemia  attending  pus-collections  anywhere,  leading  to 
exhaustion  and  death. 

Chronic  Salpingitis. — If  the  acute  onset  is  limited  in  its  invasion  and 
subsides  into  a  chronic  state,  there  will  persist  a  dull  pain  in  the  pelvis,  which 
is  aggravated  by  motion,  as  in  walking,  or  by  coition  ;  there  is  local  tenderness  ; 
menstruation  will  be  painful,  the  flow  being  increased  in  frequency  and  amount; 
the  enlarged  tubes,  more  or  less  obscured  by  adhesion  to  adjacent  viscera  and 
by  inflammatory  exudations,  will  be  perceptible  to  the  examining  finger  as  elon- 
gated swellings  at  the  side  of  or  behind  the  uterus.  The  patient  is  rendered  a 
chronic  invalid  by  reason  of  continual  pain  and  the  aggravation  of  her  suffer- 
ings Avliich  any  attempt  to  engage  in  the  activities  of  life  produces.  If  the 
aff'ection  is  bilateral,  sterility  results. 

Catarrhal  Salpingitis  declares  itself  by  pain,  tenderness,  and  SAvelling 
along  the  course  of  the  tubes,  which  fall  short  of  the  more  threatening  and 
severe  symptoms  already  detailed.  A  sudden  amelioration  of  all  symptoms 
may  occur,  with  disappearance  of  what  may  previously  have  been  a  well-defined 
tumor,  as  the  inflammation  subsides  sufficiently  to  permit  the  tube  to  empty 
itself  into  the  uterus. 

The  diagnosis  requires  a  careful  comparison  of  the  history  of  the  case 
with  the  symptoms  and  conditions  evident  to  physical  examination.  The  dif- 
ferentiation of  salpingitis  from  other  pelvic  conditions  which  may  be  confounded 
with  it  is  often  difficult,  and  sometimes  impossible,  previous  to  operation.  Doubt 
may  arise,  more  especially  in  cases  of  small  ovarian  and  parovarian  growths, 
early  tubal  pregnancies,  small  pedunculated  uterine  fibro-myomata,  exudations 
into  the  substance  of  the  broad  ligaments,  and  even  retroflexions  of  the  uterus, 
all  of  which  may  simulate  closely  the  conditions  of  chronic  salpingitis.  A  his- 
tory of  a  labor  or  abortion  complicated  by  the  development  of  peritoneal  symp- 
toms as  the  beginning  of  the  trouble  in  question,  or  of  trouble  developing 
after  some  minor  gynecological  procedure,  or  of  the  previous  existence  of  an 
acute  vaginitis  and  endometritis  possibly  or  confessedly  gonorrheal,  creates  a 
strong  presumption  in  favor  of  salpingitis.     Pain,  tenderness,  and  a  definable 


1028  ^-l^V  AMi:iU('Ay  TEXT-nOOK  OF  sunaERY. 

intrapolvic  mass,  all  may  attend  tlic  conditions  cnuiru'ratcd  as  lialtlc  to  be  con- 
founded with  salpingitis,  Imt  the  characteristic  history  is  likely  to  he  hickin<^. 
Ovarian  affections  form  swellin<;s  that  are  not  so  directly  continuous  with  the 
uterus  as  are  tubal  swellings;  broad-li;^ament  effusions,  comparatively  rare,  are 
lower  down  in  the  pelvis  and  depress  the  vault  of  the  vagina;  a  retroflexion 
of  the  uterus  will  escape  recognition  only  through  haste  or  lack  of  practice  in 
the  examiner.  Notwithstanding  these  academic  distinctions,  it  is  often  the 
case  that  adhesions  and  exudations  and  distentions  so  alter  the  relations  and 
contour  of  parts  in  the  pelvis  as  to  make  their  ])ositive  identification  impos- 
sible to  the  most  experienced  examiner.  Salpingitis  may  coexist  with  other 
intrapelvic  affections,  another  source  of  confusion  being  thus  added  to  the 
diagnosis. 

Tubercular  salpingitis  may  be  suspected  when,  in  young  women  whose  life 
is  above  susj)icion  as  regards  gonorrheal  or  other  common  septic  infection,  the 
usual  signs  of  tubal  inflannnation  and  enlargement  develop.  If  tuberculosis 
in  other  parts  of  the  body  coexists,  the  suspicion  is  strengthened. 

The  prognosis  of  the  milder  forms  of  salpingitis  is  good :  even  in  cases 
whose  onset  is  acute  and  severe,  under  proper  treatment  speedy  amelioration 
and  ultimate  recovery  may  be  hoped  for.  This  occurs  only  when  the  disease 
is  arrested  and  subsides  without  having  causetl  occlusion  of  the  abdominal 
opening  of  the  tubes.  In  some  of  these  cases,  however,  the  recovery  is  not 
absolute,  but  a  latent  infection  remains  for  an  indefinite  time  that  may  be 
reawakened  into  severe  activity  by  some  new  exciting  cause  in  after-years. 
Under  proper  treatment  decided  amelioration,  and  occasionally  entire  recovery, 
may  at  times  be  secured  in  cases  that  presented  every  evidence  of  occlusion  of 
the  tube :  in  a  large  proportion  of  such  cases,  however,  the  condition  persists 
uninfluenced  to  any  marked  extent  by  treatment,  and  is  to  be  relieved  only  by 
extirpation  of  the  tube.  When  the  suppuration  is  frankly  declared  and  is  pro- 
gressive, its  spontaneous  evacuation  through  the  vagina  or  the  rectum  may  be 
followed  by  ultimate  recovery  or  by  gradual  wasting  from  prolonged  septic 
absorption.  The  danger  of  the  bursting  of  such  an  abscess  into  the  general 
peritoneal  cavity,   with  rapid  death,   is  always  considerable. 

The  treatment  in  the  acute  stage  requires,  first  of  all,  absolute  rest  in  the 
recumbent  position.  Hot  fomentations  should  be  kept  applied  to  the  hypogas- 
trium  ;  copious  hot  vaginal  douches  at  intervals  of  four  or  six  hours  sliould  be 
administered;  the  bowels  should  be  freely  moved  by  salines;  pain,  if  severe, 
should  be  controlled  by  opiates,  but  the  amount  given  should  be  kept  at  the 
minimum  consistent  with  the  relief  of  pain.  As  the  acuteness  6f  the  symp- 
toms subsides  the  fomentations  are  omitted,  the  douches  are  diminished  in  fre- 
(juency,  and  a  gradual  restoration  to  activity  is  allowed.  If  with  the  subsi- 
dence of  the  acute  symptoms  the  evidences  of  permanent  change,  involving 
intra-peritoneal  inflammatory  exudates,  occlusion,  and  distention  of  the  tubes, 
persist,  the  further  ado])tion  for  a  time  of  means  for  promoting  absorption 
of  inflammatory  exudates  is  to  be  recommended.  The  iodides  and  saline 
laxatives  may  be  administered;  the  vault  of  the  vagina  may  be  painted 
with  tincture  of  iodine  once  or  twice  a  week.  A  weekly  insertion  of  a  vag- 
inal tampon  charged  with  boro-glyceride  may  be  resorted  to.  The  regular  use 
of  a  copious  hot  vaginal  douche  twice  daily  for  a  prolonged  period  is  to  be 
kept  up.  As  long  as  improvement  attends  these  measures  they  should  be  con- 
tinued. In  a  fair  proportion  of  cases  a  gradual  return  to  health  takes  place: 
many,  however,  remain  rebellious,  any  temj)orary  improvement  being  (juickly 
overcome  if  the  patient  attempts  to  go  about  or  to  perform  any  work.  Wlien 
the  disease  has  been  demonstrated  to  be  incurable  by  these  means  of  treatment. 


SURGERY   or   Till-:   FEMALE   GENERATIVE   ORGANS.    1029 

extirpation  of  tlu'  diseased  tubes  hv  abdominal  seetion  sboubl  be  done.  This 
extirpation  should  not  be  deferred  until  the  patient  is  worn  out  through  h)ng 
suffering,  but  should  be  resorted  to  as  soon  as  the  inefficiency  of  less  radical 
measures  lias  been  uninistakal)ly  demonstrated.  The  techniciue  of  the  ojM-ra- 
tion  retjuired  for  removal  of  the  tul»es  will  be  considered  in  connection  with 
that  re([uired  for  the  extirj)ation  of  degenerated  ovaries,  with  which  they  are 
usually  associated. 

When  the  suppuration  within  the  tube  is  abundant  from  the  outset,  and 
causes  the  rapid  accumuhition  of  a  considerable  amount  of  pus  within  the 
dilated  tube  or  in  spaces  outside  of  the  tube  shut  in  by  adhesions,  attended  by 
all  the  local  and  constitutional  symptoms  of  an  acute  abscess,  the  pus-cavity 
must  be  evacuated  as  speedily  as  possible  by  puncture  from  the  vagina  if  it 
tends  to  bulge  into  that  canal  and  its  fluctuation  is  appreciable  there ;  other- 
wise by  abdominal  section  and  enucleation  if  possible  :  in  any  event,  the  cavity 
must  be  opened  and  emptied,  the  contact  of  its  contents  with  the  general  peri- 
toneum prevented  as  far  as  possible,  and  free  drainage  provided  for  by  means 
of  glass  tubes  reinforced  Avith  iodoform  gauze  tampons. 

Neoplasms  of  the  Fallopian  Tube  are  very  seldom  met  with,  and  hardly 
merit  special  attention.  Descriptions  of  one  or  two  isolated  cases  of  myoma 
and  of  primary  carcinoma  may  be  found  in  literature.  According  to  Bland 
Sutton,  adenomata  are  not  infrequent,  being  met  with  as  papillomatous  masses 
springing  from  the  tubal  mucosa  distending  the  tube  and  sprouting  out  into 
the  free  pelvic  cavity.  They  determine  a  copious  effusion  into  the  peritoneal 
cavity,  and  are  possible  causes  of  some  otherwise  inexplicable  cases  ot  obstinate 
ascites.     Tubes  thus  affected  should  be  extirpated  by  abdominal  section. 

Tubal  Pregnancy. — For  details  pertaining  to  the  etiology  and  patho- 
logical anatomy  of  tubal  pregnancy  reference  must  be  made  to  treatises  upon 
obstetrics.  Its  diagnosis  and  treatment,  however,  engage  in  a  special  degree 
the  attention  of  the  surgeon.  When  rupture  occurs,  in  a  great  majority  of 
instances  the  immediate  and  bold  intervention  of  the  surgeon  is  re(|uired  to 
avert  impending  death.  In  the  few  instances  in  which  the  conditions  after  the 
primary  rupture  of  the  tube  make  any  further  development  of  the  embryo 
possible,  the  ultimate  intervention  of  the  surgeon  will  be  required,  according 
to  the  special  conditions  of  the  particular  case,  either  to  avert  disaster  from 
a  second  rupture,  to  secure  the  removal  of  a  sac  filled  with  an  infected  mass  of 
decaying  debris,  to  liberate  a  feeble  or  imperfectly-developed  foetus,  or  to  rid 
the  body  of  the  encumbrance  of  the  degenerated  remains  of  a  foetus  that  has 
perished.  All  forms  of  extra-uterine  gestation  pass  their  primary  stages  in 
the  Fallopian  tube.  As  the  growth  of  the  ovum  proceeds,  the  structure  of  the 
tube  is  such  as  to  make  inevitable  one  of  the  following  events : 

1.  The  vascular  relations  of  the  ovum  may  be  so  defective  that  after  a  few 
weeks  it  perishes;  an  extravasation  of  blood  from  ruptured  chorionic  villi  pro- 
duces or  attends  this  result ;  the  rapidly-increasing  distention  of  the  tube  from 
this  hemorrhage  may  be  so  great  as  to  cause  its  rupture,  or,  if  not,  there  per- 
sists a  blood-tumor  of  the  tube,  a  heviatomljnnx,  which  may  rupture  at  some 
later  time  or  remain  as, a  source  of  local  irritation,  attended  with  pain  and  pro- 
ducing disability. 

2.  If  the  ovum  has  become  fixed  in  the  outer  third  of  the  tube,  it  may 
during  the  first  eight  weeks  of  its  development  become  extruded  into  the  peri- 
toneal cavity  through  the  still  open  ostium  abdominale>  Shock  and  hemorrhage 
accompany  this  accident.  This  is  the  most  frequent  source  of  intra-peritoneal 
pelvic  hematocele. 

3.  If  the  ovum  continues  to  grow,  or  if  it  is  suddenly  enlarged  by  a  copi- 


1030 


^l.V  AMKJUCAX    Ti:XT-Ji()OK   OF  tSriidEHY. 


s  liomorrli;i<ie  into  its  villi,  rupture  of  the  tube  inevitably  results  (Fig.  408). 

ich  ruj)ture  is  tVe(iueiit  between  the  third  and  tenth  -weeks  after  impregnation, 
and  is  rarely  deferred  beyond  the  twelfth  week.  If  the  site  of  tlie  ovum  is 
along  the  middle  third  of  the  tube,  the  line  of  rupture  may  be  through  the 
floor  of  the  tube  into  the  connective  tissue  of  the  broad  ligament,  but  in  th 


OUS   1 

Sue 
an 


Tubal  Pregnancy,  rupture  at  ew\  of  second  month:  Td,  ruptured  luhe  ;  li,  i^Wo.  of  rupture;  Od,  right 
ovary;  Xrc/,  right  round  ligament :  T^s  left  tul)e  :  Acs,  left  tube  round  ligument ;  /'/',  peritoneum  ;  Oj, 
section  of  frozen  specimen  ;  MR,  Miiller's  internal  os  ;  Oe,  external  os  (Handl). 

or  it  may  become  the  subject  of  infection  and  septic  changes.  If  the  primary 
rent  is  too  small  to  permit  the  escape  of  the  ovum  through  it,  recurrences  of 
bleeding  are  induced  until  fatal  anemia  results. 

4.  If  the  rent  in  the  tube  opens  into  the  conneetive-tissue  spaces  of  the 
broad  ligament,  the  hemorrhage  becomes  restrained  by  the  resistance  of  the 
tissues,  and  a  more  or  less  extensive  hematoma  or  hematocele  of  the  broad 
ligament  results.  If  the  ovum  is  already  dead,  or  dies  as  the  result  of  the 
rupture,  it  and  the  effused  blood  will  in  time  become  absorbed,  and  recovery 
after  a  prolonged  illness  may  result.  If  the  ovum  survives  the  accident,  room 
for  its  further  growth  for  a  time  is  provided  for  by  the  gradual  opening  up  of 
the  broad  ligament. 

In  the  majority  of  cases  the  foetus,  after  a  variable  ]»eriod  of  feeble  struggle 
for  life  in  its  new  relations,  dies.  If  it  escapes  infection,  it  may  be  retained 
for  an  indefinite  time,  undergoing  mummification  or  saponification  or  becoming 


SURGERY  OF  THE  FEMALE  GENERATIVE  ORGANS.    1031 

encrusted  Avitli  limo-salts.  Mure  IViMjueiitly  iurcctiou  is  tnuisniiticd  to  it 
tlirough  adjacent  tissues,  and  the  decomposition  and  suppuration  resulting 
produce  a  higlily  septic  pelvic  abscess.  If,  however,  the  life  of  the  foetus  is 
prolonged,  its  growth  is  attended  by  the  formation  of  a  sac  by  the  stripping 
up  of  the  peritoneum  from  all  the  adjacent  jtarts.  Ruptui-c  of  this  sac  may 
occur  at  any  time  :  if  the  rupture  shoidd  involve  the  site  of  the  placenta,  pro- 
fuse and  rapidly  fatal  bleeding  results ;  otherwise  the  foetus  may  escape  into 
the  free  peritoneal  cavity,  and,  being  still  nourished  by  its  previous  placental 
attachments,  continue  its  growth  there ;  again,  rupture  may  never  occur,  but 
the  development  of  the  f(etus  may  go  on  to  term  and  spurious  labor  take 
place,  the  foetus  die,  the  liquor  amnii  be  absorbed,  and  indefinite  retention  of 
the  degenerated  fwtus  follow.  In  any  case  in  which  abscess-formation  takes 
place  the  collection  may  find  vent  externally  through  the  rectum,  vagina, 
bladder,  or  uterus,  or  may  point  through  the  abdominal   wall. 

The  diagnosis  of  tubal  gestation  before  rupture  is  very  difficult.  A 
distinction  is  to  be  made  from  inflammatory  conditions  of  the  Fallopian 
tube  or  of  the  broad  ligament  and  from  small  ovarian  growths.  At  best, 
the  decision  can  rarely,  if  ever,  be  a  positive  one.  The  early  symptoms  of 
conception  when  the  ovum  is  fixed  in  a  tube  do  not  differ  so  much  from  those 
attending  uterine  pregnancy  as  to  attract  attention,  so  that  it  is  not  until  rup- 
ture takes  place  that  suspicion  of  the  presence  of  any  trouble  is  awakened. 
The  symptoms  that  attend  rupture  are  pain,  shock,  vomiting,  and  the  signs  of 
internal  hemorrhage.  There  is  usually  some  bloody  vaginal  discharge,  accom- 
panied with  shreds  of  decidual  membrane  from  the  uterus  sufficient  to  suggest 
abortion.  The  abdominal  pain  and  general  depression  are  like  that  attending 
acute  intestinal  strangulation  or  perforation  or  axial  rotation  of  the  pedicle 
of  an  ovarian  cyst.  The  condition  may  be  confounded  with  that  due  to  the 
passage  of  renal  or  biliary  calculi.  The  analysis  of  the  symptoms  and  the 
attendant  circumstances  should,  however,  so  strongly  indicate  the  presence  of 
a  progressive  internal  hemorrhage  as  to  justify  immediate  opening  of  the  abdo- 
men, thereby  to  corroborate  or  disprove  the  diagnosis.  If  the  rent  is  minute 
and  the  hemorrhage  slight,  possibly  frequently  recurrent,  the  signs  of  acute 
anemia  are  absent  and  the  case  resembles  one  of  an  inflammatory  nature. 

When  the  rupture  takes  place  into  the  connective-tissue  spaces  of  the  broad 
ligament,  the  pain  and  shock  are  considerable,  but  are  less  threatening  of 
immediate  dissolution,  and  pass  off  after  a  time,  Avhile  to  the  touch  an  effusion 
into  the  substance  of  the  broad  ligament  is  perceptible.  If  the  embryo  lives, 
its  further  growth  will  cause  a  gradually  increasing  laterally  placed  tumor  to 
develop,  in  which  in  advanced  cases  the  outlines  of  the  foetus  may  become 
perceptible. 

The  treatment  of  a  tubal  pregnancy  should,  if  possible,  consist  in  its 
immediate  extirpation  1?y  abdominal  section.  The  improbability  of  the  con- 
dition being  recognized  in  its  earliest  stages  will  render  operation  for  its 
extirpation  at  that  period,  before  rupture,  very  rare,  although  then  it  could 
be  done  Avith  facility.  The  comparative  safety  of  abdominal  section,  the 
clearing  aAvay  of  obscurities  that  may  have  hung  about  the  diagnosis,  and 
the  definite  removal  of  the  disease  which  it  secures  combine  to  render  such 
operative  interference  desirable  as  soon  as  reasonable  ground  is  found  for 
believing  a  gravid  tube  to  be  present,  rather  than  the  adoption  of  the  electric 
currents  and  interstitial  injections  which  have  been  proposed  for  destroying 
the  ovum  and  leaving  it  in  situ. 

When  rupture  has  occurred  and  dangerous  hemorrhage  is  going  on,  the 
abdomen  must  be  opened  at  once  by  an  incision  several  inches  in  length,  free 


I0;i2  AN  AMrJilCAX   TKXT-liOOK  OF  SUIWERY. 

enouirh  to  permit  the  easy  inspection  of  tlie  cavity  of  the  pelvis:  the  ruptured 
tube  must  he  removed  and  perieet  hemostasis  be  effected  by  suitable  lifiatures, 
after  which  all  blood-clots  and  otlier  effusions  must  be  sponged  out,  followed 
by  copious  flushings  of  the  pelvic  cavity  with  warm  salt  solution.  In  many  in- 
stances great  advantage  will  be  derived  from  a  simultaneous  intravenous  infu- 
sion  of  salt  solution  to  the  extent  of  a  quart  or  more,  to  overcome  anenua  and 
shock.  If  the  o{)eration  has  been  preceded  by  a  more  or  less  prolonged  history 
of  recurrent  hemorrhages,  with  formation  of  adhesions  and  infljimmatory  exu- 
dates, the  cleansing  of  the  peritoneal  cavity  must  be  imperfect,  and  drainage  by 
tube  and  gauze  tampons  will  be  required.  If  a  secondary  rupture  of  a  broad- 
ligament  sac  has  taken  place,  after  the  peritoneal  cavity  has  been  cleansed  the 
rent  in  the  sac,  if  possible,  should  be  sewed  into  the  abdominal  wound,  and  the 
cavity  treated  thereafter  as  an  abscess-cavity  till  it  becomes  obliterated. 

In  cases  in  which  ])rimary  rupture  into  the  connective-tissue  spaces  of  the 
broad  ligament  has  been  attended  with  the  death  of  the  embryo,  no  opera- 
tive interference  is  called  for.  But  if  the  embryo  survives  and  continues  to 
grow,  it  should  be  removed  without  delay.  Before  the  fifth  month  the  gesta- 
tion mass  can  be  readily  enucleated  as  a  whole.  From  the  fifth  month  onward 
the  involvement  of  neighboring  parts  by  the  expansion  of  the  sac  will  have 
become  such  as  to  prohibit  enucleation.  The  sac  must  then  be  sewed  into 
the  incision  in  the  abdominal  wall,  and  incised,  the  foetus  removed,  and  the 
placenta  removed  if  it  is  detached;  otherwise  left  for  subsequent  spontaneous 
detachment,  while  the  cavity  of  the  sac  is  irrigated,  tamponed  with  iodoform 
gauze,  and  treated  as  an  open  abscess-cavity.  Especial  risks  attend  attempts 
to  remove  a  growing  extra-uterine  foetus  of  this  class,  owing  to  the  possibility 
of  the  placental  site  being  at  the  place  of  incision;  in  which  case  a  copious 
hemorrhage  will  result,  to  be  arrested  only  by  compression  of  the  abdominal 
aorta. 

Whenever  infection  of  an  extra-uterine  foetal  mass  has  taken  place,  the 
decomposing  suppurating  collection  must  be  dealt  with  according  to  the  gene- 
ral principles  applicable  to  such  abscesses.  It  is  only  in  cases  in  which  the 
abscess  tends  to  point  into  the  vagina  that  attempts  should  be  made  to  reach 
it  and  evacuate  its  contents  through  that  canal. 

The  hope  of  securing  the  ultimate  delivery  of  a  viable  child  should  never 
cause  postponement  of  operative  interference  after  a  diagnosis  of  extra-uterine 
pregnancy  has  been  arrived  at.  since  such  children,  if  they  arrive  at  term  and 
are  delivered  living,  are  gencrallv  punv  and  malformed  and  rarelv  survive  manv 
weeks,  while  postponement  of  operative  relief  is  always  attended  with  increas- 
ing risk  to  the  life  of  the  mother. 

SURGERY  OF  THE   BROAD  LIGAMENTS. 

Parametritis  or  Pelvic  Cellulitis. — Inflammation  of  the  connective- 
tissue  substance  of  the  broad  ligaments  is  comparatively  rare  as  a  primary  dis- 
ease. Its  general  cause  is  sepsis  conveyed  through  some  abrasion  or  other  injury 
of  the  vault  of  the  vagina  or  of  the  wall  of  the  uterus,  by  means  of  Avhich  an 
infective  inflammation  is  excited  in  the  course  of  the  veins  or  lymphatics  of 
the  broad  ligament.  The  resulting  phlegmon  may  cause  an  inflammatory  infil- 
tration of  varying  extent  of  the  pelvic  subperitoneal  connective  tissue  which 
imbeds  and  fixes  the  uterus.  The  overlying  peritoneum  shares  in  the  inilam- 
mation,  and  adds  its  own  exudates  and  adhesions  to  those  caused  by  the  changes 
in  the  cellular  tissue.  The  inflammation  tends  to  terminate  in  supj)uratiun  : 
not  infrequently  a  chronic  non-sup})urating  inflammatory  condition  is  engen- 


SURGERY  OF   Till':   FKMALI'J   (lENERATJ  VP:   ORGANS.    1033 

dered,  which  ])ro(liices  infiltrations  and  contractions  sufficient  to  cause  perma- 
nent disphiceinents  and  impairment  of  function  in  the  pelvic  viscera. 

The  symptoms  do  not  difter  from  those  already  described  in  connection 
with  intlauimations  of  the  endometrium  and  of  the  Fallopian  tubes  ;  which  con- 
ditions are  usually  in  some  degree  associated  with  the  cellulitis  itself.  In  the 
more  acute  forms  the  ]»ain  is  severe :  rigors  and  fever  attend  the  onset  of  the 
attack,  and  are  continued  by  the  establishment  of  suppui'ation.  The  pus  may 
discharge  itself  by  way  of  the  vagina,  rectum,  bladder,  or  abdominal  wall,  and 
by  the  formation  of  imperfectly  drained  pus-cavities  may  give  rise  to  a  wasting 
septicemia. 

The  diagnosis  is  to  be  made  by  careful  bimanual  examination,  which  will 
show  the  existence  of  an  infiltration  into  the  spaces  of  the  broad  ligament,  pro- 
truding downward  into  the  vagina,  displacing,  possibly,  the  uterus  to  one  side, 
and  spreading  upward  and  outward  within  the  broad  ligament  to  the  brim  of 
the  pelvis.  If  the  peritoneal  pouches  can  be  felt  to  be  empty  and  the  ovaries 
free,  the  diagnosis  is  corroborated.  The  existence  of  other  inflammatory  com- 
plications will  usually  make  all  these  conditions  obscure. 

The  prognosis  in  recent  cases,  under  proper  treatment,  is  in  general  good, 
but  when  by  long-standing  chronic  inflammatory  conditions  permanent  atrophy 
of  tissue,  with  displacement  and  adhesions,  of  organs,  has  developed,  a  state  of 
permanent  invalidism  is  created  Avhich  at  best  can  be  only  ameliorated. 

The  treatment  is  the  same  as  that  which  has  already  been  detailed 
for  other  pelvic  inflammations.  An  especially  definite  good  result  n)ay  be 
expected  in  these  cases,  when  the  acute  symptoms  have  subsided,  from  the 
use  of  local  resolvents,  as  painting  of  the  vault  of  the  vagina  with  tincture  of 
iodine,  prolonged  and  frequent  hot  vaginal  douches,  and  the  use  of  boro-glyce- 
ride  vaginal  tampons.  The  prolonged  and  free  use  of  saline  cathartics  is  like- 
wise of  great  value. 

Pelvic  Hematocele  may  be  accepted  as  a  general  term  for  all  blood- 
effusions  into  the  pelvis.  Effusions  into  the  free  peritoneal  cavity  are  desig- 
nated by  the  term  intra-peritoneal  hematocele ;  those  into  the  connective- 
tissue  interstices  of  the  broad  ligaments,  by  the  term  hematoma  of  the  broad 
ligament.  By  far  the  most  common  source  of  intra-peritoneal  blood-effusions 
is  tubal  gestation,  and  they  have  already  been  considered  in  connection  with 
that  condition.  The  production  of  hematoma  of  the  broad  ligament  as  the 
result  of  rupture  of  a  gravid  tube  has  also  been  described.  Such  hematomata 
may  also  be  caused  by  the  rupture  of  varicose  veins  situated  in  the  tissue  of 
the  broad  ligament.  Such  accidents  have  commonly  associated  with  them 
the  sudden  arrest  of  the  menstrual  flow. 

Extravasations  of  blood  in  considerable  amount  into  the  tissue  of  the  broad 
ligament  are  likewise  among  the  common  accidents  from  imperfect  hemostasis 
after  operations  for  the  removal  of  growths  from  that  structure.  The  after- 
course  of  these  hematomata  does  not  differ  from  that  of  similar  effusions  in 
other  parts  of  the  body.  The  fluid  portion  is  absorbed  ;  the  residual  elements 
gradually  disintegrate  and  are  slowly  absorbed  ;  and  ultimately  the  effusion 
disappears.  In  exceptional  instances  an  accidental  infection  is  introduced  and 
suppuration  complicates  the  course  of  the  case. 

The  occurrence  of  the  hemorrhage  is  marked  by  sudden  sharp  pain  in  the 
pelvis  and  well-marked  shock,  soon  passing  off  with  the  rapid  development  of 
a  more  or  less  extensive  tumor  within  the  layers  of  the  broad  ligament.  In 
the  more  aggravated  effusions  the  pressure  of  the  blood-mass  dissecting  into 
the  connective-tissue  spaces  about  the  rectum  and  bladder  provokes  marked 
tenesmus  of  those  parts,  and  in  the  rectum  mechanical  constipation.     Local 


]0;J4  ^I.V  AMHIilCAX   TEXT-nOOK   OF  SCIidKRV. 

exiiniination  reveals  to  the  touch  a  diflused  tuiiHtr  within  the  hroad  liframont, 
wliieh,  wlien  ot"  sullicient  extent,  can  be  apfji-eciated  hy  abdominal  j)al|)ation 
as  a  mass  rising  up  laterally  from  the  pelvis,  distinctly  confined  within  mem- 
branous barriers.  This  tumor  is  free  from  the  extreme  sensitiveness  which 
attends  inflammatory  effusions,  an<l  later  will  be  observed  to  undergo  gradual 
contraction,  finally  to  disappear.  The  suddenness  of  the  attack  and  of  the 
development  of  the  tumor  and  the  absence  of  the  characteristic  signs  of  acute 
inflammation  will  serve  to  diagnosticate  a  hematoma  from  an  inflammatory 
eflliision:  the  distinct  limitation,  the  nodular  feel,  the  lateral  position,  and  the 
speedy  cessation  of  the  constitutional  signs  of  hemorrhage  which  attend  hema- 
toma will  differentiate  it  from  the  soft,  limitless,  shifting  mass,  pushing  down- 
ward the  posterior  vaginal  vault,  which  results  from  bleeding  into  the  free  peri- 
toneal cavity — a  form  of  henutrrhage  which,  if  extensive  enough  to  produce 
marked  symptoms,  almost  invariably  goes  on  to  a  fatal  end  if  not  arrested  by 
operative  measures. 

Small  or  partly  absorbed  hematomata  may  be  confounded  with  tumors  of  the 
Fallopian  tubes,  with  fibro-myomata  of  the  uterus  developing  outward  into  the 
folds  of  the  broad  ligament,  and  with  cysts  of  the  broad  ligament :  but  careful 
study  and  repeated  observation  of  the  later  course  which  the  pelvic  mass  pur- 
sues should  suffice  for  the  distinction. 

The  treatment  of  hematoma  of  the  broad  ligament  is  purely  expectant. 
Intra-peritoneal  hematocele  requires  abdominal  incision,  exposure,  and  ligation 
of  the  bleeding  point,  involving  the  ablation  of  the  distended  and  ruptured  tube 
and  the  cleansing  of  the  peritoneal  cavity  from  the  effused  blood. 

SURGERY  OF  THE  OVARIES. 

Ovarian  Hernia. — An  ovary  has  occasionally  been  found  in  a  hernial 
sac,  in  which  relation  it  may  present  itself  as  a  tumor  as  far  down  as  the  labium 
majus.  Unless  it  becomes  inflamed  or  the  subject  of  other  disease,  such  dis- 
placement has  no  pathological  significance  and  produces  ho  symptoms  nor  dis- 
ability. Suspicion  of  the  presence  of  an  ovary  in  a  hernia  will  be  aroused  if 
a  somewhat  hard,  elastic,  ovoid  body  is  detected  in  a  la])ium  or  in  the  inguinal 
canal,  which  resists  pressure  and  temporarily  swells  during  the  menstrual 
epochs.  If  upon  examination  the  uterus  is  found  to  have  its  fundus  tilted 
over  to  the  affected  side,  and  a  connection  between  the  uterus  and  the  ovoid 
body  can  be  established  by  mani])ulation,  the  diagnosis  is  rendered  certain. 
If  the  ovary  can  be  reduced  into  the  abdominal  cavity,  it  should  be  done,  and 
its  further  escape  prevented  by  a  suitable  truss  :  if  the  ovary  is  diseased  and 
the  cause  of  suffering,  it  should  be  extirpated^  otherwise  no  treatment  is 
required. 

Prolapse  of  the  Ovary  downward  into  the  peritoneal  pouch  behind  the 
uterus,  where  it  may  readily  be  felt  by  the  examining  finger,  is  not  uncommon. 
It  may  be  due  to  relaxation  of  the  broad  ligament  from  imiterfect  involution 
after  labor  or  to  increase  in  weight  of  the  organ  from  disease.  The  pressure 
of  a  fecal  mass  from  above  may  have  dragged  it  down,  or  the  [trolapse  may 
be  consecjuent  upon  the  changes  attending  retroversion  of  the  uterus.  The 
mere  change  in  its  position  has  no  special  significance  and  gives  rise  to  no 
sym))toms,  but  Avhen  the  ovary  is  enlarged  and  congested  its  presence  in  the 
cul-(le-sac  may  expose  it  to  such  pressure  during  defecation,  walking,  or  coition 
as  to  cause  pain  and  disability.  When  such  symptoms  are  present,  it  is  gen- 
erally the  case  that  the  displacement  of  the  gland  is  only  an  incident  in  in- 
flammatory disturbances  of  the  ovary,  and  the  tube  is  often  firmly  bound  by 


SURG  Kin'  or  Till-:  female  generative  organs.  io35 


adhesions  in  its  j»l;icc.  If  tlic  <tvary  is  iiKjviihk'  and  there  is  no  coexistent 
disease  callin<;  for  its  ablation,  and  yet  the  disability  from  its  presence  in  the 
ciil-de-sae  is  such  as  to  call  for  relief,  it  may  he  lifted  uj)  by  slutrtening  the 
round  ligaments. 

Inflammation  ok  the  Ovauiks.— Three  classes  of  inflammatory  affec- 
tions of  the  ovaries  may  be  distinguished :  1.  An  acute  sejitic  inflammation, 
tending  to  rapid  disorganization,  the  organ  l)eing  implicated  in  an  acute, 
often  fatal,  spreading  septic  inflammation  of  the  uterus,  tube,  and  pelvic  peri- 
toneum. 2.  An  inflammation  likewise  excited  by  infection  from  a  pre-existing 
salpingitis  of  subacute  or  chronic  type,  in  which  first  the  capsule  of  the 
ovary,  and  later  the  deeper  structures  of  the  organ,  become  involved.  3.  A 
slowly-developing,  primary  inllammation  of  the  tissue  of  the  ovary  itself, 
chronic  in  its  tendencies,  having  its  beginning  in  a  chronic  hyperemia  of  the 
gland  due  to  functional  derangement  and  sexual  excitation,  and  displaying 
but  little  tendency  to  involve  ailjacent  organs.  Between  the  first  two  of  these 
classes  there  is  no  distinct  dividing-line:  the  difference  is  one  of  degree  and 
not  of  kind — one  of  clinical  rather  tlian  of  etiological  or  pathological  import- 
ance. In  both  classes  the  ovarian  inflammation  is  an  incident  in,  or  a  part 
of,  a  widespread  affection  involving  the  endometrium,  the  appendages,  and 
the  contiguous  peritoneum.  Tiie  conditions  attending  the  development  and 
extension  of  this  septic  inflammation,  and  the  manner  in  which  the  ovary 
becomes  involved  in  it  by  infection,  have  already  been  described  in  the  sections 
devoted  to  Inflammations  of  the  Uterus  and  of  the  Fallopian  Tubes. 

The  changes  which  are  produced  in  the  ovary  are  those  incident  to  gland- 
ular inflammations  in  general.  In  the  more  acute  and  virulent  attacks  tissue- 
necrosis     and    suppuration 

quickly  supervene,  with  de  I^'i<i.  409. 

struction  of  more  or  less  of 
the  gland,  and  with  subse- 
quent history  of  pelvic  ab- 
scess in  those  cases  in  which 
limiting  adhesions  form 
early  enough  to  shut  off  the 
general  peritoneal  cavity 
and  to  avert  speedy  death 
from  diffuse  septic  perito- 
nitis. In  the  milder  cases 
the  investing  tunic  of  the 
ovary  is  thickened  by  inter- 
stitial proliferation  and  by 
deposit  upon  it  of  plastic 
j)eritoneal  exudates,  which 
at  the  same  time  bind  it 
more  or  less  extensively 
and  firmly  to  adjacent  sur- 
faces. The  ovary  is  for  a 
time  swollen  by  congestion 
and  inflammatory  exudates 
both  into  the  follicular  cavi- 
ties and  among  the  fibers 
of  its  stroma.  Later,  this 
enlargement  gives  place  to  atrophy  and  condensation  through  absorption  of 
eflfusion,  organization   and  contraction  of  new-formed   connective  tissue,   and 


Chronic  Ovaritis  witli  Multiple  Cysts  (Winckel). 


103(;  AA  AMi:iiicAy  text-iujok  or  sinaiJiY. 

general  ])r()oe.ss  of  sclerosis  of  inflaiuinutory  origin.  This  atropliy  of  the  tissue 
of  the  «i;lau(l  may  he  more  than  ecjnijK'nsated  for  hy  jtcrsistent  ami  increasing 
cystic  dilatation  of  altered  follicles,  hy  hhjod-etVusions,  and  hy  limited  sui)|)H- 
rativc  foci,  so  that  a  very  manifest  enlargement  of  the  organ  may  persist 
indefinitely  (Fig.  409). 

Evervdegree  of  disease  in  respect  to  acuteness  or  chronicity,  and  to  the 
amount  of  tissue-damage  inflicted,  may  he  presented  in  different  cases.  Both 
ovaries  may  ))e  affected,  or  but  one.  When  hut  one  ovary  is  affected,  a  later 
affection  of  the  other  is  prone  to  occur. 

The  prognosis  will  vary  according  to  the  character  and  extent  of  the 
tissue-changes.  Under  favorable  circumstances,  with  proper  treatment,  in 
the  less  severe  cases  recovery  may  be  secured  with  more  or  less  atrophy 
and  loss  of  secreting  structure.  In  many  cases,  indeed,  there  will  be  pre- 
served sufficient  normal  structure  to  carry  on  the  process  of  ovulation  and 
to  make  impregnation  possiljle  if  the  Fallopian  tube  is  also  patent.  In  the 
more  severe  cases,  when  abscesses  have  formed,  spontaneous  evacuation  may 
occur,  most  frequently  through  the  rectum,  with  subsequent  contraction  and 
obliteration  of  the  cavity,  and  gradual  absorption  of  inflammatory  exudates 
and  atrophy  of  the  remnants  (»f  the  destroyed  organ.  In  a  large  proportion 
of  cases,  however,  the  inflammation  of  the  organ  ])ersists  for  an  indefinite 
time,  with  alternations  of  remission  and  exacerbation  of  its  symptoms,  a  con- 
stant source  of  suffering  and  of  disability.  When  the  pus-cavities  exist  in  the 
ovarv  thev  may  determine  the  signs  indicative  of  retained  pus,  and  when  not 
relieved  by  art  or  nature  may  lead  to  exhaustion  and  death  from  septic  absorp- 
tion, or  in  more  favorable  cases  may  undergo  resorption.  The  prognosis  in  a 
given  case  will  ])e  closely  bound  up  with  that  of  the  complicating  salpingitis 
and  perimetritic  peritonitis,  of  Avhich  account  must  always  be  taken. 

The  symptoms  are  not  definite,  being  usually  obscured  and  dominated 
by  those  due  to  the  pre-existing  tubal  and  peritonitic  conditions.  Often  a  tube 
and  an  ovarv  are  bound  up  together  indistinguishably  in  a  mass  of  inflamma- 
tory exudate.  Pain  in  the  ovary  is  constantly  present  as  a  dull  ache,  rendered 
worse  by  physical  exertion  or  by  local  pressure  or  concussion,  as  in  defecation 
or  coition.  Violent  pain  is  usually  excited  at  each  menstrual  jjcriod :  if  the 
loss  of  blood  is  profuse,  the  pain  may  be  alleviated  after  the  flow  has  become 
well  established.  Multiform  reflex  pains  are  prone  to  be  manifested  in  distant 
parts,  with  marked  emotional  and  neurotic  disturbances  of  the  most  varied 
character.  The  general  health  suffers,  digestion  is  interfered  with,  and  in  the 
chronic  forms  permanent  invalidism  is  entailed.  Sterility  is  the  result  of  the 
changes  in  the  tubes  and  ovaries  and  of  the  impossibility  of  enduring  the 
marital  approach  by  reason  of  the  pain  it  produces. 

In  cases  in  which  the  surrounding  disease  is  comparatively  slight,  or  in 
which  its  results  have  been  modified  by  time  and  treatment,  the  enlarged, 
nodulated,  sensitive  ovary  may  be  isolated  and  recognized  by  the  finger  in  the 
vagina  or  the  rectum  with  the  help  of  bimanual  palpation. 

The  treatment  is  that  which  has  already  been  described  as  required  for 
inflammation  of  the  Fallopian  tubes — rest,  purgation,  local  anti))hlogistic  and 
resolvent  applications,  general  hygiene,  and,  finally,  in  default  of  recovery 
under  such  measures,  extirpation  of  the  diseased  organs  by  abdominal 
section. 

Chronic  Ovaritis  not  due  to  direct  septic  infection  is  slow  and  gradual  in 
its  development,  being  preceded  for  a  prolonged  period  by  simi)le  hyperemia. 
This  long-continued  congestion  eventuates  in  degenerative  changes,  the  more 
aggravated  cases  presenting  thickening  of  the  investing  tunic  with  degeneration 


SURGERY   OF    rili:   FEMALE   <  i  F.\  Fi:ATI  V  F   OliOANS.  1037 

of  till'  follicles  into  small  cysts,  and  an  increase  in  (piantity  of  the  connective- 
tissue  stroma,  ■with  atropjiy  of  the  proper  ;:lan(iiilar  tissue/ 

Tile  etiology  of  this  (tvarian  con<;estion  and  inllaniniation  is  ohscure  :  it 
is  apparently  closely  associated  in  many  instances  with  deranged  ovarian  inner- 
vation ;  it  develops  most  frecpiently  with  excitahle.  unstahle,  emotional  natures; 
it  may  be  associated  with  un^natified,  perhaps  unrecognized,  sexual  desire,  and 
in  some  instances  it  is  excited  by  unnatural  sexual  gratificati(»n. 

The  symptoms  are  pain  in  the  region  (»f  the  ovaries,  aggravated  at  the 
menstrual  |)eriods ;  menstruation  tends  to  excess  both  in  quantity  and  in  fre- 
quency ;  the  ovaries  are  tender  and  swollen  ;  backache  and  headache,  with  the 
myria(i  vague  pains  of  neurasthenia  and  hysteria,  are  frecjuent  attendants. 

The  diagnosis  is  to  be  made  by  bimanual  palpation,  by  which  the  tender- 
ness and  the  enlargement  of  the  ovaries  are  directly  ascertained  and  the  signif- 
icance of  the  syniptonis  confirmed. 

The  prognosis  is  favorable,  as  a  rule,  under  proper  treatment.  But  when 
profound  structural  changes  have  taken  place  in  the  ovaries,  a  less  favorable 
prospect  is  to  be  acknowledged,  and  in  some  cases  nothing  short  of  the  ablation 
of  the  diseased  organs  Avill  bring  relief. 

In  the  treatment  those  measures  which  have  to  do  with  the  regulation 
of  the  general  life  play  an  important  part.  All  occasions  of  emotional  and 
sexual  excitation  are  to  be  removed.  Moderate  exercise,  the  avoidance  of 
everything  likely  to  induce  or  aggravate  pelvic  congestion,  regular  hours  of 
sleep,  rest  in  bed  during  the  menstrual  periods,  regulation  of  t^e  bowels,  and 
general  tonics,  are  to  be  enjoined,  combined  with  prolonged  counter-irritation  by 
repeated  blisters  to  the  abdominal  surface  over  the  site  of  the  ovaries.  As  a 
last  resort,  when  all  measures  have  failed  to  afford  relief,  and  chronic  suffer- 
ing and  invalidism  are  unavoidalile,  the  affected  organs  may  be  extirpated  by 
abdominal  section. 

Ablation  of  the  Uterine  Appendages  by  Abdominal  Section. — 
The  names  of  different  surgeons  are  often  attached  to  this  jirocedure.  and  the 
practice  may  possibly  be  convenient  in  the  direction  of  brevity,  but  the  above 
simple  descriptive  term  is  much  to  be  preferred.  The  term  oophorectomy  is  also 
in  frequent  use.  This  term,  however,  does  not  in  itself  include  the  idea  of  the 
removal  of  a  part  or  the  whole  of  the  Fallopian  tube,  which,  as  a  rule,  is  as 
important  a  part  of  the  operation  as  the  removal  of  the  ovary.  As  a  general 
term,  therefore,  the  designation  "ablation  of  the  uterine  appendages."  bein^r 
brief,  comprehensive,  and  descriptively  correct,  deserves  to  be  used  to  the  exclu- 
sion of  all  others. 

Ablation  of  the  uterine  appendages  has  been  advised  in  the  preceding  pages 
for  the  following  con<litions  :  1.  Cases  of  uterine  fibro-myomata  attended  with 
serious  menorrhagia;  2.  Chronic  inflammation  of  the  Fallopian  tube,  with 
retention  of  inflammatory  products  within  the  distended  tube;  3.  Chronic 
and  intractable  inflammation  of  the  ovary,  attended  with  pain  and  disability; 
4.   Early  tubal  gestation. 

In  addition  to  these  indications,  the  operation  has  been  resorted  to  many 
times  for  the  relief  of  marked  nervous  disturbances  of  maniacal,  epileptic,  and 
hysterical  character,  which  were  aggravated  or  elicited  by  each  recurring  men- 
strual epoch.  In  a  few  instances  marked  improvement  has  followed  the  opera- 
tion, but  in  so  small  a  proportion  of  cases  that  at  present  the  weight  of  authority 
is  against  the  operation  in  these  neurotic  cases  unless  distinct  evidences  of 
disease  of  the  ovaries  can  be  obtained.  In  severe  and  intractable  dysmenor- 
rhea due  to  such  arrested  development  of  the  uterus  that  the  normal  function 
of  the  uterus  in  the  processes  of  menstruation  is  imperfect,  while  the  ovaries 


1038  AX  AMi:iiI('AX  TEXT-Ji(J(JK  OF  SL'liC'ERY. 

are  snfficientlv  (Icvcloped  to  produce  their  refrular  monthly  niolimiriii,  the 
removal  of  the  a|)j)i'ii(l;i<;es  is  the  only  treatment  available,  and  is  to  he  resorted 
to  without  hesitation  alter  failure  of  j)i()loni:ed  efiorts  to  stimulate  the  "growth 
of  the  uterus. 

Operative  Teehniqiic. — The  preparation  of  the  patient  and  all  the  attendant 
details  for  the  prevention  of  septic  infection  are  the  same  as  have  been  elsewhere 
described  (]).  1012).  The  incision  through  the  alxlominal  wall  is  short,  midway 
between  the  unil)ilicus  and  the  piibcs  ;  tlic  opening  in  the  j)eritoncum  should 
be  simply  lari»;e  enou<fh  to  admit  two  fingers,  which  at  once  seek  the  fundus  of 
the  uterus  and  thence  trace  the  tubes  outward  to  the  ovaries.  If  there  are  no 
adhesions,  the  conclusion  of  the  operation  is  very  simple,  and  is  quickly  accom- 
plished by  pulling  the  ovary  up  into  the  incision  by  the  fingers  or  by  suitable 
forceps.  The  broad-ligament  pedicle  is  transfixed  by  a  needle  or  ]>ointed  for- 
ceps, which  carries  through  a  loop  of  strong  silk  thread  with  which  the  pedicle 
is  tied  in  two  parts  ;  into  the  loop  on  the  uterine  side  tiie  tube  is  pulled,  so  as 
to  secure  the  removal  of  most  of  its  length.  The  knots  having  been  strongly 
and  securely  tied,  the  pedicle  is  severed  about  a  quarter  of  an  inch  beyond  the 
ligature,  and  the  stump,  after  having  been  carefully  inspected  to  detect  any 
possible  hemorrhage,  is  dropped  back  into  the  pelvis. 

In  cases  of  uterine  fibro-myoma.  if  the  tumor  is  large  and  adherent,  great 
difficulties  may  be  experienced  in  finding  and  removing  the  ovaries.  The 
situation  of  the  ovary  will  vary  greatly  according  to  the  site  and  direction  of 
growth  of  the  tumor.  The  tumor  must  be  pulled  aside  and  each  ovary  sought 
for  after  such  enlargement  of  the  abdominal  incision  as  may  be  demanded  to 
secure  ease  and  ])rccision  of  manipulation.  If  the  difficulties  in  securing  the 
ovaries  are  found  to  l)e  insurmountable,  hysterectomy  may  be  substituted. 

AVhen  the  npj)endages  are  matted  together  or  are  glued  by  intlammatory 
adhesions  to  adjacent  structures,  their  enucleation  and  removal  introduce  com- 
plications into  the  operation  which  demand  time  and  the  greatest  amount  of 
patience  and  skill  upon  the  part  of  the  operator.  Especial  difficulty  and 
danger  attach  to  adhesions  to  the  urinary  bladder  and  to  the  intestine.  As 
a  rule,  enucleation  can  best  and  most  safely  be  accomplished  by  the  fingers. 
It  is  to  be  remembered  that  the  ovary,  swollen  and  heavy,  naturally  sinks 
down  into  the  posterior  peritoneal  pouch,  where  it  becomes  covered  in  by 
inflammatory  exudate.  Here,  therefore,  it  is  to  be  sought  by  the  linger,  which 
begins  its  work  by  breaking  down  adhesions  at  the  lowest  point  of  the  posterior 
pouch  as  it  proceeds  to  dig  out  the  ovary  from  its  bed  of  exudate.  Carefully 
keeping  close  to  the  ovary,  it  is  gradually  enucleated;  the  swollen  or  thickened 
tube  may  be  identified  as  the  enucleation  proceeds,  and  is  in  turn  liberated, 
until  finally  the  mass  is  sufficiently  unfolded  to  be  brought  up  into  sight. 
Should  the  broad  ligament  be  so  shortened  and  rigid  as  to  prevent  the  forma- 
tion of  the  usual  pedicle,  it  will  have  to  be  sewed  ofl",  as  has  been  described. 
The  arrest  of  bleeding  from  the  bed  out  of  which  the  appendages  have  been 
enucleated,  and  the  sul)sc(iuent  use  of  drainage,  are  to  be  governed  by  the 
principles  })reviously  laid  down. 

If  the  sense  of  sight  is  re([uired  to  deal  intelligently  with  any  complica- 
tion that  may  be  met  with,  the  pelvis  should  be  rMise<l  into  the  Trendelenburg 
position  (Fig.  402),  and  the  abdominal  incision  prolonged  as  needed  to  secure 
the  re(juired  exposure.  This  is  especially  desirable  if  the  tubes  or  ovaries  are 
distemled  with  pu-*,  on  account  of  the  danger  of  rupture  of  the  sacs.  In 
d'.'aling  with  such  accumulations  of  pus  the  general  ]>critoneal  cavity  should 
be  shut  off  bv  sterile  gauze  i)ads  before  much  manijiulation  of  the  |)us-filled 
sac  is  attempted.      If  the  sac  ruptures,  the  effused  pus  should   be  carefully 


SURGERY  OF   Till-:   FKyTM.K  CENERATIVE  ORGANS.    1039 

sponged  out,  mtlicr  ilnin  WMshcd  (.iit.  mid  ili-.iiiia;:*'  instituted.  If  there  is  a 
large  |iiis-eavity  vliieli  euniiot  be  eiiuclt'a(»'(l,  tlic  opcniiig  into  it  slioid<l,  if 
possible,  be  sewn  into  tiie  ubdonunal  wound  antl  a  drainage-tube  be  earried 
through  its  bottom  into  the  vagina.  It"  the  abdominal  walls  cannot  be  de- 
pressed sulliciently  to  reach  the  abi5cess-oj)ening,  reliance  will  have  to  be  placed 
on  iodoform-gauze  packing  and  the  usual  glass  drain.  The  toilet  of  the  peri- 
toneum, the  question  of  drainage,  the  closure  of  the  wound,  and  the  subseciuent 
care  are  to  be  governed  by  the  jirinciples  apj)licable  to  abdominal  operations 
in  general. 

The  niiniaJitii  following  operations  for  aldation  of  the  uterine  appendages 
depends  much  upon  the  skill  and  experience  of  the  individual  operator  and 
upon  the  character  of  the  cases  operated  upon.  It  is  susceptible  of  reduction 
to  a  very  small  figure.  Different  surgeons  have  reported  long  series  of  cases, 
amounting  to  hundreds,  with  a  mortality  of  less  than  5  per  cent. 

Ulthnate  l\e>mlts. — The  proportion  of  cases  in  Avhich  restoration  to  health 
is  secured  to  the  extent  of  freedom  from  pain  and  restoration  to  comfort  and 
usefulness  is  by  no  means  commensurate  with  the  proportion  of  recoveries 
from  the  operation.  In  many  cases,  although  the  diseased  appendages  are 
safely  removed,  there  remain  intrapelvic  indurations  and  adhesions  which 
cause  persistent  pelvic  pain,  uterine  congestions,  and  vesical  and  intestinal  <lis- 
turbances.  Fatal  intestinal  obstruction  from  angulation  of  adherent  intestine 
is  an  occasional  sequel.  Immediate  relief  to  pain  is  the  exception.  Usually 
the  pelvic  pains  persist  for  months,  gradually  but  ultimately  disappearing,  pos- 
sibly not  until  after  the  lapse  of  some  years;  in  some  cases  the  relief  is  never 
perfect.  A'^entral  herniae,  sinuses  from  retained  infected  ligatures,  and  fecal 
and   urinary  fistuhu  are  among  the  occasional  sequelae. 

Mental  disturbances  sometimes  occur  after  the  removal  of  the  appendages. 
In  most  instances  the  lapse  of  time,  the  subsidence  of  pain,  the  improvement 
in  general  health,  and  the  influence  of  reassuring  advice  suffice  to  allay  these, 
although  in  certain  instances  an  unstable  mind  is  pushed  over  into  confirmed 
insanity.  Such  a  remotely  possible  event  should  have  no  weight,  however,  in 
determining  in  a  given  case  whether  the  appendages  should  or  should  not  be 
removed.  Fecundity  has  already  been  destroyed  by  disease,  but  the  possibility 
of  marital  congress  is  in  most  cases  restored.  The  sexual  appetite  is,  as  a  rule, 
restored  to  its  normal  condition ;  in  some  cases  it  is  diminished,  in  some  it  is 
increased.  The  menstrual  function  is  generally  quickly  abolished,  but  occa- 
sionally its  arrest  is  delayed  for  months,  and  in  about  lO  per  cent,  of  all  cases, 
menstruation  continues  with  its  usual  regularity.  No  changes  in  the  tastes, 
personal  appearance,  or  sexual  characteristics  result  from  the  removal  of  the 
appendages  of  adult  women,  other  than  those  resulting  from  the  relief  of  dis- 
ease and  the  abolition  of  pain. 

OVARIAN  TUMORS. 

The  ovaries  are  frequently  the  seat  of  new  growths,  especially  of  cysts. 
Of  10,290  tumors  examined  by  Williams,  80-4  had  their  origin  in  the  ovaries, 
including  87  more  properly  classifiable  as  cysts  of  the  broad  ligament.  Of  the 
whole  number,  752  were  cysts,  27  were  carcinomas,  24  were  sarcomas,  and  1 
was  a  fibroma.  Of  the  cysts,  30  contained  dermoid  elements.  These  figures 
will  give  a  clear  idea  of  the  relative  frequency  of  the  various  neoplasms  to 
which  the  ovaries  are  liable. 

OvARiAX  Cystomata. — The  pathology  of  cystic  growths  of  the  ovary  can 
be  understood  only  by  a  study  of  their  incipient  stages.     For  what  follows 


1040 


AN  AMERICAN  TEXT-BOOK  OF  SURGERY. 


given   to   Mr.   IJlaiid  Sutton,    by   whose    work   on   Surcjical 
Jvarks  and  Fallopinn  Tubes  much  light  on  the  pathology  of 


credit   is  to    be 

Diseases  of  the  Oi  ^  _  . 

these  affections  has  been  shed.     In  Fig.  410  is  given  a  diagrammatic  repre- 


FiG.  410. 


■'^s5lc5m8,o£11 


Diagram  retresenting  the  Cyst-regions  of  the  Ovary :  a,  oophoron ;  b,  paroophoron ;  c,  parovarium ;  k, 
Kobelt's  tubes;  jf,  Gartner's  duct  (from  original  drawing  by  Sutton). 

sentation  of  the  ovary  and  parovarium,  showing  its  division  into  an  egg-bear- 
ing portion,  tlie  oophoron ;  a  region  in  which  ova  are  not  found,  the  paroopho- 

FiG.  411. 


"'i^!^^^^'"' 


A    incipient  oophoriticeysf,  /?.  paroophoron ;  /'.parovarium;  F,  Fallopian  tube,  natural  size  (from  orig- 
'  inal  drawing  by  Sutton). 

ron;  and  th«  parovarium.  Cysts  developing  in  earh  ..f  these  present  dis- 
tinctive features.  .•       ..1 

Incipient  oophoritic  cysts  are  shown  in  Figs.  411  and  412,  representing  the 
two  clinical  varieties,  unilocular  and  multilocular  cysts. 

The  development  of  the.se  cvsts  is  due  to  changes  in  the  normal  ovarian 
follicles  In  their  earlier  historv  they  are  lined  with  epithelium,  which  later 
disappears  through  the  atrophic  changes  in  the  walls  of  the  cyst  caused  by  the 


SURGERY  OF  THE  FEMALE  GENERATIVE  ORGANS.  1041 

pressure  of  the  accumulating  fluid.  As  tlie  cyst  enlarges  it  causes  rapid 
absorption  of  the  paroophoron.  In  size  these  cysts  may  vary  from  the  smallest 
appreciable  follicular  dilatation  to  a  cyst  containing  gallons  of  fluid.     The 


Fio.  412. 


Human  Ovary  in  Section,  showing  a  Multilocular  Cyst  in  an  early  stage :  A,  oophoron  ;  B,  paroophorrpn  . 
P,  parovarium  ;  F,  Fallopian  tube  (from  an  original  drawing  by  Sutton). 

contents  may  be  a  thin,  colorless  fluid  or  a  thick,  tenacious  mucus.     The  fluid 
may  be  grumous  from  admixture  with  blood. 

Frequently  in  multilocular  cysts  the  epithelium  exhibits  very  active  changes, 
resulting  in  the  development  of  glandular  masses  and  the  production  of  a  com- 
plex tumor,  a  cysto- adenoma. 

Ovarian  dermoids  are  cysts  in  whose  walls  skin  elements  occur  in  varying 
degree.    In  such  cysts  hair,  sebaceous  glands,  sweat-glands,  teeth,  mammae,  horn, 
nail,  bone,  unstriped  mus- 
cle, and  brain-matter  have  ^^^-  '^^^■ 
at    times  been    identified. 
They  contain  a  pultaceous 
matter     formed    of     shed 
epithelium   and  epithelial 
debris,   sebum,   and   shed 
hair,  oil,  and  cholesterin. 

Tumors  arising  from  the 
structure  of  the  oophoron 
occur  at  all  periods  of  life. 
In  the  foetus  they  are  not 
infrequent.  A  large  pro- 
portion of  ovarian  tumors 
occurring  in  infancy  are 
dermoids. 

Parooplioritic  cysts  are, 
as  a  rule,  unilocular,  and 
differ  from  cysts  of  the 
oophoron  in  the  following 
particulars :  1.  They  do  not  affect  the  shape  of  the  ovary  until  they  have 
attained  an  important  size.  2.  They  always  burrow  between  the  layers  of 
the  meso-salpinx,  and  when  large  between  the  layers  of  the  broad  ligament. 
3.  The  interior  is  beset  with  warts  (Figs.  413  and  414).  The  warts  in  such 
cysts  vary  greatly  in  number.      They  may  cause  a  general  papillomatous  infec- 

66 


\kv>" 


Parooplioritic  Cyst,  showing  its  relations  to  tube,  ovary,  and  meso- 
salpinx (Dorau). 


1042 


AN  AMERICAN  TEXT-BOOK  OF  SriiGERY. 


tion  of  the  peritoneum.     They  are  rare  before  tlie  twenty-fifth  year,  and  are 
paost  common  between  the  twenty-fifth  and  fiftieth  years. 


Fici.  414. 


IV" 


lt:^. 


Ruptured  Paroophoritic  Cyst :  F,  Fallopian  tube  (from  an  original  drawing  by  Sutton). 

Papillomatous  Cysts  have  also  been  noted  as  arising  within  the  oophoron 
and  within  the  layers  of  the  meso-salpinx  entirely  independently  of  the  ovary 
or  parovarium.     (See  Figs.  415  and  416.) 

Fig.  415. 


Papillarv  Cyst  growing  between  the  layers  of  the  broad  ligament,  near  the  tubo-ovarian  ligament: 
A,  ovary  ;  P,  parovarium;  F,  Fallopian  tube  (from  original  drawing  by  Sutton). 

Parovarian  Cysts. — Cystic  dilatations  of  the  parovarium  burrow  be- 
tween the  layers  of  the  meso-salpinx  ;  they  are  usually  unilocular  and  filled 
with  a  clear  fluid  of  low  specific  gravity.  The  ovary  is  generally  found 
attached  to  one  side  of  the  cyst,  and  the  Fallopian  tube  is  stretched  over  the 
cyst.  (See  Fig.  417.)  They  do  not  often  contract  adhesions.  They  are 
almost  unknown  before  puberty. 

Ovarian  cysts  in  general,  in  the  great  majority  of  instances,  develop  during 
the  period  of  greatest  sexual  activity  in  women,  although  they  are  not  rare  in 
infancy  and  in  old  age.     There  are  many  observations  of  the  occurrence  of 


SURGERY  OF  THE  FEMALE  GENERATIVE  ORGANS.   1043 


Fig.  41  G. 


Papillomatous  Cj  st  of  the  Broad  Ligament 
(original; 


the  affection  .simultaneously  in  both  ovaries.     Their  rate  of  growth  is  variable 
and  uncertain. 

The  symptoms  Avhich  they  provoke  are  due  mainly  to  weight  and  pres- 
sure and  to  accidental  complications 
Avhich  may  develop.  Their  earlier 
history  is  often  marked  by  the  ab- 
sence of  noticeable  symptoms,  so  that 
not  infrequently  they  are  first  dis- 
covered by  accident  after  they  have 
attained  some  size.  Only  Avhen  the 
free  development  of  the  cyst  toward 
the  abdomen  is  hindered,  as  in  some 
broad-ligament  cysts,  are  symptoms 
referable  to  the  bladder — e.  g.  irrita- 
tion and  tenesmus — likely  to  be  pro- 
voked early.  In  some  cases  vague 
pelvic  distress  and  sense  of  weight  are 
soon  experienced  in  a  sufficient  degree 
to  invite  examination  and  lead  to  de- 
tection of  a  growth.  Menstrual  dis- 
orders are  comparatively  rare,  menor- 
rhagia  being  the  most  frequently  ob- 
served symptom  referable  to  the  ute- 
rus. When  the  cyst  has  emerged  from  the  pelvis  a  spherical  or  irregular 
tumor  causes  a  visible  enlargement  of  the  abdomen.     This  enlargement  may 

become  enormous,  produ- 
FiG.  417.  cing  distention   and  thin- 

ning   of    the    abdominal 
walls    and    protrusion    of 
the  umbilicus,  while  many 
dilated  veins  marble   the 
cutaneous  surfiice.      This 
SAvelling  is  flat  on  percus- 
sion and  is  fluctuant ;  pos- 
sibly   at    its    sides    solid 
masses  can  be  felt,  while 
about  it  a  zone  of  reso- 
^  nance    will    indicate    the 
presence  of  the  displaced 
intestines.     As  the  tumor 
becomes  large   enough  to 
distend    the    abdomen,    a 
train    of    pressure  -  symp- 
toms is  inaugurated,  involving  all  the  abdominal  organs  to  a  greater  or  less 
degree.     The  digestive  apparatus  is  disordered;  secretion  and  excretion  are 
faulty ;  emaciation  and  debility  result. 

By  compression  of  the  ureters  the  ready  flow  of  the  urine  into  the  blad- 
der is  interfered  with,  and  various  renal  disorders  are  engendered,  resulting 
finally  in  uremic  and  cardiac  complications.  (Edema  of  the  lower  limbs  and 
varicose  enlargements  of  the  leg  and  hemorrhoidal  veins  may  be  produced. 

When  the  abdominal  distention  is  .sufficient  to  embarrass  the  action  of  the 
diaphragm,  dyspnea,  and  later  cyanosis,  result.  Adhesions  between  the  tumor 
and  the  viscera  are  prone  to  form,  and  by  their  traction  to  interfere  with  func- 


■"^^K 
"i^'-^ 

'%>-^- 


A  Cyst  of  the  Parovarium,  showing  its  relation  to  ovary  and  tube 
two-thirds  its  natural  size  :  A,  oophoron  ;  B,  paroophoron  ;  F,  Fal 
lopian  tube  (from  an  original  drawing  by  Sutton). 


1U44  AN  AMIliaCAS   TKXT-JiOOK   OFSlliUKRY. 

tion  and  fause  pain  :  with  tlic  gradual  (Iev('lo|»nient  of  tlie  condition.-;  named 
discomfort  and  j)ain  are  added  ;  sleep  is  interfered  witli  ;  the  emaciation  and 
cnfeeblement  are  })ro<:;ressive;  a  facial  expression  indicative  of  ])ain  and  mal- 
nutrition ifafics  oi'dridiui)  becomes  well  marked;  and  finally  death  occurs 
through  exhaustion  and  uremia. 

The  accidental  complications  to  which  ovarian  cysts  are  especially 
liable  are  those  of  inflammation,  twisting  of  the  pedicle,  and  rupture. 

lufiammation  may  be  excited  by  infection  derived  from  adjacent  structures, 
especially  the  Fallopian  tube,  the  intestinal  canal,  and  the  urinary  liladder,  or 
by  defective  antiseptic  precautions  during  tapping.  'J'his  inflammation  may 
be  restricted  to  a  limited  portion  of  the  cyst-wall,  and  result  sim])ly  in  the 
formation  of  circumscribed  adhesions  to  neighboring  structures,  or  it  may  dif- 
fuse itself  over  the  whole  surface  and  produce  universal  adhesions  which  may 
unite  the  sac  to  all  the  abdominal  organs.  In  some  instances  the  newly-formed 
vessels  in  these  adhesions  are  very  numerous,  and  attain  so  great  a  size  as  to 
dwarf  those  of  the  pedicle  as  a  source  of  nutrition  to  the  tumor.  During  the 
process  of  organization  of  these  adhesions,  if  the  surfaces  remain  in  apposition, 
the  adhesions  will  be  close  and  sessile.  But  by  movements  while  the  inflam- 
matory exudate  is  still  soft  this  material  may  be  stretched  into  bands  of  some 
length  and  of  varying  width. 

Suppuration  in  an  ovarian  cyst  is  not  an  uncommon  accident,  occurring 
most  frequently  in  smaller  cysts  lying  low  in  the  pelvis,  especially  'dermoids. 
The  symptoms  that  indicate  inflammation  of  an  ovarian  tumor  are  those  of 
acute  circumscribed  peritonitis,  local  pain  and  tenderness,  possibly  an  initial 
chill,  followed  by  fever  and  general  disturbance.  The  violent  symptoms 
gradually  fading,  a  more  or  less  prolonged  local  tenderness  persists  for  a  time, 
but  ultimately  disappears.  Repeated  attacks  of  this  nature  may  mark  the 
history  of  a  case.  AVhen  suppuration  of  the  sac  occurs,  the  symptoms  are  more 
severe  and  prolonged,  and  develop  the  type  of  hectic  characteristic  of  deep- 
seated  acute  abscess.  Emaciation  and  exhaustion  from  septic  absorption  are 
rapid,  and,  unless  the  pus  finds  exit,  death  soon  follows.  Such  abscesses  may 
burst  spontaneously  into  any  of  the  neighboring  cavities  or  hollow  viscera  or 
upon  the  cutaneous  surftice.  The  resulting  sinuses  in  rare  instances  are  ade- 
quate to  the  full  evacuation  and  obliteration  of  the  cyst,  with  final  cure,  but 
more  often  fail  of  such  relief,  while  continued  retention  of  ])us  and  septicemia 
remain  to  prolong  the  sufferings  of  the  patient  and  to  determine  an  ultimately 
fatal  result. 

Torsion  of  the  Pedicle. — The  stretching  and  elongation  of  the  natural 
ovarian  attachments  as  an  ovarian  tumor  develops  serve  finally  to  provide  it 
with  a  pedicle  of  varying  length  and  breadth  in  Avhich  many  and  large  blood- 
vessels run.  Occasionally  the  cyst  is  caused  to  rotate  upon  its  axis  to  such  a 
degree  as  to  cause  torsion  of  this  pedicle.  This  accident  occurs  with  marked 
frequency  wdien  pregnancy  has  complicated  the  case,  more  especially  after 
delivery.  When  the  torsion  is  sudden  and  close,  the  veins  becoming  first  com- 
pressed, a  severe  venous  engorgement  of  the  cyst  is  produced,  with  much  exu- 
dation of  serum,  blood-extravasations,  distention  of  the  cyst,  and  ultimate 
necrosis  of  its  tissue.  When  the  torsion  is  more  slowly  effected  its  consequences 
may  be  limited  to  diminishing  the  blood-supply,  and  thus  to  atrophy  of  the 
tumor,  unless  new  vascular  connections  through  adhesions  have  been  formed 
sufficient  for  its  nutrition  independently  of  the  pedicle.  The  symjitoms  pro- 
voked by  the  occurrence  of  torsion  of  the  pedicle  of  an  ovarian  cyst  are  sudden 
and  violent  pain  in  the  abdomen  and  shock,  with  pot^sibly  a  noticeable  rapid 
increase  in  size  of  the  tumor  and  alterations  in   its  relative  position   in   the 


SURGEh'V  OF   Till-:   FKMALK  dKNERATIVK  ORGANS.    l()4o 

abdomen  and  in  its  ])rossnro-symptonis.  To  tlicse  may  1)0  added  the  symptoms 
of  intiM-nal  liomorrha^a*  wlicn  nuicli  cfViision  of  hlood  into  the  cyst-cavity  has 
taken  phvee.  The  sinhh-n  deveh)pmeiit  of  tliese  symj)tonis  in  a  woman  known 
to  have  an  ovarian  tiimoi-  is  sidlieient  to  estal)lish  a  probable  diagnosis  and  to 
call  for  inimeiliate  abdominal  section  for  its  relief. 

Bupturc  of  an  ovarian  cyst  may  be  occasioned  by  a  traumatism  :  it  may 
result  s])ontaneously,  as  from  erosion  ])roduced  by  tiie  pressure  of  intracystic 
papillary  growths,  or  from  necu'osis  owing  to  defective  nutrition  of  a  part  of 
the  cyst-wall,  or  follow  from  the  infhimniatory  changes  incident  to  supj)uration. 
The  rupture  may  be  into  the  free  peritoneal  cavity,  which  is  by  far  the  most 
frequent  occurrence,  or  into  any  of  the  hollow  viscera  with  which  adhesions 
have  been  formed. 

When  tlie  ovarian  fluid  is  clear  and  of  low  specific  gravity,  it  is  well  tole- 
rated by  the  peritoneum  and  is  rapidly  absorbed,  provoking  free  diuresis. 
When  the  fluid  is  colloid  in  character,  it  is  irritating  and  provokes  peritonitis. 
Rupture  of  a  cyst  may  result  from  the  distention  and  neci'osis  caused  by  tor- 
sion of  the  pedicle,  in  Avhich  case  free,  possibly  rapidly  fatal,  hemorrhage  from 
ruptured  vessels  is  likely  to  occur. 

The  diagnosis  of  ovarian  cysts  requires  for  its  establishment  a  careful 
examination  of  the  physical  characters  and  relations  of  a  growth,  taken  in 
connection  with  its  history.  In  cases  of  doubt  greater  positiveness  may  be 
arrived  at  by  taking  -advantage  of  the  relaxation  of  the  abdominal  and  peri- 
neal tissues  to  be  secured  by  anesthesia,  while  careful  palpation  and  percussion 
are  made.  In  cases  of  great  distention  of  the  abdomen  a  preliminary  tapping 
will  facilitate  examination. 

In  its  earliest  stages  an  ovarian  cyst  is  to  be  distinguished  especially  from 
small  pedunculated  subserous  fibro-myomata,  from  inflammatory  swellings 
of  the  appendages,  and  from  tubal  pregnancy.  It  is  possible  that  these  con- 
ditions may  coexist  with  ovarian  cyst  and  thus  obscure  the  diagnosis,  so  that 
at  times  it  may  be  difficult  to  make  out  positively  the  exact  nature  of  an  intra- 
pelvic  mass.  The  absence  of  the  special  symptoms  that  attend  the  various  con- 
ditions named  (for  which  see  the  sections  descriptive  thereof)  will  serve  to  indi- 
cate that  a  movable,  clearly-outlined  globular  mass  in  the  ovarian  region,  Avhich 
is  not  especially  tender  to  the  touch  and  which  is  discernible  by  bimanual  pal- 
pation, is  an  ovarian  cyst. 

When  the  tumor  has  risen  from  the  pelvis  into  the  abdominal  cavity,  spe- 
cial difficulties  of  diagnosis  will  present  themselves,  according  as  it  still  remains 
as  a  distinctly-outlined  growth  partially  filling  the  abdominal  cavity,  or  has 
attained  a  size  sufficient  to  fill  it  to  distention.  In  the  first  class  of  cases  it  is 
to  be  distinguished  from  a  distended  urinary  bladder,  from  normal  and  from 
extra-uterine  pregnancy,  and  from  cystic  degeneration  of  fibro-myomata.  The 
distinction  will  usually  not  be  difficult  if  the  possibility  of  the  existence  of 
these  conditions  is  borne  in  mind  and  their  existence  inquired  into.  A  dis- 
tended bladder  collapses  upon  the  introduction  of  a  catheter :  the  common  signs 
of  pregnancy  Avill  usually  reveal  themselves  if  sought  for.  Pregnancy  and 
ovarian  cvst  may  coexist,  and  thus  obscure,  for  a  time,  an  exact  appreciation 
of  the  condition  present.  Amniotic  dropsy  may  cause  the  distended  uterus  to 
simulate  for  a  time  a  fluctuating  cyst,  but  careful  examination  will  show  the 
tumor  to  be  the  distended  uterus.  In  any  case  of  doubt  as  to  the  existence  of 
presnancy  a  delay  of  a  few  months  at  most  will  determine  the  question.  The 
history  of  extra-uterine  pregnancy  and  the  character  of  the  resulting  tumor  will 
declare  its  existence  if  a  sufficiently  careful  examination  be  made.  A  fibro- 
cystic tumor  of  the  uterus  will  reveal  on  examination  the  symptoms  charac- 


1040 


AN  AMERICAN  TEXT-JiOOK  OF  SURGERY. 


Lateral  View  of  Abdomen  affected  with  Am 


Ml.lTt). 


teristic  of  uterine  fibro-myomata — cnlarfjcment  of  tlic  nfcriis,  clonjratcd  uterine 
t-anal,  continuity  of  structure  of  tumor  aiul  uterus,  and  Miciion-lia^fia. 

When  the  ahchtniinal  cavity  is  filled  to  distention,  so  as  to  obscure  any 
tumor  within,  the  (juestion  of  ascites  becomes  important,  and  the  dilleientia- 
tion  from  it  of  an  ovarian  cyst  a  matter  requirin<i  care.  The  histoiT  of  the 
case  may  give  information:  the  former  existence  of  a  laterally  placed  movable 
tumor  indicates  a  cyst ;  the  existence  of  chronic  disease  of  heart,  liver,  kid- 
neys, or  peritoneum  would  account  for  an  ascites.  The  shape  of  the  abdomen 
is  to  be  noted.  If  it  is  prominent,  tending  to  protrude  centrally,  with  its  great- 
est circumference  below  the  umbilicus,  which  is  not  jtrominent,  a  cyst  is  indi- 
cated ;  if  it  flattens  in  front,  with  bulging  in  the  ilanks  as  the  jjatient  lies  on  the 

back,  with    a   prominent 
Fig.  418.  umbilicus,    at    the    level 

of  which  the  circumfer- 
ence is  greatest,  ascites 
is  indicated.  Figs,  418 
and  419  illustrate  the 
difference. 

Upon  palpation  in  as- 
cites the  abdominal  wall 
is  soft  and  lax  unless  the 
distention  is  very  great, 
and  the  fluctuation  is 
most  distinct  from  flank 
to  flank  ;  in  a  cyst  the  ab- 
dominal wall  is  tense  and 
the  fluctuation  is  most  dis- 
tinct in  front.  The  area  of  dulness  on  percussion  is  a  very  im])ortant  difleren- 
tial  indication.     In  ascites  the  abdomen  is  resonant  in  front,  from  the  floating 

of  the   intestines   on  the 
Fi«-  419.  fluid,  and  the  flanks  are 

dull ;  the  area  of  dulness 
will  vary  with  change  of 
posture,  the  part  lying 
uppermost  being  always 
resonant.  In  cystomata 
the  area  of  dulness  is  in 
the  front  of  the  abdomen  ; 
changes  of  posture  do  not 
affect  its  position ;  its  lim- 
its are  sluirply  marked, 
and  it  is  surrounded  by 
an  area  of  intestinal  res- 
onance ;  even  when  the  cyst  is  of  large  size  resonance  can  usuallv  ))e  detected 
in  one  or  both  flanks  (Figs.  420  and  421). 

The  accumulation  of  dropsical  effusions  in  cyst-like  cavities  formed  by 
intra-peritoneal  adhesions  in  the  course  of  cancerous  and  tubercular  perito- 
nitis mav  form  tumors  that  will  simulate  to  some  extent  ovarian  cystomata. 
The  history  of  their  development  and  the  absence  of  the  special  signs  which 
attend  ovarian  growths  will  indicate  their  nature.  01)esity  may  give  rise  to 
suspicion  of  ovarian  tumor,  but  careful  examination  will  fail  to  elicit  any  signs 
confirmatory  of  the  suspicion.  lU-nal  and  liver  cysts,  when  enlarged  to  such  a 
degree  as  to  extend  down  into  the  pelvis,  may  be  confounded  with  ovarian  cysts. 


Lateral  View  of  Abdomen  affected  will 


Cyst  (Albert). 


SURGERY  or   THE   I1:M.\LI':  aENERATrri':  organs.   10I7 

As  long  as  a  line  oi"  ivsoiiaiicc  exists  l.etween  the  timior  and  the  piibes,  per- 
cussioirwill   serve  to  (litVereiitiate  tiiem.      'I'lie  diilness  of  a  liver  cyst  will  also 


Fig.  420. 


Fig.  J21. 


Ana  of  Duluess  (shaded)  in  Ovarian  Cystoma  (Barnes).       Area  of  Dulness  (shaded)  in  Ascites  (Barnes). 

usually  be  continuous  with  the  ordinary  liver  dulness.  That  of  a  renal  cyst 
will  extend  up  under  the  ribs  and  into  the  flanks  around  to  the  spine,  Avhile 
downward  over  its  center  may  be  traced  the  resonant  colon  Avhen  distended 

with  gas. 

The  prognosis  of  ovarian  cystomata  is  almost  wholly  bad  unless  they  are 
subjected  to  surgical  interference.  After  they  have  attained  sufficient  size  to 
affect  the  general  health,  but  a  brief  period  of  life,  rarely  exceeding  two  years, 
is  to  be  looked  for.  The  tendency  to  death  by  malnutrition  and  uremia  has 
been  already  mentioned.  Peritonitis  and  embolism  also  are  frequent  causes  of 
death.  Papillomatous  cysts  are  prone  to  malignant  degeneration.  In  rare 
instances  spontaneous  cures  take  place ;  they  follow  rupture  of  the  cyst,  or 
atrophy  caused  by  defective  nutrition  through  a  gradually  effected  twist  of  the 
pedicle. 

The  treatment  required  for  ovarian  cysts  is,  in  all  cases  where  possible, 
their  extirpation  by  surgical  means — ovariotomy :  palliative  tapping  is  to  be 
resorted  to  only  when  symptoms  of  extreme  pressure  require  immediate  relief. 
It  should  be  done  onlv'under  rigorous  antiseptic  precautions. 

Ovariotomy  was  first  done  in  1809  in  Danville,  Ky.,  by  Dr.  Ephraim 
McDow^ell  of  "that  village.  The  patient  recovered.  It  was  not  until  fifty 
years  later  that  the  operation  became  at  all  common.  Thanks  to  the  know- 
ledge of  the  principles  of  asepsis  and  antisepsis  that  has  become  general  dur- 
ino-  the  last  quarter  of  the  present  century,  early  resort  to  the  operation  is 
now  universal,  and  the  ratio  of  successful  results  following  it  is  very  large. 

Technique  of  Ovariotomy. — The  preparation  of  the  patient,  the  anti- 
septic precautions  attending  the  operation,  and  the  preliminary  incision  of  the 
abdominal  wall  are  to  be  conducted  as  described  on  page  1012.  The  cyst  hav- 
ino-  been  exposed,  a  finger  is  swept  over  its  anterior  surface  to  note  its  imme- 
diate relations  and  to  detach  any  soft  adhesions  that  may  be  present ;  then, 
while  the  abdominal  wound  is  made  to  gape  and  the  tumor  to  project  into  it 
by  proper  pressure,  a  large  canula  is  thrust  into  it,  either  through  a  small 
opening  made  with  a  bistoury  or  by  means  of  an  attached  trocar.     As  the 


104.S  J.V    AMKRICAy    TKXT-JiOOK    OF  SCRaKRV. 

fluid  of  the  cyst  is  evacuated  through  the  canuL'i,  the  cyst-wall,  seized  by 
broad-bladed  forceps,  is  drawn  up  and  out  through  the  incision,  the  abdominal 
wall  being  kej)t  applied  to  the  collapsing  cyst  by  the  continued  pressure  made 
by  an  assistant.  If  tlie  contents  of  the  cyst  are  too  thick  to  run  freely  through 
the  canula,  the  patient  is  to  be  turned  on  her  side  and  the  opening  in  the  cyst 
enlarged  sufficiently  to  permit  the  surgeon  to  introduce  his  hand  and  scoop  it 
out.  Multijde  secondary  cysts  may  be  broken  down  and  emptied  in  the  same 
Avay  if  they  are  not  reailily  penetrated  and  evacuated  by  the  canula  through 
the  primary  cyst.  Adhesions  as  they  are  met  with  are  to  be  overcome  in 
accordance  with  the  principles  specified  on  page  1038.  The  pedicle  is  to  be 
securely  tied,  the  C3^st  cut  away,  and  the  stump  of  the  pedicle,  after  careful 
inspection  to  make  sure  that  the  hemostasis  is  complete  and  secure,  is  dropped 
back  into  the  pelvis.  Broad-ligament  cysts  which  are  sessile  must,  if  possible, 
be  enucleated  after  proper  incision  of  the  layers  of  the  broad  ligament  that 
form  the  capsule.  If  this  enucleation  is  found  im])racticable,  the  edges  of  the 
cyst  and  capsule  are  to  be  stitched  to  tlie  abdominal  wound  and  the  cavity 
drained.  The  same  device  may  be  resorted  to  in  the  case  of  universally  adker- 
ent  cysts  whose  separation  seems  impracticable.  The  cleansing  of  the  peritoneal 
cavity,  the  closure  of  the  wound,  the  use  or  not  of  drainage,  and  the  after- 
treatment  are  in  accordance  with  the  general  princijiles  specified  on  page  987. 

BesuJts. — The  removal  of  ovarian  cysts  uncomplicated  by  extensive  or 
dense  adhesions  is  quickly  accomplished,  ordinarily  occupying  less  tlian  thirty 
minutes  in  the  hands  of  surgeons  of  average  dexterity.  The  mortality  in 
such  cases  is  between  5  and  10  per  cent.  In  complicated  cases  the  operation 
is  much  graver  in  its  prognosis,  the  death-rate  rising  to  from  10  to  25  per 
cent.,  being  influenced  much  by  the  dexterity  of  the  operator.  Shock,  hemor- 
rhage, and  sejjtic  peritonitis  are  the  chief  causes  of  death.  Intestinal  obstruc- 
tion from  angulation  of  the  bowel  through  adhesions  is  responsible  for  a  mor- 
tality of  about  1  per  cent. 

Solid  Tumors  of  the  Ovaries. — The  ovaries  may  be  the  subjects  of 
carcinoma,  sarcoma,  and  fibroma,  in  relative  frequency  according  to  the  order 
in  which  they  are  here  named.  The  symptoms  which  they  present  are  not 
characteristic  at  the  onset.  They  are  with  difficulty  distinguishable  from 
pedunculated  subserous  solid  growths  from  the  uterus.  They  early  provoke 
ascites.     They  should  be  extirpated  without  delay  after  recognition. 

Tumors  of  the  Broad  Ligament. — Cysts  of  the  broad  ligaments  have 
been  studied  with  ovarian  cysts,  with  which  they  are  clinically  closely  associated. 

Papillomata  of  the  Fallopian  Tubes  and  Fibho-myomata  of  the  tubes 
and  of  the  round  ligaments,  also  Malignant  Tumors  arising  primarily  in  these 
structures,  have  been  met  with.  ^Vhen  recognized,  they  are,  if  possible,  to  be 
extirpated  by  abdominal  section. 

Hydrocele  of  the  Round  Ligament. — Small  cysts,  containing  serum, 
are  sometimes  found  within  the  peritoneal  investment  that  ensheathes  the  round 
ligament  for  a  varying  distance  within  the  inguinal  canal.  They  present  them- 
selves as  ovoid,  tense  sacs  within  the  inguinal  canal  or  at  its  external  orifice. 
They  are  to  be  distinguished  from  herni;^.  from  glandular  enlargements,  and 
from  lymphatic  dilatations.  They  may  be  extirpated  with  the  knife  if  they 
are  the  cause  of  any  discomfort.  If,  as  in  some  cases  that  have  been  described, 
they  communicate  with  the  general  peritoneal  cavity,  they  are  practically 
hernial  sacs,  and  require  the  same  treatment  of  enucleation  and  tying  off  that 
would  be  suitable  to  the  latter  condition. 


DISEASES   AM>    /.XJllUHS    OF    THE   BREAST.  104:) 

CIIAPTEll    IX. 

DISEASES  AND  INJURIES  OF  THE  BREAST. 

Surgical  Anatomy. — Tt  l)ehooves  the  suro;eon  to  Ito  :i((|iiaiiito(l  uith  the 
niinutor  anatoiiiY  of  the  niainnia,  espooially  tlie  distrihution  of  its  lyinph-vessols, 
in  oi(Un-  correctly  to  diairiiosticatc  and  treat  its  diseases.  Owing  to  tlie  age  and 
the  dift'ering  functional  changes  to  which  it  is  subject,  the  size,  appearance,  and 
consistence  of  the  breast  vary  within  wide  limits,  but  the  gland-structure 
retains  its  normal  relations  with  the  circumjacent  tissues,  except  perhaps  when 
the  organ  is  unusually  pendulous.  The  hoionhtrtrs  of  the  breast  are  often  ill 
defined,  portions  of  the  gland-structure  irregularly  penetrating  the  surround- 
ing adij)ose  tissue,  especially  on  the  axillary  side,  and  at  times  these  glandular 
masses  appear  to  be  totally  dissociated  from  the  mamma  proper.  It  is  of  import- 
ance to  recall  this  when  operating  for  carcinoma.  The  gland  prope?',  however, 
is  included  within  a  firm  fascial  envelope,  which,  as  a  rule,  strictly  limits  inflam- 
matory infiltration  ;  thus  an  interacinous  abscess,  even  when  deeply  seated,  very 
rarely  becomes  a  post-mammary  one,  nor  does  the  latter  penetrate  between  the 
gland-lobules,  and  by  the  directions  thus  compulsorily  pursued  by  the  pus  in 
neglected  cases  of  these  diseases  the  original  seat  of  the  trouble  can  often  be 
determined.  Posteriorly,  the  fascia  of  the  pectoralis  major,  serratus  magnus, 
and  external  oblique  muscles  is  separated  from  the  costal  surface  of  the  gland 
by  a  loose  layer  of  areolar  tissue,  through  Avhich  pass  numerous  blood-vessels 
surrounded  by  very  distinct  perivascular  lymph-spaces — a  fiict  to  be  borne 
in  mind  when  dealing  with  mammary  carcinoma.  Keaching  from  the  third  rib 
above  to  the  sixth  or  seventh  below,  the  gland-tissue  is  thickest  at  its  center 
and  toward  the  axillary  side,  in  which  direction  it  extends  farthest,  making  the 
long  axis  of  the  gland  pass  from  the  anterior  axillary  fold  obliquely  from  above 
downward  and  inward.  The  overlying  integument,  the  circumference  of  the 
fibrous  gland-capside,  and  the  superficial  fascia — which  is  also  attached  to  the 
clavicle — are  intimutel}^  connected  with  one  another  by  fibrous  bands,  serving 
to  hold  the  gland  in  place,  and  explaining  the  dimpling  of  the  skin — not  the 
depression  of  the  nipple — over  contracting  neoplasms. 

The  nipple  in  some  patients  forms  a  w- ell-marked  conical  projection ;  in  others 
it  is  small  and  depressed,  with  a  constricted  base :  it  may  lie  in  an  umbilicus- 
like  depression,  or,  again,  it  may  be  practically  absent,  being  on  a  level  with 
the  skin.  The  skin  is  wrinkled,  numerous  sebaceous  glands  opening  in  the  sulci 
thus  formed  ;  it  is  covered  with  papilkie,  and  varies  in  color  from  a  light  pink  to 
a  dark  brown,  according  to  the  complexion  of  the  individual,  and  to  whether 
pregnancy  has  existed  or  is  now  present ;  in  which  event  the  nipple  becomes 
much  darker — sometimes  a  deep  blackish-brown  in  brunettes.  Uterine  tumors, 
it  is  alleged,  produce  somewhat  similar  changes.  The  nipple  is  composed  of 
numerous  blood-vessels,  areolar  tissue,  the  milk-ducts,  and  considerable  un- 
striped  muscular  tissue.  The  glandrStructure  is  composed  of  numerous  minute 
lobules  aggregated  into  lobes,  each  lobule  opening  into  a  small  duct,  these 
small  ducts  in  turn  joining  larger  ones,  until  finally  the  secretion  is  emptied  by 
fifteen  or  twenty  milk-ducts  opening  upon  the  summit  of  the  nipple,  these  large 
ducts  beneath  the  areola  having  first  become  dilated  so  as  to  form  little  sacs 
(ampullce,  milk-sinuses),  but  at  the  base  of  the  nipple  contracting  into  small 
canals  whose  orifices  admit  only  a  stout  bristle.  Glandular  epithelium  lines 
both  the  gland-vesicles  and  the  ducts,  continuous  with  that  investing  the  nipple. 

Arteries,   Veins,  Nerves,  and  Lymphatics  of  the  Breast. — Blood  reaches 


lOoO  A.\    AMJ:U1LA.\    TEXT-noi)K    OF  SlRUKllY. 

the  ijland  cliiefly  through  brandies  of  the  long  and  superior  thoracjc,  inter- 
nal inauiiiiarv,  and  intercostal  ((rtcrics  ;  sometimes  there  is  a  special  branch 
from  the  axillary  trunk.  In  a  virgin  breast  these  vessels  are  small ;  during 
lactation  they  are  much  enlarged,  as  well  as  Avhen  the  breast  is  the  site  of  a 
rapidly-growing  neoplasm.  For  the  most  part  the  arteries  enter  the  upper 
and  axillary  borders  of  the  gland,  a  point  to  be  remembered  when  operating, 
since  the  organ  can  be  rapidly  excised  with  but  little  loss  of  bhjod  by  dissect- 
ing it  \\\)  toward  the  axilla,  the  deeper  attachments  in  this  region  being  divided 
last.  The  blood  is  returned  by  veins  generally  ])ursuing  a  course  similar  to  that 
of  the  arteries,  and  chiefly  emptying  into  the  internal  mammary  and  axillary 
veins.  The  nerves  are  derived  from  the  anterior  and  lateral  cutaneous  thoracic 
nerves,  and  communicate  with  the  cutaneous  branches  of  the  lower  cervical 
nerves. 

Both  the  superficial  and  tlio  deep  lymphatics  enter,  in  the  main,  the  axillary 
glands,  passing  in  two  directions — one  to  the  glands  internal  to  the  vessels,  the 
other,  more  external,  joining  the  lymphatics  of  the  arm.  Other  routes  must  be 
remembered,  since  they  account  for  systemic  infection  when  no  enlargement  of 
the  axillary  glands  has  been  detected.  Thus  the  lymphatics  of  the  nipple  and 
sternal  side  pass  through  the  second  intercostal  space  with  the  artery  and  vein 
to  the  anterior  mediastinum,  there  entering  glands;  others  join  the  first  in 
the  anterior  mediastinum  by  penetrating  the  space  between  the  fourth  and 
fifth  costal  cartilages ;  and,  finally,  the  deep  absorbents  of  the  costal  surface 
of  the  gland  accompany  the  branches  of  the  aortic  intercostals  on  the  axillary 
side,  reaching  the  thoracic  duct  in  the  posterior  mediastinum.  It  is  by  the 
passage  of  microscopic  particles  of  the  growth  along  these  cliannels  that  carci- 
nomatous disease  enters  the  cnest,  often  producing  growths  m  the  pleura,  with 
consequent  pleuritis,  etc.  ;  again,  by  this  route  the  system  may  be  contami- 
nated, the  axillary  glands  escaping  infection  entirely  or  at  least  for  a  long 
period,  although  the  axillary  route  is  the  one  almost  always  taken  by  the 
infecting  fragments.  It  is  probable  that  more  unusual  routes  are  pursued  by 
the  infected  lynipli  only  in  cases  in  which  the  axillary  lym])liatic  glands  be- 
come early  blocked  by  secondary  growths,  or  recurrence  takes  place  in  an 
operation  scar  when  the  axilla  has  been  completely  emptied  of  all  lynaphatic 
structures.  The  lymphatic  vessels  of  both  sides  of  the  chest  freely  inter- 
communicate, and  some,  passing  over  the  clavicle,  enter  the  superficial  cer- 
vical glands.  Lymph  vessels  also  pass  downward  to  accomjtany  the  superior 
and  deep  epigastric  vessels,  to  terminate  in  the  inguinal  glands,  possibly  pass- 
ing through  a  lymphatic  gland  situated  on  the  internal  surface  of  the  rectus 
abdominis  muscle  near  Douglas's  fold. 


CONGENITAL  MALFORMATIONS. 

Supernumerary  Nipples  and  Mamm^,  while  usually  situated  in  close 
relation  with  the  normal  organs,  sometimes  occupy  the  axillary  region,  and  rare 
instances  have  been  reported  of  these  organs  having  been  located  upon  the 
back,  over  the  acromion  process,  on  the  anterior  abdominal  wall,  and  on  the 
outer  aspect  of  the  thigh.  This  abnormality  is  not  confined  to  women,  but 
occurs  also  in  the  male  sex.  The  supernumerary  nipple  usually  lies  below  and 
to  the  inner  side  of  the  normally  situated  one ;  it  is  sometimes  well  developed, 
but  is  more  usually  small  or  lacking  in  one  or  more  of  the  following  peculiar- 
ities :  viz.  the  papillae,  areola,  follicles,  or  hairs.  This  abnormality  occurs  most 
frequently  upon  the  left  side.  These  accessory  glands  are  rarely  functionally 
active. 


/>/s/:as/:s  a.M)  ix.irini.s  or  riii:  /:/,•/■: a sr.         1051 

Treatment. — Sliould  tliey  cause  ineiital  or  physical  inconvenience,  they 
may  be  excised. 

Absenck  of  the  Mamm^-. — A  few  sueli  cases  are  on  recorcl,  tlie  light 
ghmd  being  the  one  commonly  al)sent ;  in  atldition,  more  or  less  of  the  mus- 
cular and  bony  walls  of  the  corresponding  portion  of  chest-wall  is  also  lacking. 

DISEASES    OF    THE    NIl'I'EE. 

INFLAMMATION. — While  this  may  result  from  any  form  of  irritation,  it  is 
hardly  ever  met  with  except  in  connection  with  lactation.  The  trouble  is 
rarely  limited  to  the  nipple,  but  extends  to  the  surrounding  skin,  the  red 
swollen  organ  itself  becoming  excoriated  and  fissured ;  ulcers  form,  these 
latter  at  times  extending  so  deeply  as  to  destroy  the  skin  around  the  base  more 
or  less  completely,  leaving  little  else  than  the  lacteal  ducts  as  a  connecting 
bond  for  what  is  left  of  the  body  of  the  organ  :  constitutional  symptoms  are 
sometimes  present.  Much  smarting  pain  is  felt,  aggravated  at  each  attempt 
at  suckling,  at  which  times  fissures  are  reopened,  the  scabs  are  torn  oft",  bleed- 
ing follows,  and  the  pain  is  so  severe  that  the  Avoman  often  abandons  the 
attempt ;  the  engorged  gland  is  not  relieved,  and  either  from  this,  or  more 
commonly  from  septic  lymphangitis  spreading  from  the  nipple,  mammary 
abscess  results.  Sometimes  the  nipple  is  destroyed  by  ulceration,  leading 
almost  inevitably  to  extensive  mastitis  and  recurring  trouble  at  each  succeeding 
delivery. 

Treatment. — The  eifect  of  frequent  applications  of  the  infant  to  the 
breast  should  be  guarded  against  as  far  as  possible  by  properly-constructed 
shields,  the  nipple  itself  being  always  moistened  before  nursing  and  carefully 
dried  afterward  :  these  measures,  combined  with  washing  Avith  a  tolerably  strong 
borax  lotioij,  will  sufiice  for  the  average  case.  Disinfection  by  non-poisonous 
antiseptics  (if  the  breast  is  being  nursed  from),  and  stimulating  and  astringent 
applications,  such  as  glycerole  of  tannin  and  sulphurous  acid,  equal  parts,  with 
double  the  bulk  of  water,  tannic  acid  (grs.  v  to  f  5J  of  glycerin),  aided  in  extreme 
cases  by  touching  the  fissures  or  ulcers  Avith  a  pointed  stick  of  nitrate  of  sil- 
ver, constitute  the  best  means  available ;  but  mechanical  protection  by  some 
form  of  shield  is  imperative  in  all  severe  cases.  Sometimes  the  use  of  the 
breast  has  to  be  abandoned,  in  which  case  gentle  centripetal  frictions  of  the 
breast  with  hot  camphorated  oil,  with  occasional  emptying  of  the  gland  by  a 
breast-pump  or  firm  compression  with  strips  of  belladonna  plaster  may  be 
tried,   both  plans  tending  to  suppress  the  secretion  of  milk. 

Retracted  Nipples. — This  may  be  a  congenital  condition,  or  may  be  the 
result  of  cicatricial  contraction  from  badly-ulcerated  nipples,  from  inflammation 
of  the  gland,  or  from  neoplasms. 

Treatment. — Sometimes  this  condition  appears  to  be  benefited  by  the 
application  of  suction  by  means  of  a  breast-pump  or  a  bottle  Avith  properly- 
formed  neck,  the  contained  air  having  been  rarefied  by  heat.  Many  Avomen 
with  retracted  nipples  can  nurse  their  children  by  the  use  of  some  one  of  the 
better  forms  of  nipple-shield. 

Paget's  Disease. — This  is  a  chronic  destructive  dermatitis  of  the  papil- 
lary layer  of  the  nipple  and  areola,  most  frequently  attacking  individuals 
betAveen  forty  and  sixty  years  of  age,  although  in  one  patient  the  disease 
commenced  at  twenty-eight  years. 

Symptoms. — According  to  BoAvlby,  this  disease  is  not  simply  eczema. 
First,  a  branny  desquamation  occurs,  either  on  the  nipple  or  areola,  followed 
by  a  slight  watery  discharge,  Avhich   may  become   very  free,   yellowish,  and 


10.12 


A.\    AMi:JiICAy    TKXT-llOOK    (iF   sriKilJlY 


sticky.  Next  small  scales  and  crusts  form,  which,  ])ocoming  separate*!,  leave 
raw  or  excoriated,  intensely  reddened  surfaces.  The  process  extends  periphe- 
rally from  the  nipple  as  a  center,  with  sharply  defined  inar^^ins,  ncfither  vesicles 
nor  pustules  forming,  until  sometimes  much  of  the  skin  covering  the  breast  is 
involved.  The  diseased  surfaces  are  much  redder  than  in  eczema.  During 
the  later  stages  the  nipple  becomes  retracted,  and  in  the  more  chronic  cases  is 
not  infreiiiiently  destroyed  by  ulceration,  which,  extending  to  the  areola,  leaves 

Fic.  42'2. 


I'a^a't's  disease  of  Hit;  Nipple  (original). 


a  circular   or  ovoidal   ulcer  with   a   papillated,   granular  surface.     Tingling, 
burning  pain  is  complained  of,  but  not  severe  itching. 

Relation  of  Psorosperms  to  Paget's  Disease. — Certain  constantly- 
found  rounded  or  oval  bodies  occupying  the  deeper  layers  of  the  epidermis 
liave  been  described  by  Darier,  Wickham,  Bowlby,  and  others.  These  have 
never  been  seen  in  eczema,  and  have  been  considered  by  the  above-mentioned 
authors,  as  well  as  others,  to  be  psorosperms  standing  in  a  causative  relation 
to  Paget's  disease.  This  claim  seems  more  than  doubtful,  wliile  none  claim  to 
have  detected  tliem  in  the  mammary  tumors  following  the  majority  of  reported 
cases  of  Paget's  disease — viz.  24  out  of  35. 

While  some  observations  have  been  supposed  to  show  that  certain  cases  are 
really  superficial  epitheliomatous  disease  of  the  orifices  of  the  lacteal  ducts,  the 
lesions  have  usually  been  of  too  long  standing  and  yield  too  readily  to  simple 
treatment  to  be  anything  except  a  form  of  dermatitis.  Nevertheless,  this  con- 
dition of  constant  irritation  unquestionably  predisposes  to  carcinoma  mamma', 
and  if  simple,  soothing  applications  do  not  effect  a  cure,  excision  of  the  dis- 
eased tissues  should  be  done,  including  the  whole  breast,  if  any  suspicious 
indurations  exist,  with  careful  exploration  of  the  axilla  where  the  condition 
of  the  mammary  glands  has  demanded  excision. 

DISEASES  OF  THE  BREAST. 

Neurotic  Conditions  of  the  Breast  are  of  common  occurrence  in  young 
unmarried  women,  but  are  never  found  in  the  aged.      The  most  important  a.s 


DISEASES    AND    IXJIINES    OF    THE    BREAST.  1053 

well  as  the  most  frequent  is  siniiile  neuralgia,  constant  or  periodic,  severe  lanci- 
nating pain  being  complained  of  in  the  armpit,  and  perhaps  extending  down  the 
arm.  The  gland  itself  and  the  skin  over  it  in  many  cases  are  exceedingly  sen- 
sitive when  even  gently  handled  (hyperesthesia),  although  nothing  abnormal 
can  be  detected.  The  patients  are  often  greatly  distressed  by  the  fear  of  can- 
cer. Ovarian  disturbance  frecjuently  coexists,  and  probably  stands  in  a  causa- 
tive relation  to  the  local  neurosis. 

Diagnosis. — Where  no  tumor  can  be  detected,  the  more  severe  the  pain  is 
and  the  greater  the  sensitiveness  the  less  need  the  practitioner  be  alarmed,  and 
the  more  confidently  can  he  ascribe  the  trouble  to  its  true  cause. 

Treatment. — As  the  mental  and  moral  condition  has  much  to  do  with  the 
development  of  the  trouble,  all  local  treatment  must  be  avoided,  while  regular 
hours  for  sleep,  open-air  exercise,  tonics,  cold  bathing,  and  the  avoidance  of  sen- 
sational novels,  with  provision  for  healthy  mental  occupation,  must  be  insisted 
upon. 

Atrophy  may  occur  in  the  unmarried  as  well  as  in  the  married,  either  from 
congenital  defect  inducing  premature  senescence  or  from  ovarian  disease,  pre- 
sumably always  atrophy.     Manifestly,  no  treatment  can  be  of  any  avail. 

Hypertrophy. — This  is  due  to  abnormal  development  of  the  constituents 
of  the  breast,  usually  commences  at  puberty,  and  commonly  afiects  both 
breasts.  The  general  health  may  or  may  not  be  impaired  ;  the  catamenia  are 
in  all  cases  established,  but  are  apt  to  be  scanty  or  irregular.  Occurring  in 
adults  (usually  before  thirty  years  of  age),  the  single  and  the  married,  the 
prolific  and  the  sterile  Avoman,  alike  may  be  attacked.  The  course  is  slow 
throughout,  or  rapid  for  a  time  and  then  perhaps  stationary  for  life  or  for 
long  periods,  but  usually  one  breast  outstrips  the  other  in  growth.  Pain  is 
rarely  complained  of  even  upon  handling,  but  the  inconvenience  from  the 
weight  (tumors  having  been  reported  of  even  sixty-four  pounds)  is  often 
excessive.  The  breasts  may  be  symmetrically  enlarged  or  may  be  pendulous, 
and  are  covered  wdth  normal  skin.  They  feel  soft  throughout  or  as  if  each 
lobule  was  uniformly  enlarged,  rendering  the  mass  somewhat  irregular,  but  no 
circumscribed  induration  is  detectable.  When  occurring  later  in  life,  while  both 
breasts  are  apt  to  be  attacked,  one  may  commence  to  enlarge  before  the  other. 

Diagnosis. — This  depends  upon  the  uniform,  gradual,  excessive  enlarge- 
ment— often  commencing  at  puberty — without  cutaneous  or  glandular  involve- 
ment, and  the  normal  feel  of  the  gland,  which  Avhen  compressed  between  the 
opened  hand  and  the  chest-wall  gives  no  sensation  of  localized  induration  : 
when  both  breasts  are  enlarged  the  condition  can  hardly  be  mistaken. 

Treatment. — Attention  to  the  general  health  and  to  the  ovarian  and  ute- 
rine functions  is  important,  compression  and  support  of  the  glands  may  be  tried. 
The  excitation  of  lactation  has  proved  successful  in  two  cases,  while  the  removal 
of  one  breast  has  in  one  or  two  reported  cases  caused  diminution  in  the  size  of 
the  other.     When  the  Aveight  becomes  unendurable,  amputation  must  be  done. 

Mammitis,  Mastitis,  or  Inflammation  of  the  Breast. — Of  course  from 
traumatisms  or  other  causes  inflammation  may  attack  the  tissues  over  and  in  the 
immediate  neighborhood  of  the  breast,  and  this  may  terminate  by  resolution 
or  suppuration  :  absence  of  the  characteristic  induration  of  the  gland  will 
serve  to  distinguish  this  from  mammitis,  and  the  treatment  must  be  conducted 
upon  general  principles. 

Mammitis  may  occur  at  any  age  and  in  either  sex.  Infants  not  uncom- 
monly present  evidences  of  mammitis  within  a  few  days  after  birth,  especially 
if  the  nurse  has  tried  to  ''break  the  strings  of  the  breast "  or  "to  rub  aAvay  the 
milk  :"  because  a  milky  or  serous  discharge  sometimes  exudes  from  the  nipple. 


1051  j.v  A^f/':/i'l('AX  T/:.\'T- /!()() h'  or  atay/a'/.t. 

Either  S])ontanooiisly  in  those  in  somewhat  feeble  health,  or  from  a  })lo\v, 
inflammation  is  not  uncommon  at  or  about  puberty  in  boys  as  well  as  in  girls, 
although  it  is  more  common  in  females :  resolution  or  suppuration  may  take 
place.  Between  sixteen  and  twenty  years  of  age  a  chronic  enlargement  of  the 
breast  in  a  girl — although  often  a  fibroma — is  exceedingly  apt  to  be  either 
a  localized  mannnitis  or  a  chronic  abscess  the  result  of  such  a  condition. 

Acute  mammitis,  however,  more  often  attacks  nursinijr  women  durinii  the 
first  week  to  a  month  after  delivery,  then  being  usually  due  to  infective  lym- 
phangitis from  "cracked  nipples,"  especially  when  these  organs  are  retracted 
or  the  ducts  are  obstructed  by  recent  or  old  inflammatory  conditions,  but  is 
often  attributable  solely  to  inability  of  the  child  to  empty  the  breast.  coml)ined 
with  exposure  to  cold.  Both  these  conditions  favor  congestion,  and  therefore 
predispose  to  mammitis,  but  the  exciting  cause  is  the  entrance  of  germs, 
either  through  an  open  surface  or  after  lodgment  in  the  deeper  portions  of 
the  milk-ducts,  by  their  penetration  into  the  periacinous  connective  tissue : 
during  the  later  stages  of  lactation,  if  the  individual  becomes  run  down  in 
health,  trivial  causes  will  induce  mammitis.  Abscess  of  the  breast  often 
follows. 

Symptoms. — At  first  only  uneasiness  and  stiffness  of  the  whole  or  part 
of  the  breast  are  complained  of;  next  a  chill  or  slight  rigor  occurs,  which  is 
followed  by  fever,  with  a  tense,  hot,  swollen,  painful  condition  of  the  breast, 
one  or  all  of  the  lobes  being  indurated  and  the  overlying  skin  reddened. 
The  inflammation  may  terminate  by  resolution  or  suppuration,  or  may  leave 
chronic  thickening  of  the  gland.  AVhen  pus  forms,  it  may  be  situated,  first, 
superficial  to  the  gland  ;  secondly,  in  its  substance,  or  rather  between  the 
lobes  (intramammary,  interlobular);  and,  thirdly,  between  the  gland  and  the 
chest-wall  (post-mammary).  The  first  variety  differs  neither  in  symptoms 
nor  in  treatment  from  any  other  superficial  abscess,  but  often  preludes  the 
second  form.  The  interlobular  form  usually  occurring  during  lactation  may 
be  single  or  multiple,  and  presents  the  usual  signs  of  deep-seated  glandular 
abscess. 

Acute  Post-mammary  Ahscei<i<. — Although  this  may  result  from  infection 
of  an  ecchymotic  collection  following  trauma,  post-mammary  abscesses  more 
commonly  result  from  propagation  of  the  inflammation  from  the  deep  lobes 
of  the  gland. 

Symptoms. — The  abscess  is  often  preceded  by  constitutional  symptoms 
of  inflammation  of  the  gland.  Avith  some  deep-seated  tenderness  and  indura- 
tion. Rapidly  the  whole  mammary  and  post-mammary  regions  become  en- 
gorged, producing  a  characteristic  elevation  of  the  whole  breast,  which  is 
unaltered  in  form.  Although  the  skin  is  hot  and  traversed  by  enlarged  veins, 
it  is  not  materially  reddened  unless  the  post-mammary  phlegmon  is  secondary 
to  an  extensive  mastitis,  which  may  coincide.  The  base  of  the  gland  early 
becomes  encircled  by  an  oedematous  ring  of  tissue.  Examination  shows  an 
elastic  resistance  when  the  gland  is  pressed  against  the  thorax.  Actual  fluc- 
tuation is  difficult  of  detection,  and  can  be  best  felt  by  placing  one  hand  at  the 
periphery  of  the  gland  over  the  oedematous  collar  and  suddenly  pressing  the 
breast  backward.  The  constitutional  symptoms  rajiidly  increase  in  severity 
until  they  fre(|uently  assume  rather  alarming  pro]iortions. 

Treatment. — This  should  be  directed  against  the  formation  of  pus,  and 
must  consist  in  the  measures  advised  for  fissured  nipple,  cessation  of  nursing 
with  the  affected  breast,  the  cautious  use  of  the  breast-pump,  in  robust  indi- 
viduals a  saline  purge,  sometimes  leeching,  and  attempts  to  arrest  the  secre- 
tion of  milk  by  extract  of  belladonna  reduced  to  a  plasma  by  glycerin,  fre- 


DISEASES   AND    IXJURIES    OF    THE   BREAST.  1055 

qiient  Imt  fomentations  if  pus  is  forming,  while  tiie  moment  tliis  is  detected  free 
antiseptic  incision  and  drainage  must  be  employed,  the  cut  or  cuts  passing. in  a 
radiating  manner  from  the  nipple  to  avoid  division  of  the  lacteal  ducts.  Sup- 
port must  be  afforded  to  the  breast  by  a  proper  sling  or  bandage,  and  the 
arm  kept  in  a  sling  or  bound  to  the  side.  The  post-mammary  form  requires 
free  incision,  preferably  at  the  lower,  outer  part  of  the  swelling.  Neglected 
cases  require  free  incisions,  freshening  of  the  sinuses  with  the  Volkmann  sharp 
spoon,  disinfection,  and  free  drainage.  More  rarely,  the  gland  must  be  par- 
tially dissected  back  from  the  chest-wall,  and  the  suppurating  sui'faces  freshened, 
after  which  the  breast  must  be  sutured  in  position  with  catgut,  carefully  effacing 
all  cavities  by  means  of  buried  animal  sutures.  Proper  attention  to  diet,  with 
quinine,  ferruginous  tonics,  and  stimulants,  is  indicated  if  the  patient's 
health  is  deteriorated. 

Cold  {Tubercular)  Post-mammary  Abscess. — This  may  be  secondary  to 
disease  of  the  thoracic  walls,  when  it  will  have  been  preceded  by  the  symp- 
toms of  a  deep-seated,  slowly-progressing  induration,  posterior  to  the  mamma. 
This  eventually  softens  and  pushes  forward  the  whole  gland.  The  skin  some- 
where at  the  periphery  of  the  breast  becomes  adherent,  infiltrated,  thinned, 
and  finally  ulcerates;  or  pyogenic  infection  occurring,  an  approach  to  the 
complexus  of  symptoms  of  acute  i)ost-mammary  abscess  is  presented.  When 
resulting  from  tubercular  mastitis,  a  slowly-growing,  infiltrating,  semi-elastic, 
ill-defined  mass  can  be  felt  deep  in  the  ghmd.  The  overlying  skin  becomes 
adherent,  and  when  situated  beneath  or  near  the  nipple  this  becomes  retracted. 
While  progressing  anteriorly  the  post-mammary  region  is  also  invaded,  when 
the  conditions  gradually  develop  as  described  above. 

Treatment. — This  is  such  as  is  adapted  to  any  tubercular  process,  neces- 
sitating removal  of  all  infected  tissues.  Amputation  of  the  breast,  evacuation 
of  the  axillary  contents,  and  resection  of  diseased  ribs  may  be  demanded. 

Milk  Fistula. — These  result  either  from  abscesses  opening  up  the  milk- 
ducts  or  from  the  surgeon's  knife,  the  secretion  of  milk  serving  to  keep  the 
orifices  patent,  so  that  the  abscesses  degenerate  into  fistulous  tracks. 

Treatment. — Stimulating  injections,  as  of  iodoform,  iodine,  or  chloride 
of  zinc,  may  be  employed,  with  compression  along  the  sinus  tracks  and  general 
support  of  the  breast.  Should  these  measures  fail,  the  sinuses  must  be  dilated, 
curetted,  antiseptically  irrigated,  and  a  drainage-tube  inserted  through  their 
whole  extent,  the  tube  being  gradually  shortened  and  compression  applied  in 
its  track  as  it  is  withdrawn. 

Chronic  Inflammation  ;  Chronic  Abscess. — As  a  sequence  of  the  acute 
process  or  from  certain  constitutional  causes  (struma  ?)  in  an  otherwise  healthy 
breast,  one  or  more  portions  may  become  the  seat  of  chronic  inflammation, 
•evidenced  by  thickening  and  perhaps  tenderness  on  pressure.  This  condition 
may  remain  stationary,  may  gradually  diminish,  or  may  terminate  in  the  forma- 
tion of  pus,  Avhich  is  very  slow  to  reach  the  surface. 

Treatment. — Attention  to  the  general  health,  support  of  the  breast 
amounting  to  pressure  if  it  can  be  borne,  counter-irritation  from  time  to  time, 
and  covering  the  part  with  a  belladonna  plaster  or  applying  equal  parts  of 
extract  of  belladonna  and  compound  ointment  of  iodine.  Avill  generally  hasten 
resolution.  If  pus  is  suspected,  the  exploring  needle  or  the  aspirator  must  be 
used,  as  it  is  of  the  utmost  importance  that  these  collections  should  be  opened 
at  the  earliest  possible  moment.  The  incisions  should  be  made  as  directed  for 
acute  abscess,  but  careful  curetting  of  the  cavity,  thorough  antiseptic  irrigation 
or  irrigation  with  weak  iodine-water,  followed  by  light  packing  with  iodoform 
gauze  around  a  drainage-tube  if  the  cavity  be  of  any  size — the  gauze  to  be 


lOoG  J.V    AM  1:111  VAX    TKXT-BOOK    OF  SLIKiEIiV. 

withdrawn  in  a  day  or  two — will  facilitate  the  liealinii;  process.      In  the  more 
refractory  cases  cuneiform  excision  with  careful  suturing  may  become  re(|uisite. 

Chronic  Lobular  Inflammation  (Irritable  Mamma). — J'athologically, 
this  is  a  chronic  interstitial  mamraitis  resulting  in  a  small-celled  infiltration 
of  the  interlobular  connective  tissue,  with  some  epitlielial  proliferation.  The 
newly-formed  connective  tissue,  contracting,  obliterates  the  ducts  and  acini, 
resulting  in  fatty  degeneration  of  the  epithelium.  Some  of  the  acini,  by  hav- 
ing only  their  ducts  compressed,  may  dilate,  forming  small  cysts.  The  import- 
ance of  this  aftection  resides  in  its  liability  to  be  mistaken  for  carcinoma  when, 
occurring  about  the  menopause. 

Symptoms. — Either  the  Avhole  or  more  commonly  a  part  of  the  mamma 
becomes  indurated  and  tender — possibly  even  the  latter,  with  but  little  of  the 
former — in  young  unmarried  or  in  sterile  married  women,  in  these  latter  perhaps 
more  often  about  or  after  the  menopause.  Disturbances  of  the  uterus,  of  the 
ovaries,  of  digestion,  with  mental  excitement  or  depression,  are  not  uncommon. 

Diagnosis. — This  must  depend  upon  the  following  facts  :  The  growth  does 
not  steadily  increase  as  in  neoplasms  ;  the  pain  and  tenderness  are  greater ;  the 
benign  tumor  is  more  circumscribed,  while  scirrhus  is  much  harder,  the  den- 
sity appearing  less — instead  of  greater,  as  would  be  true  of  scirrhus — if  the 
mass  be  examined  by  rolling  the  breast  over  the  chest-wall  with  the  flat  of  the 
hand  ;  the  swelling  is  wedge-shaped,  with  the  apex  toward  the  nipple  ;  the  pain^ 
is  referred  to  the  disti'ibution  of  one  or  more  nerves,  which,  as  Mr.  Birkett  long 
ago  pointed  out,  if  pressed  upon  at  their  exit  from  the  thorax,  will  give  rise  to- 
severe  pain,  "sometimes  confined  to  the  branch  distributed  to  the  indurated 
part,  while  the  rest  are  unaffected;"  the  axillary  glands  if  enlarged — a  rare 
event — are  not  indurated.  In  an  exceptionally  doubtful  case  a  fragment  can 
be  removed  by  antiseptic  incision  and  subjected  to  microscopic  examination. 

Treatment. — This  should  be  directed  to  the  removal  of  the  functional  dis- 
turbances mentioned :  assurance  should  be  given  that  the  disease  is  not  malignant 
and  is  curable,  and  a  belladonna  j)laster  should  be  applied,  chiefly  to  j)revent 
the  patient's  handling  the  part,  Avhile  small  doses  of  iodide  of  potassium  should 
be  given  internally.  If  these  measures  fail,  counter-irritation  and  compression, 
or  in  severe  cases  free  antiseptic  incision,  may  be  tried.  Should  the  induration 
persist  or  increase,  with  severe  pain,  despite  appropriate  treatment,  in  middle- 
aged  or  older  Avomen,  amputation  is  indicated,  because  continued  iri'itation  may 
result  in  the  development  of  genuine  carcinoma. 

OmtiiNic  CrRKHOTic  Mastitis.  Diffused  Ciihoxtc  Mastitis. — Owing^ 
to  the  difficulty  experienced  in  distinguishing  this  affection  in  the  atrophic 
stage  from  scirrhous  carcinoma  it  demands  a  brief  description.  Commonest 
near  the  climacteric  and  usually  attacking  one  breast,  the  initial  symptoms 
are  those  of  a  subacute  inflammation  producing  pain  and  swelling  of  either  a 
portion  or  the  Avhole  of  the  mamma.  The  tender  area  gradually  becomes 
indurated,  the  disease  spreads  until  in  advanced  cases  the  Avhole  gland,  nipj)le, 
overlyjng  skin,  and  ])aramammary  fat  become  involved.  Pyrexia  is  absent 
throughout.  Still  later,  irregular  contraction  occurs,  producing  a  nodulated 
tumor  Avith  retracted  nipple  covered  by  adherent  puckered  skin.  Rarely  both 
Avatery  discharges  from  the  nipple  and  enlargement  of  the  axillary  glands  are 
detectable.  The  disease  ])ursues  a  chronic  but  irregular  course,  usually  ter- 
minating by  resolution,  leaving  a  permanently  atroj)liie(l  gland,  although 
calcification   is  a  i)0ssible  se({uel. 

Diagnosis. — The  history  is  im])ortant.  The  long  duration  Avithout  infil- 
tration of  the  ])ectoral  muscle;  the  rarity  of  involvement  of  the  axillary 
glands;  Avhen  this  is  noted,  its  insignificance  and  the  absence  of  fusion  of  all 


DISEASES    AND    rXJdiJES    OF    THE   BR  EAST.  1057 

the  axillary  tissues  Ciiusiiifi  later  ))aiii  in  and  (cdema  of  the  extremity;  the 
maintenanee  of  the  <feneral  health,  the  absenee  of  viseeral  involvement,  and 
the  tendency  to  resolution,  should  render  a  diagnosis  possible  in  most  cases. 

Treatment. — Iodine,  both  internally  and  externally,  or  mercurial  oint- 
iiit'iit  in  conjunction  with  lirni  ])ressure,  will  usually  .suffice.  If  the  enlarge- 
ment continues  to  increase,  amputation  is  indicated. 

Tubercular  Affections. — Secondary  involvement  of  the  l^reast,  causing 
induration  or  abscess  and  ulceration,  may  take  place  "when  the  neighboring 
cellular  tissue,  lymphatic  glands,  or  bones  are  the  seat  of  primary  tuberculosis. 
Velpeau,  however,  has  described  certain  instances  where  at  numerous  points 
of  the  breast  there  were  isolated  masses  whose  centers  had  undergone  case- 
ous change.  This  condition  is  found  in  pale,  delicate  females,  and  coincident 
strumous  enlargement  of  the  axillary  and  cervical  glands  is  quite  common. 
The  small  masses  are  difficult  to  detect,  because  not  sharply  defined,  and  tend 
slowly  to  enlarge,  break  down,  and  open  externally  by  ulceration,  leaving  the 
gland  riddled  with  sinuses. 

Treatment. — Early  extirpation,  including  in  the  removal,  as  a  rule,  the 
entire  breast,  is  probably  the  best  practice.  Curetting,  irrigation  Avith  weak 
iodine-water,  and  packing  with  iodoform  gauze  may  be  successful.  Tubercular 
infection  of  the  neighboring  glands  is  common  :  if  any  enlarged  glands  are  de- 
tected at  the  time  of  operation  on  the  breast,  they  should  be  removed  then. 

Syphilitic  Affections. — As  in  tuberculosis,  so  in  syphilis,  secondary 
trouble  may  result  from  specific  disease  in  the  contiguous  cutaneous,  cellular, 
and  osseous  tissues.  A  primary  affection  of  the  gland,  producing  a  more  or 
less  uniform  indurated  enlargement  of  the  organ,  has  been  described  as  occur- 
ring in  syphilitics  in  the  late  secondary  or  early  tertiary  period.  Either  one 
or  both  breasts  may  be  attacked,  producing  a  not  very  painful,  hard,  smooth 
enlargement  readily  yielding  to  antisyphilitic  treatment. 

Treatment. — Iodide  of  potassium,  either  alone  or  combined  with  mercury, 
aided  perhaps  by  counter-irritation  and  pressure,  is  all  that  is  requisite. 

TUMORS  OF  THE   BREAST. 

Tumors  composed  of  nothing  but  pure  fibrous,  fatty,  myxomatous,  cartilag- 
inous, vascular,  or  nervous  tissues  are  so  rare  that  they  will  not  be  separately 
considered  here,  the  student  being  referred  to  the  general  chapter  on  Tumors. 

For  clinical  purposes  mammary  tumors  may  be  classed  under  the  following 
heads : 

1.  Those  tumors  resembling  fully-formed  connective  tissue  and 
derived  from  it.  Tumors  belonging  to  this  class  are  7ion-viaI/</iiaut,  and  com- 
prise the  fibromata  (fibrous  tumors),  the  lipomata  (fatty  tumors),  the  myxomata 
(mucous  tumors),  and  the  chondromata  (cartilaginous  tumors). 

2.  Those  tumors  resembling  embryonic  or  transitional  connective  tis- 
sue, and  derived  from  the  connective  tissue  of  the  gland :  these  neoplasms 
are  malignant.     To  this  class  the  term  sarcoma  is  applied. 

3.  Those  tumors  which  more  or  less  closely  resemble  glandular  tissue 
and  are  derived  from  the  glandular  epithelium.  They  are  non-malignant^ 
except  when  occurring  in  connection  with  sarcomatous  elements.  This  class 
comprises  adenoma  pure,  or  adenomatous  tissue  combined  with  fibrous  tissue 
(adeno-fibroma),  with  cysts  (adeno-cystoma),  or  with  atypical  cells  of  the 
connective-tissue  type,  round,  spindle,  or  giant  cells  (adeno-sarcoma). 

4.  Those  tumors  composed  of  atypical  epithelial  cells,  atypically  re- 
lated to  the  fibrous  stroma  of  the  gland.  These  tumors  are  malignant.  The 
term  applied  to  this  class  is  carcinoma. 

67 


1058  AX   ami: UK  AX    TEXT-IKX )K    OF  SURGERY. 

5.  Those  tumors  resulting  from  hypertrophy  of  such  higlily  specialized 
tissues  as  blood-vessels,  etc.  They  are  non-malupinnt.  This  class  emhraces 
angeioma  (vascular  tumor)  and  neuroma  (nervous  tumor). 

About  83  per  cent,  of  all  mammary  tumors  are  carcinomata,  ■while  the  remain- 
ing 17  per  cent,  are  sarcomata,  adenomata — including  its  varieties — and  cysts. 

Adenoma. — In  its  pure  form  this  is  one  of  the  rarest  of  mannnary  neo- 
plasms. Closely  resembling  the  mammary  tissue  in  the  pregnant  woman,  the 
epithelial  elements  are  arranged  in  a  purposeless  -way,  as  it  -were,  a  confused 
mass  of  acini  and  ducts  being  seen  microscopically.  The  cubical  ejiithelial 
elements  may  line  "with  a  single  or  double  layer  the  newly-formed  acini,  but 
are  more  apt  entirely  to  till  tlieir  lumen,  only  a  mass  of  cells  Ijcing  discernible; 
but.  unlike  carcinoma — Avliich  presents  a  very  similar  picture — the  cells  are 
separated  from  the  surrounding  connective  tissue  by  a  distinct  basement  mem- 
brane; i.  e.  they  do  not  infiltrate  the  connective  tissue. 

Diagnosis. — This  must  depend  upon  the  detection  of  a  tumor  in  the  breast 
of  a  -woman — usually  married  and  prolific — from  thirty  to  thirty-five  years 
of  age:  of  slow  growth,  re([uiring  many  years  to  roach  a  size  proiluctive  of 
annoyance ;  movable,  and  bosselated  on  the  surface.  Neither  retraction  of  the 
nipple  nor  involvement  of  the  axillary  glands  occurs,  but  where  any  portion 
of  the  mamma  is  left  there  is  sometimes  a  tendency  to  local  "  reproduc- 
tion." 

Treatment. — Free  excision  of  the  tumor  or  occasionally  removal  of  the 
entire  breast. 

Adeno-fibroma. — These  are  the  commonest  of  all  the  benign  mam- 
mary neoplasms.  They  consist  of  bypertrophied  connective  tissue,  mingled 
with  small  portions  of  normal  or  altered  glandular  tissue.  They  occur  as 
freely-movable  circumscribed,  rounded,  slightly  nodular,  usually  painless 
growths,  about  adolescence  or  at  least  under  twenty  years  of  age.  When 
no  secondary  cystic  changes  have  taken  place,  they  are  firm  and  elas- 
tic :  when  they  have  undergone  cystic  degeneration,  over  the  more  prom- 
inent bosses  they  feel  soft  or  even  fluctuating,  while  dense  elsewhere.  Pain 
is  sometimes  complained  of  by  neurotic  individuals.  These  neoplasms  are 
completely  encapsulated,  and  their  cut  surfaces  are  dry,  white,  opaque,  com- 
pact, creak  under  the  knife,  and  in  some  specimens  the  bundles  of  fibrous 
tissue  are  concentrically  disposed  around  numerous  central  ])oints  which 
project  above  the  surface.  In  slowly-formed  tumors  dense  adult  fibrous  tissue 
is  the  main  constituent :  in  more  rapidly  developing  neoplasms  interlacing 
bands  of  young,  wavy  connective  tissue  form  the  bulk  of  the  tumor, 
producing  a  more  succulent  growth,  which  is  glistening  white  or  even 
rosaceous  on  section.  In  those  of  most  rapid  growth  abundant  cellular 
elements  are  present.  Inflammation  or  supjmration  of  fibromata  is  very 
rare,  and  in  consequence  fungous  ])rotrusion  through  ulceration  of  the  skin  is 
almost  unheard  of.  Should  this  occur,  the  skin  immediately  around  the  open- 
ing is  normal,  non-adherent,  and  of  course  not  infiltrated.  Cystic  degeneration 
from  fatty  or  mucous  change  of  the  epithelium  or  myxomatous  degeneration 
of  the  interacinous  tissue  takes  place  in  about  4  per  cent,  of  all  cases,  and 
even  blood-  or  extravasation-cysts  have  been  observed,  while  telangiectatic 
change  occasionally  attacks  the  cystic  variety,  indicated  in  one-half  the  cases 
by  a  bloody  discharge  from  the  nipple :  such  tumors  are  of  rajtid  growth. 

Diagnosis. — Sometimes  a  small  solitary  adeno-fibroma  so  closely  resem- 
bles a  cyst  that  only  a  resort  to  the  hypodermatic  syringe  can  decide  the 
point.  The  age  of  the  patient,  and  the  defined,  circumscribed  outline  of  the 
tumor,  serve  to  distinoruish  it  from  both  carcinoma  and  chronic  lobular  inflam- 


i)f.sEAs/:s  .i.\/>   i.\jrini:s  or   riii:  r.nr.Asr.         l()o9 

Illation,  while  the  ahsence  of  adhcsidii  to  the  skin  and  ilccper  parts,  with  the 
iVeedom  of  the  axilhirv  jrhmds  from  involvement,  still  further  distinnfuishes  it 
from  carcinoma.      Wliile  usually  siiiL'le,  they  are  occasionally  multiple. 

Prognosis. — If  removed  they  do  not  recur. 

Adkxo-cystoma. — Since  any  adenonui  consists  of  acini  and  ducts  pos- 
sessino;  no  normal  outlet,  cysts  form  either  from  accumulation  of  their  secre- 
tion or  from  l)ein<^  drawn  asunder  by  the  contraction  of  the  periacinous  and 
pericanalicular  tissue  of  the  new  o:i'owth.  This  condition  is  apt  to  obtain  when 
there  is  primarily  but  little  hyperplasia  of  the  connective-tissue  elements  of  the 
neoplasm,  which  would  of  course  result  in  the  hard  form  or  ordinary  adeno- 
fibroma  described  in  the  last  section,  often  called,  from  its  excess  of  fibrous 
tissue,  a  fibroma.  The  cysts  are  lined  with  round,  cubical,  or  cylindrical 
glandular  epithelium.  In  many  instances  the  pericanalicular  interstitial  tissue 
projects  as  ingrowths  into  the  cavities  of  the  cysts — which  they  sometimes  com- 
pletely fill — forming  many-shaped  papillary,  cauliflower,  dendritic,  or  perhaps 
pedunculated  masses  covered  by  epithelium.  This  variety  of  adenoma  is  called 
"the  proliferous  mammary  cyst,"  "  endocanalicular "  or  "  intracanalicular 
mammary  tumor,"  and  comprises  86  per  cent,  of  the  cystic  tumors  of  the 
breast.  Upon  section  they  present  a  Avhite  or  cream-colored,  lobulated  surface, 
with  numerous  cysts,  some  small,  some  large — some  have  been  reported  even 
containing  a  quart — but  usually  of  medium  size,  filled  with  a  serous,  mucous, 
lactescent  fluid,  or  one  variously  tinted  by  blood,  rendering  it  brownish  or  san- 
guinolent.  A  distinct  capsule  envelops  the  growth,  which,  it  has  been  alleged, 
is  always  attached  by  a  pedicle  to  the  gland  tissue,  and  never  infiltrates  it. 

Diagnosis. — This  tumor  is  distinguished  from  an  adeno-fibroma  by  occur- 
ring later  in  life,  from  thirty  to  thirty-five  years  of  age,  and  from  carcinoma 
by  the  fact  that  the  latter,  as  a  rule,  appears  later.  While  it  is  bard,  it  is  mov- 
able, somewhat  nodulated,  of  slow  growth,  and  in  advanced  cases  from  the  large 
cysts  it  is  of  unequal  consistence,  giving  here  and  there,  over  the  most  promi- 
nent bosses,  a  sensation  of  elasticity,  perhaps  of  indistinct  fluctuation.  Some- 
times, after  growing  slowly  for  many  years,  it  will  suddenly  enlarge,  when  it 
may  produce  ulceration  of  the  skin,  a  fungating,  bleeding  mass  protruding, 
but  the  skin-opening  is  supple,  wuth  sharp-cut  edges — hence  not  infiltrated  with 
the  growth — and  the  axillary  glands  are  not  involved.  Possibly  from  the 
inflammation  the  glands  may  be,  in  rare  instances,  somewhat  enlarged  and 
tender  in  these  ulcerating  cases,  but  they  never  present  the  characteristic 
steady  increase  in  size,  with  matting  together  of  all  the  axillary  tissues,  termi- 
nating in  oedema  of  the  arm  from  pressure  on  the  veins. 

Prognosis. — Visceral  involvement  never  occurs,  nor  does  local  recurrence 
take  place  after  thorough  removal. 

Adeno-sarcoma. — In  the  preceding  forms  of  adenoma  the  periacinous 
and  peritubular  connective  tissue,  becoming  hyperplastic,  develops  into  a 
permanent  tissue  more  or  less  perfectly  approximating  the  type  of  normal 
fibrous  tissue,  but  in  adeno-sarcoma  the  proliferating  elements  tend  to  form, 
not  adult,  but  some  variety  of  embryonic  connective  tissue.  Thus  it  may  con- 
sist chiefly  of  small  spindle-cells,  mingled  with  a  varying  amount  of  mature 
connective  tissue,  of  large  spindle-cells,  of  imperfectly  organized  fibrous  tissue 
infiltrated  by  numerous  round  cells,  of  stellate  and  fiber  cells  with  anastomos- 
ing processes,  between  which  lies  a  mucoid  substance  ;  or,  finally,  all  these 
varieties  may  be  found  in  the  same  tumor,  each  in  a  different  portion  of  the 
growth  or  variously  combined :  scattered  cysts  are  also  frequently  found. 
Growths  of  this  nature  are  believed  to  remain  fjuiescent  for  long  periods  when 
commencing  in  early  life,  but  it  is  more  probable  in  such  cases  that  an  origin- 


I0(j0  .i.v  AMi:in(AX  THXT-nook'  OF  .si'/i(.'/':/n'. 

ally  i)eiii<i:n  growtli  has  luulerjioiie  a  secondary  malignant  (sarcomatous)  cliange. 
Originating  in  middle  life,  adeno-sarcomata  always  grow  rapidly. 

Diagnosis. — A  tumor  connnoncing  in  the  breast  of  a  woman  from  thirty 
to  forty  years  of  age  (perhaps  older),  covered  by  non-adherent  skin,  which  is 
heavy,  movable,  slightly  nodulated,  elastic,  but  of  unequal  consistence  at  its 
more  prominent  points,  and  which  grows  with  great  rapidity  without  involve- 
ment of  the  axillary  glands,  is  probably  an  adeno-sarcoma :  moreover,  a  tumoi 
which  has  jiresented  for  years  the  symptoms  given  for  adeno-cystoma,  which 
suddenly  begins  to  enlarge,  provided  the  enlargement  is  not  due  to  one  or  more 
cysts  becoming  distended,  is  probably  a  benign  adeno-cystoma  undergoing  sar- 
comatous change. 

Prognosis. — The  microscope  alone  can  determine  the  degree  of  malignancy 
of  any  given  growth,  the  appearances  varying  from  those  of  a  tumor  essentially 
benign  up  to  those  characterizing  one  whose  interacinous  tissue  is  extensively 
infiltrated  with  round  cells  or  composed  chiefly  of  spindle-cells,  when  the  growth 
is  practically  a  round-  or  spindle-celled  sarcoma,  which  is  liable  to  recur  both 
locally  and  in  distant  parts. 

Sarcoma. — For  the  specific  histological  appearances  of  the  solid  sarcomata 
the  reader  is  referred  to  the  section  on  Tumors,  p.  202.  The  round-,  spindle-, 
and  giant-celled  forms  all  occur,  mingled  with  more  or  less  adenomatous  tissue, 
but  the  large  spindle-celled  is  by  far  the  commonest.  Sarcomata  are  liable  to 
become  inflamed  or  to  suppurate,  and  may  undergo  myxomatous,  fatty,  cystoid, 
calcareous,  and  telangiectatic  metamorphoses,  the  two  former  being  the  most 
frequent  cause  of  those  large  interstitial  hemorrhages  of  such  common  occur- 
rence in  mammary  sarcomata,  sometimes  converting  them  in  Avhole  or  in  part 
into  a  grumous,  semifluid  material.  More  than  half  of  all  mammary  sarco- 
mata undergo  cystic  changes,  and  in  about  one  case  in  seven  discharge  from 
the  nipple  takes  place.  Sarcomata  usually  appear  between  the  ages  of  twenty 
and  thirty-five  years — one  has  been  reported  so  early  as  the  eighteenth  year — 
and  when  of  very  rapid  growth  there  may  be  considerable  local  elevation  of 
temperature.  They  usually  thrust  aside,  compress,  and  cause  atrophy  of  the 
gland,  but  in  rare  instances  are  only  attached  to  it,  and  then  merely  by  a  ped- 
icle. Their  usual  position  is  beneath  or  near  the  nipple  or  in  the  uj)per  inner 
segment  of  the  gland. 

Diagnosis. — Possessing  a  distinct  capsule,  they  form  rounded  or  ovoidal, 
somewhat  lobulated,  usually  single,  firm,  or  soft  and  elastic,  rapidly-growing 
tumors.  They  are  in  consistence  sometimes  so  difl^luent  that  they  feel  fluc- 
tuant, so  that  surgeons  have  incised  them,  believing  them  to  be  chronic 
abscesses.  The  veins  of  the  overlying  skin  enlarge  early,  but  the  tumor 
does  not  become  adherent  to  it  nor  to  the  contiguous  tissues  (Plate  XXIII, 
Fig.  1).  Later  there  is  a  distinct  tendency  to  ulceration,  but  this  is  due  to 
inflammation  and  gangrene  from  pressure  rather  than  to  infiltration  with 
sarcomatous  elements,  and,  as  a  rule,  the  surrounding  skin  is  at  first  neither 
discolored  nor  attached  to  the  fungous  protrusion  which  almost  invariably 
forms  after  the  skin  has  given  way.  The  ulcer  is  apt  to  be  circular,  and  some- 
times several  exist,  with  intervening  bridges  of  sound  skin.  The  discharge 
from  the  fungus  is  fetid  and  bloody,  but  may  be  purulent  from  inflammation. 

Sarcomata  usually  develop  with  great  rapidity,  and  the  viscera,  especially 
the  lungs,  may  become  involved  early,  but  the  axillary  glands  do  not  enlarge 
except  in  very  rare  instances,  and  then  only  from  inflammatory  irritation,  not 
from  the  lodgment  of  sarcomatous  elements.  The  distinction  between  solid 
and  cystic  sarcomata  may  perhaps  be  made  by  noting  that  the  latter  appear 
earlier — before  the  thirty-third  year ;    that  they  are  more  apt  to  be  located 


/>/s/:as/:.^  a.\/>  i\./rnii:s  or  riii:  r.in:Asr.        lOGl 

ne<ar  tlie  nipple;  that  tlicy  ^row  mow  rapidly:  that  they  suddenly  increase 
after  (luicsconce  or  slow  j^rowth  lor  Ioiil'  periods;  that  they  are  more  lobidated 
and  their  consistence  is  more  une((nal ;  (hat  disehari^e  from  the  nijiple  is  «(iiite 
fre(|uent;  and  that  pain,  usually  harassin<:;,  is  e.\])erienced  in  more  than  three- 
fourths  of  all  cases.  They  must  be  differentiated  from  carcinoma  by  the  earlier 
age  at  which  they  occur,  by  their  mobility,  by  their  uneijual  density,  by  the 
absence  of  retraction  of  the  nipple,  of  invasion  of  the  skin,  of  induration  of 
the  lymphatic  glands,  and  of  fixation  to  the  chest-wall,  and,  when  ulceration 
exists,  by  the  fact  that  in  sarcoma  fungous  protrusion  is  apt  to  occur  ii'lthont 
infiltration  of  tlic  skin,  the  characteristic  thickened,  infiltrated,  everted  mar- 
gins of  the  carcinomatous  ulcer  being  absent. 

Prognosis. — Many  of  the  sarcomata,  especially  those  of  the  round-celled 
form,  which  possess  but  little  intercellular  substance,  are  exceedingly  malig- 
nant. Both  local  recurrence  and  visceral  imjdication  are  the  rule,  the  former 
being  the  commoner  because  the  disease,  although  apj)arcntly  remaining  encap- 
sulated, progresses  along  the  adventitia  of  the  blood-vessels  external  to  the 
capsule,  which  serve  as  points  of  departure  for  both  the  local  recurrence  and 
the  visceral  contamination. 

Treatment  of  Adenoma,  Adeno-fibromata,  and  Sarcomata. — 
Grasping  the  mass  firndy  so  as  to  render  the  skin  tense,  an  incision  should 
be  made  down  to  and  through  the  capsule  of  an  adenoma  or  a  fibroma, 
when  it  can  readily  be  enucleated,  requiring  perhaps  a  few  touches  of  the  knife. 
Adeno-cystomata,  when  involving  much  of  the  gland,  require  amputation 
of  the  entire  breast ;  and  the  same  treatment  is  indicated  for  cases  of  cysto- 
sarcomata  and  pure  sarcomata,  with  free  removal  of  the  superjacent  skin. 

Carcinoma. — Predisposing  and  Exciting  Causes. — Heredity  has 
some  but  not  a  great  influence,  but  traumatism  and  such  lowering  in  grade  and 
vitality  of  the  tissues  as  results  from  the  chronic  thickening  and  induration 
left  after  acute  mammitis  or  abscess  seem  not  uncommonly  to  stand  in  causa- 
tive relation  to  carcinoma.  As  has  already  been  pointed  out,  the  chronic 
dermatitis  of  the  nipple  called  Paget's  disease  sometimes  precedes  and  un- 
questionably favors  the  development  of  carcinoma.  Any  slight,  prolonged 
irritation,  increasing  the  vascular  supply  to  the  epithelial  tissues  in  a  gland 
which  is  senescent  or  old — which  for  the  mamma  means  from  thirty-five  to 
fifty  years — may  excite  the  disease  in  one  predisposed  to  it,  probably  by  some 
inherited  peculiarity  of  tissue.  As  a  rule,  the  patient  when  attacked  is  in 
good  or  even  robust  health. 

The  pathological  anatomy  of  carcinoma  has  been  so  fully  described  else- 
where that  only  a  few  general  remarks  will  be  made  here.  Carcinoma  is  an 
atypical  epithelial  growth  consisting  of  a  stroma  whose  intercommunicating 
spaces  are  occupied  by  polymorphous,  spherical,  or  cubical  epithelial  cells,  no 
genuine  intercellular  cement  substance  being  apparently  present,  and  the  inter- 
communicating columns  of  cells — seen  in  cross-section  they  resemble  alveoli, 
and  are  hence  so  called — are  not  surrounded  by  a  basement  membrane,  but 
are  in  direct  relation  with  the  fibrous  stroma,  thus  differing  from  adenoma,  in 
which  a  limiting  membrane  encloses  the  cell-masses,  and  which  moreover  are 
often  not  solid,  but  possess  a  central  space,  exactly  simulating  a  normal  acinus. 

Varieties  of  Carcinoma. — According  to  the  relative  proportions  of  the 
fibrous  and  the  epithelial  elements,  a  given  carcinoma  is  classed  as  hard  or  soft. 
At  one  extreme  is  the  fibrous,  hard,  or  scirrhous  carcinoma,  in  which  the 
fibrous  tissue  is  in  excess;  at  the  other,  the  epithelial  elements  form  the  bulk 
of  the  tumor,  resulting  in  the  soft,  cellular,  medullary,  or  encephaloid 
carcinoma. 


IDC-J 


,LV  AMi:i!icAy  'j'j:xr-ii<K)K  o/-  s (/:(.' /•j/n\ 


Course,    Symptoms,   and    Termination    of    Hard    Carcinoma. — 

Scirrlius  ioniis  an  incuuliii-,  nodulated,  .^omculiat  rounded,  slony-liard,  lieavy 
mass,  inseparable  from  the  glandular  tissue,  jiossessing  no  defined  outline,  but 
gradually  merging  into  tlie  healthy  niannuary  tissue,  "with  whieh  it  I'roely 
moves  (JPlate  XXIII,  Fig.  2).  Soon  it  adheres  to  the  skin,  Avhieh  becomes 
dimpled,  and  later  to  the  pectoral  muscle ;  thus  at  first  being  partially, 
then  immovably,  fixed  to  the  chest-wall.  At  the  outset  the  tumor  grows 
slowly :  the  nipple  gradually  becomes  retracted  when  the  tumor  is  primarily 
located  close  to  or  i)enoath  the  nipple,  or  when  it  spreads  to  this  neigh- 
borhood ;  but  the  growth  never  attains  a  great  size,  as  does  the  soft  car- 
cinoma. As  a  rule,  the  upper,  outer  (axilhiry)  segment  is  attacked,  but 
scirrhus  may  originate  close  to  the  nipple  or  to  the  inner  side  of  the 
breast.  Studying  in  detail  cei'tain  symptouis,  it  will  be  seen  that  while 
the  skin  may  adhere  to  subjacent  inHamed  tissues  or  benign  growths,  it 
is  then  glazed,  thinned,  and  stretched  by  mechanical  pressure ;  but  in 
carcinoma  the  conditions  are  diff'eront,  for  the  fibrous  septa,  connecting  the 
skin  and  mammary  fascia  being  infiltrated  with  young  cells,  new  fibrous  tissue 
forms,  which,  contracting,  pulls  in  isolated  imtJiinncd  portions  of  normal  skin, 
producing  the  characteristic  delicately-j)itted  "pig-skin"  appearance. 

Betraction  of  the  nipple  due  to  carcinoma  differs  from  that  seen  occasion- 
ally in  benign  growths,  in  that  the  nipple  is  actually  di-awn  in,  and  not  buried, 
by  the  projection  of  the  tumor-mass ;  and  by  pressing  this  back  in  the  case  of  an 
innocent  growth,  the  nipple  will  be  seen  to  be  normal,  having  only  been  buried, 
not  retracted.  Genuine  retraction  of  the  nipple  results  from  the  contraction 
of  the  milk-ducts,  the  walls  of  which  have  been  infiltrated  with  young  cells 
which  have  developed  into  fibrous  tissue  (Fig.  428),      In  proportion  to  the 

propinquity  of  the  growth  to  the 
nipple  is  its  retraction  :  a  growth 
occupying  only  the  upper  outer  seg- 
ment of  the  gland  will  not  produce 
this  symptom.  When  present  it 
is  valuable  corroborative  evidence 
of  the  existence  of  a  hard  carci- 
noma, but  its  absence  under  some 
circumstances  proves  nothing.  Very 
rarely  a  small  amount  of  thin  dis- 
charge exudes  from  the  nipple  when  the  growth  is  near  it,  but  tliis  discharge 
differs  from  that  characteristic  of  some  forms  of  cystic  adenomata. 

Pain,  usually  believed  to  be  characteristic  of  carcinoma,  is  al)sent  in  the 
earlier  stages,  and  becomes  prominent  only  when  the  tumor  is  of  some  size. 
The  diagnostic  significance  of  this  symptom,  which  is  relied  upon  by  the 
public  and  too  often  by  the  ]U'ofession  until  the  best  chance  for  cure  has  been 
lost,  cannot  be  too  earnestly  combated.  Sometimes  slight  stinging  pains 
attract  attention  to  the  growth  ;  but  it  is  more  often  accidentally  discovered  : 
it  is  not  tender.  When  fixed  to  the  chest-wall  and  the  axillary  nerves  are 
compressed  by  the  secondary  lymphatic  glandular  tumors,  the  jiain  is  severe 
and  almost  ceaseless.      Its  character  is  lancinating,  darting,  or  cutting. 

Cachexia  is  usually  only  present  when  ulceration  has  taken  place  and  when 
mental  anxiety,  prolonged  pain,  or  profuse  discharge  has  exhausted  the  patient; 
but  in  nearly  every  instance  the  patient  is  in  robust  health  when  first  attacked. 
Moreover,  if  under  the  former  circumstances  the  tumor  is  removed,  and  with 
it  worry,  pain,  and  discharge,  the  patient  promptly  regains  color  and  ffesli. 
Age  is  an  important  point,  since  most  hard  carcinomata  appear  between  the 


Fto.  42.".. 


Retraclion  of  the  Nipple  in  Mammary  Carcinoma 

(Bryant). 


TUMORS  OF    rm:   breast.  Plate  XXIII. 


1.  Sarcoma  of  the  breast.    '1.  Scirrhus  of  the  breast. 


DISEASES   AXD    IXJURTES    OF    THE  BREAST.  1003 

ages  of  forty  and  fifty  years.  A  very  few  cases  have  been  reported  before 
the  thirtieth  year,  yet  this  is  a  rarity.  A  distinct  percentage  are  under 
thirty  years  of  age.  In  one  instance,  now  first  reported,  the  tumor  was  de- 
tected hite  during  the  nineteentli  year,  the  microscopic  diagnosis  being  made 
both  of  the  ))riinary  an<l  axilhiry  growths,  after  operation,  (hiring  tlie  latter 
half  of  the  twenty-third  year.  Hence  any  mammary  tumor  presenting  dis- 
tinct symptoms  of  local  malignancy  with  involvement  of  the  lymphatic 
glands  must  be  considered  malignant,  despite  the  youth  of  the  patient. 

Scirrhus,  left  to  itself,  will  involve  the  whole  mamma,  converting  it,  with 
the  overlying  skin  and  subjacent  muscular  parietes  of  the  chest,  into  one  nod- 
ular, stony-hard  mass  with  retracted,  buried  nipple.  The  cancer-cells  find 
entrance  into  the  perivascular  lymph-spaces  of  the  cutaneous  blood-vessels, 
forming;  here  and  there  smaller  or  larger  nodules.  When  this  condition 
involves  a  large  portion  of  the  chest-wall,  it  is  called  cancer  "  ew  cuirasse." 
Owing  to  the  contraction  of  the  widely-spread  and  rigid  neoplasm,  the  movements 
of  the  chest  are  sometimes  sufficiently  embarrassed  to  produce  distinct  difficulty 
in  breathing.  Usually  the  skin  over  the  afi"ected  area  is  decidedly  reddened. 
Ulceration  may  occur  (Plate  XXIY,  Fig.  1),  either  superficial  or  deep,  more 
commonly  the  latter,  producing  deep,  crater-like  cavities  with  hard,  tuberous, 
irregular,  and  everted  margins,  the  base  being  formed  of  unhealthy,  sloughing 
granulations  or  cancer-tissue  covered  with  thin,  ichorous,  sanious,  offensive  dis- 
charge :  no  fungus  ever  forms.  Severe  and  repeated  hemorrhages,  readily 
controllable,  however,  by  pressure,  are  not  uncommon.  Early  in  the  disease, 
although  often  incapable  of  detection  by  the  touch,  the  axillary  lymphatic  glands 
become  involved  in  fully  85  per  cent,  of  cases  supposed  before  operation  to  be 
free  from  this  complication :  when  the  axillary  fascia  has  been  divided,  the 
glands  are  found  to  be  carcinomatous.  Indeed,  such  a  condition  will  be 
present  in  practically  every  case  where  the  primary  disease  has  existed  even 
so  short  a  time  as  six  months.  These,  forming  masses  behind  and  in 
front  of  the  brachial  plexus  and  vessels,  finally  fuse  together,  steadily  con- 
tracting until  the  return  circulation  is  markedly  interfered  with,  as  evinced  by 
oedema  of  the  Avhole  upper  extremity,  and  most  distressing  neuralgic  pain  is  pro- 
duced. From  the  axillary  glands  the  disease  spreads  to  the  supraclavicular 
glands.  By  recalling  the  other  routes  by  which  the  lymph  is  normally  returned, 
as  described  on  page  1050,  the  surgeon  will  recognize  that  the  anterior  medias- 
tinal glands,  the  pleura,  and  the  viscera  may  all  be  involved,  even  although 
secondary  disease  of  the  axillary  lymphatics  does  not  occur.  Plate  XXIV, 
Fig.  2,  shows  the  appearances  in  local  recurrence  after  extirpation.  After  the 
lymphatic  glands  the  viscera  become  diseased,  in  order  of  frequency  as  fol- 
lows :  liver,  lungs,  pleura,  and  bones.  Cysts,  usually  from  retention  produced 
by  obstruction  of  acini  or  ducts,  are  occasionally  observed. 

The  Atrophic  or  Withering  Scirrhus,  from  the  fatty  degeneration 
and  absorption  of  the  epithelial  cells  (Fig.  424) — perhaps  induced  by  the  un- 
usually abundant  development  of  the  fibrous  stroma  contracting  so  as  to  diminish 
the  blood-supply  to  the  cells — leaves  little  more  than  a  mass  of  fibrous  tissue, 
with  here  and  there  a  few  cells  surrounded  by  granular  debris.  Although  the 
tumor  is  slower  in  its  progress  and  rather  diminishes  in  size  than  increases, 
the  malignancy  is  not  thereby  lost,  the  ultimate  result  being  the  same. 

Diagnosis. — This  depends  upon  the  detection  of  a  tumor  most  frequently 
in  the  upper,  outer  seguientof  the  breastof  a  woman  usually  over  forty  yearsold, 
heavy,  stony-hard,  Avithout  definite  outlines,  covered  by  adherent  '*pig-skiu  " 
intecrument,  at  first  moving  icitli  the  breast,  and  later  adherent  to  the  pectora- 
lis  major  muscle,  with  enlargement  of  the  axillary  glands  and  retraction  of  the 


1()(]4 


AN  AJfK/i'/CAX    TKX'f- /!()() h'    OF  SUIiilFJiy. 


Fk;.  424. 


nipple  as  the  growth  reaches  its  neigliborliood :  if  originating  beneath  or  near 
the  nipple,  retraction  of  that  organ  will  be  an  early  sign ;  if  the  neoplasm  is 
examined  when  only  one  border  of  the  gland  is  involved,  this  sym])tom  will 
be  entirely  absent.  From  sarcoma  it  is  to  be  distinguished,  in  addition  to 
the  difference  in  feel  and  absence  of  mobility,  by  the  adherent  and  jx'ciiliar- 
looking  skin  and  the  glandular  involvement. 

Soft  Carcinoma. — This  is  a  disease  of  earlier  life,  runs  a  more  ra])id 
course,  and  its  capability  of  contaminating  the  system  is  much  more  pro- 
nounced than  that  of  scirrhus.  Usually  more  deep-seated  than  scirrhus,  it 
forms  at  the  outset  a  rounded,  nodular,  movable  tumor,  at  ])oints  elastic  or 
pseudo-Huctuant,  growing  with  such  rapidity  that  it  may  sometimes  reach  the 
size  of  a  child's  head  in  a  couple  of  months.  Soon  the  skin  adheres,  reddens, 
becomes  glazed,  and.  the  ap))earances  closely  simulating  those  of  abscess,  the 

integument  gives  way  by  ulceration.  By 
this  process  and  sloughing  of  masses  of  the 
tumor  large  excavated  sores  are  formed. 
Tain  is  a  late  symptom,  but  cachexia  sets 
in  early,  as  well  as  lymphatic  and  vis- 
ceral metastases.  Cysts  are  also  formed 
occasionally,  as  described  when  speaking 
of  scirrhus,  Avhile  abscesses  have  been 
observed,  especially  in  rapidly-growing 
tumors  developing  during  pregnancy.  Col- 
loid change  likewise  very  rarely  attacks 
some  of  the  firmer  forms  of  soft  carcinoma. 
Diagnosis. — The  resemblance  to 
round-celled  sarcoma  is  great,  the  cardi- 
nal point  of  distinction  being  that  sar- 
coma is  an  encapsulated,  and  therefore  a 
distinctly  circumscribed  growth,  Avhile 
soft  carcinoma  is  a  non-circumscribed, 
infiltrating  neoplasm.  The  rapidity  with 
which  it  attains  a  great  size,  the  relative 
softness  of  the  mass,  the  late  a])pearance 
of  pain,  and  the  early  constitutional  in- 
volvement distinguish  it  from  hard  car- 
cinoma. Colloid  carcinoma  cannot  be 
diagnosticated  before  removal,  but  is  of  slow  growth,  and  glandular  infection 
occurs  late. 

Prognosis. — Without  operation  carcinoma  of  both  kinds  terminates  by 
death  ;  the  attending  operation  will  be  referred  to  later. 

The  average  duration  of  life  in  the  fibrous  form  is  about  thirty  months,  in 
the  soft  about  twelve  months,  although  life  may  be  greatly  prolonged  in  the 
former,  while  it  may 'be  much  curtailed  in  the  latter,  especially  if  the  disease 
commences  during  pregnancy,  when  a  few  weeks  sometimes  comprise  the  whole 
course  of  the  affection. 

Treatment. — Experience  having  proved  that  no  internal  remedy  is  of 
the  slightest  benefit,  the  question  resolves  itself  into  allowing  tlie  disease  to 
pursue  its  course,  relieving  pain  and  making  the  patient  as  comfortable  as  pos- 
sible,— the  so-called  palliative  method;  or  resorting  to  the  radical  plan,  mean- 
ing by  this  the  prompt  extirpation  of  all  the  diseased  tissues.       • 

Palliative  Treatment. — This  is  often  necessitated  by  the  disease  hav- 
ing reached  so  advanced  a  stage  when  first  seen  that  all  opportunity  for  the 


Atr(i|iliif  Scirrhus  (original). 


TUMORS  OF  THE  BREAST. 


Plate  XXIV. 


J > IS i: ASKS  AX/}  i.\j(  inKs  or  the  breast.         1065 

succes'?t"iil  employment  of  tlie  radical  method  has  been  lost.  The  parts  must 
be  put  to  rest  by  carrying  the  arm  in  a  sling ;  corsets  and  tight  clothing  must 
be  interdicted-,  but  at  the  same  time  the  diseased  organ  must  be  carefully  sup- 
ported. Local  apj)lications  of  extract  of  belladonna  with  opium  or  conium  at 
first  give  relief,  but  the  tVce  use  of  mor|)hia  with  small  doses  of  atropia  soon 
becomes  requisite.  The  constant  application  of  acetate  of  lead  in  the  propor- 
tion of  grs.  XV  @  3j  will  sometimes  aflbrd  relief  when  a  rapidly-growing  tumor 
becomes  reddened,  hot,  and  tense,  or  ice-bags  may  be  employed.  When  ulcera- 
tion has  taken  place,  deodorizing,  unirritating  dressings  should  be  employed, 
such  as  chloral,  grs.  v  (a)  5J  of  vaseline,  balsam  of  Peru,  etc.  The  use  of  Es- 
march's  powder  under  these  circumstances  will  often  relieve  the  pain,  check  the 
rapidity  of  growth,  and  decidedly  diminish  fetor.  Its  composition  is  arsenious 
acid  and  muriate  of  morphia,  each  0.25  part,  powdered  gum  arable  12.0  parts. 
Half  a  teaspoonful  of  this  should  be  daily  sprinkled  over  the  surface  of  the 
sore  until  a  yellowish  crust  forms,  which  after  separation  leaves  a  healthy 
granulating  surface :  this  powder  can  be  repeated  when  necessary.  Hemor- 
rhage can  be  stopped  by  pressure  or  by  the  local  application  of  styptic  cotton. 

Operative  Treatment. — The  first  question  to  be  answered  is.  Can  the 
disease  be  totally  eradicated  ?  If  not,  no  operation  should  be  attempted,  unless 
to  remove  a  foul  sore  purely  as  a  palliative  measure. 

While  each  case  must  be  a  rule  for  itself,  the  following  conditions  are  posi- 
tive contraindications  to  a  radical  operation:  great  enlargement  of  the  supra- 
clavicular glands,  cancer  en  cuirasse,  such  a  dissemination  of  small  shot-like 
bodies  in  the  skin  that  a  Avide  margin  of  healthy  skin  cannot  be  left  outside 
of  the  smallest  nodule,  or  such  extensive  axillary  involvement  that  the  thor- 
ough clearing  out  of  that  space  will  be  impossible.  Again,  the  liver,  lungs, 
and  other  viscera  should  be  carefully  examined  to  eliminate  the  probability  of 
any  metastases,  because  the  discovery  of  any  such  is  an  absolute  bar  to  opera- 
tion. To  reiterate,  unless  all  local  and  glandular  disease  can  be  thoroughly 
eradicated  and  presumptive  proof  exists  that  the  viscera  are  free,  no  operation 
should  be  done.  Moi'eover,  in  very  advanced  life  the  disease  often  progresses 
so  slowly  that  the  probabilities  of  prolonged  life  are  sometimes  greater  without 
than  with  operation. 

When  the  skin  is  merely  adherent  and  the  tumor  freely  movable  on  the 
deeper  parts,  with  simple  enlargement  of  the  axillary  glands,  the  surgeon  should 
urge  the  promptest  and  freest  possible  operative  measures.  It  is  the  surgeon's 
duty  to  endeavor  to  educate  the  public  up  to  the  recognition  of  the  necessity  for 
early  operation  before  extensive  local  and  glandular  infection  has  taken  place. 

The  results  of  early  radical  operations  performed  by  Konig,  Kiister,  Gross, 
Banks,  Estlander,  and  Gussenbauer  show  from  16.7  per  cent,  to  22.5  yier 
cent,  of  permanent  cures,  the  average  being  20.08  per  cent.  According  to 
Curtis,  Dennis,  Weir,  and  Bull,  the  average  of  permanent  cures  is  20.87 
per  cent. 

In  Halsted's  and  Cheyne's  cases  somewhat  over  50  per  cent,  have  passed 
the  three-year  limit  without  recurrence ;  Mr.  Cheyne's  cases  (1899)  number- 
ing 99  and  covering  a  period  of  nine  years.  Similar  good  results  are  ex- 
pected by  the  best  operators,  partly  from  the  more  thorough  operations  which 
are  now  done,  and  also  because  both  patients  and  the  profession  are  learn iiig 
the  equally  important  fact  that  early  operations,  before  systemic  involve- 
ment has  occurred,  are  much  more  likely  to  yield  favorable  results  than  later 
operations. 

The  mortality  from  the  operation,  which  is  a  much  more  severe  procedure 
than  was  formerly  adopted,  has  fallen,  according  to  Williams,  from  17.35  to 


10«()  AN  AMKIilVAX    TEXT-BOOK    OF  SllHiKUY. 

9.4  |>or  cent.  This  latter  percentat^e  uiKiuestionably  represents  a  much  higher 
ileath-rate  than  prevails  in  this  country,  which  is  only  aliout  ">  per  cent.,  and 
in  4(J4  cases  reported  hy  Jiidl.  Dennis,  Weir,  iialsted,  and  Keen  is  onl}-  O.iSG 
per  cent.  Williams  conclusively  shows  that  where  a  cure  is  not  effected  life 
is  prolonged,  those  operated  upon  living  upon  an  average  60.3  months,  as 
compared  with  those  not  operated  upon,  who  survive  for  only  44.8  months. 
From  the  data  given  by  Iialsted,  recurrence  in  the  practice  of  Czerny, 
Fischer,  Gussenbauer,  Kiinig.  Liicke.  and  A'olkmann  reaches  02.55  per  cent., 
but  in  his  own  practice,  with  a  still  bolder  use  of  the  knife,  only  3  recurrences 
were  observed  in  46  cases. 

Method  of  Operating. — While  no  rules  can  be  given  applicable  to  every 
case,  in  general  every  particle  of  diseased  tissue  must  be  removed,  no  regard 
being  paid  to  retaining .  enough  skin  to  cover  in  the  Avound  if  this  essential 
indicatit)n  will  be  thereby  interfered  with.  The  knife  should  sweep  wide  of 
the  apparent  limit  of  infiltrated  skin,  making,  if  necessary,  a  cut  encircling 
the  whole  base  of  the  gland.  If  it  appears  right  to  save  any  of  the  covering 
skin,  the  outline  of  the  incisions  should  include  an  ellipse  embracing  the  cen- 
tral portions  of  the  growth,  the  long  axis  of  the  ellipse  extending  from  just 
below  the  anterior  axillary  fold  downward,  forw  ard,  and  inward.  The  incisions 
should  be  boldly  made  through  the  skin  and  paramammary  fat  down  to  the 
pectoral  aponeurosis,  and  the  gland  rapidly  dissected  oft'  from  below  upward, 
leaving  the  attachments  toward  the  axilla  uncut.  Let  an  assistant  compress 
each  spurting  vessel  by  the  finger-tips  until  hemostatic  forceps  can  be  applied. 
The  pectoral  fiiscia,  and  any  remaining  portions  of  infiltrated  muscles  or  out- 
lying gland  tissue,  must  be  freely  removed. 

A  complex  network  of  lymphatic  vessels  lies  on  the  outer  surface  of  the 
muscles  and  the  upper  surface  of  the  fascijie.  These  vessels  intercommuni- 
cate, and  the  lymph-current  is  from  the  muscle  toward  the  fascia,  as  demon- 
strated by  injections.  The  presence  of  these  lymphatic  networks  shows  the 
necessity  of  removing  the  pectoral  fascia  with  the  underlying  fat  in  all  opera- 
tions for  carcinoma,  and  also  explains  the  possibility  of  a  carcinoma  being 
actually  adherent  to  tlie  fascia,  while  the  muscle  itself  may  remain  free. 

The  axilla  is  to  be  opened  by  an  incision  parallel  to  and  one  inch  below 
the  anterior  axillary  fold,  and  this  space  cleared  of  aU  glands  (Figs.  198.  200), 
h'mphatic  vessels,  and  fat  by  dissection.  Careful  use  of  the  knife,  with  double 
ligature  of  any  tissues  that  may  contain  large  vessels  before  dividing  them — even 
to  the  axillary  vein  if  endangered — will  render  this  a  safe  procedure.  It  is  safer 
to  clear  the  vein  first,  and  then  proceed  withw  hat  further  dissection  may  be  requi- 
site. Having  determined  by  careful  search  both  in  front  of  and  behind  the  axil- 
lary vessels  and  nerves  that  every  gland,  however  minute,  has  been  removed,  the 
skin  should  be  freely  loosened  by  the  scalpel  handle  or  its  edge  around  the  wound 
until  the  margins  can  be  approximated.  To  secure  this  without  tension,  either 
completely  or  partially,  relaxation  buttons  and  sutures  are  sometimes  requisite ; 
these  can  be  removed  from  the  fifth  to  the  seventh  day.  Finally,  if  thought 
necessary,  provide  for  drainage  bypassing  a  perforated  glass  or  rubber  drain- 
age-tube through  the  posterior  axillary  fold  by  an  especial  incision,  thus  drain- 
ing the  most  dependent  portion  of  the  wound.  The  skin  should  then  be 
accurately  apposed  by  superficial  sutures,  either  interrupted  or  continuous. 
If  relaxation  sutures  will  not  enable  the  surgeon  to  coaptate  thcAvhole  wound, 
the  angles  should  be  closed,  leaving  the  central  portion  to  heal  by  granula- 
tion. Skin-grafting  may  be  immediately  adopted,  provided  the  operation  have 
been  done  aseptically — /.  c.  without  the  use  of  antiseptics  :  or  after  granula- 
tions have  formed  this  procedure  may  be  employed  to  close  the  whole  gap 


DISEASES    AXn    I  X.I  TR  FES    OE    THE    BREAST. 


1067 


at  one  sittinji;.  Aseptic  sheets  or  towels  should  surround  the  field  of  opera- 
tion, and  when  a  prolon<;ed  axillary  dissection  is  re([uisite  the  hreast-wound 
should  be  temporarily  covere(l  with  aseptic  fjauze  to  prevent  shock  and  per- 
haps ])neuraonia  :  antiseptic  sponges  or  niojis  of  aseptic  ^;iu/e  should  also  ]>e 
employed,  avoiding  as  far  as  possible  all  wetting  of  tho  patient.  The  ordinary 
aseptic  preliminaries  and  some  one  of  the  forms  of  aseptic  dressings  must  be 
em])loYed,  and  the  arm  confined  to  the  side  by  a  snugly-pinned  binder.  Shock, 
wiiich  is  often  very  pronounced,  must  be  combated  by  appropriate  measures. 
The  mortality  by  this  method  of  operating,  although  small  considering  the 
magnitude  of  the  operation,  is  slightly  higher  than  by  the  older  plan  ;  but 
more  cures  will  result,  hence  more  lives  will  in  the  end  be  saved, 

Halsted    has    insisted    that   all    the  pectoralis  major  muscle,  excepting 
possibly  its  clavicular  portion,  should  be  excised  with  the    breast    in    one 

Fro.  425. 


Halsted's  Operation  for  Removal  of  the  Breast. 


piece,  including  the  axillary  contents.  Thus :  Carry  the  incisions  at  once 
through  the  fat,  fully  reflect  the  triangular  skin-flap,  and,  dividing  the 
costal  insertions  of  the  pectoralis  major,  split  the  muscle  between  its  costo- 
sternal  and  clavicular  portions  up  to  about  opposite  the  scalene  tubercle  on 
the  first  rib  ;  divide  the  clavicular  portions  of  the  muscle  with  the  overlying 
skin  close  up  to  the  clavicle,  exposing  the  apex  of  the  axilla  ;  draw  upward 
the  cut  clavicular  portion  of  the  muscle  with  a  broad,  sharp  retractor  and  dis- 
sect all  loose  tissue  from  it ;  split  the  muscle  out  to  the  humerus,  and  cut  it 
through  close  to  its  attachment,  making  tension  by  means  of  traction  upon  the 
loosened  breast  muscles,  etc.  ;  strip  everything  away  from  the  chest-wall, 
including,  when  possible,  the  sheath  of  the  pectoralis  minor,  clearing  the  exter- 
nal border  of  the  muscle,  cut  it  transversely  through  its  middle,  dividing  it 
as  far  externally  as  possible,  and  then  reflecting  inward  the  cellular  tissue 
overlying  the  coracoid  extremity  of  this  muscle,  which  then  draw  upward  with 
a  broad,  sharp  retractor ;  dissect  out  and  carefully  ligate  close  to  the  axillary 
trunks  all  the  small  vessels,  chiefly  veins,  lying  beneath  and  near  to  the  mus- 
cular insertion  ;  complete  the  extirpation  of  the  axillary  contents  by  dissecting 
the  vein,  artery,  and  nerves  clean  of  any  loose  tissue ;  making  traction  upward 
and  outward,  divide  with  the  knife  the  fascia  which  binds  the  axillary  fat  to 
the  chest-wall;  an  assistant  renders  the  triangular  skin-flaps  tense;  dissect 
the  tissues  away  from  the  subscapular,  teres  major,  and  latissimus  dorsi  mus- 


1()<)8 


j.v  AMi.iucAX   ri:.\i'-i>()()h    oi    SI  i:(n:in\ 


c-lcs.  c'Xposiii;^  ami  srciirin<j;  before  dividing  tlic  subscapular  vessels,  but  spar- 
iii;j:  the  suliscapnlnr  nerves  if  possible;  liaviiiL'  cleared  tliese.  turn  the  mass 
inward  ami  remove  it  by  a  cut  along  tlie  l)ase  of  the  triangle;  apjtruximate 
the  wound  by  a  buried  purse-string  suture,  including  only  the  base  of  the  tri- 
angular llaj),  whose  api'X  is  to  )«•  shifted  lu  a  lower  position,  so  as  to  secure  a 
loose  lining  for  the  axilla,  maintaining  contact  between  tlie  flap  and  subjacent 
tissues  by  carefully-applied  dressings.  Prolong  the  skin  incision  ujtward 
over  tlie  clavicle  and  clear  the  sujira-clavicular  s])ace  of  all  eidarged  lymjih- 
atic  glands,  carefully  avoiding  the  thoracic  duct  when  operating  upon  the 
left  side.  No  axillary  drain  need  be  emi)loyed.  the  uncovered  portion  of 
wound  healing  either  by  so-calleil  organization  of  blood-dot  or  by  granula- 
tion. Little  or  no  disability  is  said  to  be  noticeable  after  this  0]>eration.  and 
what  results  comes  from  loss  of  skin,  not  loss  of  niuscle.  and  can  sometimes 
be  rectified  by  skin-grafting. 

Cysts. — The  distinction  must  be  made  between  these  and  ci/stic  tiiinorif — 
I.  e.  cystic  degenerations  of  solid  tumors — since  all  forms  of  mammary  tumors 
may  undergo  such  changes,  even  the  carcinomata;  but  the  adenomata  and  the 
sarcomata  more  frequently  show  these  alterations. 

Hyd.\tid  Cysts. — This  is  the  only  parasitic  disease  of  the  breast,  and  is 
of  very  rare  occurrence.  Only  one  cyst  ha,s  ever  been  found  at  a  time,  but  it 
may  contain  from  one  to  four  daughter  cysts.  Hydatid  cysts  grow  .slowly, 
attain  a  moderate  size,  are  ])ainless,  forming  smooth,  round,  firm,  elastic,  some- 
times fluctuating,  movable  tumors,  adherent  neither  to  the  skin  nor  to  the 
chest-wall.  They  generally  occur  in  the  upper  outer  segment  of  the  gland, 
but  are  never  found  near  the  nipple.  From  secondary  changes  the  skin  may 
become  adherent  or  the  axillary  glands  enlarged. 

Diagnosis. — From  other  forms  of  cysts  it  will  generally  be  impossible  to 
distinguish  a  hydatid  cyst  e.xcept  by  the  use  of  the  exploring  needle  or  trocar, 
thereby  evacuating  the  characteristic  watery  fluid  and  perhaps  daughter  cysts 
and  booklets.  From  a  lacteal  cyst  it  can  readily  be  distinguished,  because 
the  latter  appears  near  the  nipple  during  lactation^  and  is  prominent,  and  of 
rapid  formation. 

Galactoceles,  or  jNIilk  Cysts. — These  are  rare,  result  from  obstruction 
and  dilatation  of  the  milk-sinuses  or  ducts,  and  in  consequence  are  situated 
close  to  the  nipple  or  beneath  the  areola.  Nearly  always  single,  they  appear 
suddenly  during  lactation,  increase  rapidly  and  form  soft,  fluctuating,  painless 
swellings,  sometimes  pendulous,  covered  with  unchanged  skin  containing 
enlarged   veins :  sometimes  milk   can  be  expressed  from   the  nipple  by  pres- 

Fk;.  426. 


r  -  \\ 


Cystic  1' 


•il<l). 


sure  on  the  cysts.    The  contents  mav  be  unchanged  milk,  like  cream,  or  con- 
sist of  a  semi-solid,  cheesy  material,  in  Avhich  case  the  history  generally  shows; 


/>/s/:as/:s  a\/>   i.wii  i;fi:s  of  the  biikast.         uxii* 

that  Huctuation  was  iiotccl  at  the  l)('Lriiniiii<r,  and  that  the  tumor  <;ra<liially  be- 
came solid  to  the  feel,  and  smaller:  sometimes  it  ean  be  indented  by  the  finger. 

Glandular  Cysts. — While  these  may  be  single,  they  are  commonly  mul- 
tiple, sometimes  being  disseminated  throughout  tho  gland.  They  originate  in 
the  smaller  rather  than  in  the  larger  ducts,  and  in  the  acini,  from  their  partial 
or  complete  occlusion,  the  former  being  rather  common,  when  their  sero-sangui- 
nolent  contents  may  escape  quite  copiously  from  the  nipple.  The  cysts  vary 
in  size  from  that  of  a  pin's  head  to  cavities  Avhicli  may  contain  many  ounces, 
but  are  oftenest  about  an  inch  in  diameter.  Their  interior  is  covered  with  a 
layer  of  epithelial  cells,  papillomatous  ingrowths  from  which,  at  times,  com- 
pletely fill  up  the  cyst-cavity.  The  contents  may  be  yellowish  serum  or  may 
be  variously  tinted  red  or  brown  from  admixture  of  old  or  more  recent  blood. 

Diagnosis. — They  are  prone  to  occur  in  patients  from  thirty-five  to  fifty 
years  of  age,  are  smooth  in  outline,  and  are  somewhat  elastic,  but  fluctuation 
is  rarely  detectable,  the  cysts  when  tensely  filled  being  often  mistaken  for  solid 
growths.  This  must  be  remembered  in  any  case  of  suspected  carcinoma  when 
neither  involvement  of  the  skin  nor  adhesion  to  the  deeper  parts  has  taken 
place,  since  cysts  occur  at  tlie  same  age,  so  that  when  in  (loubt  the  exploring 
needle  or  an  incision  should  be  resorted  to  before  sacrificing  the  breast :  the 
above  points,  with  the  absence  of  lym]iliatic  glandular  involvement  an<l  the 
slow,  benign  course,  distinguish  doubtful  cases  of  cysts  from  malignant  disease. 

Cysts  resulting  from  Degenerative  Changes  (Involution  Cysts). — 
These  mostly  occur  in  women  past  the  menopause,  and  are  usually  numerous, 
and  so  small  as  to  escape  detection.  Occasionally  one  or  more  may  enlarge, 
causing  much  embarrassment  in  diagnosticating  them  from  carcinoma.  No 
involvement  of  the  skin,  deeper  structures,  or  lymphatics,  however,  is  found : 
they  pursue  a  slow%  benign  course,  and  exploratory  incision  will  determine 
their  nature. 

Lymphatic  Cysts. — Certain  serous  cysts  w^hich  do  not  differ  materially  in 
their  symptoms,  course,  and  treatment  from  the  glandular  cysts  have  been 
ascribed  by  Birkett  and  others  to  accumulation  of  fluid  in  the  connective-tissue 
lymph-spaces,  and  have  therefore  been  termed  "connective-tissue  cysts"  or 
"•lymph-space  cysts:"  they  are  lined  Avith  endothelial  plates  instead  of  epi- 
'helial  cells,  and  resemble — except  for  their  contents — adventitious  bursas. 

Diagnosis. — This  has  been  sufficiently  indicated  in  the  description  of 
each  variety. 

Treatment. — When  thin-walled,  incision,  with  antiseptic  packing  after 
wiping  out  the  cavity  with  iodine  tincture  or  deliquesced  carbolic  acid,  will 
usually  suffice.  If  thick-walled  or  numerous,  excision  of  the  diseased  portion 
is  indicated,  and  if  the  disseminated  form  exists,  nothing  short  of  amputation 
is  worth  considerinof. 

Contusions  of  the  Breast. — When  the  relation  which  traumatism  bears 
to  the  development  of  tumors  in  the  female  breast  is  considered,  it  will  be 
recognized  that  these  injuries  should  be  carefully  treated  by  rest,  confining 
the  arm  to  the  chest  or  in  a  sling,  and  by  evaporating  anodyne  applications, 
while  any  induration  should  be  removed,  if  possible,  by  the  frequent  prolonged 
use  of  equal  parts  of  compound  iodine  and  belladonna  ointments  or  mercurial 
ointment  in  combination  with  belladonna. 

Wounds. — These  require  the  treatment  which  Avould  be  adapted  to  similar 
injuries  of  other  glands,  remembering  that  if  suppuration  occurs  it  mav  extend 
throughout  the  cellular  framework  of  the  gland,  producing  widespread  damage, 
so  that  antisepsis,  proper  drainage,  and  fixation  of  the  mamma  by  properly 
applied  bandages,  and  of  the  arm  by  confining  it  to  the  chest,  are  advisable. 


](»70  AX   AMKlilVAX    TEXT- HOOK    OF  SURGERY. 


DISEASES  OF  THE   MALE   BREAST. 

Occasionally  the  <,'lan(l  becomes  iiypertkopiiikd  and  functionally  active, 
the  result  of  frequent  applications  of  a  nursing  child  to  the  breast. 

Inflammation  of  the  Male  Breast. — This  may  result  from  injury,  with 
any  of  the  usual  conseciuences  of  inflammation,  but  sometimes  the  glands  at 
puberty  become  enlarged  and  tender  irrespective  of  traumatism,  these  attacks 
perha]is  recurring  from  time  to  time. 

Treatment. — Anodyne  applications  and  protection  of  the  parts  from  fric- 
tion, with  such  treatment  as  has  been  indicated  for  the  inflamed  female  breast, 
should  be  instituted  if  suppuration  is  threatened  or  is  present. 

Tumors. — These  may  be  either  benign  or  malignant,  examples  of  nearly 
every  variety  of  each  having  been  observed.  Of  the  former  variety,  cysts — 
even  galactoceles — and  fibromata  are  the  most  common.  Spindle-celled  sarco- 
mata and  scirrhous  carcinomata  are  the  usual  varieties  of  malignant  growths, 
carcinomata  occurring  in  the  proportion  of  about  one  male  to  forty-two  females. 
These  neoplasms  pursue  the  same  local  and  constitutional  course  as  in  the 
female. 

Treatment. — This  is  precisely  that  recommended  for  the  same  affections 
occurrincj  jn  women. 


BOOK  TV. 
OPERATIVE    SURGERY. 


CHAPTER  I. 

GENERAL  PRINCIPLES. 

Theke  are  certain  general  principles  which  must  guide  the  surgeon  in 
the  performance  of  every  surgical  operation.  These  principles  require  careful 
consideration,  and  no  operation  either  of  small  or  great  magnitude  should  be 
undertaken  without  a  full  knowledge  of  their  importance. 

Dangers  Common  to  all  Operations. — It  may  be  stated  as  an  apho- 
rism that  no  surgical  interference  is  free  from  danger  to  life.  This  must  be 
borne  in  mind  in  the  consideration  of  every  surgical  operation.  The  distinc- 
tion, however,  must  be  recognized  between  an  operation  performed  for  some 
cosmetic  effect  and-  one  performed  to  relieve  human  suffering  and  to  save  life. 
In  the  former  case  the  danger  should  enter  prominently  into  the  consideration 
of  the  propriety  of  the  operation,  while  in  the  latter  case  the  same  danger 
would  have  little  weight.  There  are  cases  that  may  stand  midway  between 
these  two  extremes,  and  under  these  circumstances  each  individual  case  must 
be  considered  upon  its  own  merits. 

The  first  general  danger  is  Hemorrh(ige.  Some  loss  of  blood  must  always 
attend  an  operation,  but  the  aim  of  the  surgeon  should  be  to  sacrifice  the  small- 
est amount  consistent  with  the  completion  of  the  operation.  The  more  blood 
lost  during  an  operation,  the  less  rapid  the  healing  process  and  the  greater 
the  shock.  The  hemorrhage  may  occur  during  the  operation,  or  it  may  ensue 
shortly  after  its  completion,  or  it  may  take  place  after  the  wound  has  nearly 
healed.  The  time  of  its  occurrence  is  of  less  importance  than  its  results. 
The  methods  of  arresting  hemorrhage  are  considered  elsewhere. 

Anesthesia  is  a  second  danger ;  hence  the  administration  of  an  anesthetic 
is  a  most  important  part  of  an  operation  and  requires  the  services  of  a  thor- 
oughly trained  and  experienced  physician. 

Shock  is  a  danger  common  to  all  operations.  By  this  condition  is  meant 
a  functional  depression  of  the  circulatory  system.  The  degree  of  depression 
depends  upon  the  situation  of  the  injury,  the  character  of  the  operation,  and 
the  idiosyncrasy  and  age  of  the  individual.  The  nervous  system  is  primarily 
affected  in  shock,  and  secondarily  the  circulatory.  This  is  evident,  because 
with  a  normal  action  of  the  heart  shock  is  impossible.  Age  likewise  is  a  factor 
to  consider  in  estimating  the  severity  of  shock,  although  age  is  a  relative  term. 
The  acred  as  well  as  children  suffer  greatly  from  shock.  The  important  differ- 
ence, however,  must  not  be  overlooked  that  the  aged  do  not  react  from  shock 
as  readily  as  children.  Shock  associated  with  traumatic  delirium  is  a  most 
serious  condition.  No  operation,  except  such  as  the  arrest  of  hemorrhage  or 
the  relief  of  a  strangulated  hernia,  should  be  undertaken  under  these  circum- 
stances. The  aged  with  healthy  viscera  suffer  less  from  shock  than  the  mid- 
dle-aged with  diseased  viscera. 

1071 


1072  ^l.V  AMERICAN    TEXT- BOOK    OE  SVRUERY. 

The  prognosis  in  shock  (k'ltciids  upon  the  natmc  of  the  injury  inflictt'<l, 
the  special  organs  involved,  and  the  individual  iiliosynrrasy.  A  tenij)erature 
])ersistently  helow  UG°  F.,  or  a  feehle  and  I'reiiuent  pulse  and  shallow  hreathing 
with  sudden  rise  of  temperature,  indicates  a  raost  grave  condition. 

Spkcial  Dangers  of  Opkuation. — Entrance  of  air  Into  vcinif  is  a  most  seri- 
ous accident  occurring  in  very  rare  instances  during  an  operation  upon  the 
nock,  where  the  cervical  fascia  holds  the  veins  j)atent,  or  as  a  result  of  a 
wound  o\'  -A  vein  in  this  region.  The  internal  and  external  jugulars,  the  suh- 
clavian,  the  veins  at  the  root  of  the  neck,  the  axillary,  subclavicular,  sub- 
scapular, and  thoracic  veins,  and  the  cerebral  sinuses,  are  the  vessels  the 
w()unds  of  which  are  most  likely  to  be  attended  with  entrance  of  atmospheric 
air.  A  wound  of  the  facial  or  of  the  femoral  vein  has  given  rise  to  this  seri- 
ous accident,  and  cases  of  sudden  death  after  delivery  have  been  ascribed  to 
the  entrance  of  air  into  the  uterine  sinuses.  Air  in  the  form  of  ])utrid  gas 
has  been  sent  to  the  heart  and  caused  death  in  cases  of  ganiirene. 

The  way  in  which  the  entrance  of  air  into  veins  causes  death  has  been  the 
subject  of  much  study  and  experimentation.  If  air  enters  through  a  wound 
of  one  of  the  veins,  it  is  carried  by  suction  to  the  right  auricle  and  ventricle, 
where  it  becomes  mixed  with  the  blood  in  these  cavities,  forming  aeriform 
emboli.  The  right  heart  endeavors  to  force  the  blood  and  air  through  the 
lungs,  but  fails,  and  as  a  consequence  the  left  heart  is  collapsed  from  want 
of  blood,  and,  no  blood  being  sent  to  the  cerebrum,  a  fatal  syncope  follows. 
Experiment  upon  animals  has  undoubtedly  shown  that  they  can  live  after  the 
direct  injection  of  large  quantities  of  air  into  the  circulation  (Hare),  but  the 
clinical  fact  remains  that  patients  have  repeatedly  died  from  the  accident,  and 
hence  it  is  to  be  carefully  guarded  against,  especially  in  all  operations  about 
the  neck. 

The  symptoms  of  entrance  of  air  into  the  veins  may  be  constitutional 
and  local.  The  constitutional  symptoms  are  syncope,  feeble  and  frequent 
pulse,  irregularity  of  respiration  amounting  to  cardiac  dyspnea,  and  dilatation 
of  the  pupils.  Auscultation  over  the  precordial  region  reveals  the  presence 
of  a  churning  sound  synchronous  with  the  ventricular  systole  and  accompanied 
by  a  violent  and  irregular  action  of  the  heart.  These  symptoms  are  usually 
preceded  by  a  gurgling  noise,  and  in  a  few  seconds  convulsions  and  fatal  col- 
lapse ensue. 

The  local  signs  are  the  appearance  of  bubbles  of  air  in  the  wound  and  a 
patent  condition  of  the  veins.  The  mouths  of  the  veins  are  prevented  from 
closing  by  the  fascia  which  surrounds  them,  and  the  canalization  exposes  them 
to  this  danger. 

The  treatment  for  entrance  of  air  into  the  veins  must  be  prompt  and 
bold.  The  head  should  be  immediately  lowered  to  prevent  fatal  anemia  of  the 
brain.  Hypodermatic  injections  of  brandy  or  digitalis  should  be  at  once 
administered,  and  artificial  respiration  resorted  to  without  delay,  in  order  to 
re-establish  the  pulmonary  circulation  and  thus  convey  more  blood  to  the  left 
heart.  Treves  has  suggested  pouring  water  into  the  wound  to  prevent  any 
further  ingress  of  air  and  at  the  same  time  to  allow  the  air  to  bubble  out  of 
the  wound.  The  patent  vein  should  be  instantly  closed  by  the  finger,  and 
then  immediately  ligated.  Elastic  bandages  can  be  applied  to  the  upper  ex- 
tremities with  a  view  of  facilitating  the  afflux  of  blood  to  the  trunk  and  heart. 
The  inhalation  of  oxygen  gas  has  been  recommended.  Tracheotomy  has  been 
suggested,  with  inflation  of  the  lungs  through  the  tube,  in  order  to  stimulate 
the  pulmonary  circulation  and  thus  force  out  the  air  emboli.  In  all  opera- 
tions upon  the  neck  when  the  veins  are  likely  to  be  interfered  with  the  surgeon 


OPERATIVE  SURGERY.  1073 

should  guard  against  the  iiiti-.iiicc  of  ;iir  into  wounded  veins  by  not  cutting 
tissues  Avhen  tensely  streteiicd,  and  hy  having  an  assistant  ready  to  compress 
the  vein  between  tlie  wound  and  tlie  heart  in  ease  of  its  division:  he  should 
use  the  handle  of  the  sealj)el  in  the  separation  of  the  deep  tissues  of  the  neck, 
and  should,  when  possible,  tie  the  veins  lying  in  the  course  of  an  operation  with 
two  ligatures  and  cut  between  them. 

Uonopldlia. — Operations  upon  persons  the  subjects  of  hemophilia — "Ideed- 
ers  " — are  most  dangerous,  because,  in  spite  of  every  possible  human  device 
to  arrest  the  hemorrhage,  it  will  often  persist.  The  pathology  of  the  disease  is 
but  little  understood.  Hemophilia  may  exist  in  several  members  of  a  family, 
and  there  seems  to  he  undoubted  foundation  for  the  opinion  that  the  disease  is 
often  hereditary.  The  slightest  traumatism,  such  as  a  scratch  or  a  laceration  of 
the  gums  with  a  toothpick,  induces  a  hemorrhage.  The  hemorrhage  may  occur 
idiopathically  from  the  nose  or  from  the  rectum,  or  may  appear  as  minute 
extravasations  under  the  skin.  ^Vllen  the  hemorrhage  occurs  from  a  wound 
either  as  the  result  of  traumatism  or  in  consequence  of  a  surgical  ojteration, 
the  blood  oozes  freely  from  the  entire  surface,  and  may  not  be  controlled  by 
heat  or  cold,  by  styptics,  by  compression,  by  ligature,  or  by  the  cautery  ;  but 
all  these  means  should  be  tried.  The  bleeding  continues  until  the  patient 
becomes  anemic  and  exsanguine.  Ergotine  has  been  used  to  contract  the  ves- 
sels, but  its  efficiency  is  doubtful. 

Preliminary  Examination  of  the  Patient. — Before  undertaking  any 
operation  certain  examinations  should  always  be  made  and  certain  indications 
and  contraindications  considered. 

The  mental  state  of  the  patient  is  of  no  little  importance.  A  patient  who 
is  in  fear  of  a  fatal  result  or  a  soldier  who  is  depressed  by  defeat  is  always  a 
much  poorer  subject  for  an  operation  than  one  who  is  cheerful  and  bright  or, 
it  may  be,  indifferent.  Hence  in  this  respect  children,  who  are  not  subject  to 
gloomy  forebodings,  and  for  a  similar  reason  the  insane,  are  very  good  patients 
surgically. 

No  patient  should  be  operated  on  without  a  careful  examination  of  the 
heart  and  lungs.  Any  serious  disease  of  the  heart  should  make  us  hesitate, 
and  if  an  operation  be  contemplated  for  mere  cosmetic  purposes,  it  should  be 
abandoned ;  if  the  necessity  for  it  be  absolute,  it  must  be  undertaken,  but  with 
great  caution,  especially  as  to  the  use  of  the  anesthetic.  If  the  lesion  be  at  all 
pronounced,  the  patient  and  the  fimily  should  be  so  informed,  and  deliberately 
make  a  choice,  Avith  a  full  knowledge  of  the  danger.  The  lungs  also  should 
be  examined,  for  in  case  of  bronchitis  an  operation  which  could  be  deferred 
should  be  postponed  until  the  bronchitis  has  been  cured,  or,  if  the  operation 
must  be  done,  chloroform  should  be  used  instead  of  ether.  Operations,  espe- 
cially on  the  brain,  on  the  eye,  and  on  the  abdomen,  should  not  be  done  during 
an  attack  of  bronchitis,  for  the  cough  suddenly  produces  great  intracranial, 
intraocular,  and  intra-abdominal  pressure  which  may  do  much  harm. 

Deformities  of  the  Chest,  such  as  are  produced  by  Pott's  disease,  if  moderate-, 
offer  but  a  slight  objection  to  operations,  and  even  if  severe  may  result  in  no 
disadvantage  to  the  patient.  The  anesthesia,  however,  in  these  cases  should  be 
as  brief  as  possible,  and  that  method  of  operation  chosen  Avhich  is  the  shortest; 
for  instance,  in  stone  in  the  bladder  lithotomy  instead  of  litholapaxy. 

The  urine  should  invariably  be  examined,  and  if  there  be  Bright's  dis- 
ease caution  should  be  exercised  as  to  the  anesthetic  and  the  functions  of  the 
kidney  watched  afterward.  Surgical  opinion  is  at  present  somewhat  divided 
as  to  whether  ether  or  chloroform  shouhl  be  preferred  in  Bright's  disease,  but 
the  weight  of  authority  is  in  favor  of  the  latter.     If  diabetes  is  found,   no 

68 


1074  AX   AMERICAN    TEXT-BOOK    OF  SURGERY. 

operation  siiould  \>c  dune  unless  the  need  is  absolute,  lor  diabetics  are  markedly 
predisposed  to  hemorrhage,  suj)puration,  erysipelas,  and  shock. 

The  jieneral  ritaliti/  of"  the  patient  should  also  be  considered,  ami  in  poor 
states  of  health  all  operations  should  be  postponed  it"  possible.  On  the  other 
hand,  it  nnist  In?  remembered  that  operations  ior  pathologic-al  causes,  such  as 
tumors,  joint  disease,  etc.,  are  borne  tar  better  by  teeble  subjects  than  similar 
surgical  interference  by  the  robust  and  hearty.  A  man  in  the  prime  of  life 
with  all  his  functions  active,  whose  leg  is  crushed  to  such  an  extent  as  to 
need  am))utation,  runs  two  or  three  times  the  risk  that  a  patient  does  who 
has  been  bedfast  for  weeks  in  consecjuence  of  a  joint  disease,  and  the  interrup- 
tion to  whose  activities  is  far  less  than  in  the  case  of  the  robust  and  hearty 
man,  as  there  is  also  present  the  additional  shock  from  the  crush  ( Fig.  2'I). 
Very  fat  patients  also  are  poor  subjects  for  operation.  Women,  for  instance, 
with  very  large,  fat  breasts  are  apt  after  operation  for  cancer  to  suffer  necrosis 
of  the  fatty  tissues,  with  development  of  butyric  fermentation,  accomjianicd  by 
al)undant  discharge  and  very  foul  odor,  even  without  infection  from  jiyogenic 
bacteria:  su]i)iuration  itself  often  occurs.  A  very  fat  abdominal  wall  is  also  an 
obstacle,  not  only  by  reason  of  the  ready  breaking  down  of  the  fat.  but  also 
in  a  mechanical  sense,  as  it  renders  access  to  the  abdominal  cavity  ditficult. 

Age. — Very  young  children  do  not  bear  operation  well.  Mr.  Dents 
statistics  show  that  under  five  years  of  age  the  mortality  after  amputation  was 
12.5  per  cent.,  between  five  and  ten  it  fell  to  3.3  per  cent.,  and  between  ten 
and  twenty  rose  again  to  16.1  per  cent. ;  so  that  children  bear  operation  better 
than  infants  or  adults.  One  reason  for  this  mortality  is  that  very  young 
children  bear  shock  badly ;  pain  is  borne,  if  possible,  still  less  well.  More- 
ovei',  it  is  difficult  to  keep  young  children  clean,  and  wounds  below  the  waist 
may  especially  easily  become  infected  through  the  urine  or  feces.  It  is  often 
stated  that  children  bear  the  loss  of  blood  badly,  but,  while  the  loss  of  the 
same  quantity  of  blood  is  borne  badly  as  compared  with  adults,  yet  if  the 
amount  of  blood  lost  be  regarded  in  relation  to  their  age  and  size,  they  prob- 
ably bear  it  quite  as  well  as  adults.  Old  age  is  likewise  a  factor  for  evil. 
After  forty,  patients  bear  operations  increasingly  less  and  less  Avell  as  their  age 
advances,  and  if  we  add  habitual  intemperance  we  have  the  worst  possible 
patients  for  an  operation. 

jSex. — Women  bear  operations,  as  a  rule,  better  than  men,  since  they  are 
less  active  ])hysically,  and  usually  are  of  a  more  ecjuable  temperament.  Ope- 
rations, naturally,  should  not  be  undertaken  during  the  menstrual  period  unless 
necessary,  nor  during  pregnancy ;  but  menstruation  is  not  an  absolute  bar,  and 
many  operations,  even  up  to  amputation  at  the  hip-joint,  have  been  done  during 
pregnancy  without  ill  results.  If  sepsis  occurs,  abortion  is  sure  to  follow.  One 
rule  should  ])e  absolute  :  never  to  operate  on  a  breast  during  lactation,  on  ac- 
count of  its  great  vascularity.  If  operation  is  necessary,  we  should  wait  until 
weaning  is  accomplished. 

Disease. — Bright's  disease  and  diabetes  have  already  been  alluded  to. 
Tubercular  patients  react  well  after  operations,  and  especially  tubercular 
children.  The  same  may  be  said  of  patients  with  accpiired  syphilis,  but 
those  subject  to  heretlitary  syphilis,  from  the  feebleness  of  their  constitution, 
stand  operations  poorly. 

Synchronous  operations — as,  for  instance,  aiuj)ut;iti()n  of  two  or  three  e.x- 
tremities — are  sometimes  necessitated  by  multiple  injuries.  Of  course  there  is 
no  choice  in  such  a  case,  but  they  should  be  done  with  all  speed,  so  as  to  dimin- 
ish shock,  and  it  is  of  advantage  if  they  can  be  done  sinndtaneously  by  two 
operators.      Hemorrhage  in  such  a  case  should  be  especially  guarded  against. 


OPERArrVE   SERVER  V.  107r> 

The  Management  of  the  Patient  Before  Operation. — The  nianajie- 
ment  of  the  patient  before  an  operation  involves  a  knowledfre  of  liis  tempera- 
ment, habits,  and  constitution.  If  the  patient  is  not  in  f^ood  physical  condition 
and  the  circumstances  of  the  case  permit,  the  operation  should  he  postjxmed  for 
a  short  time  until,  by  the  use  of  tonics,  by  i-est,  and  by  nutritious  diet,  the  gen- 
eral health  is  improve<l.  A  study  of  the^  habits  and  temperament  of  the  ))atient 
is  often  of  great  benefit  to  the  surgeon.  Sometimes  a  patient  is  very  nervous, 
irritable,  and  restless  on  account  of  the  dread  of  an  operation,  and  in  such  a 
case  the  surgeon  should  do  all  in  his  power  to  allay  his  fears,  to  assure  him  of 
the  safety  of  the  operation,  and  to  point  out  the  fact  that  modern  antiseptic 
surgery  can  ofl'er  relief  or  save  life  'with  but  little  sufl'ering  as  a  rule.  A 
thorough  examination  should  be  made  of  the  patients  viscera,  especially  the 
heart,  lungs,  kidneys,  and  liver,  in  order  to  have  a  comprehensive  knowledge 
of  all  the  emergencies  that  might  subsequently  arise.  The  technique  of  ])rep- 
aration  of  the  patient  is  fully  discussed  later. 

Hygienic  Conditions  which  Surround  the  Patient. — These  greatly 
influence  rapid  recovery  after  a  surgical  operation,  as  well  as  often  induce  or 
prevent  death  from  se])tic  causes. 

The  surgeon  should  perform  an  operation  under  the  most  favorable  hygienic 
conditions  possible  in  the  case.  The  room  in  which  the  patient  is  to  be  operated 
upon,  as  well  as  the  one  he  is  to  be  placed  in  during  convalescence,  should  be 
large,  exposed  to  the  sun,  well  ventilated,  and  scrupulously  clean.  The  bed 
and  bedding  should  be  free  of  any  contamination  from  prior  exposure  to 
infectious  disease,  and  all  the  appliances  for  dressing  the  wound  should  be 
aseptic.  The  sanitary  arrangements  of  the  house  should  be  perfect.  Too 
much  importance  cannot  be  placed  upon  the  question  of  ventilation  of  the 
sick-room.  In  the  air  of  a  room  there  are  held  in  suspension  particles  of 
organic  matter,  epithelium,  and  dust,  also  the  exhalations  from  the  lungs,  des- 
quamations from  the  skin,  and  floating  particles  derived  from  clothing  and 
other  sources.  Pasteur  has  pointed  out  the  fact  that  an  ill-ventilated  room  is 
a  source  of  great  danger,  because  the  dust  held  in  suspension  may  act  as  a 
carrier  of  septic  germs  and  cause  infection  in  a  wound.  It  is  thus  evident 
that  a  Avell-ventilated  chamber  is  an  important  condition  to  ensure  safety  and 
rapid  recovery.  An  open  fireplace  is  a  safeguard,  because  it  leaves  no  damp 
surfaces  upon  which  floating  and  germ-laden  dust  can  settle,  and  also  because 
it  produces  a  free  outward  draught  from  the  room. 

In  the  event  of  a  serious  operation  the  carpets  should  be  removed,  as  well 
as  all  the  hangings  and  upholstered  furniture.  The  ceilings  and  side  walls 
should  then  be  brushed  down  with  a  towel  saturated  in  bichloride.  Papered 
walls  require  a  dry  toAvel.  AVhen  the  room  is  thus  made  empty  and  dusted, 
the  floor  and  all  the  woodwork  and  furniture  should  be  well  scrubbed  and 
washed  with  a  solution  of  bichloride  of  mercury  of  the  strength  of  1  :  500. 
A  plain  kitchen  table  is  the  best  for  an  operating  table.  There  should  be 
placed  in  the  room  four  plain  wooden  or  cane-seat  chairs,  a  washstand,  and  a 
table  for  instruments,  medicines,  etc.  The  operating  table  should  have  a  rub- 
ber under  it.  and  a  waste-water  pail  should  be  j)]aced  under  the  table.  Five 
or  six  china  washbowls  and  as  many  pitchers  should  be  provided,  two  or  three 
of  them  filled  with  distilled  or  cooled  boiled  water.  Plenty  of  boiling  water 
must  be  provided. 

Two  blankets  should  be  placed  on  the  bed  instead  of  sheets,  and  ten  well- 
corked  hot-water  bottles  or  bags  provided  to  place  around  the  patient  after  the 
operation.  Three  or  four  sheets  and  a  dozen  or  more  towels,  wrung  out  of  a 
1  :  1000  sublimate  solution  and  rough-dried  the  night  before  the  operation. 


loTG  .l.V   AMKliK'AX    TEXT- HOOK    OF  SURCiERY. 

should  lie  provided.  Many  surgeons  prefer  to  wet  them  in  a  liot  solution  at  the 
time  of"  the  operation  and  then  spread  them  all  around  the  field  of"  operation. 

TlIK  I'UKPAKATION  ()F  TllK  Patiknt. — If"  possible,  before  the  operation 
the  patient  should  rest  in  bed  for  a  day  or  two.  The  nifiht  before  tiie  opera- 
tion he  should  have  a  mild  la.xative,  and  an  enema  the  morninr;  of  the  opera- 
tion. In  certain  operations  antiseptic  injections  sliould  l)e  used  in  tiie  va^^ina 
and  boiled  water  in  the  rectum. 

Too  much  importance  cannot  be  attached  to  the  pn-liminary  disinfection  of 
the  field  of  oj)eration.  Cheyne  has  pointed  out  the  fact  that  there  are  more 
patlio^jenic  micro-or_<;anisms  in  a  s«juare  inch  of  the  cutaneous  surface  tlian 
would  be  found  in  the  Avard  of  a  well-ventilated  hospital.  This  fact  demon- 
strates how  ina<le<|uate  is  any  attempt  to  disinfect  the  air  in  a  ward,  and  at  the 
same  time  emphasizes  the  importance  of  disinfection  of  the  field  of  operation  as 
well  as  of  the  hands  of  the  operator,  his  assistants,  and  the  nurse.  The  skin 
is  covered  with  des(juamate<l  epithelium  and  filled  with  innumerable  micro- 
organisms. The  day  before  the  ojieration,  therefore,  the  part  must  be  ."haved, 
and  then  the  micro-orn;anisms  be  got  rid  of,  first  with  soap  and  water,  then  with 
ether  or  alcohol,  and  lastly  Avith  a  sublimate  solution,  1 :  1000,  or  in  specially 
dirty  regions  1  :  500.  Some  surgeons  advise  the  prior  application  of  a  soap 
poultice  to  the  skin  with  a  view  to  separation  of  the  effete  material.  A  subli- 
mate gauze  dressing  should  then  be  applie<l  and  retained  in  place  by  a  bandage 
or  binder,  and  allowed  to  remain  until  the  operation  is  to  be  done.  In  opera" 
tions  about  the  male  genitals  the  penis  should  always  be  wrapped  round  with 
some  aseptic  gauze.  Disinfection  of  the  mouth,  nose,  and  ear  has  been 
described  on  page  512.  The  navel,  the  pubes,  the  scrotum,  and  the  armpits 
re(|uirc  especial  care,  since  they  are  peculiarly  apt  to  harbor  dirt.  The  same 
is  true  of  the  scalp,  and  in  operations  on  the  head  it  is  better,  as  a  rule,  to 
shave  the  entire  head.  On  the  scrotum  and  head  the  sublimate  solution  should 
not  be  stronger  than  1  :  2000,  lest  pustulation  or  excoriation  follow.  In  trau- 
matic cases,  where  the  patients  are  begrimed  Avith  the  ordinary  dirt  of  the 
streets,  oil  and  grease  from  machinery,  etc.,  if  sweet  oil  be  well  rubbed  over 
the  parts  the  dirt  will  be  much  more  readily  removed  by  the  soap  and  water. 
In  operations  about  the  upper  part  of  tlie  l)ody  the  arms,  and  in  operations 
about  the  lower  part  of  the  body  the  legs,  should  be  wraj)ped  in  bichloride  or 
sterilized  sheets  or  towels,  lest  the  patient  contaminate  the  wound  by  touching 
an  unclean  extremity  to  it.  In  operations  about  the  chest,  the  neck,  or  the 
face  a  bichloride  or  sterilized  towel  should  always  be  Avrapped  around  the  liair 
and  another  around  the  inhaler.  In  operations  involving  much  exposure  or 
great  shock  it  is  well  to  wrap  the  patients  body,  arms,  and  legs  in  a  thick 
layer  of  cotton,  kept  in  place  by  bandage  and  binder,  in  order  to  maintain  the 
body-heat.  This  can  be  done  also  by  hot-water  bottles,  or  in  some  cases  the 
operation  may  be  done  on  a  hot-water  bed. 

Asepsis  and  Antisepsis. — The  stage  of  controversy  and  of  argument  as 
to  the  benefits  of  asepsis  and  antisepsu?  is  past.  With  the  exception  of  a  very 
few  superfluous  laggards,  the  surgical  world  is  at  one  as  to  the  value  of  these 
methods.  Even  those  who  oppose  them  practically  apply  the  same  principles 
by  difl'erent  methods.  Heat  and  carbolic  acid  in  this  regard  are  e<iuivalent 
means.  The  bacteriological  proof  that  suppuration,  erysipelas,  pyemia,  and  all 
other  similar  dangers  arise  from  pyogenic  organisms  is  now  practically  absolute. 
The  clinical  proof  is  ecjually  strong.  The  statistics  of  all  operations  in  the 
pre-Listerian  days,  as  contrasted  with  those  of  the  la^t  twentv  vears.  show  that 
all  those  septic  diseases  which  were  rife  in  private  and  especially  in  hospital 
practice,  and  slew  their  thousands  and  tens  of  thousands,  have  almost  disap- 


OPERATIVi:   SVUCKRY.  IO77 

peared.  Conipouml  fVactiircs,  wliicli  then  wci'c  aiiioiifi  the  most  dangerous 
accidents,  are  now  scarcely  more  (lan;:;eroiis  than  simple  fractiii-es,  and  the 
mortality-rate  after  amputation  and  abdominal  section  has  fallen  nearlv  to 
zero. 

Two  methods  are  employeil,  the  aseptic  and  the  antiseptic.  In  the  aarptic 
method  chemical  antiseptics  or  heat,  or  both,  are  used  for  the  purpose  of  obtain- 
ing absolute  surgical  cleanliness,  including  in  this  the  patient's  person,  the 
hands  of  the  surgeon  and  his  assistants,  all  instruments,  dressings,  etc. ;  and 
after  this  no  chemical  antiseptic  is  used,  but  only  such  solutions,  dressings,  etc. 
as  have  been  sterilized  and  made  germ-free  by  heat.  In  tlie  antiseptic  method 
the  same  antiseptics  are  used  for  procuring  cleanliness,  and  in  addition  chemical 
antiseptic  solutions  and  dressings  impregnated  with  them  are  used  during  and 
after  the  operation.  One  thing  must  be  clearly  understood  :  that  either  metliod 
must  be  thorough  or  it  is  useless. 

Antiseptics. — As  an  antise])tic  the  most  universally  valuable  and  availal)le 
is  heat.  A  temperature  of  140°  F.  for  ten  minutes  is  fatal  to  all  pathogenic 
bacteria  except  the  tubercle  bacillus  and  anthrax  spores,  which  require  a  moist 
heat  of  212°  F.  for  at  least  four  minutes  (Sternberg).  Moist  heat  is  far  more 
efficient  than  dry  heat ;  e.  g.  the  spores  of  the  tubercle  bacillus  if  exposed  to 
dry  heat  recjuire  for  their  destruction  a  temperature  of  284°  F.  for  three  hours. 
It  is  especially  well  to  remember  that  even  in  the  country  this  method  of  abol- 
ishing sepsis  can  always  be  used.  Instruments  and  dressings  can  always  either 
be  boiled  or  placed  in  an  oven  and  thus  be  entirely  sterilized  at  a  moment's 
"warning.  It  is  not  necessary  that  the  surgeon  should  have  all  the  appliances 
of  the  modern  hospital  or  drug-store.  Old  sheets  can  be  prepared  extempo- 
raneously by  heat,  and  will  form  excellent  sterilized  dressings. 

Of  antiseptic  drugs  there  are  a  very  large  number  Avitli  more  or  less  bacte- 
ricidal power.  Among  them  should  be  especially  mentioned  carbolic  acid, 
bichloride  of  mercury,  biniodide  of  mercury,  and  hydronaphthol.  Iodoform 
is  undoubtedly  useful  in  many  cases  in  tuberculosis  and  in  inhibiting  the 
growth  of  pyogenic  organisms,  but  it  should  itself  be  sterilized  before  being 
used  :  b}'  some  surgeons,  except  in  cases  of  tuberculosis  or  chronic  suppuration, 
it  is  entirely  discarded ;  by  others  it  is  depended  upon  in  the  permanent  dress- 
ings to  the  exclusion  of  all  other  antiseptics. 

Peroxide  of  hydrogen  has  been  largely  used  as  an  antiseptic,  but  its  pre- 
cise value  has  yet  to  be  determined.  The  ordinary  solutions  are  not  invariably 
germicidal.  The  bacteria  of  tetanus,  for  instance,  have  been  grown  under  a 
fifteen-volume  solution  (Kyle).  Its  antiseptic  action  seems  to  be  dependent 
upon  its  destruction  of  the  albuminoid  element  upon  which  the  bacteria  live ; 
hence  it  has  a  definite  field  of  usefulness  in  .suppuration.  Practically,  carbolic 
acid  in  solutions  of  1  :  20  to  1  :  40,  and  bichloride  of  mercury  in  solutions 
externally  of  from  1  :  1000—4000,  and  internally  in  solutions  of  from  1  :  5000 
for  the  irrigation  of  joints  to  1  :  10,000  for  the  peritoneal  cavity,  are  the  anti- 
septics with  which  the  modern  surgeon  has  to  deal.  Most  surgeons  prefer 
to  use  boiled  water  only  in  the  peritoneal  cavity. 

Preparation  of  Surgeon,  Assistants,  and  Nurse. — The  surgeon  and 
his  assistants  may  wear  ordinary  clothing,  but  should  be  in  their  shirt-sleeves, 
■with  the  sleeves  rolled  up  well  above  the  elbows.  Partly  for  the  protection  of 
the  patient  and  partly  for  the  protection  of  their  clothing  they  can  wear  either 
white  coats  or  aprons,  or  else  should  be  protected  by  a  sheet  folded  several 
times,  so  as  to  be  about  half  a  yard  wide  and  five  or  six  feet  long.  One  end 
of  this  can  be  turned  in  next  the  person  over  a  bandage  which  is  tied  around 
the  neck,  and  another  bandage  is  tied  around  the  waist.     This  serves  an  excel- 


1078  AN  AMERICAN    TEXT- HOOK    OF  SritUERY. 

lent  purpose  as  an  extemporaneous  apron.  ^Vllicllever  is  worn,  coat,  apron, 
or  slieet,  it  sliouM  have  been  made  aseptic  by  steriliziiif;  by  heat  or  by  having 
been  dippetl  tlie  ni<;ht  before  in  a  liicliloride  sohition  and  rougli-drie<l,  but  it 
must  be  remembered  tliat  no  iln/  materiiil  is  actively  antiseptic,  or  even  reliably 
aseptic,  if  dust  or  dirt  of  any  sort  conies  in  contact  with  it.  It  is  not  uncom- 
mon to  see  the  sweat  dropping  from  the  head  or  chin  of  a  surgeon  during  an 
operation.  This,  of  course,  is  excessively  dangerous,  since  it  carries  the  germs 
of  the  face  and  hair  directly  into  the  Avound,  the  abdominal  cavity,  etc.  Per- 
sons who  sweat  ])rofusely,  therefore,  should  tie  a  towel  around  the  forehead  and 
head  to  absorb  all  this  excess.  On  no  account  should  they  wipe  it  off  with 
their  hands,  since  the  hands  are  immediately  infected  ]>y  such  contact.  A 
sterilized  towel  must  be  used.  The  nurse  should  wear  some  wash-goods,  such 
as  white  muslin  or  a  neat  calico.  If  she  assists  at  the  operation  otherwise 
than  with  the  sponges,  she  should  wear  an  apron  or  a  sheet. 

Disinfection  of  the  Hands. — When  the  antiseptic  method  was  first  intro- 
duced, it  was  thought  that  the  principal  source  of  the  germs  of  suppuration 
was  the  air,  and  hence  the  use  of  the  spray,  which  is  now  practically  aban- 
doned. Its  abandonment  has  been  due  to  the  fact  that  surgeons  have  recog- 
nized the  fact  that  the  three  chief  sources  of  infection  are,  first  and  foremost, 
their  own  hands  ami  those  of  their  assistants ;  secondly,  instruments  not  prop- 
erly disinfected  ;  and  thirdly,  sponges  and  dressings.  Hence,  above  all,  the 
hands  and  forearms  of  every  person  who  is  to  touch  the  wound  must  be  dis- 
infected. The  first  means  of  cleansing  the  hands  is  that  which  commends 
itself  to  common  sense — viz.  the  removal  of  the  dirt  rather  than  its  attempted 
disinfection.  Hence  the  hands  and  forearms  should  be  washed  with  hot  water 
and  soap  and  nail-brush  continuously  for  several  minutes.  During  this  wash- 
ing the  nails  should  be  very  thoroughly  cleaned  by  scraping  under  their  free 
ends  and  also  along  their  sides  and  bases  with  a  penknife,  nail-cleaner,  or 
other  similar  instrument.  This  portion  of  the  disinfection  is  most  imjjortant, 
since  infection  is  carried  more  frequently  by  the  hands  than  by  any  other 
means.  The  nails  should  also  be  cut  very  short.  The  nail-brush,  moreover, 
should  be  aseptic.  Especially  in  hospitals,  where  it  is  constantly  used  and  is 
apt  to  become  foul,  it  should  be  always  kept  in  a  1  :  40  carbolic  solution 
or  in  a  1  :  1000  sublimate  solution,  either  of  Avhich  should  be  frequently 
changed.  One  brush  should  be  kept  for  the  soap  and  water,  and  another 
separate  one  for  the  disinfection. 

Two  methods  are  chiefly  in  vogue  for  disinfection  of  the  hands.  The  first 
one  is  the  method  of  Furbringer,  and  is  as  follows  :  The  forearms  and  nails 
having  been  cleaned  as  just  directed,  they  are  dipped  into  absolute  alcohol 
for  at  least  one  minute,  and  then  are  plunged  while  wet  into  a  hot  subli- 
mate solution,  1  :  1000,  and  well  scrubbed  with  a  nail-brush,  the  nails  re- 
ceiving extra  attention.  This  antiseptic  scrubbing  should  be  continued  for 
not  less  than  one  minute.  Whenever  the  hands  or  forearms  touch  any  object 
which  has  not  been  disinfected  they  should  immediately  be  washed  again  in  a 
bichloride  solution.  Even  when  this  method  is  scrupulously  carried  out,  if 
the  bichloride  is  precipitated  by  sulphide  of  ammonium,  numerous  colonies 
can  then  be  grown  by  inoculating  culture-tubes  from  the  hands.  In  fact, 
sterilization  of  the  hands  is  a  relative  asepsis,  and  not  an  absolute  one.  For- 
tunately, the  human  body  does  not  provide  a  soil  in  which,  as  in  the  culture- 
tubes  of  the  bacteriologist,  everything  is  favorable  for  the  growth  of  the  pyo- 
genic or  other  micro-organism,  else  every  accident  would  be  followed  by  septic 
infection.  By  phagocytosis,  by  the  bactericidal  action  of  the  blood-serum,  or 
by  other  means  the  comparatively  few  germs  which  find  access  to  the  tissues  by 


oi'KR.  1  Trvi:  SI  lid KJi  y.  i oto 


liaiids  thus  prepared  are,  as  a  rule,  destroyed  rir  ren<lered  inert;  but  occasion- 
ally, especially  if  the  details  ar<'  not  ri;i;idly  ohserved.  infection  will  occur. 

"Weir  recommends  the  followinj^  method  for  sterilizinf.' the  hands :  scrub 
thoroujrhly  with  hot  water  and  <;reen  soa)».  cleanse  about  and  beneath  the 
nails;  a  scant  tablcspoonful  of  commercial  ehloride  of  lime  is  put  in  the  j)alm, 
then  a  piece  of  sodium  carbonate,  1  inch  wide  and  1  .V  inch  thick;  a  little 
water  is  added  to  make  a  thick  cream  ;  this  is  rubbed  into  the  palms,  hands, 
and  arms  until  the  roui^di  j^rains  of  the  chloride  disappear  or  diminish,  or 
until  there  is  a  sense  of  coolness  in  the  palms.  It  should  also  be  rubbed 
around  and  under  the  nails.  The  process  takes  three  to  five  minutes.  The 
hands  are  then  washed  with  sterile  water.  If  any  odor  persists,  it  may  be 
removed  by  a  dilute  solution  of  ammonia  water. 

The  other  method  is  by  means  of  the  potassium-permanganate  and  oxalic- 
acid  solutions  (Kelly).  The  three  steps  insisted  upon  are  as  follows  :  First,  the 
cleansing  of  the  hands  with  soap  and  water,  frequently  changed,  as  before. 
Secondly,  immersion  of  the  hands  in  a  solution  of  permanganate  of  potassium 
made  by  adding  an  excess  of  the  salt  to  boiling  distilled  water,  until  every 
part  of  "the  hands  and  forearms  is  stained  a  deep  mahogany-red  or  almost 
black  color.  They  are  then  transferred  to  a  saturated  solution  of  oxalic  acid 
until  completely  decolorized  and  of  a  healthy  pink  color.  Thirdly,  washing 
off  the  oxalic  acid  in  warm  sterilized  water.  The  chief  objection  to  this 
method  is  the  annoying  irritation  of  the  skin,  especially  of  the  forearms, 
which  often  follows.  ^  This  may  be  avoided  by  washing  with  lime-water  after 
using  the  acid. 

In  view  of  the  difficulty  of  always  securing  an  aseptic  condition  of  the 
surgeon's  hands,  Halsted  first  introduced  the  use  of  rubber  gloves,  and  they 
have  been  employed  by  many  operators.  While  they  have  some  inconven- 
iences, the  results  of  their  use  have  influenced  a  nund^er  of  surgeons  to  em- 
ploy them  in  most  operations,  especially  those  which  do  not  demand  the  great- 
est nicety  of  touch.      Cotton  gloves  have  been  recommended  by  Mikulicz. 

Disinfection  of  Instruments: — The  best  method  by  far  is  to  boil  the  instru- 
ments for  ten  minutes  in  a  1  per  cent,  solution  of  sodium  carbonate.  The  so- 
dium carbonate  is  added  to  prevent  rusting.  It  is  also  a  poAverful  antiseptic 
solution,  destroying  staphylococci  in  two  or  three  seconds  and  anthrax  spores 
in  two  minutes "^(Schimmeibusch).  When  taken  out  of  the  boiler  the  instru- 
ments should  be  placed  in  trays  in  water  which  has  been  boiled  and  allowed 
to  cool.  If  the  instruments  are  not  to  be  used  at  once,  they  should  be  placed 
in  carbolic  solution,  1 :  20,  which  is  to  be  diluted  to  1  to  60,  immediately 
before  beginning  the  operation.  To  this  some  boiling  water  may  be  added 
in  order  to  make  it  more  agreeable  to  the  hands.  On  no  account  should 
the  boiling  water  be  cooled  by  freshly-drawn  unboiled  water,  since,  as  this  has 
not  been  Serilized,  it  will  contain  many  germs.  As  the  instruments  are  soiled 
thev  should  be  cleansed  by  a  nurse  with  aseptic  hands  in  an  aseptic  solution  and 
replaced  in  the  tray.  Placing  the  instruments  in  a  1 :  20  solution  of  carbolic 
acid  for  fifteen  minutes  will  also  sterilize  them  very  well,  and  in  case  the 
instruments  have  wooden  handles  it  will  be  essential  that  this  method  be  fol- 
lowed, since  boiling  would  loosen  the  handles.  To  prevent  the  roughening  of 
the  hands  the  carbolic  solution  may  be  poured  off  just  before  the  operation  is 
begun,  and  the  trays,  etc.  filled  with  boiled  water.  When  the  operation  is  ter- 
minated the  instruments  should  be  scrubbed  with  a  nail-brush  and  carefully 
dried,  especially  in  the  joints  and  serrations  or  teeth  of  forceps,  etc.,  in  order 
to  get  rid  of  a*ll  blood,  fragments  of  tissue,  etc.  This  cleansing  is  quite  as 
important  as  their  disinfection  prior  to  the  operation.     If  the  case  has  been 


1U80 


.i.v  AMi:i:n  A.\    riixr-nooK   of  srnaiJiY. 


a  suppurating  one,  tlii'  iiistniiiicnts  .sliould  be  Ijoilcil   after  tlic   opcratinn.  in- 
ilcpeiidi'iitly  of  the  prej)arati(His  for  the  next  oiie. 

I>i>ihif('cti<)n  hi/  Minus  of  F<o'iiial)h/n/(h'. — The  r.xpcriiiicnts  of  a  luiiiilx'r 
of  writers  seem  to  show  that  iorinahlehytle  vapor  is  an  ellicieiit  agent  in  ster- 
ilizing instruments.      The  accompanying  illustration  (Fig.  427)  shows  a  con- 


Fio.  427. 


Af)7)aratus  for  use  in  Sterilization  by  means  of  Formaldehyde. 


venient  form  of  formaldehyde  sterilizer,  designed  by  Dr.  H.  0.  Reik  of  Bal- 
timore, M<1.  It  is  made  of  copper,  and  its  dimensions  are  7x12x12  inches. 
The  shelves  are  made  of  heavy,  wide-meshed  wire  gauze.  The  upper  shelf 
extends  entirely  across  the  chamber;  the  other  two  shelves  are  but  eight 
inches  long.  A  space  eight  inches  high  and  four  inches  Avide  is  thus  left  for  the 
lamp  used  in  vaporizing  the  paraform  pastils.  The  instruments  having  been 
placed  upon  the  shelves,  a  five-grain  paraform  tablet  is  placed  in  the  recep- 
tacle at  the  top  of  the  lamp  atid  the  lamp  lighted.  The  door  is  to  be  imme- 
diately closed.  Fifteen  minutes'  exposure  suffices  for  thorough  disinfection. 
It  is  necessary  that  the  sterilizing  chamber  should  be  absolutely  air-tight, 
otherwise  the  disinfection  w  ill  be  unreliable.  Larger  cabinets  may  be  employed 
for  instruments  that  are  too  large  to  be  received  in  the  one  here  described.  The- 
quantity  of  paraform  used  in  such  a  case  should  be  correspondingly  greater. 

Spo\(iES. — Most  surgeons  have  practically  given  up  marine  sj)onges.  and 
use  small  j)ads  of  sterilized  or  antiseptic  gauze  instead.  'I'hese  answer  admir- 
ably, especially  for  the  dry  method  of  Landerer.  In  the  abdomen,  gauze  pads 
about  8  or  10  inches  square  may  replace  the  large  flat  elephant's-ear  sponges 
to  advantage.  They  are  made  of  a  number  of  folds  of  the  ordinary  gauze 
used  for  surgical  dressings,  loosely  hemmed  at  the  margins,  and  then  steril- 
ized or  made  aseptic  by  sublimate  solution.  The  edges  should  not  be  cut, 
but  should  be  folded  over  and  hemmed  so  as  not  to  have  loose  threads  which 
might  be  left  in  the  abdomen. 

Marine  sponges  should  be  first  placed  in  a  bag  and  beaten  for  a  long  time  in 
order  to  free  them  from  the  sand  in  their  meshes.  They  should  then  be  ^vashed 
for  some  daj^s  in  water  which  is  frequently  changed,  and  best  in  water  which 
is  slightly  acidulated  with  hydrochloric  acid.  They  must  again  be  washed 
in  pure  water  in  order  to  remove  the  acid.  Different  methods  may  be  fol- 
lowed in  their  disinfection  :  (1)  They  may  be  soaked  for  twenty-four  hours  or 
less  in  a  solution  of  ordinary  washing  soda,  a  pound  of  the  so<la   to  a  dozen 


OPERA  Ti  1 7-;  srna  ku  v. 


1081 


sponcres,  and  the  soda  then  be  removed  by  washing  in  clean  water.     The  sponges 
are  ifext  soake.l  for  twenty-four  hours  in  a  1  :  20  carbolic  solution,  and  <lried 
bv  moderate  artificial  he:."t.      Thev  are  then  well  wrapped  up  and  kept  in  a 
d'rv  place      (2)  After  beating  the  sponges  free  from  san<l  and  washing  them  m 
the  warm  water,  they  should  be  soaked  in  a  solution  of  potassium  permanga- 
nate  half  an  ounce  to  the  gallon,  and  if  the  pink  color  ot  the  solution  is  lost 
more  permanganate  should  be  added.      If  this  addition  is  necessary  the  sponges 
should  be  takH'n  out  of  the  liquid,  the  permanganate  dissolved,  and  the  sponges 
put  back,  for  if  the  permanganate  is  put  in  upon  the  sponges  it  discolors 
Ihem  in  spots.     Thev  are  then  washed  in  warm  water  and  dipped  for  a  vejy 
few  minutes  into  a  solution  of  sulphite  of  sodium  3x  and  hydrochloric  acid  t5ij 
to  the  gallon  of  water.     If  they  are  allowed  to  remain  any  length  of  time  in  this 
solution  tliev  will  not  onlv  become  bleached,  but  very  much  softened.      Ihey 
are  then  thoroughly  washe<l  for  twenty-four  hours,  after  which  they  are  kept  in 
glass  jars  in  a  carbolic  solution,  1  :  40.     (3)  Borham's  method  is  that  adopted 
bv  Giei<^  Smith  in  preference  to  others.     The  sponges  after  being  cleansed  are 
first  soaked  in  a  1  per  cent,  solution  of  potassium  permanganate  (about  .  ograins 
to  the  pint).    The  sponges,  having  next  been  washed  repeatedly  in  boiled  water 
are  placed  in  a  gallon  of  water  in  which  has  been  dissolved  half  a  pound  of 
sodium  hyposulphite  for  a  dozen  sponges.      Four  ounces  of  oxalic  acid  are 
added,  which  bleaches  the  sponges  and  dissolves  out  any  fibrin  in  their  meshes. 
They  should  remain  in  this  solution  not  more  than  ten  minutes,  and  are  finally 

placed  in  a  carbolic  solution.  ,,         ,  ,  i.-     ii„ 

^  Ligatures  and  SuTURES.-For  ligatures,  silk  and  catgut  are  practically 
the  two' most  employed.  The  silk  may  be  either  the  plaited  silk  or,  peHmps 
better,  the  Chiies^  twisted  silk.  Ballance  and  Edmunds  have  recently 
recommended  for  the  ligation  of  arteries  in  continuity  dentists  floss  silk, 
wh~h  re  large  vessels  have  to  be  tied,  does  not  slip  so  easily  as  other 
linds  on  account  of  the  entanglement  of  its  fibers.  For  sutures  either  silk- 
worm gut  or  silk  is  the  best.  Silver  and  other  wire  sutures,  formerly  so 
popular,   are  but  little  used  nowadays. 

^  %he  ,ilk  is  made  of  different  sizes  appropriate  to  the  vessels  or  pedicles 
to  be  tied.     It  is  best  prepare*!  bv  boiling  after  it  has  been  wound  on  glass 
spools   which  are  thus  disinfected  at  the  same  time.     Another  method  consists 
n  puttin.  three  or  four  spools  into  an  ordinary  test-tube  the  mouth  of  which 
has  been" stopped  with  ordinary  jewellers'  cotton.     Absorbent  cotton  is  not 
go  d   s  nceXcomes  of  course  very  wet.     The  test-tube,  thus  prepared  as  for 
bacteriolocTical  use,  is  then  placed  in  a  sterilizer  and  exposed  to  steam  heat  foi 
an  hour  o!-  more.     In  order  to  carry  these  test-tubes  they  may  be  placed  in 
the  ordinary  tin  tubes  in  which  plasters  are  dispensed,  the  tube  having  been 
of  course    properly  cleansed,  or  holes  of  a  suitable  size  and  depth  may  be 
borJm  ;  bh4  of  wood  by  an  auger  and  stopped  with  rubber  -rks^  Just 
before  use  the  silk  should  be  placed  m  a  carbolic  solution    1  :  20,  and  alcohol, 
one-  bird  of  the  former  to  two-thirds  of  the  latter      Carbolic  acid  is  better  than 
subl  mate,  as  the  needles  may  be  threaded  and  placed  m  the  same  tray.     The 
alcohol  is  added  so  that  if  desired  the  catgut  may  be  placed  m  the  same  tray 
with  the  silk,  and  not  undergo  softening,  which  very  quickly  occurs  when  the 
catfTut  is  placed  in  plain  watery  solutions.  -,  •    i.      ii  q,^,!! 

^Simlnn  gut  ii  that  used  by  anglers,  and  is  purchased  in  bundles      Sma 
round  threads  should  be  selected  and  the  poor  ones  thrown  away.     The  threads 
should  be  soaked  in  a  carbolic  solution  for  fifteen  minutes  before  --     T^ie  dan^ 
ger  of  its  breaking  while  being  tied  can  be  obviated  V  niaking  the  first  kn^^^^  a 
double  one  and  tying  the  second  one  very  lightly  or  not  at  all  (Gieig  Smith). 


1082  ^l.V    AMKIUCAX    TEXT-IK  K)K    OF   S(  lidKI:)'. 

Cat;/uf  also  can  he  used  for  sutures,  and  especially  for  ligatures.  Raw  cat- 
gut, as  ordinarily  purchased  commercially,  has  two  «)l)jections  :  first,  it  has  a 
considerable  »|uantity  of  fat  in  it  :  and  secomlly.  it  is  infected  with  germs  from 
its  very  source,  heing  made  from  the  suhmucosa  of  the  intestine  of  the  sheep. 
There  are  very  many  methods  of  sterilizing  catgut;  of  these  the  following 
may  be  named  as  reliable.  The  Jefferson  Hospital  method  is  as  follows:  The 
catgut  is  first  ))laced  in  ether  for  48  hours  to  extract  the  fat;  then  in  a  mixt- 
ure composed  of  corrosive  sublimate  gr,  xx,  tartaric  acid  gr.  c,  and  0  ounces 
of  0')  per  cent,  alcohol.  The  smaller  sizes  are  soaked  in  this  solution  from 
.")  to  7  minutes,  the  medium  sizes  from  1"  to  1">  minutes,  the  largest  sizes 
from  20  to  8U  minutes.  It  is  then  permanently  kept  in  alcohol  (95  per 
cent  ),  to  8  ounces  of  which  two  drops  of  a  solution  of  chloride  of  palladium 
(gr.  XV  (a  .^j)  are  addetl.  If  more  is  added,  all  the  palladium  precipitates. 
At  the  University  of  Pennsylvania  Hospital  cumol  catgut,  as  first  devised  by 
Kn'iiiig.  is  emjiloyed.  The  process  is  as  follows:  Roll  12  strands  in  figure-of- 
8  form  so  that  it  can  be  placed  in  a  large  test-tube;  heat  the  catgut  to  80° 
C.  and  keep  at  this  point  one  hour;  place  in  cumol.  which  must  not  be  above 
100°  C. ;  heat  to  lGo°  C.  and  hold  at  this  point  one  hour  ;  pour  off  the  cumol 
and  dry  the  catgut  either  over  a  sand-bath  or  in  a  hot-air  oven  at  100°  C.  for 
two  hours;  transfer  with  sterile  forceps  to  sterile  test-tubes.  In  drying  or 
boiling  suspend  the  catgut  on  slender  wire  loops  or  on  cotton,  to  keep  it  from 
touching  the  bottom  or  sides  of  the  beaker-glass.  It  should  be  immersed  in 
sterile  water  a  few  moments  before  being  used,  or  it  may  be  put  into  bichlor- 
ide solution  instead  of  sterile  water.  Another  method  of  sterilizing  catgut 
is  by  boiling  it  in  alcohol.  It  can  scarcely  be  used,  however,  outside  of  hos- 
pitals, as  it  reijuires  special  apparatus.  It  may  also  be  i)repared  with  forma- 
lin. If  it  is  desired  to  make  the  catgut  less  absorbable,  it  can  be  chrom- 
icized  in  this  manner  :  200  parts  of  catgut  by  weight  are  added  to  carbolic 
aci<l  200  parts,  and  water  2000  parts,  with  chromic  acid  1  part.  The  catgut 
should  lie  in  this  preparation  for  twenty-four  or  forty-eight  hours.  It  may 
then  be  preserved  either  in  alcohol  or  in  ether,  as  before.  Catgut  and  silk 
may  be  kept  in  (juantity  in  reel-holders,  but  these  are  generally  objectionable 
on  account  of  the  great  difficulty  of  preventing  their  being  soiled  and  infected 
during  an  operation  by  the  necessary  contact  with  blood-  or  pus-covered  fingers 
and  scissors.  Robb  and  Ghrisky  made  a  bacteriologicnl  study  of  the  sutures 
removed  in  forty-five  cases  in  which  every  antiseptic  precaution  had  been  fol- 
lowed, and  without  exception  they  found  them  infected  with  a  greater  or  less 
number  of  bacteria.  J>ilkworm-gHt  was  infected  with  f;ir  fewer  germs  than 
silk  or  catgut.  Even  silver  wire  was  not  exempt.  Tension  was  a  potent  factor 
in  causing  multi|)lication  of  the  germs.  Hence  the  greater  safety  of  silk- 
worm-gut is  proved  bacteriologically  as  well  as  clinically,  and  the  importance  of 
approximating  the  wound-surfaces  with  the  least  possible  tension  is  emphasized. 

DRES.-^rXiJS. — Ordinary  cheese-cloth  is  prepared  in  the  following  manner: 
The  grea.se  is  removed  and  the  gauze  made  ab.sorbent  by  boiling  it  either  with 
soft  soap  or  .soda,  after  which  it  is  rinsed  and  dried.  The  gauze  is  then  fohled 
in  suitable  packages  and  sterilized  in  a  steam  sterilizer.  If  desire<l.  it  may  then 
be  .soake<l  in  a  .solution  of  bichloride  of  mercury,  1  :  1000.  with  twice  as  much 
common  salt  as  of  sublimate.  The  object  of  the  salt  is  to  prevent  the  sub- 
limate from  turning  into  calomel.  It  can  be  kept  either  moist  or  dry  in  dis- 
infected gla.ss  jars.  Sterilized  gauze  is  first  made  ab.sorbent  as  ])efore.  and 
then  is  boiled  for  ten  or  fifteen  minutes;  or  it  may  be  placed  in  a  sterilizer 
an<l  steame<l  f.r  the  same  length  of  time.  The  best  iodoform  gauze  is  made 
as  follows:  Four  ounces  each,  by  weight,  of  iod<»form.  glvcerine.  and  alco- 
hol.  an<l  six  grains  of  corrosive  sublimate  are  well   mixed   and   allowed  to 


OPEUATIVE   Sl'liCKRY.  1083 

stand  for  three  days.  Moist  bichloriilc  ^Miizf  is  then  saturated  with  the 
emulsion,  allowed  to  di-i)»  till  almost  dry,  and  is  then  kept  in  sterilized  cov- 
ered glass  jars.  In  iisiiiir  suhlimate  <rau/e  it  should  he  remend)ered  that  cer- 
tain j)arts  ot"  the  body — tor  instance,  the  recently-shaven  seal])  and  the  scro- 
tum— are  liable  to  be  ))ustulated  by  a  1  :  1000  gauze,  and  it  should  therefore 
be  used  of  a  strength  of  1  :  2000  or  3000  on  these  parts.  This  can  easily  be 
done  with  suificient  accuracy  extemporaneously  by  washing  the  ordinary  sub- 
limate gauze  in  sterilized  water,  and  then  in  a  solution  of  sublimate  of  the 
desired  strength.  For  making  sublimate  solutions  the  manufacturing  chem- 
ists now  sui)ply  tablets  containing  ~\  grains  of  bichloride  of  mercury  and  37^ 
grains  of  tartaric  acid,  the  object  of  the  latter  being  to  prevent  the  decom- 
position of  the  bichloride  and  the  fornuition  of  the  albuminate  of  mercury 
from  the  blood-serum.  One  of  these  tablets  added  to  one  pint  of  water  makes 
a  solution  of  1  :  1000.  Dressings  are  best  held  in  place  by  bandages  made 
of  gauze  rolled  on  slender  cylindrical  sticks  of  wood  to  give  stiffness  to  the 
roller.  These  bandages  do  not  easily  slip.  Of  course,  ordinary  roller  band- 
ages may  also  be  used.  If  pressure  is  desired  at  any  point  on  the  Haps,  it 
can  be  made  either  by  placing  a  moist  antiseptic  sponge  underneath  the 
dressing  or  by  absorbent  cotton,  or,  better,  antiseptic  wool,  outside  of  it. 

The  Operation. — The  surgeon  should  first  of  all  see  that  absolutely 
everything  is  ready  ;  not  only  that  the  patient  has  been  ])roperly  prepared, 
the  stomach  and  bowels  attended  to,  the  clothing  ready  for  operation,  instru- 
ments, dressings,  rubber  dam,  bandages,  and  all  the  drugs  and  antiseptic 
solutions  at  hand,  but  that  everything  that  can  be  needed,  from  the  most 
important  to  the  least,  is  within  reach.  During  the  operation  every  detail 
must  be  attended  to  "  with  a  thoroughness  as  minute  and  definite  as  if  that 
detail  wei'e  the  turning-point  of  success."  The  means  for  the  prevention 
of  shock  have  already  been  described  in  part,  but  still  further  we  must 
remember  that  the  time  occupied  by  the  operation  and  the  duration  of  the 
anesthesia  influence  considerably  the  amount  of  shock.  Hence  speed  without 
haste  should  be  the  rule  for  every  operation.  Of  course  the  precautions  should 
be  taken  to  remove  false  teeth,  tobacco,  or  other  foreign  bodies  from  the  mouth. 
After  the  patient  is  etherized  he  is  placed  upon  the  operating  table,  and  his 
clothing  so  arranged  that  if  possible  it  shall  not  be  soiled.  The  body  is  pro- 
tected by  blankets,  over  which  are  laid  sterilized  or  antiseptic  towels  or  sheets. 

The  incision  should  always  be  sufficiently  long.  The  question  whether  it 
shall  be  an  inch  or  two  longer  or  shorter,  as  far  as  healing  is  concerned,  i? 
of  little  matter  at  the  present  day,  but  it  is  of  great  importance  that  it  shall  be 
long  enough  to  give  ample  room  for  the  manipulations  required.  No  feats  of 
dextrous  manipulation  Avithin  narrow  limits  are  allowable.  Hemorrhage  is 
arrested  as  vessels  are  divided  by  placing  the  fingers  upon  them  until  they 
can  be  clamped  w^ith  the  hemostatic  forceps,  and  later  ligatured  if  required. 
Heat  and  pressure  by  wads  of  gauze  dipped  in  hot  w^ater  at  110°  to  120°  F. 
will  be  most  valuable  aids,  especially  for  arresting  the  bleeding  from  the  smaller 
vessels  and  any  general  oozing. 

Irrigation  during  an  operation  is  often  employed.  Normal  salt  solution  is 
the  one  most  frequently  employed.  If  bichloride  of  mercury  is  used,  it  should 
usually  be  of  the  strength  of  1 :  1000  to  1  :  3000.  In  the  abdomen,  the  blad- 
der, or  a  joint  it  should  rarely  be  used,  and  not  stronger  than  1  :  10,000. 

Landerer  s  dry  method  of  operating  is  adopted  by  many  surgeons.  In 
this,  once  the  field  of  the  operation,  and  therefore  the  wound,  are  aseptic,  no 
fluid  whatever  is  allowed  to  touch  the  wound.  Mops  or  pledgets  of  gauze 
are  packed  in  it  as  rapidly  as  the  operation  is  completed  at  one  part,  and  sub- 


10S4  J.v  AMimrcAX  ri.xr-iiook'  or  scucinn'. 

sei|UiMitly,  when  tlio  last  part  lias  Ix-cii  jiackcd.  it  will  he  foiiinl,  if  tlic  woiiml 
lit'  a  lariro  oiio,  that  the  ))art  first  packi'd  is  jicrfeetly  bh^oillcss  anil  dry. 

Ihudiuiiir. — Ik'forc  the  ('(lifcs  of  tho  wound  are  approxiiiiatcd  the  (jiics- 
tii»n  of  drainaj^o  is  to  ho  decided.  The  ))rinci])l('s  upon  which  this  must  he 
dctcnniucd  are  inciitiouod  in  various  ))arts  of  this  w<irk.  We  have  here  to 
do  only  with  the  practical  methods  which  arc  most  common  and  etlicient. 

Carbolic  acid  and  bichloride  of  mercury  and  other  antiseptic  solutions, 
while  they  prevent  suppuration,  irritate  the  tissues  to  a  certain  extent,  so  that 
provision  must  be  made  for  the  removal  of  serous  exudation.  Drainafre- tubes 
shouhl  bo  brought  out  at  the  angle  of  the  wound  which  will  be  lowest  when 
the  jiatient  is  recumbent,  or  through  an  o))ening  in  the  lower  flap  :  and  the  size 
of  the  tube  should  bo  adapted  to  the  character  of  the  wound  itself. 

Drainage  in  a  wound  can  be  secured  by  tubes  made  of  rubber,  of  glass,  of 
decalcified  bone,  or  upon  the  principle  of  capillarity.  The  tubes  should  be  cut 
the  proper  length,  and  holes  made  upon  the  sides  at  short  intervals,  and  then 
the  tube  should  be  cut  oft'  nearly  flush  with  the  skin  and  held  in  situ  by  an 
ase))tic  safety-pin,  or  often  bettor  by  a  stitch  through  the  skin  and  tube.  The 
lower  angle  of  the  wound  should  not  constrict  the  mouth  of  the  tube  by  hav- 
ing the  last  suture  too  tight.  If  the  tube  projects  much  beyond  the  wound, 
instead  of  being  flush  with  the  surface,  the  projecting  part  is  compressed  or 
bent  by  the  dressings,  and  it  will  fail  to  drain  the  wound.  In  a  very  long 
wound  it  is  better  to  phice  two  short  drain-tubes,  one  at  each  end,  rather  than 
one  very  long  one.  The  rubber  tube  may  be  removed  upon  the  first  or  second 
day  after  operation  unless  more  prolonged  drainage  be  ref|uircd  by  reason  of 
prior  su))|)uration,  etc.  If  the  wound  has  been  made  aseptic  at  the  first  dress- 
ing, there  is  no  occasion  for  a  tube  to  remain  longer  than  the  third  day  ;  it  may 
often  be  removed  sooner,  as  its  usefulness  is  over  when  it  has  drained  the  primary 
al»un<lant  secretion.  Its  longer  retention  will  tend  to  cause  a  persistent  sinus. 
Glass  tubes  are  used  in  abdominal  cavities,  but  seldom  in  wounds  of  soft  ))arts. 
The  capillary  drainage  is  oftocteil  by  strands  of  catgut  or  horsehair.  A  dozen 
strands  a  few  inches  in  length  are  laid  in  the  bottom  of  the  wound,  so  as  to 
project  beyond  the  angle  of  the  wound,  but  not  beyond  the  dressing.  In 
some  wounds  the  drainage  by  rul)ber  tube  and  by  strands  of  catgut  or  horse- 
hair can  lie  advantageously  combined,  both  being  inserted  at  the  operation, 
the  tube  removed  in  twenty-four  to  forty-eight  hours,  and  the  horsehair  later. 

Many  wounds,  if  the  hemorrhage  is  entirely  arrested  and  the  wound  abso- 
lutely aseptic  and  its  walls  in  contact,  may  be  entirely  closed  without  drainage. 
This  is  certainly  the  ideal  toward  which  the  surgeon  should  strive,  as  a  drain- 
age-tube is  always  a  possible  means  by  which  infection  may  occur.  But  the 
conditions  stated  must  be  first  realized. 

Methods  of  Suturing. — Sutures  may  be  the  continued  or  glover's,  inter- 
rupted, quilled,  twisted,  hare-lip,  button,  etc. 

In  the  continued  or  glover  n  suture  the  needle  is  introduced  about  one-quar- 
ter of  an  inch  from  the  edge  of  the  wound,  and  is  carried  first  through  one  lip 
'  ■      1'-'  of  the  wound,  and  then  through  the  other  at  a 

^•.  -  .^       point  one-quarter  of  an  inch  from  the  edge,  and 

.ifei^'-  'If^  '  "^^  '**"  #-'•  so  on  from  one  end  of  the  wound  to  the  other 
;■    ,      ,y^     ,  ■/     -/    y  (i'^'g-  428).     At  the  lower  angle  an  opening  suf- 

\  .v,>-^  ^M  .M.  ^  ft,']  fit'icntly  large  to  introduce  a  drainage-tube  may 
•^■--.:.^lj:^.^.-:^£'..~'"i^-^--'iB^  be  left  if  necessary.  The  tube  must  not  be 
continmti  ur  <;iuv(t\  siitiiri;         constrictcd.    Otherwise    it    will    not    afford    free 

, Bernard  «n,l  n.atte).  drainage. 

The  interrupted  suture  (Fig.  429)  is  made  by  approximating  the  edges  of 


<h'i:i:a  ti  i  v-;  s(  'rokr  y. 


1085 


■f 


Iiiicrruplcil   >uturc   UJi-riiard 
and  Huelte). 


YlG.  430. 


the  Avouiid  by  iiitrodiu-iiii.'  a  suture  in  the  luaniier  ali-eady  (h'scrihed.  hut  the 
knot  is  tied  and  the  ends  cut  off,  and  other  fresh 
sutures  are  intnxhu-ed  in  the  same  way.  About 
tliree  <»r  tour  stitcht^  to  the  inch  are  used,  accord- 
ing to  circumstances.  The  interrupted  suture 
must  not  be  tied  too  tightly,  as  tension  will  pro- 
duce a  stitch  abscess;  only  that  tightness  which 
will  bring  the  two  edges  of  the  wound  into  appo- 
sition is  desirable.  In  removing  the  interru[)ted 
suture  (whicli  is  the  suture  most  commonly  used)  the  stitch  is  lifted  gently 
from  the  skin  sufficiently  to  introduce  one  point  of  a  pair  of  scissors,  which 
should  then  cut  the  suture  exactly  at  one  of  the  points  where  it  penetrates  the 
skin.  The  skin  on  the  opposite  side  of  the  wound  is  then  supported  by  the 
blades  of  the  scissors,  one  on  each  side  of  the  stitch,  while  WMth  tlie  forceps  it  is 
withdrawn.  In  situations  where  a  prominent  scar  is  objectionable  an  inter- 
cuticular  stitch  in  which  the  needle  is  introduced  on  the  under  surface  of  the 
skin,  emerging  directly  at  its  cut  e<lge.  and  passing  back  and  forth  from  side 
to  side,  may  be  employed.  It  is  made  with  silver  wire,  the  ends  beino;  secured 
by  simply  bending  them.  The  result  is  an  almost  invisible  scar.  This  suture 
is  especially  adapted  to  exposed  parts,  as  the  face.  The  object  of  this  method 
is  to  avoid  infection  by  the  skin-coccus  (staphylococcus  epidermidis  albus), 

Avhich  is  constantly  found  in  the  ejjideruiis, 
and  may  be  carried  through  the  stitch- 
wound  by  the  suture  if  the  latter  is  passed 
tlirough  the  skin  from  Avithout  inAvard. 

The  quilled  suture  is  indicated  where 
there  is  considerable  tension  (Fig.  430).  The 
needle  is  introduced  half  an  inch  from  the 
edge  of  the  wound,  carrying  a  double  thread, 
Avhich  is  passed  and  then  unthreaded.  The 
quill  is  then  caught  in  the  loops  upon  one 
side  of  the  wound,  and  the  two  free  ends  are  tied  around  a  corresponding 
piece  of  quill  upon  the  opposite  side.  The  length  of  the  quill  should  exceed 
the  length  of  the  incision,  so 
that  the  Avound  will  be  evenly 
and  uniformly  draAvn  in  appo- 
sition. A  fcAv  superficial  su- 
tures may  be  passed  through  [ 
the  skin  edges,  if  need"<l  to  • 

m:ike  more  jjerfect  approxi-         ^ 
mation.  i 

The  twi-sted  suture  is  some-  I 
times  used  in  hare-lip  cases.  f 
A  steel  pin  is  thrust  tlirough 
both  lips  of  the  Avound  at  a 
distance  of  half  an  inch  from 
the  edge.  The  edges  are  then 
brought  into  accurate  apposition;  a  silk  thread  is  Avound  over  the  ends  of 
the  pin  in  an  oval  or  figure-of-8  manner  (Fig.  431);  h  shows  the  suture  com- 
pleted. Strips  of  gauze  are  placed  under  the  heads  and  cut  ends  of  the  pins 
to  protect  the  skin. 

The  hutton  suture  (Fig.  432)  consists  of  two  lead  buttons,  to  one  of  Avhich 


(.^uiiiL-d  >uuiii-  (iiL-rii;ii(.i  iiini  Hiu-tte). 


Fig.  431. 


Twistt'd  Suture  (Bernard  and  Huette). 


lo.sn 


.l.V   AMFJill'AX    TEXT-HOOK    OF  SURGERY 


Fi<;.  -l; 


Huttoii  Siitiiiv  iHrvaiit). 


Fig.  433. 


The  Quilted  Suture  (Bernard  anil  Huette). 


is  attached  a  silver  wire.     The  button  is  phiccd  about  two  inches  from  the  edge 

of  the  wound,  and  the  wire  is  threaded  to  a  needle 
which  is  passeil  throuirli  under  the  tissues  and  across 
tlie  wound  and  out  the  other  side  at  a  point  two  inches 
from  the  edge  of  tlie  wound.  'iTie  second  button  is 
now  placed  at  this  point,  and  the  silver  wire  is  passed 
through  the  perforated  centre  and  wound  across  the 
edges  or  wings  of  the  buttons.  The  button  suture  is 
used  where  the  wound  is  extensive  and  there  is  a 
tendency  for  it  to  gape  from  tension.  After  amputa- 
tion of  the  breast  the  button  suture  is  sometimes  used  with  advantage  as  a 
deep  or  relaxation  suture  in  addition  to 
the  sutures  of  the  edges  of  the  wound  ('//>- 
proriniatiou  .suture).  Such  sutures  can  be 
made  extemporaneously  also  by  perforated 
glass  beads  or  other  similar  objects,  the 
wire  suture  after  passing  tiirough  the 
beads  being  twisted  on  bits  of  disinfected 
Avood.  such  as  pieces  of  a  match.  Small 
pledgets  of  aseptic  gauze  may  be  substi- 
tuted for  the  buttons,  one  being  caught  in 
the  loop  of  the  thread  and  the  free  ends 
tied  over  the  opposite  pledget.  In  all  forms  of  this  suture  care  must  be 
taken  that  the  tension  is  not  too  great,  or  it   will  favor  suppuration. 

The  quilted  suture  {¥\^.  433)  is  often  used  to  act  as  a  sort  of  splint,  and 
to  keep  the  edges  of  the  wound  quiet  where  there  is  a  tendency  for  the  lips  to 
gape  or  to  contract,  as  in  the  scrotal  tissue,  where  the  action  of  the  cremaster 
prevents  absolute  quiet. 

Suhcutayieous  or  Buried  Sutures  are  often  necessary  in  deep  wounds.  In 
this  case  each  layer  of  tissue  beneath  the  skin  must  be  sutured  separately.  A 
divided  tendon  must  be  sutured  to  its  other  end,  the  fiber  of  a  muscle  must  be 
united  to  its  other  fibers :  fascii^,  aponeuroses,  nerves,  and  any  other  structures 
must  be  brought  into  contact  each  with  its  own  divided  part.  Where  we  have 
to  deal  with  deep  wounds  from  aponeurotic  and  muscular  tissue,  as  in  the 
abdominal  wall,  buried  sutures,  either  of  catgut  or  silk,  can  be  used.  Different 
layers  should  be  united  each  to  its  fellow,  and  especial  care  be  taken  that  the 
aponeurotic  structures  of  the  abdominal  wall  are  included  in  the  sutures.  As 
Treves  has  Avell  stated,  the  surfaees  of  the  wound,  and  not  only  the  overlying 
skin,  are  to  be  approximated. 

For  details  as  to  the  sutures  of  nerves,  tendons,  muscles,  and  bones  see  the 
articles  on  the  surgery  of  those  structures. 

Seeondary  Sutures  are  used  in  wounds  which  immediately  after  operation 
have  been  packed  with  iodoform  or  other  antiseptic  gauze  to  secure  complete 
hemostasis  or  asepsis  not  obtainable  by  the  usual  methods.  The  packing  is 
withdrawn  in  two  or  three  days,  when  the  sutures  which  may  have  been  inserted 
and  left  long  at  the  time  of  operation,  or  may  be  put  in  later,  are  tie<l  in  the 
customary  manner.  Union  by  first  intention  can  fretjuently  be  secured  in  this 
way  in  wounds  that  would  have  been  infected  or  distended  by  blood-clot  if 
closed  immediately. 

After  the  continuous  or  interrupted  sutures  have  been  applied,  if  no  drain- 
age has  been  used,  the  wound  may  often  be  sealed  by  covering  it  with  small 
strips  of  gauze  painted  over  with  iodoform  collodion  or  with  a  mercurialized 
solution  of  collodion,  1  :  30,000. 


OPKUATIVE   SURGERY.  1087 

If,  although  formal  drainage  is  dispensed  with,  fiome  oozing  is  to  be 
expected,  it  would  be  better  to  use  interrupted  sutures  at  wide  intervals, 
thus  permitting  of  the  escape  of  the  fluids  of  the  wound  from  between  its 
edges. 

A  dry  method  of  dressmq  icowuh  is  often  employed.  This  is  especially 
adapted  to  small  wounds.  Iodoform,  aristol,  salicylate  of  bismuth,  acetani- 
lid,  or  some  other  innocuous  but  antiseptic  powder  which  forms  a  thin  film 
over  the  surface  of  the  wound,  may  be  dusted  upon  it  after  it  has  been  sutured, 
and  thus  by  inspissating  the  blood  and  serum  a  dry  aseptic  crust  is  formed 
which  when  hard  prevents  putrefaction.  As  this  fihn  is  exposed  to  the  air, 
it  soon  dries,  and  the  hard,  firm  crust  prevents  the  entrance  of  particles  of 
dust  into  the  wound.  Under  this  artificial  scab  the  healing  process  rapidly 
progresses.  The  scab  thus  formed  should  not  be  removed,  but  alloAved  to 
fall   off  after  the  part  is  healed  beneath  it. 

An  illustration  of  the  usefulness  of  this  method  may  be  found  in  the  plan 
of  treatment  of  compound  fractures  adopted  by  Treves,  and,  following  him, 
bv  White.  When  the  case  is  admitted  to  the  hospital  the  wound  and  sur- 
rounding parts  are  cleansed  as  thoroughly  as  Avould  be  done  for  an  aseptic 
operation,  but  no  attempt  is  made  to  arrest  the  oozing  of  blood,  Avhich  in 
the  great  majority  of  these  cases  is  still  going  on.  Iodoform  is  sjirinkled 
in  large  ([uantities  and  at  short  intervals  over  the  wound  and  adjoining 
parts,  and  this  is  continued  sometimes  for  two  or  three  days.  At  the  end 
of  that  time  a  scab  has  formed,  beneath  which  cicatrization  and  repair  take 
place  aseptically.  The  infiltration  of  the  muscles  and  connective  tissue 
which  sometimes  follows  the  sealing  of  the  wound  in  compound  fracture  while 
oozing  is  still  going  on,  is  thus  avoided,  and  with  the  least  possible  disturbance 
of  the  parts.  During  the  entire  course  of  the  case  the  affected  limb,  with  the 
necessary  fixation  apparatus,  is  covered  by  sterile  towels  only  and  kept  outside 
of  the  covering  of  the  bed.  as  the  atmosphere  Avhich  surrounds  such  a  part 
beneath  the  bed-clothes  is  much  more  likely  to  be  septic  than  the  general 
atmosphere  of  the  ward.  Results  in  a  large  number  of  cases  justify  confi- 
dence in  this  method. 

Healing  beneath  a  Moist  Blood-clot. — This  method  of  healing  is 
adapted  to  those  cases  in  Avhich  there  has  been  a  loss  of  substance  in  the 
soft  parts  and  the  edges  of  the  wound  cannot  be  brought  into  apposition. 
It  is  also  applicable  in  cases  of  resection  of  joints  and  of  compound  fracture 
of  the  long  bones,  especially  where  there  is  slight  separation  of  the  fracture 
due  to  the  loss  of  comminuted  fragments.  In  operation  for  removal  of  necrosed 
bone  it  is  also  a  method  of  repair  that  has  many  advantages.  Schede  has  re- 
introduced this  method,  and  to  him  is  due  the  credit  of  perfecting  the  technique 
of  a  process  of  repair  in  cases  in  which  the  healing  would  never  have  taken 
place,  or,  if  it  had  taken  place,  would  have  done  so  very  imperfectly.  The 
wound  is  thoroughly  cleansed  and  made  perfectly  aseptic,  and  then  blood  is 
allowed  to  fill  up  the  cavity.  The  blood-clot  thus  formed  affords  protection  to 
the  raw  surfaces  of  the  wound,  and  if  the  clot  does  not  contract  and  desiccate  on 
the  one  hand  or  undergo  decomposition  on  the  other,  it  will  form  a  nidus  for 
granulation-tissue  w-hich  develops  and  finally  cicatrizes.  In  order  to  utilize 
a  blood-clot  for  the  purpose  of  healing  it  is  essential  to  keep  the  clot  moist. 
To  provide  for  this,  a  small  strip  of  rubber  tissue  or  protective  is  placed  over 
the  surface  of  the  wound  and  made  to  overlap  its  edge.  This  fine  rubber 
tissue  should  be  rendered  perfectly  aseptic  and  immersed  in  carbolic  acid 
before  its  application  to  the  wounded  surface.  Over  the  protective  a  strip  of 
iodoform  gauze  may  be  placed,  and  over  the  iodoform  gauze  is  placed  loosely 


1088  .-liv^  AMi:iii<'A.\  ri:xr-i:<K)K  of  .sLiiuEnv. 

an  abuiulanc'o  of  l»iclil<>ri(lo  <;auzo,  Avhicli  jjvovidcs  ample  drainai^e  by  absoi-ltintr 
fioiii  the  uoiiml  all  sui|)lus  serous  and  lieinoniiai^ie  disehaiires.  Tiie  wounds 
that  are  best  adapted  for  this  process  of  healiiii:  are  those  in  which  the  struc- 
tures and  tissues  are  highly  vascular.  Tendons,  fasciic,  and  other  tissues  pos- 
sessing a  low  grade  of  vascularity  are  not  suitable  for  it. 

Open  Wounds  can  be  treated  on  the  same  aseptic  principles  that  govern 
the  surgeon  in  the  management  of  closed  wounds.  If  a  wound  is  allowed  to 
remain  oi)en,  it  can  l>e  kept  aseptic  if  provision  is  made  for  fi-ee  drainage  and 
oxvgen  is  admitted  to  the  wounded  surface.  By  free  drainage  is  meant  a  pro- 
vision to  prevent  any  retention  of  discharges  that  may  undergo  ])Utrefaction. 
A  clean,  healthy  granulating  surface  is  a  barrier  to  the  entrance  of  septic 
germs  into  the  circulation.  Frequent  irrigiation  and  the  avoidance  of  the 
retention  of  discharges  afford  immunity  from  sepsis  in  any  wound.  The  small 
amount  of  discharge  from  the  granulation-tissiu^  left  after  irrigation  under- 
goes a  sort  of  desiccation  and  concentration  which  renders  the  soil  unsuitable 
lor  the  growth  of  septic  germs.  Pasteur  has  demonstrated  that  germs  will 
not  multiply  upon  a  surface  bathed  in  a  concentrated  discharge.  The  free 
admission  of  oxygen  to  the  o])en  wound  is  in  itself  somewhat  of  a  safeguard 
against  putrefaction.  Many  of  the  special  germs  concerned  in  the  develo])- 
ment  of  putrefaction  are  ofteti  incapable  of  multiplication  in  the  j)resence  of 
oxygen. 

After-treatment. — As  soon  as  an  operation  is  terminated  the  patient 
should  be  put  to  bed  between  blankets  and  surrounded,  if  necessary,  with  hot- 
water  bottles  or  hot-water  bags,  great  care  being  taken  that  the  patient  is  not 
burned  bv  them — an  accident  which  has  often  produced  serious  conse(iuences. 
The  room  should  be  darkened  for  the  first  few  hours  at  least,  and  the  utmost 
quiet,  both  of  mind  and  body,  obtained.  No  visitors  should  be  alloAved, 
except  .perhaps  either  the  husband  or  the  wife.  Very  frequently  for  want  of 
this  direction  friends,  and  especially  a  number  of  members  of  the  family,  may 
greatly  disturb  the  patient  by  conversation.  Not  only  should  rest  of  the 
body  as  a  whole  be  insisted  upon,  but  also  and  especially  rest  of  the  part. 
For  example,  after  an  amputation  of  the  breast  the  arm  of  that  side  should  be 
secured  to  the  trunk  by  a  ])inder  or  bandage.  After  an  operation  on  or  near 
a  joint  the  extremity  should  be  placed  upon  a  splint.  In  the  early  stages  of 
union  of  wounds,  the  fine  connective-tissue  fibers,  which  are  developed  and 
bind  the  parts  together,  and  the  delicate  slender  vessels,  should  be  preserved 
intact  by  absolute  rest  of  the  part. 

The  patients  comfort  should  be  the  chief  object,  and  hence  a  change  of  posi- 
tion  may  be  allowed,  not  by  the  active  eftbrts  of  the  patient,  but  by  the  aid  of 
the  nurse.  All  such  little  attentions  as  placing  a  pillow  for  proper  support  of 
the  part,  or  relaxing  a  bandage,  or  the  insertion  of  a  little  cotton  at  a  point 
of  undue  pressure,  or  gentle  friction  applied  to  the  back  or  extremities,  suspen- 
sion of  an  extremity,  or  its  being  placed  on  a  double  inclined  plane, — all  these 
means  and  the  many  others  which  will  suggest  themselves  to  a  thoughtful 
nurse  are  to  be  employed  for  the  comfort  of  the  patient.  ^loreover,  we  must 
not  forget  that  many  patients  are  made  uncomfortable  by  too  heavy  and  too 
warm  bed-clothing.  That  amount  of  clothing  which  is  the  most  conducive  to 
comfort  is  the  best.  For  the  treatment  of  shock  external  heat  has  already 
been  mentioned  as  one  of  the  most  important  means.  Sometimes,  again,  irri- 
tation by  nuistard  for  a  short  time  to  the  abdomen  or  to  the  extremities  may 
be  used.  If  the  shock  is  due  to  great  loss  of  blood,  the  foot  of  the  bed  should 
be  raised  and  pillows  and  bolsters  removed,  thus  favoring  the  access  of  blood 
to  the  brain  by  gravitation.      Strychnine,  digitalis,  and  enemata  of  hot,  strong 


OPERATIVE  ^SUIIGERY.  1089 

coffee,  Avhiskey — if"  lu'iuorrha^^c  lias  been  excessive,  iioriiiiil  salt  solution  by 
intravenous   injection  or  subcutaneously — one  or  all,  may  be  used. 

One  of"  the  most  annoying  post-operation  symptoms  is  ether-voiiutiny .  This 
usually  occurs,  and  often  continues  for  two  or  three  hours,  and  sometimes  as  many 
days.  If  vomiting  continue  for  ovot'  twelve  to  eighteen  hours,  some  other 
cause  than  ether-nausea  should  be  sought  for,  especially  peritonitis  if  the  ope- 
ration has  been  an  abdominal  section.  The  best  treatment  for  ether-vomit- 
ing is  the  administration  of  one-fourth  of  a  grain  of  coca'ine  every  hour  or  two 
until  four  or  five  doses  have  been  taken,  with  small  doses  of  brandy  and  finely 
divided  ice  or  champagne  and  ice.  The  ice  is  best  pulverized  by  placing  a 
small  lump  in  a  loop  of  a  clean  towel  and  striking  it,  as  if  it  were  a  hammer, 
on  a  marble  w'ashstand.  Very  hot  water  will  often  arrest  the  vomiting  better 
than  ice.  Mustard  over  the  epigastrium  is  also  found  useful,  and  occasionally 
lavage  of  the  stomach  by  the  stomach-tube,  Avhich  has  been  successfidly 
employed  in  desperate  cases  of  this  character.  The  vomiting  is  usually 
accompanied  by  marked  thirst.  This  can  be  best  relieved  by  a  rectal  enema 
of  six  to  eight  ounces  of  warm  Avater,  to  which  may  be  added  a  little  brandy 
or  whiskey. 

Any  other  than  a  trifling  operation  is  usually  followed  by  some  pain. 
Since  the  introduction  of  antise})tics  the  amount  of  pain  which  patients  suffer 
has  been  greatly  diminished.  It  is  no  uncommon  thing  nowadays,  after  an 
amputation  of  an  extremity  or  of  a  breast,  to  have  the  patient  pass  the  entire 
period  from  the  operation  to  complete  convalescence  with  practically  no  pain. 
Occasionally,  however,  moderate,  and  sometimes  severe,  pain  will  be  experi- 
enced ;  it  is  likely  to  occur  if  infection  takes  place.  Formerly  morphia  was 
practically  the  only  remedy  that  was  used  to  relieve  this  pain,  but  it  evidently 
had  its  disadvantages  in  the  constipation,  the  furred  tongue,  and  other  digest- 
ive disturbances  which  it  induced.  For  severe  pain  morphine  must  still  be 
employed  in  doses  of  i  to  ^  grain,  best  given  hypodermically.  But  in  most  cases 
the  moderate  pain  after  an  antiseptic  operation,  unless  the  remedy  is  contra- 
indicated  by  great  shock  and  a  weak  heart,  can  be  controlled  and  sleep  in- 
duced by  small  doses  (5  to  15  grains)  of  almost  any  on^  of  the  antipyretics, 
all  of  which  act  as  analgesics.  Antipyrine,  antifebrin,  phenacetin,  acetan- 
ilid,  etc.  may  be  used,  unless  contraindicated  by  some  cardiac  weakness. 
Opium  is  to  be  resorted  to  only  if  these  fail.  In  operations  on  the  abdomen  the 
pain,  tenderness,  and  other  symptoms  of  a  beginning  peritonitis  are  best  met, 
in  the  opinion  of  many  surgeons,  by  repeated  and  fre(iuent  small  doses  of  a 
saline  aperient  {h  to  1  teaspoonful  of  RocheJle  or  Epsom  salt  every  hour 
until  free  purgation  has  been  secured). 

The  bladder  must  be  carefully  attended  to  after  an  operation.  Sometimes 
the  patient  will  be  able  to  urinate  voluntarily,  but  in  many  cases  the  catheter 
must  be  used.  This  should  be  most  carefully  disinfected,  as  has  already  been 
described.  As  a  rule,  it  need  not  be  passed  before  the  patient  feels  the  need 
for  it,  from  five  to  eight  hours  after  the  operation. 

Food  and  Drink. — After  any  serious  operation  a  patient  may  readily  go  a 
number  of  hours,  and  even  two  or  three  days,  without  food  by  the  stomach. 
In  operations  on  the  stomach  and  intestines  this  should  be  a  cardinal  rule. 
No  food  whatever  is  required  for  from  four  to  six  hours  after  the  operation, 
during  which  time  the  stomach  may  possibly  right  itself  and  retain  small 
quantities.  If  there  is  difficulty  in  retaining  it,  the  patient  should  be  fed  by 
rectal  enemata  of  peptonized  milk,  beef-tea,  etc.  If  given  by  the  mouth,  the 
food  should  be  at  first  in  quantities  of  not  more  than  two  or  three  ounces  every 
two  hours,  the  amount  being  increased  and  the  intervals  lengthened  as  the  con- 

G9 


1090         A.y  AMKnuAy  tkxt-iuxjk  of  ^^I'UGEny. 

(lition  of  the  stomach  Avill  warrant.  As  a  rule,  the  bowels,  which  have  been 
thoroughly  evacuated  the  morning  before  the  operation,  will  not  be  opened  the 
<lay  after  it;  but  on  the  second  day,  or  certainly  on  the  third  day,  they  should 
be  moved,  either  by  an  enema  or  by  a  gentle  laxative.  After  the  second  or 
third  day  they  should  be  carefully  seen  to  either  every  day  or  every  second 
day.  Often  after  operations  for  hemorrhoids  comfort  will  be  attained  better 
by  daily  evacuations,  which  prevent  the  feces  from  becoming  hard  and  defeca- 
tion painful.  The  surgeon  should  be  careful  to  direct  that  until  the  patient  is 
able  to  rise  a  bed-pan  should  be  used,  and  on  no  account  should  he  rise  to  use 
the  commode,  still  less  to  go  to  the  water-closet. 

After  the  first  or  second  day  the  patient's  comfort  is  greatly  increased  by 
a  daily  sponge  bath  of  hot  water  and  alcohol,  which  should  be  done  without 
any  exposure  of  the  person.  Careful  notes  should  be  taken  by  the  nurse, 
either  on  a  printed  blank  or  on  one  prepared  extemporaneously  by  the  surgeon. 

Renewal  of  Dressings. — As  a  rule,  the  less  frequently  the  dressings  are 
disturbed  the  better  it  will  be  for  the  patient,  since  even  the  gentlest  renewal  is 
apt  to  cause  some  pain,  and  also  since  the  handling  of  a  wound  always  exposes 
it  to  the  possibility  of  infection.  So  soon,  however,  as  the  wound-fluids 
have  wet  the  dressings  to  their  edge  they  must  be  reinforced,  or,  better  still, 
renewed ;  in  some  cases  this  will  be  required  within  a  few  hours  in  con- 
sequence of  the  free  oozing.  In  other  cases  even  a  number  of  days  may 
elapse  before  the  dressing  is  changed.  If  a  drainage-tube  has  been  inserted, 
the  dressings  should  be  changed  in  from  twenty-four  to  forty-eight  hours  in 
order  to  take  it  out.  Usually  by  the  fifth  or  sixth  day  the  sutures  Avill  cause 
a  little  tension  and  produce  stitch-abscess  unless  they  are  removed.  These 
abscesses  are  especially  due  to  the  skin-coccus,  the  staphylococcuH  epidermidis 
aUnis  (Welch),  which  is  constantly  and  normally  found  in  the  epidermis,  and 
certainly  cannot  be  removed  by  any  of  the  present  methods  of  disinfection  of 
the  skin.  The  renewal  of  dressings  should  be  done  with  the  same  antiseptic 
care  as  their  first  application  :  the  hands  of  the  surgeon  and  the  nurse  should 
be  disinfected  with  care  similar  to  that  exercised  at  the  time  of  operati'in. 
The  instruments — usually  a  pair  of  scissors,  dissecting-forceps.  a  probe,  a 
grooved  director,  and  a  pair  of  dressing-forceps  are  all  that  are  required — 
should  be  disinfected  by  being  placed  in  a  1  :  20  carbolic  solution  for  at  least 
fifteen  minutes,  and  the  new  clean  dressings  should  be  ready  for  application 
before  the  wound  is  uncovered.  The  bed-clothes  should  be  turned  down  and 
covered  with  antiseptic  or  sterilized  towels.  If  the  wound  is  in  the  abdomen, 
the  chest  should  be  protected  by  a  shawl  also  covered  by  a  similar  towel. 
Great  care  should  be  taken  not  to  chill  the  patient.  If  they  have  to  handle 
the  body  or  bed-clothing,  the  binder  or  bandage,  the  surgeon  and  nurses  should 
again  disinfect  their  hands.  Soiled  dressings  having  been  removed,  the  wound 
may  be  gently  washed  with  an  antiseptic  solution,  and  after  such  attention  to 
the  wound  as  seems  necessary  the  dry  clean  dressings,  followed  by  the  binder 
or  bandage,  should  be  applied.  It  is  very  important  to  change  the  position 
of  the  patient  from  time  to  time,  to  prevent  be<l-sores. 

Bed-rests  are  often  of  great  service  during  convalescence.  They  should, 
however,  be  employed  with  judgment,  as  it  is  sometimes  dangerous  to  allow  a 
patient  to  assume  the  upright  position  even  in  bed  unless  the  heart's  action  is 
sufficiently  strong.  One  which  enables  a  patient  gradually  to  sit  up  after  a 
serious  surgical  operation  and  during  the  repair  of  a  wound  hastens  recovery. 

Air-cushions  may  serve  as  useful  adjuvants  by  contributing  to  the  comfort 
of  a  patient  during  convalescence.  These  may  be  used  to  remove  pressure 
from  parts  which  have  shown  a  tendency  to  bed-sore  formation,  or  they  may 


OPERATIVE   SURGERY.  1091 

be  employed  to  rest  extremities  upon,  or  to  make  uniform  and  equable  pres- 
sure upon  certain  parts  of  the  body. 

WaU'r-cushlons  are  often  found  to  contribute  to  the  comfort  of  a  patient. 
They  can  be  used  to  afford  support  to  the  back,  or  can  be  filled  with  hot  water 
and  serve  as  a  conductor  of  heat  to  a  part.  Care  should  be  exercised  lest  the 
water  be  too  hot  and  thus  burn  a  patient  who  may  ]>e  in  shock  after  an  injury. 
Sinqle  and  double  inclined  planes  are  indicated  wlien  it  is  necessary  to  place 
one  of  the  extremities  in  a  position  of  flexion.  In  compound  fracture  of  the  leg 
in  which  there  is  a  tendency  for  the  fragment  to  protrude  through  the  wound 
the  double  inclined  plane  relaxes  the  muscles  and  prevents  the  accident.  A 
single  inclined  plane  is  indicated  in  a  fracture  of  the  patella  or  a  wound  of 
the^'quadriceps  extensor  muscle  of  the  thigh,  or  in  a  case  of  cellulitis  of  the 
forearm  where  elevation,  compression,  and  fixation  of  the  part  are  simultan- 
eously required. 

Suspension  apparatus,  especially  for  the  lower  extremities,  is  necessary 
where  a  certain  amount  of  movement  of  the  body  in  bed  must  be  allowed, 
while  at  the  same  time  it  is  necessary  to  secure  physiological  rest  to  the 
wounded  part  itself. 

Splints  are  often  a  necessity  in  wound-treatment.  They  serve  to  secure 
absolute  rest  to  the  part  until  healing  takes  place.  Whatever  material  is  em- 
ployed for  the  splint,  it  should  be  carefully  and  evenly  padded  with  absorbent 
cotton.  If  the  padding  becomes  stained  by  the  discharges,  a  new  one  should 
be  substituted,  as  it  might  be  the  means  of  carrying  infection  to  a  wound. 

COxMPLiCATiONS  AFTER  OPERATION. — The  most  important  danger  is  that 
of  septic  inflammation.  There  will  usually  be  a  post-operation  rise  of  tem- 
perature to  100°,  or  occasionally  to  101°,  which  will  persist  for  from  twenty- 
four  to  forty-eight  hours.  If  the  temperature  rises  after  this  latter  time,  sepsis 
should  be  suspected,  the  dressing  be  removed,  and  the  wound  inspected.  If 
sepsis  has  occurred,  the  wound  should  be  disinfected  through  the  drainage-tube 
if  one  has  been  used,  or  in  some  cases  it  may  be  necessary  to  reopen  the  wound 
by  removing  the  stitches,  and  follow  this  by  disinfection.  If  hemorrhage 
has  occurred  and  any  considerable  clot  has  formed,  evinced  by  bloody  oozing, 
by  swelling  and  tension,  and  by  a  rise  of  temperature  to  101°  or  over,  the 
probabilities  are  that  the  clot  is  too  large  to  be  absorbed.  One,  two,  or  more 
stitches  should  be  removed  and  the  clot  completely  evacuated,  and  any  bleed- 
ing vessels  secured,  followed  by  a  redisinfection  with  scrupulous  care.  If  this 
is  "done  within  from  twrnty-four  to  forty-eight  hours,  very  frequently  the  case 
will  still  run  an  aseptic  course.  If  in  an  abdominal  case  peritonitis  arises,  the 
saline  treatment  should  be  instituted  at  once.  Sometimes  the  bowels  become 
greatly  distended  with  flatus,  in  which  case  great  comfort  may  be  obtained  from 
inserting  a  soft  catheter  or  rectal  tube,  which  may  be  held  in  place  and  secured 
from  loss  within  the  bowels  by  a  moderately  long  thread  tied  to  its  extremity. 
If  the  distention  does  not  yield,  a  saline  laxative  in  repeated  doses,  or  a  tur- 
pentine enema,  will  usually  relieve  it. 

Not  uncommonly,  especially  in  hospital  patients,  delirium  tremens  Avill 
occur  after  an  operation  :  this  must  be  treated  in  accordance  with  the  prin- 
ciples already  laid  down  in  connection  with  that  affection.  Occasionally  in- 
sanity follows  surgical  operations,  especially  those  about  the  head,  uterus,  or 
ovaries.  The  attack  may  often  be  only  temporary,  but  in  some  cases  it  is 
more  or  less  permanent. 

Causes  of  Death  after  Surgical  Operations. — This  may  be  due  to 
hemorrhage,  either  primary  or  secondary ;  to  the  administration  of  the  anes- 
thetic, directly  or  indirectly,  as,  for,  example,  by  choking  from  the  entrance 


101)2  AN   AMKRICAy    TEXT- HOOK    OF  Si: HOE II  Y. 

nf  vomited  matter  into  the  trachea;  to  sliock  of  tlie  operution,  due  in  part  to 
hemorrhage  a-s  wi-ll  as  narcosis,  and  also  to  the  traiiinatisni  calling  for  the  ope- 
ration ;  to  entrance  of  air  into  the  veins;  to  sepsis  from  incomplete  or  im})erfect 
antiseptic  technique;  to  shock,  either  primary  or  secondary,  from  some  organic 
disease  of  one  of  the  vital  org-ans  of  the  body  ;  to  tetanus  ;  to  persistent  vomit- 
ing ;  to  delirium  tremens  ;  to  the  formation  of  emboli  or  thrombi ;  to  the  devel- 
opment of  some  intercurrent  disease,  as  jjncumonia,  peritonitis,  bronchitis,  or 
some  other  affection  which  may  be  indirectly  or  directly  attributed  to  the  opera- 
tion itself;  to  oedema  glottidis,  caused  by  an  intlammation  of  the  surrounding 
tissues  in  the  neck  ;  to  an  extension  of  an  inHa^nmation  from  one  organ  or  tissue 
to  another,  as  a  surgical  kidney  from  a  cystitis  the  result  of  an  operation  for 
removal  of  a  calculus;  to  perforation  of  the  bowel,  owing  to  a  slough  caused 
by  tearing  up  adhesions  during  a  l:ij)arotomy,  or  to  the  formation  of  a  slough 
produced  by  adhesive  inthimmation  between  the  intestine  and  bladder,  for 
example,  when  a  fistulous  communication  was  established ;  or  to  over-stimu- 
lation of  the  heart  in  an  attempt  to  bring  about  reaction  after  operation. 


CHAPTER  II. 

ANESTHESIA. 


Anesthetics  have  contributed  much  to  the  present  success  of  surgery. 
The  first  recorded  instance  of  a  surgical  operation  having  been  performed 
while  the  patient  was  under  the  influence  of  anesthesia  was  the  removal 
of  a  tumor  from  the  neck  by  Dr.  Crawford  W.  Long  of  Atliens,  Ga.,  in 
1842.  No  further  attotnpt,  however,  was  made  to  introtUice  an  anesthetic 
until  1844,  whcTi  Dr.  Horace  ^Yells,  a  dentist  of  Hartford,  Conn.,  first  inhaled 
nitrous-oxide  gas,  and  had  a  tooth  extracted  without  any  sensation.  With- 
out doubt,  the  merit  of  introducing  ether  as  an  anesthetic  belongs  to  Dr.  Mor- 
ton, who  in  1846,  at  the  suggestion  of  Dr.  Jackson,  a  chemist,  selected  this 
agent  for  the  purpose  of  extracting  teeth.  Dr.  John  C.  Warren,  the  senior 
surgeon  of  the  Massachusetts  General  Hospital  in  Boston,  was  applied  to  by 
Dr.  Morton  in  the  autumn  of  184(3,  who  informed  him  tluit  he  had  discovered 
a  means  of  preventing  pain  in  dental  operations,  angl  wished  to  have  an  oppor- 
tunity to  try  it  in  a  surgical  operation.  The  first  operafion  was  {x^'formed  by 
Dr.  Warren  at  the  hospital  on  October  IC,  1846,  and  consistoil  in  the  removal 
of  a  vascuhir  tumor  of  the  neck  from  a  young  man  in  the  public  operating 
room.  Dr.  Morton  administered  the  ether.  In  a  few  months  anesthesia, 
hitherto  a  dream,  had  become  a  reality  throughout  the  civilized  world.  In 
1847,  Prof.  James  Y.  Simpson  of  Edinburgh  first  introduced  chlorof(M*m  into 
surgical  practice. 

Anesthetics  act  by  p»oducing  a  p.aralysis  of  the  cerebral  and  spinal  nerve- 
centers.  There  is  first  a  stage  of  cerebral  excitement,  followed  by  a  stage  of 
cerebral  insensibility,  then  a  loss  of  voluntary  movement,  followed  by  a  loss 
of  reflex  aetion.  Consciousness  is  lost  before  the  paralysis  of  the  muscles 
supervenes,  and  a  patient  is  said  to  be  fully  anesthetized  when  the  nerve-cen- 
ters are  paralyzed,  with  the  exception  of  those  presiding  over  the  respiration 
and  circulation. 

Ether  is  chemically  the  oxide  of  eihyl,  with  the  formula (C2H5)20.    It  is  a 


A  NESTHESTA .  1 093 

hi<:lilv  volatile  and  clear  li(|ui(l.  with  a  piin^rent  odor,  a  sharp  taste,  and  a  spe- 
ciiic  i«;ravity  of  .Too  (at  ^)AJy°  F.),  and  boils  at  Ito^  F.  It  is  highly  inflanmiablo 
and  explosive.  This  fact  shouhl  always  bo  borne  in  mind,  because  during  an 
operation  a  lighted  candle  or  gas-jet  brought  near  the  ether  may  cause  a  serious 
explosion.  Ether  vapor,  being  heavier  than  air,  always  falls  ;  hence  if  a  light 
has  to  be  used,  it  should  be  held  above  the  ether  to  avoid  the  danger  of  such 
an  explosion.  If  an  explosion  occurs,  the  patient's  face  should  instantly  be 
covered  witii  a  towel  or  pillow  to  prevent  l)urning ;  the  inhaler  may  be  thrown 
U]ion  the  floor,  but  in'iu'i-  the  ether-can  or  bottle,  for  fear  of  the  spilling  of  the 
ether  and  its  catching  fire. 

Ether  is  prepared  by  the  action  of  sulphuric  acid  upon  strong  alcohol 
heated  to  a  temperature  of  260°  to  300°  F.  A  simple  test  as  to  the  purity 
of  ether  is  to  add  a  little  oil  of  copaiba  to  it,  when  the  mixture  should  remain 
clear:  if  an  emulsion  forms,  it  indicates  impurity  of  the  ether  from  the  pres- 
ence of  alcohol  or  water. 

There  are  some  contraindications  to  the  use  of  ether  as  an  anesthetic.  In 
cases  of  renal  disease  ether  is  generally  thought  to  be  less  safe  than  chloro- 
form, owing  to  the  danger  of  suppression  of  the  urine  and  shock,  although 
the  opposite  opinion  is  held  by  some  surgeons.  The  presence  of  nephritis 
certainly  calls  for  care  in  the  administration  of  either  ether  or  chloroform. 
The  minimum  (piantity  should  be  administered.  Chloroform  is  often  well 
borne  when  administered  with  pure  oxygen.  In  atheroma  of  the  vessels  it  is 
not  expedient  to  use  ether,  owing  to  the  vascular  excitement  incident  to  the 
primary  stage,  which  might  result  in  rupture  of  the  vessels  from  increased 
tension.  In  patients  suffering  from  emphysema,  asthma,  or  chronic  bron- 
chitis ether  is  unsuitable,  owing  to  its  irritation  of  the  pulmonary  and  bron- 
chial organs.  Ether  is  also  contraindicated  in  serious  and  prolonged  operations 
about  the  face  and  mouth  where  the  patient  cannot  be  kept  constantly  breath- 
ing the  vapor.  Ether  can  be  safely  employed  when  it  is  necessary  to  use  the 
actual  cautery  or  a  lighted  candle  near  the  face  of  the  patient  by  suspending 
its  administration  for  a  few  moments,  and  fanning  away  its  vapor  before 
using  the  cautery. 

Ether  is  best  administered  by  means  of  Allis's  inhaler.  The  latter  should 
be  placed  over  the  nose  and  mouth  dry,  and  the  ether  put  on  it  drop  by 
drop,  increasing  the  amount  gradually  as  the  mucous  membranes  become 
accustomed  to  the  vapor.  Cough,  spasm  of  the  larynx,  etc.  are  thus 
largely  avoided.  After  a  few  inhalations  the  patient  is  bewildered,  the  face 
flushed,  the  respiration  rapid,  and  the  pulse  at  first  slightly  accelerated  and 
somewhat  stimulated.  Then  follows  the  period  of  ''primary  anesthesia," 
which  continues  for  a  brief  time,  and  during  which  short  operations,  such  as 
opening  an  abscess,  dilating  the  sphincter,  etc.,  may  be  done  without  pain 
and  with  almost  instantaneous  recovery.  If  during  the  earlier  part  of  the 
administration  the  patient  is  repeatedly  directed  to  hold  his  arm  up,  its  fall  is 
a  good  indication  of  the  induction  of  this  stage.  Many  surgeons,  however, 
consider  this  a  dangerous  practice. 

A  period  of  excitement  soon  supervenes,  and  it  is  often  necessary  at  this 
period  to  restrain  the  patient.  After  the  stage  of  excitement  the  patient  passes 
into  a  state  of  muscular  relaxation ;  the  respirations  are  regular,  accompanied 
often  by  snoring,  and  attended  by  a  considerable  secretion  of  mucus  in  the 
mouth.  The  face  is  flushed  and  the  skin  soon  becomes  moist.  During  the 
period  of  muscular  rigidity  which  precedes  that  of  relaxation  the  breathing 
sometimes  ceases,  and  artificial  respiration  must  be  resorted  to  at  once. 

While  administering  ether  the  fact  must  always  be  borne  in  mind  that  its 


105M  AX   AMI-J^CAy    TKXT-naoK    OF   SiliiUim'. 

vafior  commonly  kills  by  asphyxia,  and  nut  by  syncope;  conseciuontly,  the 
j)uise  usually  keeps  up  lonji;  after  the  patient  has  ceased  to  breathe,  although 
in  rare  cases  the  i'ailure  of  the  heart  is  primary,  the  patient  dying  of  syncope. 
Hence,  though  the  pulse  is  to  be  watched,  the  resjiiratioii  should  be  the  jirin- 
cipal  object  of  solicitude.  'I'he  symptoms  of  asphyxia  come  on  gradually,  and 
thus  a  warning  is  given,  and  the  first  appearance  of  dangerous  symptoms  must 
be  met  with  prompt  and  suitable  remedies.  There  are  certain  patients  who 
take  ether  with  great  difficulty,  and  in  whom  its  administration  is  attended 
with  some  danger.  Patients  with  cardiac  obstruction  and  sluggish  circulation 
are  very  apt  to  take  ether  badly.  If  the  face  is  florid  or  there  is  much  capil- 
lary stasis,  the  administration  of  ether  is  attended  with  especial  difficulty. 

The  hypodermatic  injection  of  -^  of  a  grain  of  morphine  with  -j-^  of  a 
grain  of  sulphate  of  atropine  has  been  suggested  as  a  valuable  addition  in 
securing  the  anesthetic  state.  It  should  be  given  about  fifteen  minutes  before 
the  ether  is  administered. 

Chlokofoum  (formula  CIICI3)  is  a  clear  rK}ui<l.  with  a  specific  gravity  of 
1.407  at  G2.5°  F.,  with  a  sweetish  taste  and  an  ethereal  odor.  The  drug 
should  not  be  allowed  to  stand  exposed  to  the  light,  since  the  article  thus 
becomes  impure  by  decomposing  and  forming  hydrochloric  acid  and  chlorine. 

In  admiyiistering  chloroform  a  toAvel  may  be  placed  over  the  patient's  mouth 
and  be  kept  moistened  by  chloroform  drop  by  drop,  or  about  a  half  teaspoonful 
should  be  poured  upon  a  napkin  and  held  about  an  inch  from  the  face,  but  never 
allowed  to  touch  it,  on  account  of  its  irritant  action  on  the  skin.  The  patient 
should  be  instructed  to  close  the  eyes,  since  the  vapor  may  inflame  the  con- 
junctivae. A  little  vaseline  may  be  smeared  over  the  face  to  prevent  erythema 
of  the  skin.  After  the  patient  has  inhaled  the  chloroform  a  few  minutes,  con- 
sciousness is  lost,  the  conjunctivae  become  insensitive,  and  the  breathing  assumes 
a  stertorous  character.  During  the  inhalation  the  na])kin  must  be  ke|)t  at  least 
one  inch  from  the  patient's  face,  not  only  because  if  held  nearer  than  this  the 
vapor  might  act  as  a  vesicant,  but  also  and  especially  because  experiment  has 
shown  that  the  vapor  is  inhaled  under  the  condition  just  stated  in  the  strength 
of  about  5  per  cent,  admixture  with  the  air,  which  is  a  proper  proportion.  The 
vapor  must  not  be  given  too  suddenly  nor  continued  too  long  without  alloAving 
fresh  air  to  be  inspired.  The  patient  should  be  always  placed  in  the  recumbent 
posture,  and  never  allowed  under  any  circumstances  to  sit  up  erect.  Before 
the  patient  is  fully  anesthetized  convulsive  movements  often  take  place  and 
the  face  becomes  cyanosed.  It  is  best  in  such  case  not  to  struggle  with  the 
patient,  but  to  discontinue  the  inhalation  until  the  cyanosis  has  disappeared, 
when  the  napkin  can  be  replaced  over  the  face.  Occasionally,  without  con- 
vulsive movements  or  lividity  of  the  face,  the  patient  passes  ((uickly  into  an 
unconscious  state.  The  pupils  should  be  closely  watched  to  ascertain  if  they 
respond  to  light  or  if  they  are  dilated.  Failure  of  the  pupils  to  respond  to 
light,  or  their  wide  dilatation,  is  a  sign  of  approaching  danger,  and  the  inha- 
lation should  be  at  once  discontinued,  the  head  lowered,  the  tongue  drawn 
well  out  of  the  mouth,  the  heart  stimulated,  and  artificial  respiration  begun. 
The  loud  stertor  indicating  the  closure  of  the  larynx  by  the  epiglottis  is  a  sign 
of  danger,  and  must  not  be  mistaken  for  snoring,  in  which  a  patient  often  in- 
dulges while  profoundly  under  the  influence  of  an  anesthetic. 

In  beginning  anew  to  place  the  chloroform  over  the  face  of  a  patient  upon 
whom  its  use  has  been  discontinued  on  account  of  some  serious  signs,  the  vapor 
should  be  carefully  and  slowly  given,  otherwise  fatal  syncope  may  follow  in  a 
heart  already  aff'ected  by  a  previous  overdose.  During  the  entire  period  of 
taking  chloroform  the  finger  should  be  kept  over  the  temporal  artery,  to  detect 


ANESTHESIA .  1 095 

immediately  the  slightest  change  in  its'  character  or  volume.  Every  respira- 
tion should  be  watched.  It  is  not  enough  to  watch  the  movements  of  the  chest, 
because  the  glottis  may  be  closed  and  the  chest-wall  move,  and  yet  but  little 
air  enter  the  lungs.  Tlie  hand  may  be  placed  over  the  mouth  and  the  current 
of  air  recognized.  In  case  the  glottis  is  closed  and  the  vapor  has  filled  the 
pharynx,  the  patient  becomes  asphyxiated,  and  as  soon  as  the  glottis  is  open  a 
condensed  volume  of  vapor  instead  of  fresh  air  is  drawn  into  the  lungs.  If  the 
patient  is  suffering  from  a  weak  and  feeble  heart,  this  sudden  overdose  may  cause 
a  fatal  termination.  A  patient  may  die  either  on  account  of  asphyxia  or  from 
heart-failure.  The  asphyxia  may  be  due  to  the  presence  of  a  foreign  body  in 
the  larynx  from  vomited  material,  or  to  a  too  condensed  form  of  vapor  which 
the  patient  has  been  allowed  to  inhale.  Heart-failure  is  a  frequent  cause  of 
death  during  the  administration  of  chloroform.  The  face  becomes  pale,  the 
finger-nails  turn  blue,  the  pupils  become  dilated,  the  pulse  flickers,  and  the 
heart's  action  is  arrested.  As  a  rule,  this  accident  occurs  only  in  a  heart  which 
has  undercrone  fattv  deereneration  or  in  which  mitral  or  aortic  valvular  lesions 
exist.  The  respiration  often  keeps  up  even  after  the  heart  ceases  to  beat.  Ilence 
in  giving  chloroform  the  great  importance  of  watching  especially  the  pulse  in 
addition  to  the  breathing.  Death  may  occur  from  syncope  during  the  first  few 
inhalations,  or  it  may  occur  at  the  end  of  the  period  of  anesthesia,  but  under 
these  circumstances  some  warning  of  impending  danger  is  given  by  the  gradual 
onset  of  the  symptoms. 

Of  course  in  giving  any  anesthetic  it  is  highly  important  that  the  lungs  as 
well  as  the  heart  and  the  kidneys  should  be  sound.  The  anesthetic  is  probably 
never  eliminated  entirely  by  the  lungs,  but  only  with  the  aid  of  the  excretory 
organs  crenerallv.  If  the  lungs  have  a  smaller  area  than  usual  on  account  of 
disease,  just  so  much  more  strain  is  thrown  on  the  kidneys,  and  if,  in  addi- 
tion, the  latter  are  contracted  or  fatty,  the  danger  is  greatly  increased,  espe- 
cially if  ether  is  used.  Chloroform  usually  kills  by  its  depressing  action  on 
the  heart,  and  it  seems  highly  probable  that  it  often  does  this  by  the  prop- 
erty which  it  has  been  shown  to  have,  of  destroying  the  contractile  power 
of  the  cardiac  muscle  when  it  reaches  it  in  a  sufficiently  concentrated  form. 
Various  circumstances  mav  greatly  affect  the  degree  of  its  concentration  in 
the  luTigs  and  the  circulation,  and  thus  increase  or  decrease  the  danger  of  its 
employment.  Of  these  the  most  important  are  those  connected  with  the  cha- 
racter of  the  respiration  of  the  patient  and  the  circulation  through  the  lungs- 
For  example,  a  given  quantity  of  chloroform,  say  one  dram,  will  exert  its 
greatest  effect  when  the  respiration  is  deep  and  quick,  because  the  vapor 
is  then  carried,  in  a  given  period  of  time,  in  larger  quantity  into  the  air- 
spaces of  the  lungs.  If,  at  the  same  time,  the  patient,  being  only  partially 
anesthetized,  stops  suddenly  after  breathing  deeply — i.  e.  closes  his  glottis  and 
strains — he  increases  the  rapidity  of  absorption  of  the  chloroform  vapor  into 
the  blood ;  or  if  the  movement  of  blood  through  the  lungs  is  exceptionally 
slow,  as  shown  by  a  dusky  or  congested  appearance  of  the  face,  the  opportunity 
for  absorption  will  likewise  be  greater,  and  the  blood  will  reach  the  heart  over- 
charged with  chloroform,  and  possibly  produce  its  poisonou^  effect. 

A  combination  of  these  conditions,  therefore,  should  put  the  anesthetizer, 
especially  one  who  employs  chloroform,  on  his  guard.  During  the  preliminary 
stages  of  chloroformization  at  least  it  may  be  said  that  a  patient  who  is  suffering 
from  shock  after  injury  or  accident,  who  is  only  partially  anesthetized,  whose 
face  is  dusky  or  congested,  and  who  is  struggling  against  the  anesthetic,  is  in 
the  greatest  danger.  Manv  deaths  have  occurred  from  chloroform  under  these 
circumstances  and  in  this  first  stage,  or  so-called  "stage  of  excitement." 


101»6  .1-V   A. V /:/.'/(  AX    TKXT-B(J()k'    OF   SlRdKIiY. 

The  secofiJ  stage  is  the  period  of  true  anesthesia,  during  which  conscious- 
ness and  sensibility  are  abolished,  the  muscles  partly  relaxed,  the  pulse  weak, 
the  breathinj:  often  shallow  and  feeble:  it  is  during  this  stage  that  operations 
should  be  performed,  and  great  care  observed  to  limit  the  quantity  of  chloro- 
form used  to  the  least  amount  necessary  to  continue  the  condition  without 
causing  it  to  pass  into  the  third  stage,  or  that  of  dangerous  narcosis,  in  which 
there  are  increasing  weakness  of  the  pulse,  stertorous  breathing,  complete  abo- 
lition of  the  reflexes,  and  other  indications  of  ]trofound  involvement  of  the  nerve- 
centers.  This  is  still  more  dangerous  than  either  of  the  other  stages.  There 
may  be  no  premonitory  symptoms  of  danger,  or  it  may  be  indicated  by  either 
great  paleness  or  congestion  of  the  face  or  by  marked  irregularity  and  failure 
of  the  pulse. 

It  seems  probable  that  the  position  of  the  patient  during  the  administration 
of  chloroform  has  something  to  do  in  increasing  or  diminishing  the  risks  of 
respiratory  or  cardiac  failure.  It  is  said  that  during  gynecological  and  obstetric 
operations,  in  which  the  patients  are  kept  lying  on  the  left  side,  the  pulse  and 
respiration  have  been  more  satisfactory  during  anesthesia  from  chloroform  than 
when  the  patients  have  taken  it  in  the  dorsal  position.  It  may  be  that  the  view 
which  attributes  special  safety  to  the  drug  in  obstetrical  cases  took  its  origin  in 
the  fact  that  the  customaiy  obstetrical  position  in  England  and  in  this  country 
is  upon  the  left  side.  Buxton  thinks  that  the  influence  of  position  is  unques- 
tionably important,  and  is  due  to  the  fact  that  the  condition  of  the  heart,  lungs, 
tongue,  and  larynx  is  more  nearly  correct  physically  and  physiologically  when 
a  patient  is  placed  in  the  left  lateral  position  instead  of  on  the  back.  In  hip 
opinion,  the  difference  in  the  condition  of  the  pulse  and  respiration  of  patients 
chlorofonned  in  the  dorsal  and  lateral  positions  has  been  so  striking  as  grad- 
ually to  force  on  one  the  lesson  of  placing  every  patient,  where  it  is  possible, 
on  the  left  side  while  chloroforming  him. 

Poisoning  from  Ether  and  Chloroform. — In  his  address  before  the 
Berlin  Congress  of  1800.  Dr.  II.  C.  Wood  calle<l  attention  to  the  value  of  forced 
artificial  respiration,  and  to  its  superiority  to  the  ordinary  plans  as  practised 
upon  the  human  being.  He  stated  that  he  had  repeatedly  taken  dogs  in  which 
both  respiratory  and  heart  movements  had  been  absolutely  arrested  by  chloro- 
form or  by  ether,  and  had  restored  them  to  life  by  pumping  air  in  and  out  of 
the  lungs.  He  further  called  attention  to  the  fact  that  Dr.  Fell  of  Buffalo  had 
demonstrated  the  extraordinary  efficacy  in  man  of  forced  artificial  respiration 
in  severe  morphine-poisoning,  so  that  the  methods  of  the  physiological  labora- 
tory must  be  considered  as  applicable  to  human  beings.  Dr.  Fell  s  a]iparatus 
consists  of  a  pair  of  foot-bellows,  by  which  air  is  forced  into  a  receiving  cham- 
ber, which  is  connected  with  an  apparatus  for  warming  the  air.  and  a  valve 
■which  can  be  opened  and  shut  by  a  movement  of  the  finger.  This  valve,  in 
turn,  leads  to  a  trachea-tube  which  is  inserted  into  the  trachea  of  the  narco- 
tized subject.  When  the  valve  is  opened,  the  air  rushes  through  the  chamber 
into  the  lungs  and  expands  them  ;  the  finger  is  lifted,  the  valve  shuts,  the 
lungs  contract,  and  so  the  respiration  goes  on.  Experiments  upon  the  dead 
body  convinced  Dr.'  Wood  that  the  trachea-tube  is  not  necessary,  and  that  a 
closely-fitting  face-mask,  such  as  is  employed  for  the  inhalation  of  nitrous 
oxide,  will  suffice  in  most  if  not  all  cases,  and  that  an  intubation-tube  makes 
a  good  substitute  for  the  trachea-tube.  All  the  apparatus  that  Dr.  Wood 
believes  necessary  is  a  pair  of  bellows  of  proper  size,  a  few  feet  of  India- 
rubber  tubing,  a  face-mask,  and  two  sizes  of  intubation-tul>es  (in  case  the  face- 
mask  should  not  suffice) ;  there  should  also  be  set  in  the  India-rubber  tubing 
a  metal  tube  with  an  opening  similar  to  that  commonly  found  in  the  tracheal 


A  NESTHESIA .  1097 

canula  of  the  physiological  laboratory,  so  that  the  operator  can  allow  the  escape 
of  anv  excess  of  air  thrown  hv  tlie  bellows. 

In  using  this  apparatus  the  mask  should  ]>e  first  tried  care  being  exercised 
to  see  that1)y  a  thread  passed  through  it  the  tongue  is  well  drawn  forward  and 
held  in  place,  so  that  the  epiglottis  is  kept  up.  If  the  lungs  do  not  fully 
expand,  the  intubation-tube  may  be  employed.  The  lungs  should  be  thor- 
ouc^hlv  but  slowlv  expanded  bv  each  stroke  of  the  bellows,  and  a  respiratory 
rat'e  of  about  si.xteen  to  twentv  a  minute  be  steadily  maintained.  It  is  essen- 
tial to  free  the  lungs  and  bloo<l  as  rapidly  as  possible  of  chloroform  by  quickly 
chaiK^ing  the  residual  air  of  the  lungs :  but  of  course  due  care  must  be  exer- 
cised^'that  no  force  sufficient  to  rupture  the  air-vesicles  l)e  employed.  A\  hen 
the  symptoms  are  protracted  and  the  body  temperature  fails,  external  warmth 
must  be  used,  and  the  temperature  of  the  room,  unless  the  air  entering  the 
lun<TS  be  artificially  heated,  should  not  be  less  than  85°  F. 

Nitrous-Oxide  Gas  (formula  NjO)  consists  of  nitrogen  and  oxygen  in  chem- 
ical union.  The  gas  is  made  from  nitrate  of  ammonium,  which  is  heated  in  a 
glass  retort  until  at  226°  F.  the  salt  melts,  and  at  460°  F.  it  gives  off  the  gas. 
This  gas  is  stored  for  use  in  gasometers  or  in  steel  cylinder  in  whicli  it  has 
been  liquefied  by  pressure.  This  is  the  best  form  for  surgical  use.  On  turn- 
in<T  a  key  the  gas  escapes  into  a  rubber  bag  (Avhich  comes  with  the  apparatus), 
in°which  it  is  instantly  vaporized  and  from  which  it  is  inhaled.  When  the  gas 
is  administered  it  enters  the  blood  bv  diffusion  through  the  thin  walls  of  the 
air-cells  in  the  lungs.  The  physiological  eff"ects  are  diminution  m  the  number 
of  the  respirations!  and  the  breathing  also  becomes  shallow.  If  the  gas  is 
pushed  to  a  dangerous  dose,  the  eff"ect  is  entire  cessation  of  respiration,  ihe 
heart,  however,  pulsates  until  some  time  after  breathing  has  ceased.  It  is 
therefore  of  the  greatest  importance  to  watch  carefully  the  respirations  when 
this  anesthetic  is  administered.  i -i      v 

The  duration  of  unconsciousness  is  about  one  minute  :  hence,  while  this  gas 
is  the  safest  of  all  anesthetics,  its  great  drawback  is  the  short  interval  of  time 
durin-T  which  anesthesia  continues.  Nitrous  oxide  can  be  administered,  how- 
ever bv  one  accustomed  to  giving  it  so  that  an  operation  occupying  consider- 
able' time  can  be  performed.  In  over  400.000  recorded  administrations  of 
the  aas  by  Dr.  J.  D.  Thomas  of  Philadelphia  and  the  Colton  Dental  Asso- 
ciation in  New  York,  only  one  death  has  occurred,  and  it  is  not  positively 
certain  that  this  death  was  due  to  the  gas. 

In  adminhterinq  the  gas  a  cork  or  a  piece  of  wood  with  a  long  safety-string 
attached  to  it  is  placed  between  the  molar  teeth.  The  mouth-piece  is  then 
inserted,  the  nostrils  are  closed  bv  the  thumb  and  finger,  and  the  pa- 
tient be<-ins  to  inhale  the  gas.  No  mask  should  be  used,  as  this  prevents  the 
adminisfrator  from  observing  the  color  of  the  face  and  lips.  NNhen 
the  lun^rs  are  filled  there  is  a  slight  cyanosis  visible  about  the  tace 
and  earl  and  the  tips  of  the  fingers.  In  a  few  seconds  later  the 
patient  be^rins  to  lose  consciousness.  During  this  time  the  room 
should  be  l<?pt  quiet,  and  no  loud  talking  indulged  in,  as  this  is  apt  to  dis- 
turb the  patient  and  bring  him  back  to  consciousness.  ^^  ithm  one  minute  from 
the  inhalation  the  pupils  dilate,  the  face  loses  all  its  expression,  and  strabismus 
is  observed.  In  a  very  short  time  deep  anesthesia  supervenes,  accompanied  by 
stertorous  breathing  and  muscular  twitchings :  the  conjunctiva  become  insensi- 
tive to  touch,  and  the  eveball  itself  oscillates.  The  respirations  soon  become 
slower  and  shallow.  The  pulse  at  this  stage  should  be  watched,  and  if  there 
is  any  change  the  inhalation  of  the  gas  should  be  immediately  discontinued. 
The  stertor  and  cyanosis  are  the  signs  indicating  that  the  patient  is  anesthe- 


1098  .I.V   AMKincAX    TEXT- HOOK    OF  SURGERY. 

tize<l.  The  cessation  of  stertor,  the  disappearance  of  the  cyanosis,  and  the 
absence  of  convulsive  movements  indicate  the  return  to  consciousness,  ■svhicli  is 
sometimes  usliered  in  by  a  shriek  or  cry.  Durinj:  the  stage  of  anestliesia  pro- 
duceil  by  nitrons-oxide  gas  there  are  no  emerirencies  which  are  ])eculiar  to  tliis 
anestlietic,  and  none  which  are  not  fully  covered  by  the  rules  laid  down  for  the 
manatrement  of  accidents  during  the  administration  of  any  anesthetic. 

Rules  for  Giving  Ether  and  Chloroform. — The  patient  should  not 
eat  any  solid  food  fur  eight  Imurs  before  taking  an  anesthetic,  nor  any  fluid  food 
less  than  two  hours  before  the  operation.  lie  may  take  some  brandy  and 
cracked  ice  ten  minntes  before  inhaling  the  anesthetic. 

The  anesthetizer  should  always  listen  to  the  patient's  heart,  and  at  the  same 
time  assure  the  patient  that  this  act  is  a  part  of  the  routine  treatment  in  giving 
an  anesthetic.  If  he  is  adroit,  he  can  turn  this  to  good  advantage  by  assuring 
the  patient  that  his  heart  is  free  from  any  disease. 

The  patient  should  always  assume  the  recumbent  position,  which  facilitates 
the  circulation  between  the  heart  and  the  brain.  Syncope  is  more  likely  to 
occur  when  the  patient  is  in  the  sitting  posture. 

All  articles  of  dress  should  be  loosened,  so  as  to  have  nothing  to  impede  or 
constrict  the  respiration  and  the  circulation,  especially  about  the  neck  and 
abdomen. 

The  urine  should  always  be  examined,  especially  before  ether  is  given. 

In  giving  chloroform  apply  vaseline  over  the  face  to  prevent  irritation  and 
excoriation  of  the  skin  by  the  vapor.  The  ej^es  must  be  closed,  so  that  a  con- 
junctivitis will  not  be  produced. 

False  teeth  must  be  removed,  and  tobacco  or  any  other  foreign  body  in 
the  mouth  taken  out,  lest  it  might  foil  back  into  the  pharynx  or  larynx. 

In  applying  the  towel  or  inhaler  to  the  mouth  allow  at  first  a  free  admix- 
ture of  air  Avith  the  vapor.  Assure  the  patient  that,  though  the  first  few 
inhalations  are  disagreeable,   they  are  free  from  danger. 

Instruct  him  to  take  a  fcAv  full,  deep  inspirations  in  quick  succession  and 
count  out  loud  up  to  fifty. 

Watch  the  number  and  character  of  the  respirations,  and  also  feel  every 
pulsation  of  the  temporal  artery  from  the  beginning  to  the  end.  Clear  the 
mouth  and  throat  from  mucus  whenever  it  seems  to  impede  the  free  entrance 
of  air  into  the  larynx.  If  mucus  accumulates  to  any  serious  extent  in  the 
bronchial  tubes,  inversion  of  the  patient  will  get  rid  of  it. 

When  the  eyelids  can  be  raised  without  resistance  and  the  cornea  is  insen- 
sitive, the  patient  is  usually  fully  anesthetized.  Do  not  begin  an  operation 
until  the  patient  is  entirely  under  the  influence  of  the  anesthetic,  as  it  is  dan- 
gerous to  operate  during  partial  anesthesia. 

If  vomiting  occurs,  turn  the  patient's  head  well  to  one  side,  open  the  mouth 
widely,  and  clear  the  throat  and  pharynx. 

Under  no  circumstances  should  an  anesthetic  be  given  unless  the  adminis- 
trator has  tongue  forceps,  a  mouth-gag,  the  necessary  cardiac  stimulants,  and  a 
hypodermatic  syringe  at  hand.  Tracheotomy  instruments,  the  battery,  and 
an  apparatus  for  forced  artificial  respiration  should  always  be  within  reach  in 
a  hospital. 

3Iortality. — It  is  not  surprising  that  any  drug  which  is  capable  of  depriv- 
ing a  patient  of  consciousness  and  of  rendering  him  insensible  to  pain  is  not 
entirely  devoid  of  danger.  Death  from  an  anesthetic  can  often  be  traced  to 
some  carelessness.  When  carefully  watched  and  administered  properly  there 
is,  as  a  rule,  but  little  danger.  Sometimes,  however,  even  with  the  best  of 
care,  sudden  death  will  occur. 


ANESTHESIA.  1099 

Gurlt's  statistics  of  1897  cover  over  330,000  cases.  These  show  one 
death  in  every  207;')  eases  from  chloroform  ;  one  in  every  5112  from  ether; 
one  in  every  7()lo  from  (•hh)r()lorm  and  i-tlier  to;^etiier  ;  one  in  every  3370 
from  tlie  mixture  of  ak-ohol,  cidoroform,  ami  ether;  and  one  in  every  5396 
from  etiiyl  bronnde.  Some  deaths  have  resulted  from  the  cases  having  need- 
lessly been  anesthetized  in  the  sitting  posture,  often  by  incompetent  persons, 
and  without  the  proper  means  at  hand  to  meet  the  sudden  emergencies  that 
may  arise.  More  and  more  is  it  coming  to  be  recognized  that  no  anesthetic 
should  bo  administered,  unless  in  an  emergency,  by  anyone  but  a  |)ractised 
and  skilful  anesthetist,  and  no  operation  of  imj>ortance  be  done  except  in  a 
hospital  which  attbrds  plenty  of  assistants  and  is  suj)plied  with  everything 
needful  for  every  possible  complication  and  danger.  Every  surgeon  should 
observe  the  above  rules,  and  should  inform  himself  in  detail  in  regard  to 
every  patient  before  an  anesthetic  is  administered. 

ACCIDENTS  OCCURRING  DURING    THE  ADMINISTRATION   OF  AN  ANESTHETIC. 

Death  may  occur  suddenly  from  paralysis  of  the  heart.  This  accident  is 
likely  to  happen  when  the  vapor  is  administered  in  too  concentrated  a  form  to 
a  patient  suftering  from  a  fatty  or  enlarged  heart.  The  respirations  continue 
after  the  heart  has  ceased  to  beat.  In  sudden  syncope  produced  by  an  over- 
dose of  the  anesthetic  the  patient's  head  should  be  immediately  lowered  almost 
to  the  floor. 

Death  may  occur  by  asphyxia  due  to  a  falling  back  of  the  tongue  over  the 
epiglottis.  The  tongue  in  this  case  should  be  forcibly  drawn  well  out  of  the 
mouth.  Death  may  also  occur  by  a  tetanic  fixation  or  by  relaxation  of  the  res- 
piratory muscles.  In  the  two  latter  conditions  the  heart  pulsates  while  the  res- 
pirations have  ceased.  Artificial  respiration  should  be  kept  up,  and  nitrite  of 
amyl  administered  by  inhalation  in  three-drop  doses. 

Death,  again,  may  occur  from  coma  on  account  of  a  violent  congestion  of 
the  brain.  This  accident  is  more  likely  to  arise  in  patients  addicted  to  the 
alcoholic  habit  or  in  cases  of  renal  disease  or  in  epileptics. 

Death  may  also  be  caused  by  entrance  of  vomited  material  into  the  larynx 
and  trachea. 

Finally,  death  may  occur  from  a  combination  of  the  causes  already  men- 
tioned, associated  with  traumatic  or  surgical  shock.  In  exceedingly  nervous 
patients  tympanites  of  the  stomach  often  irritates  the  pneumogastric  nerve  and 
enfeebles  the  heart's  action.  Removal  of  the  gas  in  the  stomach  is  to  be 
secured  if  possible,  in  order  to  avoid  danger. 

When  any  of  these  conditions — which  are  likely  to  occur  during  anesthesia 
from  chloroform,  but  may  also  be  produced  by  ether  and  other  anesthetic 
agents — are  threatened,  the  duty  of  the  anesthetizer  should  be  the  same  in 
every  case.     He  should  promptly  take  the  following  precautions : 

1.  Remove  the  anesthetic,  and  secure  a  plentiful  supply  of  fresh  air  about 
the  head  and  face  of  the  patient. 

2.  Place  the  fingers  back  of  the  angles  of  the  inferior  maxilla  and  press  it 
strongly  forward,  thus  carrying  with  it  the  tongue. 

3.  Seize  the  tongue  with  forceps  and  draw  it  forward. 

4.  Lower  the  head  of  the  patient,  and,  if  the  case  is  grave,  raise  the  lower 
limbs,  pelvis,  and  trunk  higher  than  the  head  and  shoulders. 

5.  Use  forced  artificial  respiration,  or,  if  the  apparatus  for  this  is  not  at 
hand,  then  begin  the  movements  of  artificial  respiration,  catching  the  arms  at 
the  elbows  and  carrying  them  outward  and  upward  until  they  almost  meet  in  a 


1100  A.y   AMKIUCAX    TKXr-lif)<>K    OF  SURGERY. 

line  alx)ve  the  head,  then  bringing  them  down  again  until  they  touch  the  ante- 
rior surface  of  the  chest:  at  each  movement  moderate  pressure  should  be  made 
upon  the  lower  portion  of  the  chest.  These  motions  should  be  repeated  not 
oftener  tlum  sixteen  or  eighteen  times  per  minute. 

^').  Dax'iJi  alternately  hot  and  cold  water  or  ether  on  the  front  of  the  chest 
and  ab«lomen. 

7.  Give  hypodermatic  injections  of  strychnine,  tincture  of  digitalis,  or  nitro- 
glycerin. 

8.  Rub  the  extremities  strongly  toward  the  heart. 

9.  Compress  the  abdominal  aorta. 

The  last  two  methods  are  intended  to  keep  the  blood  in  the  region  of  the 
heart  and  great  nerve-centers,  where,  at  least  during  the  period  of  shock,  its 
presence  is  vitally  imjxjrtant. 

10.  Faradize  the  diaphragm  through  the  phrenic  nerve,  placing  one  pole 
on  the  pit  of  the  stomach  and  the  other  over  the  base  of  the  neck  at  the 
external  border  of  the  stemo-mastoid  muscle. 

11.  Small  lumps  of  ice,  or  "ice  suppositories,"  inserted  into  the  rectum, 
will  sometimes  by  reflex  action  bring  about  deep  breathing,  as  Avill  also  forci- 
ble dilatation  of  the  sphincter  ani. 

12.  As  soon  as  the  power  of  swallowing  returns,  use  diffusible  cardiac 
stimulants — alcohol  and  ammonia,  etc. 

Choice  of  an  Anesthetic. — The  general  conclusions  may  be  formulated 
as  follow- : 

1.  As  a  rule,  ether,  as  the  safest  of  the  more  powerful  anesthetics,  is  to  be 
preferred ;  the  lessene<l  risk  to  life  more  than  counterbalances  its  minor  dis- 
advantages. 

2.  Chloroform  may  be  employed  when  ether  has  failed  or  cannot  be  pro- 
cured, or  when  there  is  a  distinct  record  of  serious  trouble  during  a  previous 
etherization.  It  is  jx>ssibly  safer  in  children  than  in  adults,  and  it  is  said  to 
be  exceptionally  adapted  for  administration  in  obstetrical  cases.  It  has  some 
distinct  advantages  over  ether  in  cases  of  stenosis  of  the  larynx  or  trachea, 
and  may  be  considered  in  those  cases  of  emergency  in  which  an  operation  has 
to  be  performed  a  short  time  after  a  solid  meal.  As  secondary-  indications  for 
its  employment  the  following  may  be  mentioned :  (a)  protracted  operations 
about  the  mouth,  jaws.  nose,  or  pharynx  which  necessitate  the  mouth  and 
nose  being  uncovered ;  {h)  operations  calling  for  the  employment  of  the  actual 
cautery  in  the  vicinity  of  the  mouth,  though  ether  may  be  used  as  above 
directed ;  (c)  severe  bronchitis,  emphysema,  or  asthma ;  {d)  extensive  renal 
disease :  {e)  marked  atheroma. 

3.  Nitrous  oxide  should  be  employed  in  operations  which  can  be  completed 
in  from  two  to  five  minutes. 

4.  Methylene,  methylene  ether,  and  the  various  anesthetic  mixtures,  such 
as  the  A.  C.  E.  mixture  (yilcohol  one  part,  Cliloroform  two  parts,  and  -Fther 
three  parts)  are  not  so  safe  as  ether  alone,  and  have  no  decided  advantages  to 
compensate  for  the  increased  risk. 

Local  Anesthesia. — It  often  is  necessary  to  perfonn  certain  minor  ope- 
rations where  it  is  undesirable  to  administer  a  general  anesthetic.  The  open- 
ing of  a  felon  or  an  abscess,  paracentesis  thoracis,  the  removal  of  a  toe-nail  or 
a  Avart,  the  extraction  of  a  splinter,  are  some  of  the  minor  operations  where 
local  anesthesia  is  most  valuable. 

There  are  several  ways  to  produce  local  anesthesia.  One  of  the  simplest 
is  to  place  over  the  part  to  be  incised  a  small  muslin  bag  containing  some  ice 
pounded  very  fine,  with  salt,  which  must  be  kept  in  contact  with  the  skin  for 


A  NESTHESIA .  1101 

two  or  three  ininiites  or  until  tlie  skin  is  l)lanclic(l.  Another  way  is  by  spray- 
inf;  j»ure  etlier  or  rhi^folene  over  the  part  by  a  hand-atouiizer.  Recentlv  the 
sprays  of  ehhiride  (»f"  etliyl  and  anestile  have  been  employed  to  advantage. 
They  are  sold  in  small  iilass  tubes  provided  with  means  to  deliver  a  fine  jet 
of  the  volatile  Hiiid,  whieh  quickly  chills  or  even  freezes  the  surface  with 
which  it  comes  in  contact.  In  certain  tissues,  among  which  may  be  men- 
tioned the  scrotum,  a  slough  may  result  from  local  anesthesia;  judgment, 
therefore,  must  be  exercised  in  its  employment. 

FAhyl  CJiloride  is  a  local  anesthetic  Avhich  possesses  superior  advan- 
tages. It  is  made  by  the  action  of  either  hydrochloric  acid  or  phosphorous 
chloride  upon  alcohol.  The  great  volatility  has  been  overcome  by  the  use  of 
glass  bulbs  upon  one  end  of  which  is  a  capillary  orifice  to  which  is  attached  a 
copper  screw  thread  for  the  cap.  The  bulbs  contain  enough  of  the  ethyl 
chloride  to  produce  anesthesia  in  at  least  a  dozen  cases.  The  action  is  very 
rapid,  and  it  is  said  to  produce  no  local  injury  or  any  constitutional  danger. 
For  such  minor  operations  as  opening  abscesses  or  carbuncles,  removal  of 
splinters,  extraction  of  teeth,  removal  of  small  subcutaneous  tumors  and 
ingrowing  toe-nails,  this  local  anesthetic  is  of  great  value.  The  thermo- 
cautery can  be  applied  to  a  surface  upon  which  this  local  anesthetic  is  applied, 
provided  only  the  cautery  iron  does  not  approach  the  jet  of  spray  and  a  suffi- 
cient time  has  elapsed  to  permit  of  evaporation,  Avhich  requires  but  a  few 
seconds.  A  little  vaseline  smeared  over  the  surface  of  the  skin  which  is  to  be 
anesthetized  will  prevent  the  transient  redness.  In  order  to  produce  local 
anesthesia  the  bulb  should  be  held  in  the  palm  of  the  surgeon's  hand,  and 
then  the  cap  unscrewed  and  the  jet  of  spray  directed  to  the  spot,  with  the 
nozzle  about  six  inches  from  the  s.kin.  The  integument  almost  instantly 
becomes  red,  which  is  at  once  followed  by  a  white  color,  which  is  indicative  of 
insensibility.  The  effect  continues  about  two  minutes.  The  action  of  the 
drug  can  be  hastened  by  blowing  on  the  skin  upon  which  the  jet  falls. 

In  dentistry  a  special  bulb  is  prepared,  and  this  jet  is  directed  to  the  gum, 
which  has  been  previously  dried  and  over  which  some  vaseline  has  been 
smeared.  The  rest  of  the  gum  and  the  teeth  should  be  protected  by  a  piece 
of  linen. 

The  Hydroclilorate  of  Cocaine,  as  suggested  by  Dr.  Koller,  is  another  means 
of  producing  insensibility  to  pain.  It  can  be  best  employed  in  parts  where  the 
circulation  can  be  confined  within  a  limited  area.  In  incision  of  a  felon,  for 
example,  a  stout  ligature  should  be  placed  around  the  finger,  the  cocaine  in- 
jected into  the  skin,  and  the  drug  allowed  to  remain  in  the  finger,  the  blood 
of  Avhich  is  thus  cut  off  from  the  general  circulation  by  the  ligature.  The 
use  of  the  ether  spray  as  a  preliminary  measure  to  the  hypodermatic  injection 
will  make  the  operation  absolutely  painless.  In  operations  upon  mucous  sur- 
faces the  cocaine  is  found  to  possess  remarkable  anesthetic  properties.  The 
solution  need  only  be  applied  to  the  mucous  membrane  by  a  small  swab  of  cot- 
ton. Insensibility  follows  in  about  three  to  five  minutes,  and  continues  for 
from  fifteen  to  twenty  minutes.  Operations  of  considerable  magnitude  have 
soMetimes  been  done  under  cocaine,  using  it  first  by  hypodermatic  injection, 
and  then  dropping  it  in  the  wound  from  time  to  time. 

The  drug  must  be  used  Avith  caution,  especially  about  the  head,  as  not  a 
few  alarming  cases  of  syncope,  delirium,  and  paralysis  or  tetanic  fixation  of 
the  respiratory  muscles  have  been  observed.  In  those  mild  cases  of  cocaine- 
poisoning  which  are  characterized  merely  by  pallor,  tremor,  restlessness,  and 
weak  pulse,  stimulants  and  recumbency  are  all  that  will  be  required.  In 
severe  cases  death  may  occur  in  two  modes — by  paralysis  of  the  respiratory 


1102         j.v  A^ff:^/(■A^'  tkxt-hook  nr  scnai-jn'. 

center  and  bv  tetanic  fixation  of  the  respiratory  muscles  (Mosso).  In  those 
which  manifest  respiratory  failure  the  hypodermatic  use  of  strychnia  is  atten<led 
with  the  hest  results.  In  those  ca.«es  in  which  tetanic  fixation  of  the  chest- 
muscles  occurs  (as  a  part  usually  of  ireneral  convulsions)  chloral  by  enema  is 
of  great  value.  In  convulsive  cases  inhalations  of  amyl  nitrite  or  hypoder- 
matics of  nitro-glycerin  are  to  be  employed.  When  delirium  is  violent,  if  tiie 
heart  be  not  verv  weak,  chloral  can  be  useil.  or  hyo.scine  in  small  doses  hypo- 
demiatically.  The  patient  when  very  delirious  will  require  to  be  restrained. 
The  bladder  should  be  emptied  and  the  action  of  the  kidneys  stimulated.  The 
subsequent  tendency  to  sleeplessness  is  to  be  antagonized  by  a  hypnotic. 

SvJdeich' Si  iniiltration-inetliod  i»f  htcal  aiu'>tht.r>ia  is  ba-st-il  uj»un  Liebreich's 
discovery  that  the  injection  of  water  into  tiie  subcutaneous  tissue  pro<luces 
local  anesthesia  by  causing  an  artificial  edema  of  the  parts.  Schleich 
availed  himself  of  this  method  and  improved  upon  it  by  employing  small 
quantities  of  cocaine  and  morphine  in  a  weak  saline  solution.  The  anes- 
thesia is  produced  by  causing  artificial  ischemia  <lue  to  tension  and  pressure 
in  the  tissues.  The  action  of  the  drugs  assists  also  in  producing  loss  of 
sensation. 

The  skin  covering  the  field  of  operation,  with  the  syringe  and  its  needle, 
should  be  made  aseptic,  and  the  solution  injected  under  the  integument.  As 
soon  as  the  first  injection  is  made,  the  second  one  should  be  made  at  the 
extreme  limit  of  the  zone  of  anesthesia,  and  so  on  until  the  field  of  operation 
is  covered.  The  introduction  of  the  needle  at  the  beginning  can  be  made 
painless  by  the  employment  of  the  ethyl  chloride  spray. 

This  method  of  local  anesthesia  has  a  wide  range  of  usefulness  in  minor 
surn-erv.  and  has  also  been  employed  in  some  capital  operations,  such  as 
herniotomy,   amputations,  etc. 

Schleich's  formula  are  as  fdlows: 

Solution  Xo.  1,  strong,  for  inflamed  tissues: 

R   Cocainfe  hydrochloratis, 

Morphine  hydrochlor., 

Sodii  chloridi  sterilisati. 

Aquae  destill.  sterilisati.  q. 

M.  et  adde 

Solut.  formalini  (40  per  cent.). 

Or  Solut.  acid,  carbol.  (oO  per  cent.), 

Solution  No.  2.  for  moderately  hyperesthetic  areas,  is  the  same,  except 
that  the  quantity  of  cocaine  is  reduced  to  gr.  iss. 

Solution  No.  3  is  still  Aveaker,  the  amount  of^  cocaine  being  only  gr.  \  and 
of  morphine  gr.  yV- 

All  of  these  ingredients  are  sterilized  individually,  except  the  cocaine 
and  morphine,  which,  if  pure,  are  practically  sterile.  These  solutions  should 
be  kept  in  a  cool  place,  or  they  become  inefficient. 

In  practice  as  many  as  2o  syringefuls  of  Solution  No.  1.  50  syringefuls 
of  Solution  No.  2,  and  500  syringefuls  of  Solution  No.  o  may  be  used. 

Encn'ine,  CjgHj^NO^.  is  a  local  anesthetic  which  is  insoluble  in  water:  but 
a  solution  can  be  made  by  first  dissolving  the  eucaine  in  a  little  alcohol  and 
then  adding  water.  It  has  a  special  advantage  over  cocaine  in  that  it  does 
not  decompose  nor  lose  its  efficacy  after  boiling.  This  enables  the  surgeon  to 
use  a  sterile  solution.  A  2  per  cent,  to  a  5  per  cent,  solution  produces  anes- 
thesia of  the  conjunctiva  and  cornea  in  less  than  three  minutes.      Congestion 


gr- 

"j; 

gr- 

i; 

gr. 

"j; 

s. 

ad  fsiiiss ; 

gtt. 

.j; 

gtt- 

j'j- 

A  NESrilESIA .  IK  »3 

of  tlio  (•(»iijiiiiftiv;i  (Iocs  Mot  Inllou  the  apjdifatioii  of  the  drug,  as  is  the  case 
Avith  cocaine.  In  optlitlialniological  surgery  eucaine  is  of  special  advanta<'e. 
The  pupil  is  not  dilated  and  reacts  to  light  during  the  application.  From 
doses  as  high  as  30  grains,  according  to  Kiesel,  no  toxic  eflects  have  been 
observed.  The  action  of  eucaine  on  the  heart  is  to  reduce  the  ninri])er  of 
beats,  which  is  in  marked  contrast  to  the  action  of  cocaine,  uhich  increases 
the  heart's  fre(|U('ncv.  To  produce  local  anesthesia  a  subcutaneous  injection 
of  a  solution  of  from  1  |)er  cent,  to  0  per  cent,  may  be  emi)loyed.  From  a 
clinical  point  of  view,  eucaine  produces  just  as  rapid,  profound,  and  lasting 
anesthesia  as  cocaine,  but  is  less  dangerous.  It  also  produces  a  larger  area 
of  anesthesia  than  cocaine,  and  its  effect  lasts  longer.  Occasional] v,  how- 
ever, local  gangrene,  as  a  result  of  vasomotor  constriction,  has  been  observed. 
Guaiacol  has  been  used  to  relieve  pain  in  acute  neuralgia.  A  solution 
can  be  prepared  consi.sting  of  fifteen  grains  of  guaiacol  in  five  drams  of  alco- 
hol. The  solution  is  painted  over  the  painful  part  with  a  camel's-hair  brush. 
It  has  also  been  used  in  the  form  of  an  ointment  of  the  strength  of  five  parts 
of  guaiacol  to  thirty  parts  of  vaseline.  This  drug  has  also  been  emploved 
hypodermatically  in  a  solution,  1  :  10  to  1  :  20,  of  olive  oil ;  but  the  drug 
used  in  this  way  is  not  free  from  deleterious  effects. 


1104  AX  AMERICAN  TEXT-BOOK  OF  SURGERY. 


CHATTER    III. 

PLASTIC    SURGERY. 

General  Principles. — This  branch  of  surgery  includes  all  operations  for 
the  repair  of  deficiencies  of  embryonal  development,  as  hare-lip  or  exstrophy  of 
the  bladder,  for  the  replacement  of  parts  lost  by  accident  or  disease,  as  lupous 
or  syphilitic  destruction  of  the  nose,  and  for  the  restoration  of  the  function  of 
parts  restrained  by  cicatricial  contraction  from  injury  or  disease,  as  eyelids 
bound  down  by  scars,  a  joint  fixed  by  the  cicatrices  left  by  a  deep  burn,  etc. 
The  tissues  employed  are  commonly  those  obtained  from  other  portions  of  the 
patient's  body,  or  they  may  be  transferred  from  a  donor.  The  termination 
'•  plasty  "  is  often  appended  to  the  name  of  the  organ  or  part  to  be  repaired  or 
replaced,  and  the  word  thus  formed  becomes  synonymous  with  such  restoration, 
as  ••  cheiloplasty."'  the  formation  of  a  lip.  Retrenchment  of  abnormally  large 
noses  or  ears  belongs  to  this  branch  of  surgery. 

Although  bone,  muscle,  nerve,  periosteum,  and  mucous  membrane  have  all 
been  used  in  certain  plastic  operations,  the  skin  with  its  subcutaneous  tissue  is 
that  most  frequently  employed.  With  the  exception  of  bone  and  nerve,  the 
portions  of  tissue  used  must  be  about  one-tliird  larger  than  the  defect  to  be 
repaired,  since  they  are  sure  to  shrink  both  immediately  and  for  many  weeks 
subsequently.  Flaps  should  have  their  pedicles  as  broad  as  possible,  fashioned 
with  curved  outlines,  thus  admitting  of  greater  stretching ;  they  should  include 
the  larger  vessels  of  the  parts,  with  which  their  long  axis  should  coincide  ;  and 
they  should  never  be  subjected  to  either  tension  or  torsion  if  these  can  possi- 
bly be  avoided  ;  indeed,  when  a  choice  exists  between  a  simple  operation  involv- 
ing one  or  both  of  these  procedui-es  and  another  more  difficult  and  elaborate, 
the  latter  should  be  chosen. 

Favorable  and  Unfavorable  Conditions. — xVs  syphilis  and  lupus  are 
frequently  the  causes  of  deformities  which  require  plastic  operations,  it  is  abso- 
lutely essential  in  the  first  disease  that  some  months  shall  have  elapsed  since 
any  manift-stations  of  syphilis  were  detectable,  and  that  the  patient  shall  have 
been  treated  for  a  prolonged  period  with  antisyphilitic  remedies;  while  in  a 
patient  who  has  suffered  from  lupus  it  is  imperative  that  all  the  diseased  tissue 
shall  have  been  long  since  destroyed,  as  shown  by  a  perfectly  sound  cicatrix 
which  has  remained  healthy  for  some  months.  Hare-lip  or  cleft-palate  opera- 
tions must  never  be  attempted  when  there  is  any  disturbance  of  either  the 
gastro-intestinal  or  respiratory  mucous  membranes,  for  manifest  reasons  over 
and  above  the  distinctly  increased  risk  to  life.  Rigid  asepsis  is  far  better  than 
antisepsis,  and  is  essential  if  Thiersch's  method  of  skin-grafting  has  to  be  em- 
ployed to  fill  up  the  gaps  left  by  deficient  flaps  or  to  close  the  surfaces  from 
which  these  have  been  dissected. 

The^r«i  atei)  in  any  plastic  operation  must  consist  in  the  proper  freshening 
of  the  edges  of  the  parts  to  be  apposed  or  of  the  surfaces  to  which  flaps  are  to 
be  transferred.  This  may  be  incidentally  done  when  removing  cicatricial  tis- 
sue, loosening  up  the  bound-down  alar  cartilages  of  a  partially  destroyed  nose, 
or  the  surface  may  have  to  be  specially  freshened,  as  in  the  case  of  hare-lip. 
The  largest  attainable  raw  surface  must  be  secured  wherever  merely  the  edg^es 
of  flaps  are  to  be  apposed,  provided  that  this  does  not  entail  such  destruction 
of  tissue  as  will  add  a  worse  evil — viz.  tension  of  flaps  from  lack  of  tissue,  as 
in  cleft  palate ;  but  the  same  end  can  often  be  secured  without  any  removal  nf 
tissu^e — or  at  least  with  very  little — by  splittinij  the  edge  of  the  cleft  on  one  side 


PLASTIC  SURGERY. 


1105 


and  removing  a  strip  of  tissue  on  tbe  other.     It  is  rarely  advisable  to  freshen 
both  surfaces  by  splittinj;,  because  proper  coa])tation  will  then  be  difficult. 

The  second  step  must  be  the  arrest  of  hemorrhage,  otherwise  })rimary  union 
may  fail  from  the  interposition  of  a  clot.      This  should  be  done  either  before 


Fig.  V.'A. 


++ 


% 


^ 


^ 


Diagrams  of  Various  Methods  of  Plastic  Surgery.  The  shaded  portions  represent  the  parts  removed. 
The  arrows  indicate  the  direction  in  which  the  flaps  are  displaced.  The  second  and  fourtli  columns 
show  the  results  of  the  operations  represented  in  the  first  and  third  (Esmarch  and  Kowalzig). 


coaptation  or  by  using  such  methods  of  suturing  as  will  secure  this  arrest  after 
closing  the  wound :  this  is  peculiarly  necessary  when  transplanting  mucous 
membrane.  The  tJdrd  step  is  to  adjust  the  parts  with  so  little  tension  that  the 
sutures  merely  retain,  but  do  not  pull,  the  parts  together :  this  is  the  secret  of 
success  in  operations  for  cleft  palate.  The  foin-th  step  is,  Avhen  flaps  from  other 
parts  have  been  employed,  to  close  the  gap  left  by  their  transplantation.  The 
fifth  step  is  to  dress  either  aseptically  or  antiseptically  in  such  a  way  as  to 
avoid  motion  or  frequent  handling  of  the  parts. 

70  f 


km; 


AN  AMERICAN   TEXT-BOOK   OF  SURGERY. 


Whore  the  rt'itair  of"  the  doloct  or  the  overcoming  of  a  defonnity  recjuires  a 
series  of  operations,  as  often  happens,  sufficient  time  should  be  allowed  for  all 
shrinkage  and  readjustment  of  parts  to  have  taken  place  before  any  further 
operation  is  attempted.  Sutures  which  it  is  desired  should  last  for  many 
days  must  be  of  wire,  or  preferably  of  silk,  both  as  fine  as  will  hold.  Where 
extensive  and  deep  wounds  are  to  be  apposed,  buried  sutures  of  catgut  are 
best,  although  fine  aseptic  silk  will  do.     Sometimes  coaptation  with  immobility 


Mw'.  ^         mm  ymiii, 

Plastic  Operation  for  Extroversion  of  the  Bladder  (Ashhurst). 

of  the  wound-surfaces  and  of  the  tissues  for  some  distance  around  is  best 
secured  by  the  "splinting"  action  of  hare-lip  pins  with  figure-of-8  ligatures. 
An  admirable  means  of  removing  tension  from  the  wound-edges  so  that  the 
superficial  sutures  shall  merely  hold  the  margins  together  is  the  "  relaxation 
suture"  in  some  one  of  its  forms.  Catgut  is  unreliable,  and  should  be  used 
only  in  the  form  of  "  buried  sutures,"  or  perhaps  in  between  silk  sutures. 
Classification  of  Methods. — Deformities  and  lesions  are  repaired  by 
one  of  four  methods — viz.  (1)  approximation  of  parts;  (2)  interpolation  of 
flaps  derived  from  contiguous  or  distant  parts,  a  pedicle  being  left ;  (3)  trans- 
plantation of  flaps  without  pedicle ;  (4)  retrenchment  of  redundant  parts. 
Roberts'  table,  v/hich  is  here  reproduced,  slightly  condensed,  gives  an  admir- 
able epitome  of  the  whole  subject : 

Methods  used  in  Plastic  Surgery. 

Displacement — stretching  or  sliding  of  tissues. 

I.  Simple  approximation  after  freshening  the  edges,  as  in  hare-lip,  vesico- 
vaginal fistulse,  etc. 
II.  Sliding  into  position  after  transferring  tension  to  adjoining  localities, 
as  in  V-shaped  incisions  for  ectropion  and  cicatricial  contraction  of 
joints  after  burns,  and  in  linear  incisions  to  allow  stretching  of  skin 
to  cover  large  wounds  and  to  relax  contracted  parts. 


PLASTIC  SURGERY.  11<>7 

Interpolation— burrowii.-  material   fVui.i   adjacent  regions,  from  a  limb,  or 
from  another  person. 

I.  Transferring  a  flap  with  a  pedicle. 

A.  Putting  in  place  at  once: 

1.  By  rotating  the  flap  and  the  pedicle  in  its  own  plane  through 

'one-fourrh  or  one-half  of  a  circle,  as  in  making  an  upper 
eyelid  or  a  nose  from  the  forehead. 

2.  By  twisting  the  flap  on  its  pedicle,  as  in  making  the  side  of 

nose  from  a  lip. 

3.  By  everting  the  flap  entirely  with  the  raw  surface  uppermost, 

*as  in  covering  exstrophy  of  the  bladder  by  a  scrotal  flap. 

4.  By  superimposing  one  flap'  on  another  which  has  been  everted, 

*as  in  Wood's  operation  for  exstrophy  of  the  bladder. 

5.  By  carrying  the  flap  across  an  intervening  portion  of  skin, 

and  fixing    only  its    end    to    the  part  to  be    repaired— a 
method    rarely    employed;    when    the    flap   has    become 
attached  the  pedicle  is  severed. 
B.   Gradually  carrying  a  flap  into  its  permanent  position  by  a  series 
of  partial  sliding,  transferring,  or  twisting  operations— seldom 
employed,  and  advisable  only  when  there  is  nothing  but  cica- 
tricial tissue    in    the  immediate  vicinity  of  the   part  to  be 
repaired. 

II.  Transplanting  ivithout  a  pediele. 

(a)  By  accurately  suturing  in  position  portions  of  tissues  recently  re- 
moved from  the  part  itself,  from  other  regions  of  the  patient's 
own  body,  or  from  a  lower  animal ;  e.  g.  replacing  the  bone 
after  trephining,  interpolating  pieces  of  nerve-trunks  between 
the  freshened  ends  of  divided  nerves  in  secondary  operations 
where  there  has  been  loss  of  substance. 
(5)  By  skin-grafting  in  some  one  of  the  forms  presently  to  be 
described.*  .        . 

Retrenchment— removing  redundant  material  and  causing  cicatricial  con- 
traction. 
I.  By  cutting  out  elliptical  or  semi-elliptical  pieces  of  tissue,  as  in  ptosis, 

cystocele,  etc.  r    •  ■ 

II.  By  cutting  out  triangular  or  wedge-shaped  portions  of  tissue,  as  in 
'closing  the  vaginal  aperture,  decreasing  the  size  of  a  lip,  nose,  etc. 
Reverdin's°  Method  of  Skin-grafting. — Strictly  speaking,  the  term 
"epidermic  trraftinc^,"  by  which  Reverdin  originally  designated  the  procedure, 
is  the  only  correct  one,  since  "  the  epidermis  by  itself,  but  the  living  epidermis, 
that  of  the  deep  laver,  is  alone  necessary  for  the  success  of  the  graft.  lor 
success  the  general  health  of  the  patient  must  be  good  and  the  granulations  ot 
the  ulcer  healthy ;  moreover,  when  possible,  complete  asepsis  should  be  secured 
and  maintained,  because  all  antiseptics  endanger  the  vitality  of  the  grafts.  If 
antiseptics  are  requisite  to  secure  asepsis  of  a  freely  suppurating  ulcer,  they 
must  be  thoroughly  removed  by  prolonged  douching  with  sterilized  normal  salt 
solution  (6  :  1000).  Small  grafts  about  the  size  of  a  large  pin's  head  will  do 
quite  as  well  as  large  ones,  and  are  far  less  painful  to  obtain  from  the  donor. 
When  procured  from  another  individual,  it  is  imperative  that  all  possibility  of 
specific  trouble  be  excluded,  and  that  the  donor  be  young. 

Amputated  limbs— even  the  skin  of  recent  cadavers  has  been  used— may 

*  Readjustment  of  recently  severed  finger-tips,  nose,  etc.  is  sometimes  incorrectly  classed 
among  the  plastic  operations. 


1108  AX   AMKIilCAX    TKXT-IH K >K    OF   Sll^drJiV. 

supply  tlie  grafts,  since  Martin  has  sliown  that  after  many  hours  of  exposure 
in  the  open  air  at  a  temperature  of  nearly  32°  F.  grafts  could  be  successfully 
applied,  but  that  at  such  temperatures  as  82°  F.  exposure  of  from  six  to  seven 
hours  destroyed  their  vitality,  so  that  the  limb  of  a  healthy  individual  ampu- 
tated for  some  accident  may  be  utilized  for  grafting  purposes  for  at  least  twenty- 
four  hours  if  kept  cool — in  a  refrigerator,  for  instance.  The  skin  of  any  of 
the  lower  animals  may  be  employed,  especially  that  covering  the  abdomen  of 
the  frog.  In  most  instances  some  other  portion  of  the  patient's  own  skin  must 
be  utilized.  Much  difference  of  opinion  seems  to  exist  as  to  whether  grafts 
from  the  skin  of  a  black  transferred  to  a  Avhite  patient  will  remain  pigmented, 
and  vice  vcrsd,  so  that  it  will  be  better  always  to  graft  ])lacks  from  blacks  and 
whites  from  whites. 

Method  of  Performing  the  Operation. — Having  rendered  the  ulcer, 
the  neighboring  skin,  and  the  part  from  which  the  grafts  are  to  be  taken  asep- 
tic, the  point  of  an  ordinary  (aseptic)  sewing  needle  should  be  thrust  under  the 
epidermis,  the  skin  elevated,  and  the  graft  shaved  off  by  a  sharp  scalpel  or  cut 
off  with  a  pair  of  small  curved  scissors.  To  ensure  obtaining  the  deeper,  active 
epithelial  layers,  a  small  portion  of  the  derm  should  always  be  removed.  The 
graft  must  then  be  gently  deposited,  cut  surface  downward,  upon  the  granula- 
tions by  means  of  the  needle,  avoiding  any  pressure  such  as  will  induce  bleed- 
ing. Having  placed  as  many  grafts  as  desired,  very  narrow  strips  of  protective 
or  of  thin  pure  rubber  or  gutta-percha  tissue  should  be  applied  over  the  grafts, 
extending  for  a  couple  of  inches  on  each  side  of  the  ulcer,  interlaced  in  such  a 
manner  as  to  ensure  retention  of  the  grafts  and  at  the  same  time  allow  of  free 
escape  of  any  serous  or  purulent  secretions.  Over  the  protective  a  compress  wet 
with  the  salt  solution  must  be  applied.  Next  a  piece  of  oiled  silk  or  protective 
must  follow,  then  a  pad  of  absorbent  cotton  and  a  gently  applied  bandage ; 
sometimes  a  light  plaster-of-Paris  or  silicate-of-sodium  bandage  is  advisable, 
especially  on  the  limbs  of  children  when  the  grafting  is  done  near  the  joints. 
In  from  twenty-four  to  forty-eight  hours  all  dressings  but  the  lattice-work  of 
protective  should  be  removed,  the  parts  gently  irrigated  Avith  warm  salt  solu- 
tion, and  a  dressing  identical  with  the  primary  one  applied,  repeating  this  pro- 
cedure from  time  to  time,  and  at  the  end  of  a  Aveek  removing  the  protective 
strips  next  the  grafts  and  reapplying  if  necessary.  In  many  instances  the 
grafts  shed  their  cuticle,  which  floats  off  in  the  discharges,  the  operation 
apparently  having  failed  from  loss  of  the  entire  graft,  but  at  the  next  dress- 
ing commencing  growth  of  epidermis  will  often  be  shown  by  bluish-white 
spots,  not  only  where  the  grafts  were  supposed  to  have  taken,  but  also 
where  they  were  thought  to  have  been  shed.  As  the  grafts  extend  eccen- 
trically, each  capable  only  of  producing  an  area  of  about  half  an  inch  of  cica- 
trix, and  stimulating  to  healing  the  contiguous  sluggish  borders  of  the  sore, 
they  should  be  placed  about  half  an  inch  from  one  another  and  from  the  bor- 
ders of  the  ulcer,  or,  when  this  is  irregular  in  outline,  rows  of  grafts  should  be 
placed  so  as  to  cut  the  surface  up  into  triangles  and  irregular  figures,  which  if 
skilfully  planned  will  diminish  the  extent  of  surface  each  graft  must  cover,  and 
conseqiiently  their  number  and  the  pain  incident  to  their  removal.  If  one 
grafting  will  not  suffice,  the  operation  should  be  repeated.  The  spots  from 
which  the  grafts  have  been  taken  are  best  treated  by  dusting  them  over  with 
sterilized  iodoform  and  covering  them  with  dry  absorbent  cotton  and  a  band- 
age, the  dressing  not  to  be  removed  for  about  ten  days. 

Unfortunately,  but  little  diminution  of  the  cicatricial  contraction  is  effected 
by  Reverdin's  method,  and,  while  healing  is  more  rapidly  secured,  too  often  an 
almost  equally  rapid  breaking  down  of  the  new  cicatrix  results,  either  from  no 


PLASTIC  SURGERY.  1109 

recognizulilc  cause  or  iVom  causes  which  wouhl  be  inadequate  to  produce  such 
a  result  in  a  scar  formed  by  the  ordinary  processes  of  healing. 

TiiiKKPcn's  Method  of  Skin-grafting. — Thiersch  contends  that  healing 
of  a  granulating  surface  results,  first,  from  a  conversion  of  the  soft,  vascular 
granulation  papillnc — by  contraction  of  some  of  their  elements  which  have 
developed  into  young  connective-tissue  cells — into  "dry  cicatricial  papillae," 
actually  approximating  the  surrounding  tissues,  thus  diminishing  the  area  to 
be  covered  by  epidermis ;  and,  secondly,  by  the  covering  of  these  papillae  by 
epidermic  cells.  Contraction  having  gone  on  as  far  as  the  laxity  of  the  tissues 
will  admit,  and  the  capacity  for  developing  new  epidermic  cells  by  the  margins 
of  the  wound  being  limited,  the  granulations  of  the  unhealed  central  portion 
remain  stationary — i.  e.  vascular  and  soft:  few  if  any  of  their  component  cells 
having  undergone  development  into  connective  tissue,  the  maximum  of  con- 
traction has  not  yet  been  attained,  but  will  be  promptly  reached  if  they  are 
covered  in  Avith  epidermis.  Moreover,  any  trivial  mechanical  or  vascular  irri- 
tation will  give  rise  to  exudation  from  the  soft  subjacent  papillye,  resulting  in 
separation  of  the  newly-formed  skin.  Still  further,  microscopically  two  layers 
of  granulation-tissue  are  discernible,  the  more  superficial  possessing  vertically 
disposed  capillaries,  the  deeper  containing  a  horizontal  network  of  vessels,  from 
which  the  former  spring,  coursing  through  a  structure  more  or  less  dense  accord- 
ing: to  its  age — i.  e.  stage  of  conversion  into  connective  tissue.  A  free  removal 
of  this  upper,  soft  layer  of  granulations,  yet  capable  of  full  contraction,  must 
be  effected  to  prevent  cicatricial  distortion  and  the  risk  of  separation  of  the 
epidermis,  these  evils  being  avoided  by  laying  the  grafts  directly  upon  the 
layer  of  granulations  with  horizontally  disposed  capillaries,  to  which  layer 
the  transplanted  portions  will  become  firmly  adherent,  and  will  remain  so, 
undisturbed  by  cicatricial  contraction. 

Favorable  and  Unfavorable  Conditions. — Syphilis  may  prevent 
the  grafts  from  taking.  The  best  results  are  attained  when  the  granulations 
are  about  six  weeks  old,  are  firm,  and  have  reached  this  condition  by  repeated 
cauterization  and  compression.  Most  careful  disinfection  of  the  hands,  instru- 
ments, and  parts,  with  subsequent  removal  of  all  antiseptics,  is  essential,  as  is 
complete  arrest  of  hemorrhage.  The  salt  solution  should  be  freshly  sterilized. 
All  portions  of  the  wound  must  be  covered  with  the  grafts  if  possible,  and  they 
in  turn  with  the  protective  strips.  After  the  second  or  third  day,  daily  dress- 
ings, with  free  irrigation,  are  imperative.  Grafts  applied  to  loose  connective 
tissue,  to  fascia,  or  to  periosteum  do  not  succeed  so  well  as  on  freshened  gran- 
ulations, while  on  glandular  and  muscular  tissues  the  results  are  only  fair.  On 
cancellous  bone  or  tendons  the  results  are  not  permanent,  while  grafts  will  not 
even  primarily  adhere  to  compact  bone. 

Metlnod  of  Operating. — Complete  asepsis  having  been  secured,  as  before 
indicated,  and  all  antiseptics  washed  away  with  the  salt  solution,  the  soft  gran- 
ulations are  to  be  scraped  away  with  the  sharp  spoon,  including  a  small  portion 
of  the  newly-healed  margins  if  they  do  not  appear  healthy,  and  the  bleeding 
surface  irrigated,  covered  with  protective,  a»d  compressed  for  a  few  minutes 
to  check  all  oozing.  Any  portion  of  skin  relatively  free  from  underlying  fat 
— that  of  the  arm  or  thigh — having  been  pi-eviously  sterilized  and  shaved,  is 
put  upon  the  stretch  by  one  hand  while  with  the  other  a  long  wide  razor  or 
microscopic  section-knife  is  applied  flatwise,  and  the  upper  layers  of  the  skin 
removed  by  a  to-and-fro  movement  of  the  knife,  which  is  kept  flooded  with  the 
salt  solution.  Mixter  of  Boston  has  devised  an  excellent  apparatus  which  facil- 
itates the  cutting  of  these  long  grafts,  and  McBurney  some  hooks  for  lifting  and 
stretching  the  skin.     Each  graft  should  be  as  broad  and  long  as  possible,  and 


1110 


AiX  AMKlili'Ay    TEXT- HOOK    OF  SUROKHY 


be  immediately  laid  upon  the  prepared  siiriaee,  upon  which  it  is  floated  from  the 
knife  by  salt  solution,  A  probe  may  be  used  to  facilitate  this  manccuver,  draw- 
ing the  edge  of  the  graft  on  to  the  wound-surface  while  slipping  the  blade  away. 
Subsequent  correction  of  position  may  be  effected  by  the  probe  or  by  a  camel's- 
hair  brush.  Each  graft  must  l)e  gently  pressed  into  ])lace  with  a  s[)atula,  and 
must  be  in  contact  with  its  neigiibor,  better  slightly  overlapping  its  fellow  and 
the  margins  of  the  wound,  otlierwise  separation  of  the  grafts  is  apt  to  occur, 
commencing  at  the  edges,  or  a  spreading  ulcerative  destruction  is  liable  to  set  in. 
Skin  from  the  abdomen  or  back  of  a  living  frog  may  be  substituted  for  or  used 
to  supplement  human  grafts :  indeed,  the  hairless  skin  of  the  young  of  any  of 
the  lower  animals  will  do.  The  dressing  should  consist  of  the  lattice-work  of 
protective  strijis,  a  compress  moistened  with  salt  solution  and  covered  in  with 
protective,  outside  dry  cotton,  and  possibly  the  fixed  dressing  described  for  ordi- 
nary epidemic  grafting.  Mayer  has  recently  devised  a  better  method  (Fig. 
430).     The  limb  is  encircled  by  two  collars  of  sterilized  gauze  wet  with  the 

Fig.  436. 


Mayer's  Dn'ssing  for  Thiersch's  Method  of  Skin-grafting  (from  original  photograph  by  J.  M.  Bertolet). 


salt  solution,  one  above  and  the  other  below  the  site  of  the  grafts.  These  col- 
lars should  be  an  inch  or  more  thick.  Strips  of  sterilized  wood  covered  with 
gauze  and  long  enough  to  reach  from  one  collar  to  the  other  are  laid  in  place 
and  fixed  by  gauze  bandages.  Over  this  "cage"  are  placed  several  gauze 
pads  wet  with  the  salt  solution.  The  whole  dressing  is  then  covered  with  rub- 
ber dam  and  a  bandage.  A  hot-water  bag  keeps  the  grafts  in  a  warm,  moist 
chamber  untouched  by  any  dressing  which  might  displace  them.  The  outer 
gauze  dressing  need  only  be  wet  once  daily.  After  a  few  days,  ■when  the 
grafts  have  taken,  the  whole  dressing  is  removed  and  borated  albolene  oint- 
ment is  applied.  When  employed  as  an  adjunct  of  a  plastic  operation,  hav- 
ing checked  all  hemorrhage  by  compression,  the  epidermic  strips  must  be 
placed  and  dressed  as  just  directed,  and  will  usually  unite  with  the  subjacent 
tissues.  Blood  beneath  a  graft,  indicated  by  a  bluish  tint,  although  endanger- 
ing the  vitality  of  the  graft,  does  not  necessarily  cause  its  loss.  A  pink  tint 
at  the  close  of  a  few  days  usually  indicates  success,  while  if  the  grafts  be  at 
this  time  of  a  dead  white  they  will  probably  exfoliate,  although  only  the  outer 
layers  may  float  away,  while  the  deeper,  active  ones  remain.  Sometimes  the 
grafts  are  perforated  by  the  granulations,  and  disappear  for  a  time  to  reappear 
as  epidermic  islets  later  on.  The  surfaces  from  which  the  grafts  have  been 
removed  must  be  dusted  with  sterilized  iodoform,  and  dry  cotton  bandaged  on, 
this  dressing  to  be  left  on  for  about  ten  days ;  or  they  may  be  dressed  precisely 
like  the  grafts  themselves. 

Trauitplantation  of  Skin. — Krause  has  revived  tliis  practice.     The  granu- 


rLASTic  srii(ii':iiY.  ^^ 


fivl'.lays,  -vny  epidennic  blebs  are  punctured,  and  a  dressing  s.nulai  to  the 
^''VS^.PLANTATION  OF  Mucous  Membka>- K—Where  this  measure  is  de- 

the  pait.— in  ^^  f ^'*;"^^,,'' r",  •  .  ^,^,^1^  yet  Wblller  has  resected  the  cica- 
success  less  in'obabie  than  m  sKin-giaiuug,  j^i^  >  „;^^„iar  .rraft 

tridal  tissue  of  uvetl,.-a,l  strictures,  ami,  suturing  .n  position  a  c  rcukr  gratt 
:'f'mir:nen,brai,e,  has  .oiiiicHt  adiiere  -'^f  "^^  oT'^X  e'' ^ie"  „t 

rthrrw^;;rVbt;*^df:m^^^^^^^^^^^     tu.  »„«.,.  the 

o  at"  vb  concerned  or  if  the  conjunetiva  -^^'^'^r^  "^^  J^"^ 
M  .  <^,~,f  s  mav  be  taken  from  the  rectum  ;  again,  the  conjunctiva  of  the  labbit 
Z  S"iemb™,e  of  the  frog's  stomach,  of  the  esophagus  ot  the  pigeon  oi 

™^^'peTa\r:n -'m  saml'::!:|S;";e^Hminre;,  freshening  of  surfaces,  ,oos- 

Xirom'  :un  lu'bj^s  and  placed  '^  ^^::^:tZt tl^ :^, 
fV,^  wVinlA  tbirkness  of  the  membrane  must  be  emplo\ea,  ami  me  ^^^  y 

tl  ^olcf  orr:ew":tth°\hrfiSLrsu..faces  of  the  old  tissues  are 
:a-rear:^FT'SE3  =  ^^ 

--'^;^^:t^rl:t-^t':ii:]^^ 
;te^^rcLr«»'»^^^^^^^ 

and  must  be  carefully  fixed  in  position  D}   du  ^^    be 

s:iu  !^;r =d|  «^:^  - --^     . 

aereTS^^'rn:!::^^^^^^^^^^^ 
l^er:,:i''^ab:rrrroFrt^^^^^^^^^^^^^    "^'  edge;  from  t.o  to  four 


1112  AN  AMERICAN   TEXT-BOOK    OF  SURGERY. 

.sutures  will  be  ie(|uir('d,  aiul  where  there  is  a  distinct  sheath  this  had  better 
be  separately  secured  by  a  couple  of  stitches.  If  the  nerve-ends  cannot  be 
readily  approximated,  careful  but  thorough  stretching  of  both  the  proximal 
and  distal  portions  of  the  nerve  -will  often  secure  this  end,  but  if  not,  a  nerve 
freshly  removed  from  some  lower  aninud  or  from  a  recently  amputated  limb 
should  be  carefully  sutured  in  position.  Either  stretching  the  nerve  or  insert- 
ing a  graft  is  better  than  the  interposition  of  a  decalcified  bone  drainage-tube 
or  a  bundle  of  catgut  threads,  as  has  been  advised. 

Bone-grafting. — The  method  depends  somewhat  upon  whether  the  skull- 
bones  are  concerned  or  one  of  the  long  bones.  Thus,  when  trephining  the 
bone  the  button  or  fragments  removed  must  be  at  once  transferred  to  a  warm 
(100°-10">°  F.)  aseptic  salt  solution,  and  kept  at  that  temperature  until  re- 
placed. If  the  operation  is  for  accident,  any  foreign  matter  must  be  re- 
moved, even  to  paring  with  the  bone  chisel,  and  disinfection  effected  by 
weak  solutions  of  mercuric  bichloride  before  placing  in  the  warm  aseptic 
solution.  When  but  little  aseptic  bone  can  be  saved,  the  fragments  may  be 
laid  on  an  aseptic  surface,  minced  into  fragments  with  a  chisel,  and  scattered 
over  the  dura. 

If  a  defect  in  a  long  bone,  the  continuity  of  which  has  not  been  destroyed, 
requires  repair,  after  exceptional  precautions  to  render  the  part  aseptic,  prop- 
erly shaped  bone-grafts  from  a  recently  amputated  limb  or  removed  from  a 
living  animal  must  be  placed  in  situ,  or  bone  chips  may  be  packed  in  so  as  to 
fill  up  the  gap.  When  non-union  results  after  compound  fracture  with  short- 
ening from  loss  of  bone,  after  preparing  a  longitudinal  sulcus  in  the  tissues 
between  the  ends  of  the  bones — which  must  be  carefully  freshened — bone- 
grafts,  either  human  or  from  the  lower  animals,  may  be  secured  in  position  : 
success  has,  as  yet,  been  rarely  attained.  Shifting  of  bone  has  been  done  by 
dividing  a  strip  of  the  hard  palate,  covered  w^ith  its  soft  parts,  parallel  to  the 
fissure  in  cleft  palate,  but  leaving  unsevered  the  bony  attachments  in  front, 
and  partially  fracturing  the  pedicle,  drawing  the  bony  flaps  together  with 
sutures ;  or,  when  forming  a  new  nose,  turning  down  with  the  skin  and  perios- 
teum the  outer  table  of  the  frontal  bone  split  off  with  a  chisel  after  cutting  a 
groove  around  the  part  to  be  removed. 

A  modification  of  bone-grafting  has  been  suggested  by  Senn.  whereby 
aseptic  bone-cavities  and  defects  left  by  trephining  may  be  filled — in  the  first 
case  by  chips,  and  in  the  second  by  decalcified-bone  plates  carefully  fashioned 
to  fit  the  opening. 

Method  of  Preparing  Decalcified  Bone. — Select  the  compact  layer  of  the 
fresh  tibia  or  femur  of  the  ox,  remove  all  periosteum  and  medullary  tissue, 
divide  into  longitudinal  strips  about  one-eighth  of  an  inch  Avide,  and  immerse 
in  a  relatively  large  quantity  of  10-1.5  per  cent,  watery  solution  of  hydrochloric 
acid,  which  must  be  renewed  daily  for  from  one  to  two  weeks :  then  wash 
thoroughly  in  water  or  a  weak  solution  of  caustic  potash,  cut  into  small  chips, 
soak  for  forty-eight  hours  in  1  :  1000  mercuric  bichloride  solution,  remove  and 
store  in  a  saturated  solution  of  iodoform  in  ether.  When  about  to  be  used,  wrap 
in  aseptic  gauze,  dissolve  out  the  excess  of  ether  and  iodoform  with  alcohol, 
and  put  in  1  :  2000  mercuric  l)ichloride  solution  until  recjuired,  when  careful 
drying  with  iodoform  gauze  should  precede  their  implantation.  For  cranial 
defects  large  plates  must  be  sawn  out  of  the  compact  tissue  and  decalcified,  as 
already  described. 

Operation. — Having  cleansed,  sterilized,  and  dusted  the  cavity  with  iodo- 
form, it  is  to  be  carefully  packed  with  chips  until  filled,  a  capillary  drain  intro- 
duced at  the  most  dependent  part,  and  the  periosteum  and  soft  parts  united  by 


LIGATION   OF  ARTERIES.  HI'' 

buried  ciitgut  sutures :  if  a,  delict  of  the  soft  parts  exists,  an  iodoform  gauze 
tampon  mjw  be  employed  to  keep  the  chips  in  position.  Wlien  an  opening  in 
the  skull  is  to  be  filled,  the  plate  or  plates  should  accurately  fill  the  gap,  but 
must  be  perforated  in  numerous  places  to  allow  the  wound-secretions  to  escape. 
It  is  alleged  that  ordinary  l)one-grafts  undergo  decalcification,  and  are  only 
then  infiUrated  with  bone-forming  cells,  thus  merely  acting  as  a  scaffolding, 
for  which  purpose  decalcified  bone  will  do  ef^ually  well,  requires  no  decalcifica- 
tion, and  is  not  only  aseptic,  but  actively  antiseptic. 


CHAPTER    IV. 

LIGATION  OF  AKTERIES. 


The  Ligation  of  Arteries  requires  a  precise  knowledge  of  anatomy, 
which  can  be  acquired  only  in  the  dissecting-room.  The  technique  of  the 
operative  work  must  be  learned  by  practice  upon  the  cadaver.  The  region  in 
which  the  vessel  is  situated  should  be  thoroughly  prepared  for  an  aseptic  ope- 
ration.    (See  p.  10-76.)  t     i,     n  u 

The  INCISION  should  vary  in  length  from  two  to  four  inches.  It  should  be 
made  from  left  to  right,  and  from  above  downward,  and  at  an  angle  of  five  de- 
grees over  the  course  of  the  vessel.  The  integument  lying  over  the  vessels  should 
be  held  firmly  between  the  middle  finger  and  the  thumb  of  the  left  hand  of  the 
suro-eon.  The  skin  must  not  be  stretched  or  pulled  aside,  otherwise  the  incision 
will" not  be  over  the  underlying  vessel.  The  knife  should  be  held  between  the 
thumb  and  index  finger  of  the  right  hand  of  the  surgeon.  When,  however, 
the  incision  has  been  made  through  the  superficial  tissues,  the  knife  may  be 
held  for  the  deeper  dissection  in  the  same  manner  as  a  pen.  When  the  ves- 
sel is  reached,  the  handle  of  the  scalpel,  an  AUis'  dry  dissector,  or  the  index 
fincrer  may  be  used  to  tear  and  gently  push  aside  the  loose  connective  tissue  sur- 
roimding  die  arterv.  The  depth  of  the  skin-incision  should  be  the  same  from 
the  begmning  to  the  end,  and  not  terminate  obliquely  at  either  extremity. 
After  cutting  through  the  skin,  the  fascia  should  be  raised  and  a  small 
opening  made,  through  which  a  director  is  passed  with  the  point  constantly 
turned  upward.  The. fascia  is  slit  along  the  entire  length  of  the  wound. 
Instead  of  a  director,  two  pair  of  thumb  forceps  can  be  used  in  the  fol- 
lowing manner :  The  surgeon  seizes  with  the  forceps  the  fascia  at  a  certain 
point,  and  the  assistant  grasps  the  fascia  at  a  point  directly  opposite ;  then 
both  the  surgeon  and  the  assistant  together  lift  up  the  fascia  from  the  wound, 
and  the  operator  cuts  between  the  two  forceps.  The  surgeon  then  releases  the 
hold  upon  the  tissue  with  the  forceps,  and  the  assistant  follows  his  example, 
and  the  same  procedure  is  repeated.  In  this  manner  no  structure  of  import- 
ance can  be  cut  when  the  fascia  is  lifted  up  from  the  wound. 

The  retractor  should  first  be  placed  in  the  wound  by  the  surgeon,  and 
when  properly  adjusted  he  requests  the  assistant  to  hold  it  in  si^w  just  as  he 
has  placed  it.  Two  retractors  are  used,  and  in  this  way  the  wound  is  kept 
well  open,  so  that  light  enters  into  its  depth. 

The  SHEATH  of  the  artery  is  now  reached,  and  great  care  must  be  used  in 
opening  it.  It  should  be  seized  by  a  pair  of  forceps  upon  the  side  opposite  the 
accompanying  vein,  lest  that  vessel  be  injured.     A  small  aperture  is  cut  or 


14 


^.y  AMERICAN    TEXT-BOOK   OF  SURGERY. 


torn  in  the  sheath  only  larfje  enon<ih  to  admit  the  point  of  an  aneurysm  needle. 
It  is  important  to  remember  that  the  sheath  should  be  disturbed  as  little  as 
possible,  because  the  vasa  vasorum  lie  in  it.  Any  unnecessary  disturbance 
might  be  a  cause  of  secondary  hemorrhage.  In  passing  the  aneurysm  needle 
(Figs.  437,  438)  around  the  artery  it  should  be  always  passed  away  from  the 


Fig.  437. 


Ordinary  Aneurysm  Needle  threaded  (MacCormao). 


vein — i.  e.  inserted  first  between  the  artery  and  vein.     The  nerve  must  not  be 
included  in  the  ligature.     When  the  needle  has  been  passed  around  the  artery 


Pig.  438. 


Aneurysm  Needles  (MacCormac). 


the  vessel  must  not  be  lifted  up  from  its  bed.  as 
this  act  would  be  likely  to  set  up  some  cellular 
inflammation.  Before  the  ligature  is  finally 
tightened  an  examination  should  be  made  to 
ascertain  if  any  tissue  besides  the  artery  itself 
is  included  in  the  ligature.  The  two  thumbs 
can  be  placed  on  top  of  the  artery  and  the  liga- 
ture lifted  by  the  two  hands,  so  that  the  artery 
is  occluded  by  simultaneous  pressure  produced 
by  the  thumbs  above  and  the  ligature  below. 
An  assistant  should  now  ascertain  if  pulsation 
is  lost  in  the  vessel  upon  its  distal  side.  The 
ligature  is  tied  with  a  reef  knot  in  the  manner 
shown  in  Fig.  439. 

The  INDICATIONS  for  the  ligation  of  arteries 
are — 1,  hemorrhage ;  2,  aneurysm;  3,  arrest  of 

Fig.  439. 


Manner  of  Tightening  Ligature  (MacCormac). 

malignant  growths  and  control  of  acute  inflammations.     (For  the  discussion 


LIGATION  OF  ARTERIES. 


1115 


of  these  special  indications  and  the  contraindications  the  reader  is  referred 
to  each  subject.) 


LIGATION   OF  SPECIAL  ARTERIES. 

The  Innominate  Artery  (Pis.  XXV  and  XXVI)  arises  from  the  arch  of 
the  aorta  upon  the  right  side,  and  at  the  sterno-clavicular  articulation  divides 
into  the  right  primitive  carotid  and  right  subclavian  arteries.  The  artery 
begins  at  a  point  about  the  middle  of  the  manubrium  and  ascends  to  the 
upper  edge  of  the  clavicle.  As  the  clavicle  is  movable,  the  termination  of 
the  artery  may  be  slightly  above  or  below  the  bone.  The  incision  should 
be  made  along  the  anterior  margin  of  the  sterno-cleido-mastoid  muscle  down 
to  the  sternal  notch.  An  incision  at  an  angle  to  this  should  be  made  out- 
ward along  the  upper  border  of  the  clavicle.  The  inner  attachment  of  the 
sterno-cleido-mastoid  muscle  is  now  divided  in  order  to  allow  of  more  room  to 
reach  the  vessel.  After  tearing  with  the  fingers  the  loose  areolar  tissue,  the 
surgeon  must  look  out  for  the  anterior  jugular  vein,  and  secure  it  between  two 
ligatures  or  else  draw  it  out  of  the  way  with  a  blunt  hook.  The  sterno-hyoid 
and  sterno-thyroid  muscles  must  be  divided.  The  pericardial  cervical  fascia 
is  now  divided  on  a  director,  and  the  inferior  thyroid  vein  must  be  ligatured 
or  drawn  to  one  side.  The  bifurcation  of  the  innominate  can  now  be  felt,  and 
the  needle  passed  from  beloAV  upward  so  as  to  avoid  wounding  the  pleura  and 
the  innominate  vein.  The  internal  jugular  vein  must  be  carefully  guarded, 
and  also  the  innominate  vein  which  occasionally  overlaps  the  artery.  The 
pneumogastric  nerve  and  the  phrenic  must  be  held  out  of  the  way  in  passing 
the  ligature.  Only  two  patients  out  of  twenty-four  have  survived  the  opera- 
tion. Banks's  patient  lived  fif- 
teen weeks,  and  Smyth's  (of  Fig.  440. 
New  Orleans),  the  first  success- 
ful case,  lived  ten  years. 

The    COMMON    CAROTID    (Pls. 

XXV  and  XXVI)  is  formed  by 
a  bifurcation  of  the  innominate 
upon  the  right  side  and  from  the 
arch  of  the  aorta  upon  the  left. 
The  artery  extends  from  the 
sterno-clavicular  articulation  to 
the  superior  border  of  the  thyroid 
cartilage.  It  runs  for  the  most 
part  just  under  the  internal  bor- 
der of  the  sterno-cleido-mastoid 
muscle.  Its  course  is  marked  by 
a  line  from  the  sterno-clavicular 
articulation  to  a  point  midway  be- 
tween the  angle  of  the  jaw  and 
the  mastoid  process.  It  lies  in 
two  triangles  of  the  neck,  the  su- 
perior and  inferior  carotid  trian- 
gles. The  superior  carotid  tri- 
angle, or  the  triangle  of  election, 
is  bounded  behind  by  the  sterno- 
cleido-mastoid,  in  front  by  the 
anterior  belly  of  the  omo-hyoid,  and  above  by  the  posterior  belly  of  the  digas- 


Position  of  the  lines  of  incision  for  ligation  of  temporal, 
facial,  lingual,  common  carotid  (above  the  omo-hyoia). 
subclavian,  axillary  (first  portion),  and  internal  mam- 
mary arteries  (MacCormac). 


llli;  AN  AMF.RIVAN  TEXT- HOOK  OF  SURGERY. 

trie.  The  inferior  earotid  triangle,  or  the  triangle  of  necessih/,  is  bounded  in 
front  by  tlie  median  line,  above  by  the  anterior  belly  of  the  omo-hyoid,  and 
below  liy  tiie  sterno-cleido-niastoid. 

The  internal  jugular  vein  is  upon  the  outer  side.  Upon  the  right  side,  at 
the  root  of  the  neek,  the  vein  is  separated  from  the  carotid  artery,  forming  two 
legs  of  a  triangle  the  base  of  which  is  formed  by  the  subclavian  artery.  The 
common  carotid  is  ligated  about  the  middle  of  its  course,  either  just  above  or 
just  below  the  tendon  of  the  omo-hyoid  muscle  (Fig.  440).  In  studying  the 
anatomy  of  the  neck  it  is  necessary  to  remember  that  the  primitive  carotid 
terminates  at  the  ui)per  border  of  the  thyroid  cartilage,  and  is  slightly  over- 
lapjted  by  the  sterno-cleido-mastoid  ;  that  the  point  of  election  for  ligating  the 
artery  is  on  a  level  with  the  cricoid  cartilage ;  that  the  omo-hyoid  tendon 
crosses  in  front  of  the  carotid  artery  and  upon  a  level  with  the  cricoid  car- 
tilage ;  that  the  inferior  thyroid  artery  crosses  behind  the  carotid  upon  this 
same  level:  and  that  the  pneumogastric  nerve  lies  on  a  plane  behind  the 
artery,  between  it  and  the  internal  jugular  vein,   upon  its  outer  side. 

In  ligating  the  artery  the  patient's  head  should  be  turned  to  the  opposite  side. 
The  surface  guide  is  the  anterior  margin  of  the  sterno-cleido-mastoid  muscle, 
and  the  deep  muscular  guide  is  the  tendon  of  the  omo-hyoid  muscle.  An 
incision  (Fig.  440)  about  three  inches  long  should  be  made  parallel  to  the  ante- 
rior edge  of  the  sterno-eleido-mjistoid  muscle.  The  center  of  this  incision  should 
be  opposite  to  the  cricoid  cartilage.  The  skin  and  the  two  layers  of  the  super- 
ficial fascia  between  which  is  the  platysma  myoides  should  be  divided.  The  deep 
fascia  attached  to  tlie  border  of  the  sterno-cleido-mastoid  muscle  is  next  divided 
upon  a  grooved  director.  The  tendon  of  the  omo-hyoid  muscle  will  now  be 
exposed.  The  tendon  must  be  loosened,  so  that  it  can  be  pulled  down  or 
raised  upward  in  the  wound  by  a  blunt  hook,  according  as  the  ligature  is  to  be 
applied  to  the  carotid  above  or  below  the  muscle.  The  index  finger  of  the  sur- 
geon should  be  introduced  into  the  wound  for  the  purpose  of  exploring  the  dif- 
ferent structures.  The  sheath  of  the  carotid  artery  should  be  opened  upon  its 
inner  side,  so  as  to  avoid  wounding  the  internal  jugular  vein,  which  might 
overlap  the  artery  during  a  deep  inspiration. 

The  needle  should  be  passed  from  without  inward,  so  as  to  direct  its  point 
between  the  two  vessels  and  away  from  the  vein.  There  are  some  important 
structures  that  the  surgeon  must  avoid  wounding  in  ])assing  the  needle  around 
the  carotid  artery.  In  front  there  are  three :  the  descendens  noni  nerve,  the 
sterno-mastoid  artery,  and  the  lobe  of  the  thyroid  gland.  Behind  there  are 
also  three :  the  pneumogastric  nerve,  the  sympathetic  nerve,  and  the  inferior 
thyroid  artery.  Upon  the  outer  side  there  is  one,  the  internal  jugular  vein  ; 
and  upon  the  inner  side,  likewise  one,  the  lobe  of  the  thyroid  gland. 

The  Collateral  Circulation  is  established  in  the  following  manner: 

1.  Internal  carotid  of  one  side  with  the  internal  carotid  of  the  opposite  side, 
through  the  circle  of  Willis. 
'     2.    Vertebral  artery  of  one  side  with  the  vertebral  artery  of  the  opposite 
side,  through  the  circle  of  Willis. 

3.  Superior  thyroid  of  one  side  Avitli  the  inferior  thyroid  from   the  sub- 

clavian of  the  same  side. 

4.  Arteria  prineeps  cerricis  from  the  occipital  with  the  profunda  cervicis 

from  the  superior  intercostal  of  the  same  side. 

5.  Ophthalmic,  from  the  internal  carotid  with  the  angular  from  the  facial 

of  the  same  side. 

6.  Superior  thyroid,  lingual,  and  facial  with  corresponding  arteries  from 

the  opposite  side. 


PLATE    XXV. 


-■■..cviZlC&t*^^^'?!'*^^^*'''^ 


(Maclise.) 


A.  innominate  artery  at  point  ol  bifurcation  ;  B,  subclavian  artery,  crossed  by  vagus  nerve  :  C,  common 
carotid  artery,  with  vagus  nerve  at  outer  side,  and  descendens  noni  nerve  on  it  ;"o,  external  carotid  artery 
E  internal  carotid  artery,  with  descendens  noni  nerve  on  it;  F,  lingual  arterv,  passing  nntUr  the  tibers  of 
the  hyoglossus  muscle  :  G,  facial  artery;  H,  teinporo-maxillarv  arterv  ;  I,  occipital  arterv,  crossing  internal 
carotid  artery  and  jugular  vein  ;  K,  internal  jugular  vein,  crossed  bv  branches  of  cervical  plexus,  which 
join  descendens  noni  nerve;  L,  spinal  accessory  nerve,  which  pierces  sterno-mastoid  muscle,  to  be  distrib- 
uted to  It  and  trapezius  ;  M,  cervical  plexus  of  nerves,  giving  oil  the  phrenic  nerve  to  descend  the  neck 
on  the  outer  side  of  the  internal  jugular  vein  and  over  the  scalenus  muscle;  N,  vagus  nerve,  between 
carotid  artery  and  internal  jugular  vein  ;  O,  ninth  or  hvpoglossal  nerve,  distributed  to  muscles  of  tongue  ; 
P,  P,  cords  of  brachial  plexus  of  nerves;   Q,  subclavian  arterv  in  connection  with  brachial  plexus  of 


mastoid  muscle  of  right  side;  3,  scalenus  posticus  muscle  ;  4,  splenius  muscle;  5,  mastoid  insertion  of 
steniomastoid  muscle;  6,  internal  maxillary  arterv;  7,  parotid  duct;  S,  genio-hvoid  muscle-  9  mvlo- 
hyoid  muscle,  cut  and  turned  aside  ;  10.  superior  thyroid  arterv;  11,  anterior  half  "of  omo-hyoid  muscle; 
IJ.  sierno-hyoid  muscle,  cut ;  13,  sterno-thvroid  muscle,  cut 


LTGA  TION  OF  A  Ji  TKR  TES.  1117 

The  Internal  Carotid  (PI.  XXV)  Ijegins  at  the  l)ifnrcation  of  the  primi- 
tive carotid,  upon  a  level  with  the  superior  border  of  the  tliyroid  cartilage, 
passes  upAvard,  and  enters  the  skull  through  the  carotid  foramen  in  the  petrous 
portion  of  the  temporal  bone.  As  the  vessel  ascends  in  the  neck  it  lies  in 
front  of  the  transverse  processes  of  the  upper  three  cervical  vertebrje.  At  the 
beginning  the  internal  carotid  lies  behind  and  a  little  external  to  the  external 
carotid  anery.     The  surface  guide  is  the  sterno-cleido-mastoid. 

The  incision  for  ligature  of  the  internal  carotid  artery  is  practically  identi- 
cal Avith  that  to  be  described  for  securing  the  external  carotid.  Having  divided 
the  inte<mment,  the  two  layers  of  the  superficial  fascia  between  which  lies  the 
platvsmS  mvoidos,  and  the  deep  fascia  attached  to  the  anterior  border  of  the 
sterno-cleido-mastoid  muscle,  the  posterior  belly  of  the  digastric  muscle  and 
the  stylo-hyoid  muscle  are  brought  into  view.  The  superior  thyroid,  lingua  , 
and  facial  veins,  and  also  some  lymphatic  glands,  are  to  be  carefully  avoided. 
The  hypoo-lossal  nerve  will  be  seen  crossing  the  external  carotid  artery.  Ihe 
muscles  and  the  veins  are  to  be  retracted  and  the  small  glands  removed,  and 
the  internal  carotid  will  be  fully  exposed.  In  passing  the  ligature  around 
the  vessel  the  needle  should  be  carried  from  without  inward,  and  the  pneumo- 
gastric  nerve  and  the  internal  jugular  vein  should  be  carefully  avoided  in 
the  center  of  the  wound  and  behind  the  vessel,  and  the  pharynx  upon  the 

inner  side.  ,  ,       ,     ,  .<.        ,•         i-  ^u 

The  External  Carotid  (PI.  XXV)  is  formed  by  the  bifurcation  ot  the 
primitive  carotid,  the  division  of  which  takes  place  upon  a  level  with  the  supe- 
rior border  of  the  thyroid  cartilage.  The  artery  passes  upward  in  the  neck  in 
a  curved  direction,  with  its  convexity  forward,  until  it  reaches  a  point  midway 
between  the  external  auditory  meatus  and  the  condyle  of  the  inferior  maxilla. 
In  the  upper  part  of  its  course  it  is  imbedded  in  the  substance  of  the  parotid 
gland.     The  surface  guide  is  the  sterno-cleido-mastoid.  ^   ,     •  f 

The  incision  should  begin  at  a  point  midway  between  the  angle  ot  the  inte- 
rior maxilla  and  the  mastoid  process  of  the  temporal  bone,  and  extend  down- 
ward parallel  with  the  anterior  border  of  the  sterno-cleido-mastoid  muscle  to 
the  upper  border  of  the  thyroid  cartilage  of  the  larynx.  The  integument,  the 
two  layers  of  the  superficial  fascia  between  which  lies  the  platysma  myoides, 
and  the  deep  fascia  which  is  attached  to  the  anterior  border  of  the  sterno-cleido- 
mastoid  muscle  are  to  be  divided.  The  superior  thyroid,  lingual,  aiid  facial 
veins,  and  also  the  lymphatic  glands,  are  to  be  carefully  avoided,  ihe  pos- 
terior belly  of  the  digastric  muscle  and  the  stylo-hyoid  muscle  are  to  be 
retracted  upward  and  inward,  and  the  sterno-cleido-mastoid  is  to  be  drawn 
outward.  The  hypoglossal  nerve  is  now  fully  exposed  to  view  as  it  crosses  m 
front  of  the  external  carotid  artery,  and  must  be  drawn  inward.  A  branch  of 
the  artery  should  be  sought  and  found  in  order  to  exclude  the  internal  carotid 
artery,  which  at  this  point  lies  close  to  the  external  carotid  and  might  be  mis- 
taken for  it.  Unlike  the  external,  the  internal  carotid  gives  ofi  no  branches 
in  the  neck.  At  the  bifurcation  the  internal  carotid  is  the  more  external  of 
the  two  vessels,  and  lies  on  a  plane  posterior  to  it.  The  needle  shi)uld  now  be 
passed  from  without  inward,  and  any  branch  that  is  given  off  from  the  external 
carotid  near  the  site  of  the  ligature  should  be  tied  also,  m  order  to  ensure  the 
formation  of  a  thrombus  at  the  point  of  ligation. 

The  internal  jugular  vein  sometimes  overlaps  the  artery,  and  great  care 
must  be  exercised  lest  the  vein  be  wounded  during  the  necessary  manip- 
ulations. Before  the  ligature  is  finally  tightened  the  operator  should  see  the 
effect  upon  the  temporal  by  compressing  the  external  carotid  between  the  liga- 
ture behind  and  the  thumb  upon  the  front  of  the  vessel.     The  internal  carotid 


1118  AX   A}n:iM('AX    TEXT-noOK    OF   sritCKllY. 

must  not  l>o  includt'd  in  tlic  li^^ature.  a  mistake  that  niav  <mciii-  if  the  exter- 
nal earotitl  is  tied  close  to  the  hi  furcation. 

The  Sl'I'KKlou  TllYROlli  (IM.  \\\')  is  the  first  hrancli  <:ivcn  r. IV  from  the 
external  carotid  artery.  This  vessel  arises  from  the  external  carotid  by  a 
single  trunk,  while  the  lingual  and  facial  often  arise  from  a  common  trunk 
which  bifurcates  to  form  these  two  vessels.  The  artery  as  it  leaves  its 
parent  trunk  passes  upward  and  forward  quite  superficially.  This  vessel  is 
irenerally  injured  in  attempts  to  commit  suicide,  because  it  stands  out  promi- 
nentlv  uj»on  the  anterior  aspect  of  the  neck.  The  artery  .><o(tn  curves  down- 
ward, and  runs  deep  in  the  neck  to  enter  the  thyroid  gland.  The  surface  guide 
is  an  oblique  line  drawn  parallel  with  the  anterior  border  of  the  sterno-cleido- 
mastoid  muscle,  while  the  muscular  guide  is  the  muscle  itself.  During  the 
operation  the  patient's  head  should  be  turned  to  the  opposite  side  and  the  chin 
be  elevated.  An  incision  should  be  made  parallel  to  the  anterior  border  of  the 
sterno-cleido-mastoid  muscle,  its  center  being  at  a  point  corresponding  to  the 
superior  border  of  the  thyroid  cartilage.  The  skin,  the  two  layers  of  the  super- 
ficial fascia  between  which  is  the  platysma  myoides,  and  the  fascia  along  the 
anterior  border  of  the  sterno-cleido-mastoid  muscle  are  next  divided.  This 
will  permit  the  latter  muscle  to  be  drawn  outward.  The  superior  thyroid  artery 
will  now  be  visible  crossing  the  floor  of  the  superior  carotid  triangle.  As  it 
crosses  the  triangle  it  is  situated  between  the  primitive  carotid  artery  and  the 
lobe  of  the  thyroid  gland,  into  which  it  passes.  The  carotid  sheath  should  be 
brought  fully  into  view,  and  the  superior  thyroid  artery  will  be  found  along  its 
inner  border.  The  surgeon  must  exercise  care  lest  the  superior  thyroid,  the 
lingual,  or  the  facial  vein  be  Avounded. 

The  Lingual  Artery  (Pis.  XXY  and  XXA^I). — This  vessel  is  reached 
by  a  curved  incision  beginning  a  little  below  and  to  the  right  or  left  of  the 
symphysis  menti,  and  extending  downward  and  outward  to  the  greater  cornu 
of  the  hyoid  bone  (Fig.  440).  This  incision  is  then  to  be  carried  upward 
toward  the  angle  of  the  inferior  maxillary  bone,  terminating  at  a  point  on  a 
level  with  the  beginning  of  the  incision,  but  short  of  the  facial  artery.  The 
integument  is  divided  throucrliout  the  lenorth  of  the  curvilinear  incision;  then 
the  two  layers  of  the  cervical  fascia  between  which  is  the  platys'.na  myoides. 
The  apex  of  the  submaxillary  gland  is  now  visible,  which  should  be  seized  by 
a  tenaculum  and  drawn  upward  by  gentle  traction,  at  the  same  time  tearing 
carefully  with  the  handle  of  the  scalpel  the  loose  connective  tissue  which  binds 
the  gland  to  the  subjacent  parts.  This  dissection  will  expose  Lesser  s  triangle. 
The  base  of  this  is  uppermost,  and  is  formed  by  the  hypoglossal  nerve,  while 
the  two  sides  lying  beloAv  are  formed  by  the  anterior  and  posterior  bellies  of 
the  digastric  muscle.  The  floor  of  this  triangle  is  formed  by  the  hyoglossus 
muscle,  upon  which  lies  the  ranine  vein  just  below  the  hypoglossal  nerve. 
Beneath  the  hyo-glossus  muscle  is  found  the  lingual  artery.  The  movements 
of  the  hyoid  bone  during  respiration  can  be  controlled  by  holding  the  bone 
steady  with  a  tenaculum,  as  suggested  by  Thiersch.  The  lingual  veins  accom- 
pany the  lingual  artery  as  a  rule,  but  are  of  small  size.  The  greater  cornu  of 
the  hyoid  bone  is  also  a  very  serviceable  guide. 

The  Facial  Artery  (PI.  XXV). — This  vessel  is  secured  at  the  point 
where  it  crosses  the  inferior  maxillary  bone  in  a  groove  just  in  front  of  the 
anterior  border  of  the  masseter  muscle.  To  expose  the  artery,  an  incision 
one  inch  in  length  should  be  made  from  the  anterior  inferior  angle  of  the 
masseter  muscle  in  the  line  of  the  artery  (Fig.  440),  dividing  the  integument, 
fascia,  and  platysma  myoides.  The  vessel  can  be  ligated  just  as  it  dis- 
engages itself  from  beneath  the  submaxillary  gland.    Tlie  facial  vein  is  found 


PLATE    XXVr 


"^ ^  ^>  If.  \8    ' 


(Maclise.) 


A,  root  of  common  carotiri  artery;  B,  subclavian  artery  at  origin;  C,  trachea;  D,  thyroid  axis  of  sub- 
clavian artery;  b,  vagus  nerve,  crussing  origin  of  subclavian  artery  ;  F,  subclavian  artery  at  third  division 
of  arch  ;  G.  i».st-scapular  brancli  of  subclavian  ;  H,  transversalis  humeri  tiranch  of  subclavian  ;  I,  traiis- 
ver.sjilis  colli  branch  of  subclavian  ;  K,  posterior  belly  of  omo-hyoid  muscle,  cut :  L,  median  nerve  branch  ; 
M,  iiiu.scul(i-s|.iral  nerve;  N,  anterior  scalenus  muscle ;  O,  cervical  plexus,  giving  off  the  phrenic  nerve, 
which  talics  tributary  branches  from  brachial  plexus  of  nerves  ;  P,  upper  part  of  internal  jugular  vein  ; 
Q,  upper  part  of  internal  carotid  artery;  R,  superior  cervical  ganglion  of  sympathetic  nerve  ;  S,  vagus 
nerve,  lying  external  to  sympathetic  nerve,  and  giving  off  <,  its  laryngeal  branch;  T,  superior  thyroid 
artery;  U,  lingual  artery,"  separated  bv  hyoglossus  muscle  from  V,  hypoglossal  nerve;  W,  s.iblingual 
glaiui  ;  X,  genio-h  void  muscle  ;  Y,  mvlo-hvoid  muscle,  cut  and  turned  aside  ;  Z,  thyroid  cartilage  ;  1,  upper 
part  of  sterno-hvoid  muscle  ;  2,  upper  part  of  omo-hyoid  muscle;  3,  inferior  constrictor  ol  pharynx;  4, 
cricoid  cartilage';  5,  crico-thvroid  muscle  ;  6,  thyroid  body;  7,  inferior  thyroid  artery  of  thyroid  axis  ;  3, 
sternal  tendon  of  sterno-mastoid  muscle,  turned  down;  9,  clavicular  portion  of  sterno-mastiud  muscle, 
turned  down;  10,  clavicle;  11,  trapezius  muscle;  12,  scalenus  posticus  muscle;  13,  rectus  capitis  anticus 
majnr  muscle;  14,  stylo-hyoid  muscle,  turned  aside;  15,  temporal  artery;  16,  internal  maxillary  artery; 
17,  inferior  dental  branch  of  fifth  pair  of  cerebral  nerves;  18,  gustatory  branch  of  fifth  pair  of  nerves; 
I"),  external  pterygoid  muscle  ;  20,  internal  pterygoid  muscle  ;  21,  temporal  muscle,  cut  to  show  the  deep 
icinixiral  liranches  of  fifth  yjair  of  nerves ;  22,  zygomatic  arch ;  23,  buccinator  muscle,  with  buccal  nerve 
and  parutid  duel ;  24,  masseter  uiUbclc,  cut  on  the  lower  maxilla  ;  26,  middle  constrictor  of  pharyr^x. 


LIGA  TION  OF  AR TEBIES.  1119 

upon  the  outer  side.  In  niakinj^  the  incision  the  skin  should  be  drawn  upward 
over  tlie  bone,  so  that  when  the  skin  retracts  the  scar  will  not  be  visilWe  upon 
the  face. 

Middle  Meningeal. —  For  a  descrij)tion  of  the  method  of  ligation  of  this 
vessel  see  Intracranial  Hemorrhage  (p.  r)14). 

The  Temporal  Artery  (Pis.  XXV  and  XXVI)  is  found  by  a  vertical 
incision  one  inch  in  length  made  half  an  inch  in  front  of  the  tragus  and  just 
above  the  zygomatic  arch  (Fig.  440).  After  dividing  the  skin,  the  fascia, 
and  the  dense  cellular  tissues,  the  finger  of  the  surgeon  can  distinctly  feel 
the  pulsation  of  the  vessel.  In  order  to  avoid  the  temporal  vein  and  the 
auriculo-temporal  nerve,  the  aneurysmal  needle  should  be  passed  from  behind 
forward,  as  the  temporal  artery  lies  superficial  to  and  in  front  of  the  vein  and 
nerve. 

The  Subclavian  Artery  (Pis.  XXV  and  XXVI)  springs  from  the  innom- 
inate artery  upon  the  right  side,  and  from  the  arch  of  the  aorta  upon  the  left 
side.  The  vessel  extends  from  the  sterno-clavicular  articulation  to  the  lower 
border  of  the  first  rib.  It  lies  behind  the  scalenus  anticus  muscle  in  the  second 
part  of  its  course.  In  the  third  portion  it  lies  in  the  subclavian  triangle, 
which  is  bounded  helow  by  the  clavicle,  on  the  outer  side  by  the  posterior  belly 
of  the  omo-hyoid,  and  on  the  inyier  side  by  the  posterior  border  of  the  sterno- 
cleido-mastoid. 

The  artery  is  ligated  in  the  third  portion  of  its  course,  just  outside  of 
the  outer  border  of  the  scalenus  anticus  muscle.  Ligation  of  the  subclavian 
behind,  and  upon  the  inner  side  of,  the  scalenus  anticus  has  proved  uni- 
formly fatal.  The  surface  guide  is  a  line  drawn  parallel  to  and  half  an 
inch  above  the  clavicle,  extending  from  the  outer  edge  of  the  sterno-cleido- 
mastoid  muscle  to  the  inner  edge  of  the  trapezius  muscle.  The  muscular 
guide  is  the  outer  border  of  the  scalenus  anticus  muscle.  The  tubercle  on 
the  first  rib  into  which  the  scalenus  anticus  is  inserted  is  the  deep  anatom- 
ical guide. 

In  ligating  the  subclavian  artery  in  its  third  portion  the  shoulders  should 
be  lifted  by  a  pillow,  the  head  turned  toward  the  opposite  side,  and  the  shoul- 
der corresponding  to  the  side  upon  which  the  artery  is  to  be  ligated  drawn 
downward.  Before  beginning  the  incision  the  external  jugular  vein  should 
be  compressed  and  its  course  distinctly  outlined,  so  that  this  vessel  may  be 
avoided.  The  skin  is  now  drawn  down  over  the  clavicle,  and  an  incision  is 
made  directly  upon  the  upper  margin  of  the  clavicle  and  extending  down  to 
the  bone,  and  from  the  outer  margin  of  the  sterno-cleido-mastoid  muscle  to  the 
inner  border  of  the  trapezius  muscle  (Fig.  440).  By  drawing  the  integument 
well  down  over  the  clavicle  the  external  jugular  vein  is  retracted  under- 
neath the  clavicle,  and  thus  escapes  injury.  When  all  the  tissues  are  divided 
to  the  bone  the  integument  is  allowed  to  assume  its  normal  position,  and  the 
line  of  the  incision  is  found  to  be  about  half  an  inch  above  the  clavicle  and 
directly  over  the  course  of  the  artery.  The  superficial  structures  having  been 
divided,  the  external  jugular  must  be  pulled  to  one  side.  The  loose  areolar 
tissue,  with  the  deep  fascia  which  engages  in  its  meshes  the  suprascapular  and 
transverse  cervical  veins,  is  separated  with  the  index  finger  and  the  handle  of 
the  scalpel.  The  tendon  of  the  omo-hyoid  muscle  is  exposed,  and  this  must  be 
pulled  upward  with  a  blunt  hook,  and  at  the  same  time  the  suprascapular  artery 
must  be  avoided.  The  surgeon  should  now  feel  for  the  outer  border  of  the  sca- 
lenus anticus  muscle,  and  carry  his  index  finger  down  along  the  edge  of  the  mus- 
cle until  the  tubercle  on  the  first  rib  is  felt.  The  subclavian  vein  lies  in  front 
of  this  muscle  and  upon  a  lower  plane  {i.  e.  lower  in  the  erect  posture),  while  the 


1120  AN  AMERICAN  TEXT-HOOK  OF  SURGERY. 

subclavian  artery  lies  beliind  tlio  muscle.  Tlic  artery  having  been  thus  exposed 
and  its  })ulsation  clearly  tV'lt  with  the  tip  of  the  sur<:eon's  finger,  the  aneiirvsra 
needle  shouhl  be  passed  from  below  upward  and  from  before  backward.  In 
passing  the  needle  around  the  artery  in  the  manner  just  described,  the  vein 
and  the  pleura  must  be  avoided  below,  and  the  cords  of  the  brachial  plexus, 
especially  the  lowest  cord  above. 

The  Collateral  Circulation  is  established  by  tiiree  sets  of  vessels: 

1.  The  sujirdscti^niliir  and  the  posterior  seupuhir  from  the  transversalis 

colli,  with  the  dorsalis  scapulce  from  the  subscapular. 

2.  The  internal  mammary,  the  superior  intercostal,  and  the  aortic  inter- 

costals  with  the  long  thoracic  and  superior  thoracic  from  the  axillary, 
and  the  dorsalis  scapuhv  from  the  subscapular. 

3.  Small  branches  given  off' from  the  subclavian,  anastomosing  with  unnamed 

branches  from  the  axillary  artery. 

The  Inferior  Thyroid  Artery  (PL  XXVI)  can  be  ligated  by  the  same 
incision  that  is  employed  for  the  purpose  of  tying  the  primitive  carotid. 
Having  exposed  the  carotid  artery  and  the  internal  jugular  vein  at  a  point 
just  below  where  the  omo-hyoid  tendon  crosses  in  front  of  the  carotid,  the 
sheath  and  its  contents  should  be  gently  drawn  outward  and  the  tendon 
upward  by  blunt  retractors.  The  inferior  thyroid  artery  will  now  be  exposed 
to  view  as  it  crosses  behind  the  carotid,  nearly  upon  the  same  level  as  that  at 
which  the  omo-hyoid  tendon  crosses  in  front  of  the  carotid.  The  artery 
enters  the  thyroid  gland  opposite  to  the  fifth  cervical  vertebra.  This  vessel 
crosses  behind  nearly  on  the  level  of  the  cricoid  cartilage.  Care  must  be 
exercised  by  the  surgeon  not  to  include  in  the  ligature  the  middle  cervical 
ganglion  or  the  recurrent  laryngeal  nerve,  nor  to  injure  the  oesophagus.  If 
the  artery  is  tied  low  down,  the  thoracic  duct  must  be  carefully  avoided. 

The  Vertebral  Artery  (PI.  XXVI)  is  reached  by  an  incision  four  inches 
in  length,  beginning  below  the  mastoid  process  and  extending  downward  and 
forward  parallel  with  the  posterior  margin  of  the  sterno-cleido-raastoid  muscle, 
terminating  about  one  inch  above  the  clavicle.  The  external  jugular  vein 
must  be  avoided  in  making  this  incision.  The  transverse  process  of  the  sixth 
cervical  vertebra  is  the  deep  anatomical  guide  to  the  vessel.  Having 
exposed  the  posterior  edge  of  the  sterno-cleido-mastoid  muscle  by  drawing  it 
toward  the  mesial  line,  the  scalenus  anticus  muscle  should  become  visible. 
Upon  this  lie  the  phrenic  nerve  and  the  transverse  cervical  artery,  which 
should  be  protected  from  injury.  The  border  of  the  scalenus  anticus  should 
be  made  distinct,  and  in  the  interval  between  it  and  the  longus  colli  muscle 
the  vertebral  artery  will  be  found,  with  its  vein  lying  superficial  to  tlie  artery. 
The  needle  should  be  passed  from  without  inward  and  from  behind  forward, 
avoiding  injury  to  the  pleura  and  drawing  aside  the  vertebral  vein. 

The  Internal  Mammary  Artery  may  be  tied  in  any  part  of  its  course, 
according  to  the  site  of  injury  of  the  vessel.  It  lies  just  beyond  the  borders 
of  the  sternum.  In  the  upper  t/co  intercostal  spaces  the  vessel  lies  upon  the 
pleura  :  and  if  the  vessel  is  injured  in  this  place,  the  pleura  is  most  likely 
to  be  injured  also,  and  hemorrhage  takes  place  into  the  cavity  of  the  pleura. 
If  the  vessel  is  wounded  below  the  third  intercostal  space,  the  pleural  cavity 
is  not  necessarily  opened,  since  the  triangularis  sterni  muscle  is  between  the 
artery  and  the  pleura.  If  the  vessel  is  wounded  below  the  third  intercostal 
space,  the  wound  can  be  tamponed,  as  the  triauiiularis  sterni  muscle  is  behind, 
and  pressure  can  be  made  against  this  muscle.  Of  course  above  the  third 
intercostal  space  strips  of  antiseptic  gauze  should  not  be  introduced  into  the 
wound.     If  the  injury  to  the  internal  mammary  artery  is  above   the  third 


PLATE     XXVII, 


r^^^:^t^ 


"w^^^ 


(Maclise.) 


A,  axillary  vein,  drawn  from  the  artery  to  show  the  nerves  lying  becween  both  vessels.  On  the  bicipi- 
tal border  of  the  vein  is  seen  the  internal  cntaneous  nerve  ;  on  the  trieipital  border  is  the  nerve  of  Wris- 
berg,  communicating  with  some  of  the  intercosto-humeral  nerves;  a,  the  common  trunk  of  the  vena 
coniiies,  entering  the  axillarv  vein;  B,axillarv  arterv  crossed  by  one  root  of  the  median  nerve  ;  b.  basilic 
vein,  forming  with  a  the  axillarv  vein,  A  ;  C,  c6raco-b"rachialis  muscle  ;  D.coracoid  head  of  biceps  muscle; 
E,  pectoralis  major  muscle;  F.pectoralis  minor  muscle;  G,  serratus  magnus  muscle,  covered  hy  g,  the 
axillarv  fascia,  and  perforated  at  regular  intervals  by  nervous  branches  called  intercosto-humeral;  H, 
conglobate  gland,  crossed  bv  nerve  called  "  external  respiratory"  of  Bell,  distributed  to  the  serratus  mag- 
nus muscle;  I,  subscapular  arterv;  K,  tendon  of  latissimus  dorsi  muscle;  L,  teres  major  muscle. 


LIGATION  OF  ARTERTES. 


1121 


intercostal  space,  the  symptoms  of  hemorrhage  in  general  are  present,  and  in 
addition  groat  difficulty  of  respiration.  In  a  wound  of  the  internal  mammary 
artery  both  ends  of  the  divided  vessel  should  be  tied,  or  return  of  the  hemor- 
rhage will  take  j)lace  through  the  deep  epigastric.  Fig.  440  shows  incisions 
for  reaching  the  internal  mammary  artery. 

The  Axillary  Artery  (IM.  XXVll). — The  surface  guide  to  the  axil- 
lary artery  is  a  line  drawn  })arallel  to  the  anterior  border  of  the  axillary  space, 
at  the  junction  of  the  anterior  with  the  middle  third.  The  artery  extends  from 
the  lower  border  of  the  first  rib  to  the  lower  border  of  the  tendon  of  the  teres 
major  and  latissimus  dorsi  nmscles,  its  three  portions  being  respectively  above, 
behind,  and  below  the  pectoralis  minor  muscle.  The  deep  muscular  guide 
is  the  lower  border  of  the  pectoralis  minor.  In  operating  on  the  third  por- 
tion the  arm  should  be  drawn  outward  at  right  angles  to  the  trunk  and 
abducted  (vide  Fig.  441),  and  an  incision  made  three  inches  in  length  along 
the  junction  of  the  anterior  with  the  middle  third  of  the  axillary  space. 
The  integuments  and  fascia  are  to  be  divided  along  the  inner  border  of  the 
coraco-brachialis  muscle.  The  median  nerve  is  to  be  drawn  to  the  outer  side 
and  the  axillary  vein  to  the  inner  side.  The  ulnar  nerve  lies  upon  the  inner 
side. 

Collateral  Circulation. — If  the  ligature  is  applied  above  the  acromial 
thoracic  artery,  the  collateral  circulation  is  the  same  as  in  ligature  of  the  third 
portion  of  the  subclavian.  If  the  ligature  is  applied  to  the  axillary  below  the 
acromial  thoracic  branch,  then  the  subscapular  and  long  thoracic  anastomose 
with  the  internal  mammary,  superior  intercostal,  and  aortic  intercostals. 

The  Brachial  Artery  (PI.  XXVIIl). — The  surface  guide  is  a  line 
drawn  from  the  junction  of  the  anterior  with  the  middle  third  of  the  axillary 
space  to  a  point  midway  between  the  two  condyles  of  the  humerus.  The 
muscular  guide  is  the  inner  border  of  the  biceps  muscle.  The  artery  lies 
upon  the  triceps,  coraco-brachialis,  and  brachialis  anticus  muscles.  It  is 
overlapped  in  the  upper  part  for  a  few  inches  by  the  biceps  and  coraco- 
brachialis  muscles.  The  deep  anatomical  guide  is  the  median  nerve, 
which  lies  usually  in  front  of  the  artery  as  it  comes  from  the  outer  to  the 
inner  side  of  the  vessel.  The  incision  should  be  made  about  the  middle  of  the 
arm  obliquely  along  the  inner  margin  of  the  biceps  muscle  (Fig.  441).     Dur- 

FiG.  441. 


Lines  of  Incision  Ibr  ligation  of  tlie  axillary  (third  portion),  brachial,  radial,  and  ulnar  arterieg 

(MacCormac). 

ing  the  operation  the  arm  should  be  rotated  outward  and  placed  at  right  angles 
to  the  trunk,  and  the  forearm  supinated;  the  back  of  the  arm  should  not  be 
allowed  to  rest  upon  anything;  lest  the  triceps  muscle  push  away  the  biceps 
and  the  muscular  guide  be  lost.  After  the  integument  and  fascia  have  been 
divided  the  median  nerve  will  appear  in  view.  The  nerve  is  to  be  pulled  out- 
ward and  the  basilic  vein  and  ulnar  nerve  inward  with  blunt  hooks.  The 
71 


1122  AN  AMKRK'AX  rKXT-BOOK  OF  Si'RGERY. 

arterv  will  be  found  directly  under  the  nerve.  The  operator  must  avoid  mak- 
ing his  incision  too  low  down  and  too  far  internally,  lest  he  mistake  the  ulnar 
nerve  for  the  median  and  liLMte  the  inferior  profun<la  artery  for  the  brachial. 

Collateral  Circulation, — The  superior  profunda  with  the  radial  recur- 
rent, the  inferior  profunda  with  the  ulnar  recurrent,  and  the  anastomotica 
magna  with  the  interosseous  recurrent. 

The  Radial  Artery  (PI.  XXIX). — The  surface  guide  is  a  line  drawn 
from  a  point  midway  between  the  two  condyles  of  the  humerus  to  a  point  lialf 
an  inch  internal  to  the  styloid  process  of  the  radius.  The  muscular  guide 
is  the  intermuscular  space  between  the  supinator  longus  and  flexor  carpi 
radialis  muscles.  As  the  artery  passes  down  the  forearm  it  rests  upon  the 
biceps  tendon,  supinator  brevis,  pronator  radii  teres,  radial  origin  of  the 
flexor  sublimis  digitorum,  flexor  longus  poUicis,  and  pronator  quadratus  mus- 
cles. At  the  lower  end  of  the  forearm  the  artery  rests  upon  the  radius  itself. 
The  nerve  is  upon  the  radial  si<le  in  the  middle  of  the  forearm,  but  at  the 
wrist  it  has  no  relation  with  the  artery,  having  passed  to  the  back  of  the 
forearm. 

The  incision  should  be  made  three  inches  above  the  wrist-joint,  the  forearm 
being  extended  and  supinated.  It  should  be  two  inches  in  length,  and  between 
the  tendons  of  the  supinator  longus  and  flexor  carpi  radialis  (Fig-  441). 

Collateral  Circulation. — The  interosseous  aiieries  with  the  anterior  and 
posterior  carpal  arteries  from  the  radial. 

The  Ulxar  Artery  (PI.  XXIX). — The  surface  guide  is  a  line  drawn 
from  a  point  midway  between  the  two  condyles  of  the  humerus  to  the  radial 
side  of  the  pisiform  bone.  The  artery  in  its  course  down  the  forearm  lies 
upon  the  brachialis  anticus  and  flexor  profundus  digitorum  muscles.  The 
flexor  carpi  ulnaris  muscle  is  situated  upon  the  ulnar  side  of  the  vessel.  The 
nerve  lies  to  the  ulnar  side  of  the  artery. 

During  the  operation  the  wrist  should  be  extended  and  the  forearm  supi- 
nated. The  incision  should  be  three  inches  in  length,  its  lower  end  termi- 
nating about  an  inch  above  the  wrist-joint  (Fig.  441).  The  skin,  the  super- 
ficial fascia,  and  the  deep  foscia  lying  above  the  ulnar  artery  are  to  be  divided 
upon  a  director  or  between  forceps,  and  the  artery  Avill  be  exposed.  The  needle 
should  be  passed  from  within  outward,  to  avoid  including  the  ulnar  nerve  in 
the  ligation. 

Collateral  Circulation. — The  interosseous  arteries  with  the  anterior  and 
posterior  carpal  arteries  from  the  ulnar  artery.  In  case  both  radial  and  ulnar 
arteries  are  ligated  simultaneously,  the  collateral  circulation  is  carried  on  by 
the  carpal  arteries  of  both  of  these  vessels,  which  anastomose  with  the  iiiter- 
osseoiis  arteries. 

The  Superficial  Palmar  Arch  (PI.  XXX)  may  be  ligated  at  the  point 
of  injury.  An  Esmarch  elastic  bandage  should  be  applied,  so  as  to  afford  a 
drv  dissection  of  the  parts.  The  divisions  of  the  median  and  ulnar  nerves,  as 
well  as  the  tendons  of  the  flexor  muscles  of  the  fingers,  lie  beneath  the  super- 
ficial palmar  arch,  while  the  integument,  palmaris  brevis  muscle,  and  palmar 
fascia  cover  the  vessel. 

The  incision  to  secure  the  superficial  palmar  arch  should  be  made  trans- 
versely across  the  palm  of  the  hand  along  a  line  drawn  from  the  palmar  border 
of  the  root  of  the  thumb,  when  hyperextended,  to  the  ulnar  border  of  the 
hand  (Fig.  442).  To  prevent  the  recurrence  of  hemorrhage  both  ends  of  the 
divided  arch  should  be  ligated,  as  well  as  any  branches  of  the  arch  that  are 
wounded. 

The  Deep  Palmar  Arch  (PI.  XXX)  is  formed  by  the  radial  artery  and 


PLATE     X  X  Vlll 


iMaclise.) 


LIGATION  OF  ARTERIES. 


1123 


Fig.  442. 


The  Fiq;ure  shows  the  position  of  the 
.'^u])frficial  ralniar  Arch,  and  the 
direction  and  jKjsition  of  the  wound 
which  would  liave  to  be  made  in 
order  to  reach  it  (MacCormac). 


a  branch  from  tlie  ulnar  artery.      The  arch  lies  upon  the  interosseous  muscles, 

and  likewise  upon  the  bases  of  the  metacarpal  bones,  and  is  covered  by  the 

flexor  tendons  of  the  fingers  and  flexor  brevis 

pollicis.     The  deep  arch  if  wounded  can  be  tied 

by  a  dissection,  having  first  applied  Esmarch's 

elastic  bandage.     The  wound  in  the  palm  of  the 

hand  must  form  the  guide  to  it.     Injury  of  the 

deep  structures  of  the  palm  must  be  carefully 

avoided. 

The  Intercostal  Arteries  are  given  off 
from  the  posterior  part  of  the  aorta  on  each 
side.  Each  artery  divides  into  a  posterior  and 
an  anterior  branch,  the  latter  running  forward 
to  supply  the  structures  in  its  intercostal  space. 
The  artery  runs  in  a  groove  along  the  lower 
border  of  the  rib,  Avhere  it  may  be  tied,  a  rib 
being  resected  if  necessary.  If  the  pleural 
cavity  is  filled  with  blood  in  consequence  of  a 
hemorrhage  from  this  vessel,  the  cavity  should 
be  washed  out  with  an  antiseptic  solution  and 
drained. 

The  AbdOxMINAl  Aorta  is  a  continuation 
of  the  thoracic  aorta,  and  extends  from  the  last 
dorsal  vertebra  to  the  left  side  of  the  fourth 
lumbar  vertebra,  at  which  point  it  divides  into 
the  common  iliac  arteries.  The  artery  lies  upon  the  front  of  the  bodies  of  the 
vertebrae.  The  stomach,  transverse  colon,  and  the  small  intestine,  the  pan- 
creas and  the  splenic  vein,  the  peritoneum,  mesentery,  and  sympathetic  nerve 
plexus,  lie  in  front  of  the  artery,  while  behind  it  are  found  the  left  lumbar 
veins,  thoracic  duct,  receptaculum  chyli,  and  the  anterior  ligaments  connect- 
ing the  bodies  of  the  vertebrie.  To  the  right  of  the  abdominal  aorta  lie  the 
inferior  vena  cava,  the  thoracic  duct,  and  the  vena  azygos,  while  to  the  left 
of  the  aorta  no  important  parts  are  contiguous  except  the  gangliated  chain  of 
the  sympathetic  nerve. 

The  abdominal  aorta  can  be  ligated  by  an  incision  about  four  inches  in 
length,  the  center  of  which  is  opposite  to  the  umbilicus  and  a  little  to  its  left 
side.  The  skin,  superficial  fascia,  aponeurosis  of  the  external  and  internal 
oblique  muscles,  the  transversalis  muscle,  and  the  peritoneum  are  all  divided. 
The  peritoneum  should  be  held  by  two  sutures  to  prevent  its  edges  from  retract- 
ing out  of  reach.  The  patient  is  now  turned  upon  the  right  side,  so  that  the 
abdominal  viscera  will  gravitate  to  that  side,  and  the  peritoneum  can  be  torn 
through  upon  the  left  side  of  the  artery.  The  aneurysm  needle  should  be 
passed  between  the  vena  cava  and  the  artery,  care  being  taken  not  to  include 
the  sympathetic  nerve.  The  abdominal  aorta  can  also  be  reached  by  a  lateral 
incision,  which  begins  at  the  tenth  rib  and  extends  downward  to  near  the 
anterior  superior  spinous  process  of  the  ilium.  The  skin,  superficial  fascia, 
the  aponeurosis  of  the  external  and  internal  oblique  muscles  and  the  trans- 
versalis muscle  and  fascia  having  been  divided,  the  peritoneum  is  carefully 
stripped  up  from  its  attachment  to  the  abdominal  parietes,  and  the  vessel 
reached  behind  the  peritoneum  and  without  opening  into  the  general  peritoneal 
cavity.  The  needle  should  then  be  passed  around  the  artery  in  the  same  man- 
ner as  described  in  reaching  the  vessel  by  the  median  incision. 

The  abdominal  aorta  has  been  li orated  eleven  times,  with  eleven  deaths. 


1124 


AN  AMERICAN  TEXT- HOOK  OE  SURGERY 


Fio.  AV.\. 


The  Common  Iliac  Artkriks  (1*1.  XWi)  are  about  two  inches  in  length, 
be<'in  at  the  left  side  of  the  body  of  the  fourth  lumbar  vertebra,  and  extend 

to  their  bifurcation  into  the  internal  and 
external  iliac  arteries  at  the  sacro-iliac 
synchondroses.  1'he  right  common  iliac 
artery  is  a  trifle  longer  than  the  left,  be- 
cause the  two  common  iliac  veins  join  to 
form  the  vena  cava  upon  the  right  side  of 
the  fifth  lumbar  vertebra. 

The  common  iliac  arteries  may  be  li- 
gated  either  by  an  incision  which  opens  the 
peritoneal  cavity,  or  by  a  lateral  incision 
which  reaches  the  vessel  beiiind  the  peri- 
toneum. The  surface  guide  of  the 
common  iliac  arteries  is  a  line  drawn  from 
a  little  below  and  to  the  left  of  the  um- 
bilicus to  a  point  midway  between  the 
symphysis  pubis  and  the  anterior  superior 
spinous  process  of  the  ilium.  An  incision 
is  made  six  inches  in  length  along  the 
linea  semilunaris,  beginning  from  the 
lower  border  of  the  seventh  rib  and  ex- 
tending to  nearly  the  spine  of  the  pubes 
(Fig.  443).  Having  divided  all  the  tis- 
sues, including  the  peritoneum,  the  intes- 
tines are  carefully  removed  and  wrapped 
in  hot  aseptic  gauze,  the  peritoneum  below 
scratched  through,  and  the  needle  passed 
from  without  inward  upon  the  right  side, 
and  from  within  outward  upon  the  left 
side.  In  passing  the  needle  in  this  way 
the  point  is  carried  away  from  the  vein. 
The  other  method  of  reaching  the  common  iliac  artery  is  by  a  lateral  incis- 
ion and  by  stripping  up  the  peritoneum,  so  as  to  secure  the  vessel  without 
opening  the  peritoneal  cavity.  The  incisitm  should  begin  from  the  eleventh 
rib,  and  extend  downward  to  a  point  two  inches  above  the  center  of  Poupart's 
ligament;  all  the  tissues  are  to  be  divided  until  the  peritoneum  is  reached. 
The  subserous  areolar  tissue  and  the  peritoneum  are  to  be  carefully  stripped 
upward  and  forward  from  the  iliac  fossa  until  the  fascia  covering  the  psoas 
muscle  comes  into  view.  Just  above  the  sacro-iliac  synchondrosis  and  upon 
the  inner  margin  of  the  psoas  muscle  the  common  iliac  artery  is  felt  pulsating. 
As  the  two  vessels  difier  slightly  in  their  relative  anatomy,  the  needle  must  be 
passed  in  a  different  direction  in  each  case.  In  ligating  the  left  common  iliac 
artery  the  needle  must  be  passed  from  within  outward,  carefully  avoiding  the 
superior  hemorrhoidal  artery,  which  must  be  pushed  aside,  together  with  the 
mesocolon  belonging  to  the  sigmoid  flexure.  The  ureter  crosses  the  common 
iliac  below,  and  is  generally  raised  with  the  peritoneum.  In  ligating  the  right 
common  iliac  artery  the  needle  must  be  passed  from  without  inward,  carefully 
avoiding  the  iliac  veins,  which  have  crossed  underneath  the  artery  in  order  to 
form  the  vena  cava.  The  ureter,  as  in  the  case  of  ligating  the  left  common 
iliac,  is  usually  raised  out  of  reach,  but  if  it  is  not  lifted  from  the  vessel  with 
the  peritoneum  it  must  be  pulled  downward  by  a  blunt  hook,  so  as  not  to  be 
included  in  the  ligature. 


Direction  of  the  Common  and  External  Iliac 
Arteries,  and  the  positions  of  the  superficial 
incisions  adopted  for  their  ligature.  On  the 
right  side  is  that  for  the  external  iliac,  and 
on  the  left  side  that  for  the  common  iliac 
artery  (MacCormac). 


PLATE     XXIX 


placlise.) 


F 

artery 

municating 

middle 


io-  1  _A  fascia  covering  biceps  muscle  ;  B, basilic  vein,  with  internal  cutanemis  nerve  :  C  brachial 
-."with  veiiffi  com'ites;  D.  cephalic  vein,  with  external  cutanwrns  nerve;  (?,  mediaii  nerve ;  E.  a  cuin- 
catint?  vein,  joining  veme  comites  :  F, median  basilic  vein;  G,  lymphatic  gland  ;  H,  radial  arter>  at 
le  •  I   radial  arterv  of  the  pulse  ;  K,  ulnar  artery,  with  ulnar  nerve  ;  L,  palmaris  brevis  muscle. 


lomm  subliniis:  P,  flexor  pollicis  longus  ;  Q.  median  nerve;  R,  lower  end  of  radial  artery  ;S,lo\Ner  end 
of  ulnar  artery,  in  company  with  ulnar  nerve  ;  T,  pisiform  bone;  U,  extensor  metaearpi  pollicis. 


LIGATION  OF  ARTERIES. 


112;-) 


The  Internal  Iliac  Aktkries  (IM.  XXXI)  arise  at  the  bifurcation  of  the 
common  iliac  near  the  sacro-iliac  synchondroses.  The  internal  iliacs  run  down 
into  the  pelvic  cavity  to  supply  the  pelvic  organs.  These  vessels  can  be 
ligated  in  either  of  the  two  ways  already  described  for  reaching  the  common 
iliac  arteries.  After  the  abdominal  cavity  is  opened  or  the  peritoneum  is 
pushed  aside  by  the  lateral  incision,  the  pulsation  of  the  artery  can  be  dis- 
tinctly felt  as  the  vessel  descends  into  the  pelvis  upon  the  inner  side  of  the 
psoas  muscle  and  along  the  sacro-iliac  synchondroses.  The  needle  used  to 
secure  this  vessel  should  be  made  with  the  curve  at  right  angles  to  the  shaft, 
and  one  must  be  made  for  the  right  and  one  for  the  left  internal  iliac  artery. 
The  ligature  should  be  applied  about  one  inch  below  the  bifurcation,  and  the 
needle  passed  from  within  outward  and  from  behind  forward.  The  ureter  lies 
in  front  of  the  artery,  and  the  external  iliac  vein  must  be  carefully  avoided. 
Dennis  of  New  York  has  re- 
ported three  cases  of  ligation  Fig.  444. 
by  the  intraperitoneal  ope- 
ration. Two  recovered ;  the 
third — in  which  both  internal 
iliacs  were  tied  for  the  first 
time — died.  In  lio-aturing  all 
the  vessels  in  the  abdominal 
cavity,  the  bowels  should  be 
thoroughly  emptied  by  a  ca- 
thartic the  night  previous  to  the 
operation,  and  by  an  enema  a 
short  time  before  the  opera- 
tion. The  bladder  should  also 
be  emptied,  as  in  all  abdom- 
inal operations. 

The  Gluteal  Artery  is  a 
branch  of  the  internal  iliac  ar- 
tery, and  emerges  from  the  pel- 
vis at  the  upper  part  of  the  great 
sacro-sciatic  foramen  above  the 
pyriformis  muscle.  The  gluteal 
artery  can  be  ligated  at  the 
point  where  the  vessel  comes 
out  of  the  pelvis.  The  patient 
should  be  placed  upon  his  ab- 
domen with  the  thigh  extended 
and  the  hip-joint  rotated  inward. 
The  surface  guide  is  a  line 
drawn  from  the  posterior  supe- 
rior spinous  process  of  the  ilium 
to  the  middle  of  the  trochanter 
major.  At  the  junction  of  the 
upper  with  the  middle  third 
of  this  line  the  artery  emerges 
from  the  pelvis  (Fig.  444). 
The  muscular  guide  is  the 
upper  border  of  the  pyriformis 
muscle.  The  gluteus  raaximus  muscle  cavers  the  artery.  An  incision  six 
inches  in  length  should  be  made  along  the  course  of  the  artery,  as  indicated  by 


Position  and  Direction  of  the  Superficial  Incisions  which 
must  be  made  in  order  to  secure  the  gluteal  artery  and  the 
sciatic  and  pudic  arteries  :  j4,  posterior  superior  iliac  spine; 
B,  great  trochanter  ;  C,  tuberosity  of  the  ischium  ;  D,  ante- 
rior superior  iliac  spine  ;  ^i?,  ilio-trochanteric  line,  divided 
into  thirds.  This  line  corresponds  in  direction  with  the 
fibers  of  the  gluteus  maximus  muscle.  The  incision  to 
reach  the  gluteal  artery  is  indicated  by  the  darker  portion 
of  the  line.  Its  center  is  at  the  junction  of  the  upper  and 
middle  thirds  of  the  ilio-trochanteric  line,  and  exactly  cor- 
responds with  the  point  of  emergence  of  the  gluteal  artery 
from  tlie  great  sciatic  notch.  AC,  ilio-ischiatic  line.  The 
incision  to  reach  the  sciatic  artery  and  internal  pndic  is 
indicated  by  the  lower  dark  line.  It  also  is  to  be  made  in 
the  direction  of  the  fibers  of  the  gluteus  maximus  muscle. 
The  center  of  the  wound  corresponds  to  the  junction  of  the 
lower  with  the  middle  third  of  the  ilio-ischiatic  line 
(MacCormac). 


1 1  '2i]  A  N  A  M ERICA  N  TEXT-B  O  OK  OF  S UR GER  Y. 

the  linear  guide.  Alter  dividing  the  skin  and  fascia,  the  gluteus  maximus 
muscle  will  appear,  the  fibers  of  which,  running  parallel  to  the  incision,  can 
be  separated  and  held  apart  by  retractors.  The  deep  fascia  beneath  the  mus- 
cle is  to  be  divided,  and  the  artery  will  now  be  felt  in  tiie  bottom  of  the  wound 
and  at  the  upper  ])art  of  the  foramen  above  the  tendon  of  the  pyriformis. 
The  vena?  comites  must  be  separated  and  the  needle  j)assed  around  the  artery. 

The  Sciatic  Artery  is  a  branch  of  the  internal  iliac  artery,  and  leaves 
the  pelvis  through  the  great  sacro-sciatic  foramen  at  its  lower  part  and  below 
the  tendon  of  the  pyriformis  muscle.  The  artery  descends  between  the  tuber- 
osity of  the  ischium  and  the  trochanter  major.  This  vessel  has  close  to  it  the 
internal  pudic  artery.  The  patient  is  placed  upon  the  abdomen  with  the  thigh 
extended  and  the  hip-joint  rotated  inward.  The  surface  guide  is  a  line 
drawn  from  the  posterior  superior  spinous  process  of  the  ilium  to  the  tuberosity 
of  the  ischium.  The  muscular  guide  is  the  lower  border  of  the  tendon  of 
the  pyriformis  muscle.  An  incision  is  made  along  the  linear  guide  already 
mentioned  (Fig.  444) :  after  division  of  the  skin  and  fascia,  the  gluteus  max- 
imus muscle  comes  into  view  ;  its  fibers  are  separated  by  tlie  handle  of  a 
scalpel  and  held  apart  by  retractors.  Having  divided  the  fascia  beneath  the 
gluteus  maximus,  the  sciatic  artery  can  be  felt  pulsating  just  below  the  inferior 
mar<^in  of  the  pyriformis.  The  sciatic  nerve  accompanies  the  sciatic  artery  as 
it  emerges  from  the  pelvis,  and  the  internal  pudic  artery  lies  internal  to  the 
sciatic  artery.  The  course  which  the  two  arteries  take  will  dispel  any  doubt 
as  to  which  vessel  is  the  sciatic.  The  ligature  is  passed  around  the  artery, 
carefully  avoiding  the  nerve,  the  internal  pudic  artery,  and  the  venoe  comites. 

The  Internal  Pudic  Artery. — This  vessel  may  be  tied  either  within 
the  pelvis  in  the  perineum  or  outside  of  the  pelvis  as  the  artery  emerges  from 
the  greater  sacro-sciatic  foramen  just  below  the  pyriformis  muscle.  The  vessel 
can  be  tied  by  the  same  incision  that  has  been  already  described  to  secure  the 
sciatic  artery^  since  the  artery  lies  just  internal  to  it  at  the  lower  part  of  the 
greater  sacro-sciatic  foramen  (Fig.  444).  The  internal  pudic  nerve  accom- 
panies the  artery,  which  has  venae  comites.  The  artery  enters  the  pelvis  by 
passing  through  the  lesser  sacro-sciatic  foramen,  and  skirts  along  the  outer  side 
of  the  ischio-rectal  fossa  lying  upon  the  obturator  internus  muscle  and  covered 
over  with  the  obturator  fascia. 

The  internal  pudic  can  also  be  ligated  in  the  perineum.  The  patient  is 
placed  in  the  same  position  as  for  lithotomy,  and  an  incision  is  made  from  a 
point  just  beneath  the  symphysis  pubis  to  the  inner  side  of  the  tuberosity  of 
the  ischium.  The  vessel  can  be  felt  pulsating  an  inch  and  a  half  above  the 
tuberosity.  The  skin,  fascia,  and  tissues  are  divided,  and  the  artery  found 
with  its  venae  comites  and  the  internal  pudic  nerve.  The  crus  penis  is  liable 
to  be  wounded  in  the  upper  part  of  the  incision. 

The  External  Iliac  Artery  (PI.  XXXI)  is  formed  by  the  bifurcation  of 
the  common  iliac,  and  extends  from  the  sacro-iliac  synchondrosis  to  Poupart's 
ligament.  The  external  iliac  artery  runs  along  the  inner  margin  of  the  psoas 
muscle,  to  which  it  is  bound  down'by  a  reflection  of  the  fascia.  The  genito- 
crural  nerve  lies  upon  the  outer  side  of  the  artery,  and  near  Poupart's  ligament 
the  spermatic  vessels  cross  it.  The  left  external  iliac  vein  lies  upon  the  inner 
side  of  the  artery,  but  it  is  under  the  artery  at  its  beginning  upon  the  right 
side.  Just  above  Poupart's  ligament  the  circumflex  iliac  vein  crosses  the 
artery,  and  the  vas  deferens  winds  around  the  epigastric  artery  and  descends 
into  the  pelvic  cavity  upon  the  inner  side  of  the  external  iliac  artery. 

The  external  iliac  artery  can  X>e  ligated  by  first  performing  a  laparotomy 
by  an  incision  in  the  linea  semilunaris,  and  then  tearing  through  the  posterior 


PLATE    XXX, 


"— <5S^ 


(Maclise.) 


vi^  1      A    r-i.Tifll  artprv  B  median  nerve:  b,b,b,  its  branches;  C,  ulnar  artery,  forming  F,  sujier- 

bone  of  the^humb^   tendons  of  extensor  digitorum  communis:  A*,  tendon  overlying  that  of  indicator 

n?l^ttnsor  earn  radfalis  brevier  G,  tendon  of  extensor  carpi  radialis  longior  :  H,  tendon  of  third  ex- 
?en\or"of  the  th^umbTl  tendon  of 'second  extensor  of  the  thumb ;  K.  tendon  of  extensor  minimi  dig.ti. 
joining  a  tendon  of  extensor  communis. 


LIGATION  OF  ARTERIES.  1127 

layer  of  the  peritoneum  in  the  same  manner  that  has  already  been  described 
for  tying  the  common  or  the  internal  iliac  artery.  The  artery  can  also  be  tied 
by  a  lateral  incision  about  four  inches  in  length  about  one  inch  above  Poupart's 
ligament.  The  incision  should  begin  just  external  to  the  origin  of  the  deep 
epigastric  artery,  "which  is  about  the  center  of  Poupart's  ligament,  and  con- 
tinue outward  and  upward  along  the  crest  of  the  ilium  internal  to  the  circum- 
flex iliac  artery  (Fig.  443).  The  incision  made  in  this  manner  avoids  wound- 
ing these  two  brandies  of  the  external  iliac  artery,  and  thus  preserves  a  most 
important  collateral  circulation.  The  skin,  the  superficial  fascia,  the  aponeu- 
rosis of  the  external  oblique  muscle,  and  the  internal  oblique  and  transversalis 
muscles,  are  all  divided  to  the  full  extent  of  the  external  incision.  The  trans- 
versalis fascia  is  now  severed  upon  a  grooved  director,  carefully  avoiding  the 
peritoneum.  The  peritoneum  and  the  subperitoneal  areolar  tissue  are  next  gently 
stripped  up  from  the  iliac  and  psoas  fasciae  with  the  finger  or  the  handle  of  the 
scalpel,  and  with  its  contained  viscera  is  pushed  inward  toward  the  umbili- 
cus. The  spermatic  vessels  and  the  ureter  are  usually  adherent  to  the  perito- 
neum, and  are  thus  pushed  out  of  the  way.  The  surgeon  should  exercise  great 
care  in  stripping  up  the  peritoneum,  as  any  rough  manipulation  would  be  likely 
to  favor  the  development  of  a  purulent  oedema  or  a  pelvic  cellulitis  or  pelvic 
peritonitis.  The  finger  should  now  be  carried  to  the  bottom  of  the  wound,  and 
the  inner  margin  of  the  psoas  muscle  felt,  along  the  edge  of  which  the  artery 
runs.  The  needle  should  be  passed  from  Avithin  outward,  so  as  to  avoid  the 
external  iliac  vein,  which  lies  upon  the  inner  side  of  the  artery.  The  ureter 
crosses  the  artery  at  its  extreme  upper  end,  and  must  be  pushed  upward  if  for 
any  reason  it  should  cross  lower  down  than  usual.  The  genital  branch  of  the 
genito-crural  nerve  is  seen  lying  upon  the  front  of  the  vessel,  and  must  not  be 
included  in  the  ligature.  The  ureter  usually  is  out  of  reach,  but  the  possi- 
bility of  its  presence,  owing  to  its  non-attachment  to  the  peritoneal  mem- 
brane, must  not  be  overlooked. 
The  Collateral  Circulation  : 

1.  The  internal  mammary  wdth  the  deep  epigastric  artery. 

2.  The  ilio-luonhar  with  the  circumjiex  iliac  artery. 

3.  The  gluteal  with  the  external  circumjiex. 

4.  The  obturator  with  the  internal  circumjiex. 

5.  The  internal  pudic  with  the  extertial  pudic. 

6.  The  sciatic  with  the  perforating  branches  of  the  deep  femoral. 

7.  The  comes  nervi  ischiadici  with  the  branches  of  the  deep  femoral. 

The  Deep  Epigastric  Artery  is  given  off  from  the  external  iliac  just 
above  Poupart's  ligament,  and  runs  upward  toward  the  umbilicus.  At  its 
beginning  it  lies  just  to  the  inner  side  of  the  internal  abdominal  ring,  and  in 
its  course  runs  between  the  peritoneum  and  the  fascia  transversalis. 

The  epigastric  artery  can  be  ligated  by  an  incision  beginning  one  inch 
above  Poupart's  ligament  and  carried  parallel  to  the  ligament  for  three  inches. 
The  center  of  the  incision  should  be  over  the  artery.  The  surface  guide  is 
a  line  drawn  from  the  middle  of  Poupart's  ligament  to  the  umbilicus.  The 
muscular  guide  is  the  transversalis  muscle  with  the  transversalis  fascia. 
The  integument,  two  layers  of  superficial  fascia,  the  aponeurosis  of  the  ex- 
ternal oblique  muscle,  and  the  internal  oblique  and  transversalis  muscles  and 
fasciae  are  to  be  divided,  and  when  the  transversalis  fascia  is  reached  it  should 
be  cut  upon  a  director  and  the  artery  exposed.  The  needle  should  be  passed 
in  such  a  manner  as  to  avoid  the  veins. 

The  Circumflex  Ilii  is  another  branch  of  the  external  iliac  artery,  and 
takes  a  direction  upward  and  outward  parallel  with  Poupart's  ligament  and  the 


1128 


AN  AMEincAX   TEXT- HOOK  OF  SURGERY. 


crest  of  the  ilium.  It  runs  close  to  the  inner  lip  of  the  crest.  The  circum- 
flex iliac  artery  can  be  ligated  by  the  same  incision  that  has  been  mentioned 
for  securing  the  opi^jastric  artery,  or  the  vessel  may  be  tied  by  another  iticis- 
ion  just  above  and  parallel  to  l*ouj)art"s  ligament  and  the  crest  of  the  ilium, 
'riic  diti'erent  layers  must  be  cut  down  upon  until  the  transversalis  fascia  is 
reached.      The  artery  lies  between  this  fascia  and  the  peritoneum. 

The  Femoral  Aktkry  (PI.  XXXI)  is  a  continuation  of  the  external  iliac 
vessel.  It  extends  from  a  point  midway  between  the  anterior  superior  spinous 
process  of  the  ilium  and  the  symphysis  pubis  to  the  opening  in  the  adductor 
magnus  muscle,  through  which  the  femoral  artery  passes  to  become  the  pop- 
liteal. The  artery  lies  in  a  triangle  known  as  Scarpa's  triangle,  which  is 
bounded  as  follows :  the  bane  of  the  triangle  is  Poupart's  ligament,  the  outer 
side  is  the  inner  margin  of  the  sartorius  muscle,  and  the  inner  side  is  the 
inner  margin  of  the  adductor  longus  muscle.  The  inner  border  of  both  mus- 
cles must  be  taken  as  the  boundaries  of  the  triangle,  which  excludes  the  sarto- 
rius from  taking  part  in  the  floor  of  the  triangle,  but  includes  the  adductor 
longus.  The  femoral  artery  is  covered  by  integument,  superficial  and  deep 
fasciae,  and  the  sheath  of  the  vessels.  A  branch  of  the  internal  cutaneous 
nerve  and  the  crural  branch  of  the  genito-crural  nerve  lie  upon  the  sheath  of 
the  vessels.  The  internal  saphenous  vein  lies  superficial  to,  as  well  as  upon, 
the  inner  side  of  the  artery. 

The  ligation  of  the  femoral  artery  is  usually  performed  at  the  apex  of 
Scarpa's  triangle,  about  five  inches  below  Poupart's  ligament.  The  surface 
guide  is  a  line  drawn  from  a  point  midway  between  the  anterior  superior 
iliac  spine  and  the  symphysis  pubis  to  the  adductor  tubercle  upon  the  inner 
condyle  of  the  femur.  The  muscular  guide  is  the  inner  margin  of  the 
sartorius  muscle.  The  patient  should  lie  upon  his  back,  with  the  knee 
slightly  flexed  and  the  hip  rotated  outward,  the  femur  also  being  slightly 
flexed  and  abducted.     The  incision  should  begin  three  inches  below  Poupart's 


Fig.  445. 


The  lines  indicate  the  incisions  to  be  made  for  tlio  ligature  of  the  foniniiiii  feinnnil.  of  the  femoral  in 
Scarpa's  triangle  and  in  Hunter's  canal,  and  of  the  posterior  tiliiul  in  the  calf  and  hehind  the  mal- 
leolus (MaeCormae). 

ligament  (this  should  be  a  measured  distance,  or  the  incision  will  probably  be 
made  too  low),  and  be  carried  downward  about  three  inches  along  the  line  of 


PLAT  E     XXXI. 


--;:^'^~:c  ■:-<CX^ 


(Maclise.) 


A,  aorta  at  point  of  bifurcation ;  B,  anterior  superior  iliac  spine;  C.  symphysis  pubis;  D.  Poupart's 
iigament,  immediately  above  which  are  seen  the  circumflex  iliac  and  epigastric  arteries,  with  vas  deferens 
and  spermatic  vessels  :  E,  E*,  right  and  left  iliac  muscles,  covered  by  peritoneum  :  the  external  cutaneous 
nerve  is  seen  through  the  membrane  ;  F,  the  vena  cava  ;  G,  G*,  common  iliac  arteries,  giving  ort'  internal 
iliac  branches  on  the  sacro-iliac  symphyses;  gr,  a,  right  and  left  ureters;  H,  H*,  right  and  left  common 
iliac  veins ;  I,  I,  right  and  left  external  iliac  arteries  :  each  is  crossed  bv  circumflex  iliac  vein  ;  K,  K,  right 
and  left  external  iliac  veins;  L,  urinary  bladder,  covered  by  peritoneum;  M,the  rectum;  N,  profunda 
branc'n  of  femoral  artery  ;  O,  femoral  vein ;  o,  saphena  vein  ;  "P,  anterior  crural  nerve  ;  Q,  sartorius  muscle, 
cut;  S,  pectineus  muscle;  T,  adductor  longus  muscle ;  U,  gracilis  muscle;  V,  tendinous  sheath  given  off 
from  long  adductor  muscle,  crossing  vessels  and  becoming  adherent  to  vastus  internus  muscle  (forming 
Hunter's  canal y ;  W,  femoral  artery. 


LIGATION  OF  ARTERIES.  1129 

the  femoral  artery  (Fig.  44')).  Tlic  integument,  the  superficial  fascia,  and  the 
fascia  lata  are  all  divided.  The  lymphatic  glands,  if  they  are  in  the  field 
of  operation,  must  he  pushed  aside  or  removed.  The  internal  saphenous  vein 
lies  upon  the  inner  side  of  the  incision,  and  its  position  can  be  readily  made 
out  by  making  pressure  upon  the  vein  near  its  entrance  into  the  femoral. 
The  surgeon  should  now  look  for  the  sartorius  muscle,  the  fibers  of  which  run 
downward  and  inward.  The  sartorius  must  not  be  mistaken  for  the  adductor 
longus,  the  fibers  of  which  run  downward  and  outward.  Just  under  cover  of 
the  sartorius  muscle  the  sheath  of  the  femoral  vessels  will  be  found.  The 
sheath  should  be  opened  upon  the  outer  side,  so  as  to  avoid  wounding  the 
femoral  vein  in  the  event  of  its  overlapping  a  part  of  the  artery.  Upon  the 
sheath  lies  the  crural  branch  of  the  genito-crural  nerve.  In  passing  the  needle 
around  the  femoral  artery  it  should  be  carried  from  within  outward.  The 
femoral  vein  in  this  situation  is  posterior  as  well  as  internal  to  the  artery. 
The  long  saphenous  nerve  must  be  avoided  as  it  lies  over  the  artery. 

Collateral  Circulation. — 1.  The  profunda  femoris  with  the  articular 
bratu'/ti's  of  the  jmpUteal  and  the  tibial  recurrent. 

2.  The  arteria  comes  nervi  ischiadici  with  the  perforating  branches  of  the 
profunda  femoris  and  the  articular  branches  of  the  popliteal  and  tibial  recur- 
rent. 

The  Popliteal  Artery  (PI.  XXXII)  is  a  continuation  of  the  femoral 
from  the  opening  in  the  adductor  magnus  muscle  to  tlie  lower  border  of  the 
popliteus  muscle.  The  artery  as  it  runs  obliquely  downward  lies  at  first  upon 
the  posterior  border  of  the  condyloid  surface  of  the  femur,  in  its  middle  por- 
tion upon  the  posterior  ligament  of  the  knee-joint,, and  in  its  lower  portion 
upon  the  popliteus  muscle.  Behind  the  popliteal  artery  is  the  popliteal  vein, 
which  is  joined  by  the  short  saphenous  vein  from  below,  while  the  internal 
popliteal  nerve  is  superficial  and  a  little  external  to  the  vein.  The  space 
through  which  the  artery  runs  is  covered  over  by  a  dense  fibrous  fascia  which 
is  a  continuation  of  the  fascia  lata,  and  this  binds  down  the  vessels  and  nerves 
and  lymphatic  glands.  The  lateral  boundaries  of  this  space  are  formed  above 
by  the  inner  and  outer  hamstrings,  and  below  by  the  divergence  of  the  two 
heads  of  the  gastrocnemius  muscle. 

The  ligation  of  the  popliteal  artery  may  be  best  accomplished  in  the  upper 
part  of  the  space.  The  surface  guide  is  a  line  drawn  from  a  point  about 
one  inch  internal  to  the  upper  .angle  of  the  space  to  the  apex  of  the  inferior 
angle.  The  muscular  guide  is  the  external  margin  of  the  semi-membra- 
nosus  muscle.  An  incision  should  be  made  beginning  at  the  upper  part  of  the 
space  and  continuing  obliquely  downward  through  the  space,  about  four  inches 
in  length.  This  incision  should  be  just  external  to  the  outer  margin  of  the 
semi-membranosus  muscle.  The  integument  and  superficial  fascia  having  been 
divided,  the  fibers  of  the  semi-membranosus  appear  in  view.  This  muscle 
should  be  drawn  inward  with  a  blunt  retractor.  The  space  will  be  found  to 
contain  loose  areolar  tissue,  which  must  be  carefully  teased  away  with  the 
handle  of  the  scalpel  until  the  sciatic  nerve  is  exposed.  Just  to  the  inner 
side  of  the  nerve  lies  the  popliteal  vein,  while  the  artery  lies  slightly  more 
internal  and  almost  covered  by  the  vein  to  which  it  is  closely  connected.  The 
sciatic  nerve  and  the  popliteal  vein  must  now  be  drawn  to  the  Outer  side  by  a 
blunt  hook,  when  the  artery  will  be  fully  exposed  to  view.  The  aneurvsm 
needle  should  be  passed  in  a  direction  from  without  inward. 

The  Posterior  Tibial  Artery  (Pis.  XXXII  and  XXXIII)  arises  at  the 
bifurcation  of  the  popliteal.  It  begins  at  the  lower  margin  of  the  popliteus 
muscle,  and  extends  down  the  back  of  the  leg  to  a  point  between  the  internal 


]];30  AN  AMEIZICAN  TEXT-BOOK  OF  SURGERY. 

malleolus  and  the  tuberosity  of  tlie  os  calcis,  avIktc  the  artery  divides  to  forra 
the  internal  and  the  external  ])lantar.  The  artery  in  its  course  down  the  leg 
lies  upon  the  deep  layer  of  muscles  of  the  calf  and  is  covered  in  by  the  super- 
ficial layer.  The  surface  guide  is  a  line  drawn  from  the  middle  of  the  pop- 
liteal space  to  a  point  half  an  inch  behind  the  tip  of  the  internal  malleolus. 
The  muscular  guide  is  the  outer  border  of  the  flexor  lon<^fus  di^^itorum  in 
the  lower  part  of  its  course,  and  the  soleus  muscle,  beneath  whicli  it  lies,  in 
the  upper  part  of  its  course.  It  can  be  lifjated  through  an  incision  in  the  mid- 
dle of  the  calf  while  the  patient  is  lying  upon  the  abdomen.  This  should  be 
made  slightly  to  the  inside  of  the  median  line  of  the  leg,  and  be  about  six 
inches  in  length  in  order  to  reach  the  artery  at  this  depth  and  fully  to  expose 
it.  The  muscles  of  the  calf  are  then  divided  down  to  the  deep  fascia  beneath 
which  the  artery  lies.  This  fascia  being  divided  upon  a  director,  the  artery  is 
exposed,  the  nerve  lying  to  its  outer  side.  The  artery  is,  however,  more  com- 
monly ligated  by  an  incision  four  inches  in  length  parallel  to  the  inner  border 
of  the  tibia  and  three-quarters  of  an  inch  behind  it  (Fig.  445).  In  dividing 
the  skin  and  the  fascia  the  internal  saphenous  vein  must  be  carefully  avoided. 
The  thin  tibial  attachment  of  the  soleus  is  next  carefully  divided  throughout 
the  entire  length  of  the  incision.  The  ankle-joint  is  now^  extended,  thus  relax- 
ing the  soleus,  which  is  lifted  by  a  retractor,  and  the  deep  fjiscia  comes  into  view. 
The  artery  can  be  felt  pulsating  under  it,  near  the  external  border  of  the  tibia, 
and  is  exposed  by  dividing  the  fascia  upon  a  grooved  director.  The  artery 
needle  should  be  passed  from  without  inward  to  avoid  the  nerve. 

The  posterior  tibial  artery  can  be  also  ligated  just  behind  the  internal  mal- 
leolus. A  crescentic  incision  is  made  with  the  convexity  downward,  the  center 
of  which  should  be  at  a  point  midway  between  the  tip  of  the  internal  malleolus 
and  the  inner  tuberosity  of  the  os  calcis  (Fig.  445).  Tlie  skin,  the  superficial 
and  the  deep  fasciae,  and  the  internal  annular  ligament  having  been  divided, 
the  artery  is  exposed.  The  relations  of  the  parts  from  above  downward  are  as 
follows :  the  tendon  of  the  tibialis  jiosticus,  the  tendon  of  the  flexor  longus 
digitorum,  the  artery  with  a  vena  comes  on  each  side  of  it,  the  posterior  tibial 
nerve,  and  the  tendon  of  the  flexor  longus  pollicis. 

The  Peroneal  Artery  begins  about  an  inch  below  the  popliteus  muscle, 
and  passes  obliquely  down  the  leg  parallel  Avith  and  just  posterior  to  the  shaft 
of  the  fibula.  The  incision  should  be  about  four  inches  in  length  upon  the  outer 
part  of  the  calf,  while  the  leg  is  rotated  so  that,  its  inner  surface  rests  upon  the 
operating  table  and  its  outer  surface  is  turned  upward.  The  skin,  the  fas- 
ciae, the  fibular  origin  of  the  soleus  muscle,  and  the  deep  fascia  separating  this 
muscle  and  the  flexor  longus  pollicis,  are  all  to  be  divided.  The  soleus  and 
flexor  longus  pollicis  muscles  can  be  relaxed  by  extending  the  ankle-joint, 
and  the  cut  fibers  of  the  soleus  can  be  retracted  inward.  The  peroneal  artery 
will  be  found  upon  the  inner  side  of  the  flexor  longus  pollicis :  it  has  occa- 
sionally been  observed  in  the  substance  of  that  muscle.  It  lies  close  to  the 
fibula,  and  unless  this  fact  is  observed  the  posterior  tibial  might  be  tied  in  its 
place. 

The  Anterior  Tibial  Artery  (PI.  XXXIII)  is  formed  by  the  bifurca- 
tion of  the  popliteal,  and  begins  at  the  lower  border  of  the  popliteus  muscle. 
It  passes  between  the  tibia  and  the  fibula  just  above  the  interosseous  mem- 
brane, and  then  runs  down  upon  this  membrane  to  the  ankle-joint,  from  which 
point  the  vessel  is  known  as  the  dorsalis  pedis.  The  anterior  tibial  artery  in 
the  upper  third  of  the  leg  lies  between  the  tibialis  anticus  muscle  and  the 
extensor  communis  digitorum  ;  in  the  middle  third  of  the  leg,  between  the 
tibialis  anticus  and  the  extensor  proprius  pollicis ;  in  the  lower  third  of  the 


PLATE    XXXII. 


r^km^,.-^ 


(Maclise.) 


Fig:.  1 — A,  tendon  of  gracilis  muscle  ;  B,  B,  fascia  lata  :  C,  C,  tendon  of  semimembranosus  ;  D,  tendon 
of  semitendinosus,  E,  E,  the  two  heads  of  gastrocnemius :  F,  popliteal  artery:  G,  popliteal  vein,  joined 
by  short  saphena  vein;  H,  middle  branch  of  sciatic  nerve;  K,  posterior  tibial  nerve,  continued  from 
middle  branch  of  the  sciatic,  and  extending  to  K*;  L,  posterior  (short  saphena  vein  ;  M,  M,  fascia,  cover- 
ing gastrocnemius  ;  N,  short  (posterior)  saphena  nerve,  formed  by  union  of  branches  from  peroneal  and 
posterior  tibial  nerves  ;  O,  posterior  tibial  artery,  appearing  from  beneath  soleus  muscle  in  lower  part  of 
leg;  P,  salens  muscle,  joining  tendo  Aehillis;  Q,  tendon  of  flexor  communis  digitorum ;  R,  tendon  of 
flexor  longus  poUicis  ;  S,  tendon  of  peroneus  longus;  T,  peroneus  brevis  muscle  ;  U,  U,  internal  annular 
ligament,  binding  down  vessels,  nerves,  and  tendons  in  hollow  behind  inner  ankle  ;  V,  V,  tendo  Aehillis: 
w,  tendon  of  tibialis  posticus  muscle  ;  X,  the  venae  comites  of  posterior  tibial  artery. 

FisT.  2.— A,  C,  0,  E,  F,  G,  H,  I,  refer  to  same  parts  as  in  Fig.  1 ;  B,  inner  condyle  of  the  femur;  K, 
plantaris  muscle,  lying  upon  popliteal  artery;  L.popliteus  muscle;  M,  M,  M.the  tibia:  N,  N,  the  fibula; 
O,  O,  posterior  tibial  artery ;  P,  peroneal  artery ;  Q,  R,  S,  T,  U,  V,  W.  refer  to  same  parts  as  in  Fig.  1 :  X, 
the  astragalus. 


LIGATION  OF  ARTERIES. 


1131 


Fig. 44G. 


leg,  between  the  extensor  communis  digitorum  and  tlie  extensor  proprius  pol- 
lici's.     It  has  the  anterior  tibial  nerve  in  the  ujjper  third  of  its  course  upon 
the  outer  side,  in  tlie  middle  third  anterior  to 
it,  and  in  the  lower  third  again  upon  the  outer 

side. 

The  ligation  of  the  anterior  tibial  may  be  ac- 
complished in  the  lower  part  of  the  upper  third 
of  tlie  leg.    The  surface  guide  is  a  line  drawn 
half  an  inch  from  the  inner  sitle  of  tlie  head  of  the 
fibula  to  a  point  midway  between  the  two  mal- 
leoli.    The  muscular  guide  is  the  outer  mar- 
gin of  the  tibialis  anticus  muscle.     The  incision 
should  be  made  four  inches  in  length  along  the 
line  indicated  by  the  surface  guide  (Fig.  446). 
The  skin  and  superficial  fascia  are  divided,  and 
then  the  deep  fascia  upon  a  grooved  director. 
The  foot  should  now  be  strongly  extended  and 
everted,  in  order  to  make  tense  the  marginal 
border   of  the   muscular   guide.     This  muscle 
must  be  separated  by  retractors  from  the  ex- 
tensor  communis   digitorum.     The   artery  will 
be    found    lying    upon    the   interosseous   mem- 
brane, with  the  anterior  tibial  nerve  in  front 
of  it  or  to  its  outer  side.     The  two  muscles  are 
to  be  widely  separated,  the  nerve  drawn  out- 
ward, the  vems  isolated  from  the  artery,  and  the 
aneurysm  needle  passed  from  without  inward. 

The  anterior  tibial  artery  can  be  ligated 
also  above  the  ankle-joint.  The  surface 
guide  is  a  line  drawn  in  front  of  the  ankle- 
ioint  midway  between  the  two  malleoli.  The 
muscular  guide  is  the  outer  edge  of  the 
extensor  proprius  pollicis.  An  incision  is  made 
along  the  linear  and  muscular  guides,  dividing 
the  skin  and  superficial  fasciae.  The  tendon 
of  the  tibialis  anticus  is  made  taut  by  eversion 
of  the  foot,  and  the  extensors  by  flexion  of  the 
toes  and  extension  of  the  foot.  The  tendons  of  the  two  extensors  are  now 
separated  by  retractors,  and  the  artery  is  felt  pulsating  in  the  mtertendmous 
space,  with  the  anterior  tibial  nerve  upon  the  outer  side.  The  needle  is  to  be 
passed  from  without  inward,  avoiding  the  venpe  comites  and  the  nerve. 

The  DoRS\Lis  Pedis  Artery  (PI.  XXXIII)  is  a  continuation  of  the  ante- 
rior tibial  artery,  and  its  course  would  be  indicated  by  a  line  drawn  from  a 
point  midway  between  the  two  malleoli  to  the  interosseous  space  between  the 
^reat  and  second  toes  (Fig.  446).  The  linear  guide  to  the  artery  is  the  pro- 
loncration  of  a  line  indicating  the  guide  to  the  anterior  tibia  ,  and  the  mus- 
cular guide  is  the  outer  margin  of  the  extensor  proprius  poUicis. 

In  licratincr  the  dorsalis  pedis  arterv  the  ankle-joint  should  be  extended  and 
the  toes%tron"gly  flexed,  which  will  bring  out  in  relief  the  tendons  ^liich  are 
to  serve  as  a  guide  to  the  arterv.  The  skin  and  superficial  fascia  are  divided 
by  an  incision  about  three  inches  in  length,  and  the  above-mentioned  tendons 
are  separated  by  retractors  after  dividing  the  dense  fascia  attached  to  the 
extensor  proprius  pollicis.     The  artery  will  be  felt  pWsating  at  the  bottom  of 


Position  and  direction  of  the  incisions 
which  may  be  made  to  ligate  the  an- 
terior tibial  and  dorsalis  pedis  arte- 
ries (MacCormac). 


1132  AX  AMERICAN  TEXT-ROOK  OF  SURGERY. 

the  wound,  witli  the  nerve  lying  u{)on  the  outer  side  and  the  venae  comites 
upon  the  two  sides  of  the  artery.  The  inner  tendon  of  the  extensor  brevis  digi- 
torum  erosses  tlie  dorsalis  pedis  artery,  and  this  tendon  must  be  retracted  out- 
ward in  order  fully  to  expose  the  dorsalis  pedis  artery. 


CHAPTER    V. 
OPERATIONS  OX   BONES  AND  JOINTS. 

Operations  on  bones  and  joints  are  numerous  and  of  many  kinds — the 
enucleation  of  non-malignant  tumors,  the  removal  of  sequestra,  the  wiring  of 
fragments  after  fracture,  division  for  the  relief  of  deformity,  trephining,  aspi- 
ration, and  incision  to  give  exit  to  fluids,  pus,  blood,  and  excessive  secretion, 
or  for  the  extraction  of  foreign  bodies,  etc.  ;  and  especially  the  taking  away 
of  a  part  or  the  whole  of  a  bone  or  a  joint  for  injury  or  disease — resection  or 
excision,  for  the  terms  are  commonly  used  interchangeably. 

Resection  or  Excision. — Whenever  the  condition  of  the  diseased  or 
injured  part  is  such  that  life  will  be  seriously  imperilled  by  the  long  contin- 
uance of  suppuration  and  protracted  confinement  that  must  be  associated  with 
non-operative  treatment,  or  when  the  functional  value  of  the  articulation  or 
limb  so  preserved  Avill  be  but  slight,  or  the  resulting  deformity  will  be  great, 
or  the  existing  disease  in  all  probability  will  extend  to  contiguous  parts  or 
be  carried  to  those  at  some  distance,  or  when  amputation  is  the  alternative, — 
then  resection  is  indicated,  provided  the  condition  of  the  patient  permits  of  its 
performance.  The  danger  of  its  execution  is  not  excessive;  the  likelihood 
of  the  complete  removal  of  the  disease  is  in  many  cases  at  least  fair ;  and 
the  part  saved  will  be  serviceable,  or  can  be  rendered  so  by  the  aid  of  some 
apparatus. 

The  ItiHtrumnnts  required  for  its  performance  are  knives  and  scissors  for 
such  laying  open  of  the  soft  parts  as  may  be  necessary  to  uncover  the  bone  or 
joint  and  to  remove  infected  tissues :  retractors  to  keep  the  field  of  operation 
exposed  ;  saws  and  cutting  forceps  for  division  of  bone ;  gouge  forceps,  sharp 
spoons,  chisels,  and  hammer  for  the  removal  of  limited  portions  of  bone;  ele- 
vators and  periosteotomes  for  removing  the  periosteum ;  drills  and  pins  and 
sutures  of  wire  or  other  suitable  material  for  the  after-fixation  of  the  parts 
if  this  be  necessary ;  and  the  ordinary  instruments  and  dressings  for  closing 
wounds.  Barker's  sharp  spoon,  which  permits  the  flushing  of  the  field  of 
operation  through  its  hollow  handle,  will  often  be  found  of  niucli  service. 
The  Esmarch  bandage  is  generally  useful,  but  in  some  of  the  operations  it 
cannot  be  employed,  and  in  others  is  of  doubtful  value  because  of  the  great 
amount  of  after-oozing.  As  immobilization  of  tiie  limb  will  generally  have 
to  be  secured  for  a  considerable  length  of  time  splints  of  special  form  may  be 
required. 

Whenever  practicable — and  this  is  almost  always  the  case — the  operation 
should  be  performed  antiseptically  and  the  strictest  antisejitic  after-treatment 
employed,  the  mortality  thus  being  reduced  to  a  minimum,  early  union  secured, 
the  general  strength  of  the  patient  economized,  and  the  inconvenience  and  risk 
of  frequent  dressing  saved  to  both  operator  and  patient.  Whenever  it  can  be 
done  the  periosteum  should  be  lifted  off  the  bone,  not  in  shreds,  but  in  as  com- 
plete a  sheet  as  possible,  and  preserved,  that  regeneration  more  or  less  complete 


PLATE     XXXIII. 


(Maclise.) 


Fi«.l.-A,  tendon  of  t,,etibiaUsa„tiev.jnu^^ 
alls  posticus  muscle;  D  the  ">»•}  ^''•J'\';,  ""^\ 'V/il  ^    q'     'leiis  muscle:   H,  tendon   of  the  plantans 
;;;S;  r',^?^:f^r;;itnl^f i^;^'T^J^o^tS  a^ryf\^L,  posterior  tibial  nerve, 
""rt.  2.-A.  tibialis  anticusmuscle;  a  itstendon;Bexten^^^^^^^ 
four  tendons;  C,  extensor  longus  PoHicis  miiscle     D   D  the  tu^m^^  ^  ^^.^^^.  ^ 

descending  to  the  dorsum  ot  the  toot. 


OPERA  T/O AS  ON  HONES  AND  JOINTS.  ll").'^ 

accordin<:f  to  circuinstaiices  may  take  jdat-f.  Such  subperiosteal  resection 
may  coiiiinonly  be  done  in  cjuses  of  disease,  but  in  cases  of  injury,  especially  if 
recent,  it  will  frecjuently,  if  not  generally,  be  found  impossible  to  effect  it. 

In  all  cases  tlie  least  possible  injury  should  be  done  to  the  soft  structures 
consistent  with  due  exjiosure  (»f  the  part  to  be  ojterated  upon,  the  muscles  being 
divided  longitudinally  rather  than  cut  across,  and  important  vessels  and  nerves 
avoided  or  pushed  aside.  Hemorrhage  should  be  temporarily  controlled  by 
forceps,  as,  speaking  generally,  it  is  inadvisable  to  sj)end  time  in  the  applica- 
tion of  ligatures,  as  at  the  close  of  the  operation  many  of  them  will  be  found 
unnecessary. 

When  a  portion  (»f  bone  is  removed,  not  liecause  it  is  diseased,  but  in 
order  to  get  at  deeper-seated  j)arts,  as  in  certain  operations  upon  the  Jaws 
and  in  the  skull,  it  should  be  sejjarated  otilji  in  /xoi,  to  be  later  re])laced  and 
attached — the  so-called  osteoplastic  resection. 

When  the  excision  is  of  a  part  of  the  shaft  of  a  bone,  it  is  one  in  con- 
tinuity;  when  of  an  articular  extremity,  in  contiguity.  Speaking  generally, 
operations  in  continuity  are  much  less  satisfactory  than  those  in  contiguity  ; 
and  this  is  particularly  true  if  they  be  done  upon  the  femur  and  the  humerus. 
Non-union  has  not  seldom  been  observed,  and  an  ununited  fracture  of  the 
thigh  is  a  great  inconvenience — much  more  so,  of  course,  than  one  of  the  arm, 
though  this  is  troublesome  enough.  Besides  this,  in  the  thigh  the  resulting 
shortening  may  mucb  disable  the  patient. 

In  the  forearm  and  leg,  when  one  bone  only  is  operated  upon  and  any  con- 
siderable piece  is  taken  away,  the  ends  of  the  fragments  cannot  be  brought 
together,  and  the  re-formation  necessary  to  fill  in  the  gap  is  apt  to  be  imper- 
fect :  often  it  is  so  in  an  extreme  degree.  Bone-grafting  as  now  done  prom- 
ises something  toward  the  filling  up  of  such  defects,  but  how  much  may  be 
accomplished  by  it  the  future  must  determine.  Compensatory  overgrowth  of 
the  other  bone  may,  and  often  does,  render  the  limb  a  serviceable  one,  but 
there  has  frequently  been  observed,  especially  in  the  forearm,  a  gradually  pro- 
duced deformity  at  once  unsightly  and  crippling.  It  is  much  better  in  these 
cases  to  cut  out  so  much  of  the  other  healthy  bone  as  will  enable  the  operator 
to  bring  the  fragments  of  both  bones  into  proper  apposition.  Very  generally, 
when  the  case  is  one  of  injury,  informal  removal  of  detached  fragments,  with, 
if  necessary,  the  cutting  off  of  sharp  ends  of  the  others,  gives  a  much  better 
ultimate  result  than  resection  in  continuity. 

When  in  an  excision  in  contiguity  the  entire  articulation  is  removed,  it  is 
complete  ;  when  the  end  of  only  one  bone  or  a  portion  thereof,  partial.  At 
times  an  entire  bone  is  taken  away.  When  the  excision  is  done  in  a  regular 
way  and  after  some  established  method,  it  is  a  formal  or  typical  one  ;  when 
partial  and  adapted  to  the  peculiar  condition  of  the  particular  case,  informal 
or  atypical.  If  performed  for  inj»ry  and  within  a  few  hours  after  its  receipt,  it 
is  primary;  when  in  the  period  of  local  and  general  disturbance  accompany- 
ing and  following  reaction  and  before  the  occurrence  of  suppuration,  inter- 
mediary;  when,  without  regard  to  the  nature  of  the  cause,  after  suppuration 
has  become  established,  secondary.  Under  ordinary  circumstances  inter- 
mediary operations  should  not  be  done. 

When  in  a  limited  portion  of  the  shaft  a  tumor  is  present,  if  non-malig- 
nant it  should  be  shelled  out  and  the  healthy  bone  preserved ;  if  malignant, 
the  entire  hone  should  be  resected  or  the  limb  amputated  or  the  case  left  un- 
operated  upon,  according  to  circumstances. 

In  joint  rejections  the  question  of  partial  or  total  excision  will  be  settled 
by  the  nature  and  extent  of  the  cause  and  the  probable  functionaH'alue  of  the 


1134  AX  A.VFRrr.lX   TKXT-IlOOk'  OF  ST'Ra KRV, 

limb  after  one  operation  or  the  other.  If  there  has  })een  received  an  injury 
nfteeting  a  part  of  tlie  articuhition,  that  part  only  should  be  removed,  provided 
the  ultimate  usefulness  of  the  joint  will  be  as  great  as  if  complete  resection 
had  been  done.  The  rule  to  sacrifice  nothing  unnecessarily  holds  good,  and 
late  experience  of  the  results  of  improved  wound-treatment  has  been  favor- 
able to  partial  excisions  and  those  of  informal  character. 

But  if  the  case  is  one  of  disease  almost  certainly  tubercular,  \\'\\\  j)artial 
removal  get  rid  of  the  entire  disease  ?  If  the  lesion  is  confined  to  one  bone, 
there  is  no  reason  for  complete  excision  unless  a  better  result  functionally  can 
thus  be  secured;  but  it  is  generally  the  case,  at  least  in  the  elbow,  knee,  wrist, 
and  ankle,  that  by  the  time  the  operation  is  warranted  the  tubercular  deposit 
is  not  thus  limited,  and  complete  removal  in  those  Joints  will  usually  be  best. 
Infected  synovial  and  perisynovial  tissues  must  always  be  thoroughly  removed; 
and  it  is  in  doing  this  that  much  of  the  difficulty  of  the  operation  often  lies, 
and  the  fiiilure  to  accomplish  it  is  the  frequent  cause  of  relapse. 

The  prognosis  has  of  late  years  become  very  good,  certainly  so  far  as 
recovery  from  the  operation  is  concerned.  Until  the  introduction  of  antisepsis 
the  mortality  was  heavy  from  exhaustion,  septic  infection,  amyloid  disease  of  the 
kidney  or  intestines,  tubercular  meningitis,  or  tuberculosis  of  the  lungs,  often 
greatly  aggravated  by  the  resection  and  its  direct  results.  At  the  present  time 
the  patient  is  not  likely  to  die  if  in  any  fit  condition  for  operation  and  if  properly 
protected  against  the  dangers  of  suppuration. 

A  thoroughly  aseptic  excision  is  almost  certain  to  be  followed  by 
prompt  healing,  even  if  rliere  is  coexisting  tubercular  disease  in  another 
joint  or  bone  or  in  the  lung,  and  improvement,  greater  or  less,  of  longer  or 
shorter  duration,  in  the  condition  of  such  other  part  may  be  expected  to  fol- 
low. If  the  tubercular  deposit  is  not  thoroughly  removed,  the  recovery  will 
be  incomplete ;  sinuses  will  remain,  necessitating  reopening  and  scraping ;  or 
the  apparently  healed  wound  will  reopen,  or  the  disease  will  so  extend  in  the 
bone  and  soft  parts  as  to  compel  amputation:  or  a  general  dissemination  of  the 
bacilli,  at  times  set  free  by  the  operation  itself,  may  occur  and  speedily  cause 
death.  The  large  number  even  of  those  successfully  operated  upon  die  before 
many  years,  commonly  of  pulmonary  tuberculosis. 

AETHRECTOMY  OR   ERASION. 

The  ideal  operation  in  cases  of  tubercular  joint  disease  is  one  in  which  all 
unhealthy  tissue  is  taken  away  and  all  healthy  tissue  left  undisturbed.  This 
cannot  be  the  case  when  excision  is  done,  since  more  or  less  unaffected  tissue 
must  be  removed  :  often  the  error  will  be  in  both  directions,  and  some  infected 
tissue  will  be  left. 

Erasion  is  a  better  term  than  arthrectoray.  The  latter  term  should  be 
restricted  to  complete  extirpation  of  tlie  synovial  membrane  and  diseased  peri- 
articular structures,  leaving  the  bone  untouched — an  operation  which  is  neces- 
sarily of  limited  application.  Erasion  is  intended  exactly  to  satisfy  the 
requirements,  to  cut  away  and  with  sharp  spoon  to  scrape  away  the  tubercular 
material  present  in  membrane,  ligament,  and  bone,  and  nothing  more. 

If  it  were  possible  to  ascertain  before  or  at  the  time  of  operation  just 
where  the  tubercular  deposits  were  and  their  full  extent,  erasion  would  afford 
complete  relief,  or  at  least  relief  as  complete  as  can  be  effected  in  a  case  of 
local  tuberculosis,  since  there  must  always  be  a  chance  of  operative  dissemi- 
nation or  of  coexisting  tubercular  disease  in  near  or  remote  parts.  It  is  not 
possible,  however,  to  do  this,  although  much  can  be  learned  by  inspection,  by 


OPERATIOXS  OX  liOXES  A XI)  JOIXTS.  ll.i") 

pressure  through  the  soft  parts  or  directly  upon  the  exposed  bone  (limited  ten- 
derness, which  is  often  pathognomonic,  being  thus  discovered),  or  by  puncture, 
diminished  resistance  indicating  locali'/e<l  softening,  due,  it  may  be  safely  con- 
cluded, to  disease. 

15ut  while  it  is  true  that  erasion  may  not  accomplish  the  desired  object,  the 
considerable  experience  of  many  surgeons  in  various  parts  of  the  world  in  the 
last  few  years  has  shown  that  both  in  children  and  in  adults  thorough  cleaning 
out  by  knife,  scissors,  and  spoon  will,  in  a  large  proportion  of  cases,  be  fol- 
lowed by  highly  successful  results,  even  to  the  preservation  of  the  function  of 
the  articulation  operated  upon.  The  operation  may  be  done  much  earlier  than 
an  excision  is  likely  to  be  performed,  it  is  less  severe,  an<l  if  unsuccessful  the 
major  operation,  typical  resection,  is  still  in  reserve,  can  be  readily  executed, 
is  attended  with  no  more  risk  than  if  primary,  and  if  delayed  by  the  erasion 
until  after  full  growth  of  the  limb  has  been  secured,  the  ultimate  shortening  is 
much  less. 

In  doing  an  erasion  the  joint  must  be  fully  opened,  and  that  method  of 
incision  is  the  best  which  most  completely  and  with  least  injury  to  the  parts 
permits  of  thorough  exploration,  since  success  can  be  looked  for  only  after 
removal  of  all,  or  nearly  all,  of  the  diseased  tissue,  although  without  doubt 
very  small  portions  of  tubercular  material  can  be  spontaneously  got  rid  of 
by  degeneration  and  cicatrization  or  by  encapsulation. 

Most  of  the  arth'rectomies  have  been  done  upon  the  knee-joint.  The  term 
arthrotomy  is  at  times,  but  improperly,  employed  as  synonymous  with  erasion 
or  arthrectomy.  If  used  at  all,  it  should  be  in  its  proper  sense,  to  indicate 
simple  incision  of  a  joint,  without  regard  to  the  purpose  or  extent  of  the 
opening. 

OSTEOTOMY. 

Division  of  a  long  bone  for  the  relief  of  deformity  is,  as  a  rule,  easy  of 
performance,  is  attended  with  but  little  danger,  and  is  satisfactory  in  result. 
The  section  is  ordinarily  a  linear  one,  but  it  may  be  cuneiform,  a  wedge  being 
removed  (Fig.  447),  or  trochleiform,  the  section  being  a  curved  one. 

Generally  it  is  done  subcutaneously,  the  incision  down  to  the  bone  being 
only  large  enough  to  admit  of  the  ready  passage  of  the  saw  or  chisel  employed, 
or  even  this  may  be  omitted  and  the  chisel  driven  in  ;  but  at  times  the  portion 
of  bone  to  be  operated  upon  is  fully  exposed,  and  with  aseptic  precaution  this 
open  method  is  attended  with  little  or  no  more  risk  than  the  other.  Either 
saw  or  chisel  may  be  employed,  the  latter  being  generally  preferred,  as  being 
more  under  control,  easier  to  use,  and  making  no  dust.  Two  or  three  chisels 
of  different  sizes  may  be  used  in  dividing  the  bone,  or  a  single  one,  according 
to  the  preference  and  habit  of  the  operator.  Of  saws,  the  choice  lies  between 
the  chain  saw  and  the  narrow  stiff  one,  and  ordinarily  the  latter  will  be  se- 
lected. A  sand-bag  to  rest  the  limb  on  will  much  facilitate  the  operation. 
Complete  instrumental  division  of  the  bone  need  not  be  made,  as  a  thin  por- 
tion of  the  surface  opposite  the  point  of  entrance  can  readily  be  broken,  and 
the  risk  of  injury  to  the  soft  parts  by  the  chisel  or  saw^  avoided. 

The  dangers  are  two — septic  inflammation  and  wounding  of  important 
nerves  or  blood-vessels,  especially  the  latter.  The  former  will  be  prevented 
by  antisepsis  or  asepsis  during  the  operation  and  after-treatment ;  the  latter 
by  care  at  the  time  of  the  section,  though  the  accident  has  happened  in  the 
practice  of  even  the  most  prudent  and  skilful  operators.  When  it  does  occur, 
the  existing  conditions  will  determine  whether  it  is  better  to  let  the  damaged 
part  alone  or  to  cut  down  and  suture  the  nerve  or  tie  the  vessel.     The  bone 


1136 


^.y  AMERICAN  TEXT-BOOK  OF  SURGERY 


having  been  divided,  rectification  of  the  malposition  should  be  effected  at  once, 
an  aseptic  dressing  with  an  abundance  of  cotton  placed  around  the  area  of  ope- 


Viii.  447. 


Diagram  representing  a  Curved  Tibia:  ,-1,  with  a  wedge  removed  on  the  convex  side  for  the  purpose 
of  straigiitening  the  bone ;  B,  the  same  with  the  bone  straightened ;  C,  the  same  with  a  wedge 
removed  from  the  concave  side  and  the  bone  straightened,  thus  necessarily  leaving  a  gap  in  the 
bone  (after  Little). 


ration,  and  the  limb  immobilized  by  a  plaster-of-Paris  dressing  or  a  splint  for 
a  number  of  weeks — four  to  eight  or  more  according  to  the  age  of  the  patient 
and  the  kind  and  locality  of  the  operation.  Unless  the  wound  becomes  infected 
there  are  not,  at  any  time,  constitutional  symptoms  of  serious  import. 

Osteotomy  for  Genu  VAL(iUM. — One  of  the  most  useful  of  these  oste- 
otomies is  Macewen's  supracondyloid  osteotomy  for  genu  valgum.     The 
patient  lies    recumbent,    with   the  leg  flexed   upon   the 
Fig.  448.  thigh  and  the  abducted  thigh  flexed  upon  tlie  pelvis, 

and  laid  upon  its  outer  side,  on  a  sand-pillow.  Mac- 
ewen's description  of  his  operation  is  as  follows:  "A 
sharp-pointeil  scalpel  is  introduced  on  tlie  inside  of  the 
thigh,  at  a  point  where  the  two  following  lines  meet,  one 
drawn  transversely,  a  finger's-breadth  above  the  superior 
tip  of  the  external  condyle,  and  a  longitudinal  one  drawn 
half  an  inch  in  front  of  the  adductor  magnus  tendon.  The 
scalpel  here  penetrates  at  once  to  the  bone,  and  a  longi- 
tudinal incision  (Fig.  448,  ,4)  is  made,  sufficient  to  admit 
the  lar<:est  osteotome  and  the  finjrer,  should  the  surgeon 
deem  it  necessary.  Before  withdrawing  the  scalpel  the 
largest  osteotome  is  slipped  by  its  side  until  it  reaches 
the  bone.  The  scalpel  is  withdrawn,  and  the  osteotome, 
which  was  introduced  longitudinally,  is  now  turned  trans- 
versely in  the  direction  recjuired  for  the  osseous  incision 
(Fig.  448,  B).  In  turning  the  osteotome  too  much 
pressure  must  not  be  exerted,  lest  the  periosteum  be 
scraped  oft".     It  is  then  convenient  to  pass  the  edge  of  the  osteotome  over  the 


Macewen's  Operation 
•■or  Genu  Valgum  :  A, 
skin  incision ;  B.  os- 
teotome incision  ;  (', 
epiphyseal  line;  D, 
inner  condyle  (orig- 
inal). 


OPERATIONS  ON  BONES  AND  JOINTS.  1137 

bone  until  it  reaches  the  posterior  internal  border,  when  the  entire  cutting 
edge  of  the  osteotome  is  a})|»lied,  and  the  instrument  is  made  to  penetrate  from 
behind  forward  and  toward  the  outer  side. 

"  After  completing  the  incision  in  that  direction,  the  osteotome  is  made  to 
traverse  the  inner  side  of  the  bone,  cutting  it  as  it  proceeds,  until  it  has  divided 
the  uppermost  ])art  of  the  internal  border,  when  it  is  directed  from  before  back- 
ward toward  the  outer  posterior  angle  of  the  femur. 

"  In  cutting  on  these  lines  there  is  no  fear  of  injuring  the  femoral  artery. 
The  bone  may  be  divided  without  paying  heed  to  this  order  of  procedure,  but 
it  is  better  that  the  operator  should  have  a  definite  plan  in  his  mind,  so  that 
he  may  be  certain  as  to  what  has  been  divided  and  what  remains  to  be  done. 
The  writer  is  persuaded  that  accidents  have  happened  by  not  paying  heed  to 
this.  In  using  the  osteotome  the  left  hand,  in  which  it  is  grasped,  ought  to 
give,  after  each  impulse  supplied  by  the  mallet,  a  slight  movement  to  the  blade 
— not  transversely  to  its  axis,  but  longitudinally — so  as  to  prevent  any  disposi- 
tion to  fixity  which  it  might  assume. 

"After  the  inner  portion  of  the  bone  is  divided  a  finer  instrument  may  be 
slipped  over  the  first,  which  is  then  withdrawn  ;  and  even  a  third,  if  necessary, 
mav  take  the  place  of  the  second  when  the  outer  portion  of  the  bone  comes  to 
be  divided.  Whether  one  or  more  osteotomes  be  used  depends  much  on  the 
resistance  met  with.  If  the  tissue  is  yielding,  one  may  sufiice ;  if  hard  or 
brittle,  two  or  three  will  effect  the  division  more  easily  and  with  less  risk  of 
breaking  or  splitting  the  bone  longitudinally.  In  the  adult  the  dense  circum- 
ferential layer  of  bone  resists  the  entrance  of  the  osteotome  at  the  outset,  but 
several  strokes  cause  the  instrument  to  penetrate  this  superficial  dense  portion, 
■when  it  will  pass  easily  through  the  cancellated  tissue, 

•'After  a  little  experience  the  surgeon  recognizes,  by  touch  and  sounds 
when  the  osteotome  meets  the  hard  layer  on  the  outer  aspect  of  the  bone.  If 
it  be  considered  desirable  to  notch  or  penetrate  this  outer  dense  part  of  the 
bone,  in  doing  so  the  osteotome  ought  to  be  grasped  firmly  by  the  left  hand, 
the  inner  border  of  the  hand  resting  on  the  limb,  so  a^s  to  check  instantly  any 
impetus  which  may  be  considered  too  great.  It  is  better  to  snap  or  bend  this 
layer  rather  than  cut  it. 

"  When  the  instrument  is  to  be  altered  in  position,  it  ought  not  to  be  pulled 
out  in  the  ordinary  way,  as  it  is  then  liable  to  be  removed  from  the  wound  in 
the  soft  parts,  as  well  as  from  the  bone.  Instead,  let  the  left  hand,  with  its 
inner  border  resting  on  the  limb,  grasp  the  instrument,  while  the  thumb  is 
pressed  under  the  ridge  afforded  by  the  rounded  head,  and  gently  lower  the 
osteotome  outward  by  an  extension  movement  of  the  thumb.  In  this  way  the 
movement  may  be  regulated  with  precision.  It  is  desirable  to  complete  all  the 
work  intended  by  the  osteotome  before  removing  it  from  the  wound. 

"  When  the  operator  thinks  that  the  bone  has  been  sufiiciently  divided,  the 
osteotome  is  laid  aside  and  a  sponge  saturated  in  1  :  40  carbolized  watery  solu- 
tion is  placed  over  the  Avound.  While  the  surgeon  holds  the  sponge  he  at  the 
same  time  employs  that  hand  as  a  fulcrum,  while  with  the  other  he  grasps  the 
limb  lower  down,  Hsing  it  as  a  lever,  and  jerks  if  the  bone  be  hard,  or  bends 
slowly  if  the  bone  be  soft,  in  an  inward  direction,  when  the  bon«  will  snap  or 
bend  as  the  case  may  be. 

"  No  drainage-tube  is  required,  and  sutures  need  not  be  employed.  The 
wound  is  dressed  antiseptically,  the  extremity  is  put  up  in  a  splint  which  cor- 
rects the  deformity,  and  the  case  is  treated  like  an  ordinary  compound  fracture." 

Osteotomy  for  Ankylosis  of  the  Hip-Joint. — In  certain  cases  of  dis- 
eases of  the  hip-joint  ankylosis  results,  with  faulty  position  (flexion)  of  the 

72 


1138 


AN  AMERICAN  TEXT-BOOK  OF  SURGERY. 


Fig.  44y. 


limb.     Osteotomy  may  be  required  to  correct  the  deformity  and  bring  the  limb 
into  a  straiglit  position. 

The  section  of  the  bone  may  be  made  tlirough  the  neck  or  through  the 
shaft  just  behnv  the  lesser  trochanter. 

Osteotomy  through  the  Neck  of  the  Femur. — 1  With  a  saw 
(Ada/ns's   Operation). — Mr.  Adams  describes  this  procedure  as  follows  : 

"  The  left  thumb  is  placed  firmly  so  as  to  compress  the  soft  tissues  solidly 
af^ainst  the  bone  at  a  point  situated  at  the  center  of  the  top  of  the  great  tro- 
chanter and  the  breadth  of  one  finger  above  it. 

"  At  this  point  the  narrow-bladed  knife  is  pushed  in  till  it  reaches  the  neck 
of  the  femur,  at  a  right  angle  across  the  front  of  which  it  is  then  carried  (Fig. 
449,  A).  The  knife  is  then  gently  moved  to  cut  a 
space  for  the  easy  insertion  of  the  saw,  which,  travers- 
ing the  course  of  the  knife,  reaches  the  front  of  the  neck 
of  the  femur,  and  gradually  cuts  it  completely  through. 
The  surgeon  cuts  until  he  feels  that  the  saw  is  free  of 
tiie  bone,  and  moving  it  in  the  soft  tissues  only  behind 
the  bone."  The  limb  is  to  be  at  once  straightened,  and 
in  order  to  do  this  it  will  often  be  necessary  to  cut  with 
a  tenotome,  under  strict  aseptic  precautions,  the  con- 
tracted tendons.  The  wound  is  dressed  antiseptically, 
and  the  limb  is  maintained  in  extension  by  the  exten- 
sion apparatus  of  Buck  or  by  the  long  external  splint 
of  Desault. 

"  2.  With  the  Osteotome. — A  longitudinal  incision 
is  to  be  made,  penetrating  to  the  bone  and  about  |  inch 
in  length,  in  the  axis  of  the  femoral  neck  and  just  above 
the  summit  of  the  great  trochanter.  The  osteotome  is 
pushed  in  alongside  of  the  knife,  which  is  now  with- 
drawn, and  the  osteotome  is  turned  so  that  its  edge  is  at  right  angles  to  the 
axis  of  the  femoral  neck.  The  neck  is  now  divided  by  striking  with  a  mallet. 
The  dressing  is  the  same  as  al)ove  indicated." 

Osteotomy  through  the  Shaft,  just  below  the  Lesser  Trochanter 
(Gant's  Operation). — The  osteotome  should  be  employed  in  Gant"s  operation, 
though  the  saw  can  be  used.  A  longitudinal  incision  is  made  over  the  outer 
aspect  of  the  femur  at  the  level  of  the  lesser  trochanter  (Fig.  449,  B).  the 
osteotome  is  introduced  and  turned  on  its  axis,  as  described  in  the  previous 
operation,  and  the  bone  is  divided  just  below  the  level  of  the  lesser  trochanter. 
The  straightening  and  dressing  are  to  be  done  in  the  same  wav  as  after  Adams's 
operation. 

SPECIAL  EXCISIONS. 

Upper  Jaw. — The  upper  jaAv  may  be  removed  because  of  existing  disease, 
non-malignant  or  malignant,  sarcomatous  or  carcinomatous,  or  to  facilitate  the 
removal  of  retro-maxillary  tumors.  Though  the  operation  is  a  bloody  one,  it  is 
remarkably  free  from  danger,  reunion  of  the  soft  parts  is  rapid,  and  the  result- 
ing deformity  is  slight  and  capable  of  much  relief  by  the  a])plication  of  a  den- 
tal plate.  To  avoid  the  annoyance  of  the  blood  collecting  in  the  patient's 
throat,  the  Trendelenburg  posture  may  be  employed,  as  recommended  by 
Keen.  When  done  for  sarcoma,  a  cure  may  often  be  effected  or  recurrence 
may  be  long  postponed ;  and  if  for  carcinoma,  life  may  be  made  more  com- 
fortable, though  perhaps  not  prolonged ;  it  may  even  be  somewhat  shortened. 

The  bone  is  best  exposed  by  an  incision  over  the  infraorbital  ridge  from 


for  Ankylosis 
,  intrii-capsular, 
iperation ;  B,  ex- 
tra-capsnlar,  Gaut's  opera- 
tion (original). 


(}/'/■: Jx' A  T/OXS    (>.\    liOXES   AM>    JOLXTS. 


11:59 


the  malar  lioiit-  to  near  tlie  internal  cantlius.  then  aiun;^  the  side  of  the  nose 
around  the  ala  to  the  median  line,  and  down  through  the  central  part  of 
the  u{>])er  lij)  (Fig.  450,  .1).  Fig.  450,  i>',  shows  the  incision  of  Yelpeau, 
■which   is   carried  throuijh   the  cheek   from   the  angle  of  the   mouth   to   the 


I'm;.  4')(). 


Excision  of  the  Jaws;  .4,  by  a  median  incis- 
ion ;  B,  by  Velpeau's  metiiod ;  C,  excision 
of  tlie  lower  jaw  (original). 


Excision  of  the  Upper  Jaw:  ^,  by  Lan^enbeck's 
method;  B,  by  Gensoul's  method  (original). 


center  of  the  malar  bone.  The  flap  so  formed  is  drawn  inward.  Fig.  451,  A, 
shows  Langenbeck's  operation.  This  incision  begins  on  the  lateral  aspect  of 
the  nose  at  the  junction  of  the  nasal  bone  with  the  cartilage,  and  is  terminated 
by  sweeping  upward  and  outward  to  the  middle  of  the  malar  bone.  It  forms  a 
U-shaped  flap,  with  the  convexity  downward,  reaching  as  far  as  the  junction  of 
the  cheek  and  upper  lip.  Fig.  451,  .B,  shows  the  incision  of  Gensoul  of  Lyons, 
who  was  the  first  successfully  to  remove  the  upper  jaw.  The  flap  thus  outlined 
by  any  of  the  above  methods  is  dissected  off"  the  bone  and  the  free  hemorrhage 
arrested  by  hemostatic  forceps,  pressure,  and  hot  water.  With  a  fine  saw  or 
the  cutting  forceps,  preferably  the  former,  the  malar  bone  itself  is  cut  through 
(Fig.  452,  B),  and  later  the  ascending  process  close  to  its  junction  with  the 
frontal  (Fig.  452,  A).  After  median  division  of  the  mucous  membrane  of  the 
roof  of  the  mouth  back  to  the  soft  palate  with  the  knife,  and  laterally  between 
the  hard  and  the  soft  palate,  the  horizontal  plates  of  the  two  maxillae  are  sepa- 
rated from  above  downward  with  the  saw  or  cutting  forceps  (Fig.  452,  C).  The 
bone  can  then  be  removed  with  the  lion  forceps,  the  pterygo-maxillary  union 
readily  yielding,  or  if,  as  not  seldom  happens  in  cases  of  malignant  disease,  the 
posterior  wall  is  left  behind,  it  can  be  easily  seized  and  brought  away.  When 
not  diseased,  and  when  its  removal  is  not  required  in  order  that  sufficient  room 
may  be  secured  for  necessary  further  work,  the  orbital  or  alveolo-horizontal 
plate  may  be  left,  the  bone  being  sawn  across  just  below  the  one  or  above  the 
other ;   but  it  is  generally  necessary  to  take  away  at  least  the  latter. 

Bleeding  vessels,  if  necessary,  having  been  tied  and  general  hemorrhage 
stopped  (in  which  the  cautery  is  often  very  useful),  the  soft  parts  are  to  be 
apposed  as  accurately  as  possible  along  the  line  of  incision  and  secured  by  the 
requisite  number  of  fine  stitches,  the  cheek-cavity  filled  with  cotton  or  gauze 


1140 


AN  AMERICAN   TEXT- HOOK   OF  SURGERY. 


Fig.  4r,i>. 


j»lu«;s,  if  rp(juiro(l  t'itlier  to  prevent  oozing  or  to  support  the  flap,  and  antiseptic 
gauze  and  cotton  applied  externally  and  secured  by  a  li<;lit  baiida^j^c.     J*riinary 

union  usually  takes  place.  When 
onlv  the  lower  part  of  the  bone  is 
to  be  removed,  the  operation  may 
ordinarily  be  done  through  the 
mouth. 

If  done  to  render  possible  or 
easy  the  taking  away  of  a  pharyn- 
geal growth,  only  the  upper  or 
inner  bony  attachments  (malar 
and  frontal,  frontal  and  intermax- 
illary) should  be  divided,  and  the 
bone  tui-ned  downward  or  out- 
ward, to  be  later  replaced  ;  it  w  ill 
almost  certainly  reunite.  Fig. 
4r)2  shows  the  long  incisions  for 
the  removal  of  nasal  polypi  by 
the  methods  of  Poeckel  and  Lan- 
genbeck.  (See  NavSO-pharyngeal 
Polyp,  p.  607.)  Such  osteoplastic 
resection,  though  somewhat  more 
difficult  of  performance,  saves  the 
deformity  and  later  application  of 
a  plate,  which  are  necessarily  con- 
nected with  the  ordinary  complete 
removal  of  the  upper  jaw.  The 
soft  parts  need  not  be  removed 
from  the  bone,  but  only  incised  at 
the  point.  Where  they  remain 
attached  externally,  they  are  util- 
ized as  a  "  hinge." 

Lower  Jaw. — Resection  of 
this  bone  may  be  in  continuity,  or  of  one  half  or  of  the  whole,  for  injin-y  or 
for  disease.  If  in  continuity  and  on  one  side,  it  can  often  be  readily  effected 
through  the  mouth,  the  soft  parts  being  carefully  cleared  away  and  the  bone 
divided  with  the  straight  or  chain  saw%  or  in  an  informal  way  wnth  the  cutting 
and  gouge  forceps.  Extensive  operations  in  continuity  or  involving  a  half  or 
all  of  the  bone  should  be  done  through  an  external  incision  of  sufficient  length, 
and  just  below  the  lower  })order  of  the  bone,  with  or  without  central  division 
of  the  lower  lip  and  soft  parts  of  the  chin  according  to  circumstances  (Figs. 
450,  C,  452,  G).  If  the  middle  portion  is  taken  away,  as  all  the  attachments 
to  the  genial  tubercles  are  severed,  dropping  back  of  the  tongue  must  be 
guarded  against  by  passing  a  ligature  through  it  until  sufficiently  strong  adhe- 
sions of  the  soft  parts  luive  formed  to  prevent  the  occurrence  of  such  an 
accident. 

In  resecting  the  half  or  the  whole  of  the  lower  jaw,  after  separation  of  the 
soft  parts,  external  and  internal,  well  back  toward  the  angle,  the  bone  is  divided 
in  the  middle  line  (Fig.  452,  G),  and  firmly  held  off  while  the  further  separation 
of  the  soft  parts  is  continued  up  to  and  including  the  coronoid  process,  after 
whii^h  disarticulation  can  be  readily  effected,  either  by  dragging  or  by  a  few- 
cuts  with  knife  or  scissors  kept  close  upon  the  condyle.  When  ])erformed  for 
disease  the  periosteum  should  be  preserved  as  far  as  possible,  unless  the  disease 


Lines  for  Various  Excisions  of  both  Upper  and  Lovver 
Jaws :  A,  B,  C,  excision  of  the  upper  jaw  ;  I),  Poeckel's 
operation  (nasal  polypus) ;  EC,  (JutJrin's  operation 
(partial  excision) ;  F,  F,  Langenbeck's  operation  (nasal 
polypus) ;  G,  excision  of  lower  jaw  ;  //,  removal  of 
portion  of  alveolus  ;  /,  Esmarch's  operation,  ankylosis 
of  lower  jaw  (original). 


OPERATIONS  ON  JiONKS  AND  JOINTS. 


41 


is  malignant;  and  whoncvcv  the  object  of  tlio  resection  can  he  secured  by  saw- 
ing through  the  body  or  at  tiie  bases  of  the  processes,  division  at  such  level 
should  be  made. 

Clavicle. — A  part  or  the  whole  of  the  clavicle  may  be  removed  for  dis- 
ease, generally  sarcoma.  Exposure  is  made  by  a  longitudinal  incision,  the 
soft  parts  dissected  off  carefully,  but  as  rapidly  as  possible,  the  bone  divided 
internally  to  the  aflected  area  or  separated  at  the  sternal  junction,  lifted  up  and 
cleared  posteriorly  as  far  as  may  be  necessary  toward  or  to  the  scapular  attach- 
ment, and  there  sawn  through  or  disarticulated.  The  hemorrhage,  often  very 
great  when  operating  for  malignant  disease,  is  to  be  temporarily  checked  as 
the  operation  proceeds  by  the  application  of  hemostatic  forceps.  By  keeping 
close  to  the  bone  and  the  diseased  mass  there  is  little  danger  of  wounding  the 
important  deep  vessels  and  nerves.  Provision  for  drainage  having  been  inade, 
the  edges  of  the  external  incision  arc  to  be  brought  together  and  sutured,  an 
antiseptic  dressing  applied,  and  the  arm  securely  fastened  to  the  side.  If  sep- 
tic infection  is  prevented,  death,  if  it  follows,  will  be  from  shock  or  hemorrhage 
or  later  from  recurrence  of  the  malignant  affection. 

When  done  for  cause  other  than  malignant  and  the  periosteum  has  been 
saved,  regeneration,  at  times  quite  perfect,  may  be  reasonably  expected. 

Scapula. — Removal  of  the  shoulder-blade,  partial  or  complete,  may  be 
rendered  necessary  or  advisable  on  account  of  necrosis  following  injury  or  of 
the  presence  of  a  tumor  benign  or  malignant,  the  latter  cause  indicating  com- 
plete resection,  although  occasionally  a  partial  operation  has  not  been  followed 
by  recurrence.  When  done  for  necrosis  the  operation  is  comparatively  simple 
and  easy ;  when  for  osteo-sarcoma,  it  is  not  seldom  difficult  and  dangerous. 

In  complete  resection  a  single  vertical  incision  may  be  made  on  a  line  a 
little  posterior  to  the  middle  of  the  spine,  and  the  soft  parts  reflected  forward 
and  backward  (Fig.  453,  ver- 
tical line  of  1);  or,  better,  an  Fig.  458. 
incision  along  the  whole  pos- 
terior border,  inclined  forward 
at  the  upper  end  and  forward 
and  upward  for  a  short  dis- 
tance at  the  lower  end,  fol- 
lowing the  anterior  border, 
with  usually  an  associated  one 
over  the  course  of  the  spine. 
Fig.  458  shows  the  incisions 
of  Syme,  Langenbeck,  and 
Collier  for  extirpation  of  the 
scapula,  as  well  as  the  incision 
for  resection  of  the  glenoid 
cavity  of  the  scapula.  The 
overlying  soft  parts  having 
been  turned  aside,  and  the 
spinal  muscles  saved  or  left  attached  to  the  bone  according  as  the  resection  is 
not  or  is  for  malignant  disease,  the  superior  angle  and  adjacent  upper  border 
is  freed  from  its  attachments,  then  the  posterior  border  and  inferior  angle,  the 
knife  being  constantly  kept  as  close  as  possible  to  the  bone.  Lifting  up  the 
scapula,  its  anterior  surface  is  cleared,  and  then  the  anterior  border  toward  the 
glenoid  fossa,  the  dorsal  and  subscapular  arteries  being  tied  when  reached. 
The  acromion  process  being  freed,  the  attachments  of  the  scapular  muscles 
divided  close  to  the  humerus,  and  the  coracoid  process  separated  from  its  liga^- 


Extirpationof  the  Scapula  :  1,  after  Syme  ;  2,  after  Langenbeck  ; 
3,  after  Collier ;  4,  incision  for  resection  of  the  glenoid  cavity 
of  the  scapula  (Tillmanns). 


1142 


AN  AMi:iilVAy   TKXT-llOUK   OF  SVIHiEltV 


Fig.  454. 


ments  and  imiscles,  only  the  region  of  tlie  glenoid  fossa  remains  to  ])e  cleared, 
after  which  the  hone  is  lifted  out,  hemorrhage  arrested,  drainage  pntvided  for, 
the  Ihips  adjusted  and  united,  and  an  ordinary  compressing  and  retaining  dres.s- 
ing  applied.  By  such  method  of  operating  control  of  hemorrhage  is  well 
secured. 

Shoulder. — Resection  of  the  shouldei- — or  rather,  in  the  great  majority 
of  cases,  of  the  head  of  the  humerus — has  generally  been  for  severe  injury, 
especially  gunshot,  rarely  for  the  compound  fractures  of  civil  life,  occasionally 
for  the  relief  of  deformity,  as  that  following  unreduced  lu.xation  or  hadly- 
united  fracture  of  the  neck  of  the  humerus,  and  at  times,  though  but  seldom, 
for  chronic  joint  disease,  from  which  this  articulation  is  in  an  extraordinary 
degree  e.xempt.  Under  the  present  method  of  wound-dressing  purely  conser- 
vative treatment,  with  the  informal  removal  of  completely  detached  fragments 
when  necessary,  may  commonly  be  expected  to  give  good  results,  better,  indeed, 
than  those  after  typical  excision. 

It  may  be  done  by  a  single  straight  incision  from  above  downward  (Fig. 
454,  £),  or  by  a  flap  raised  from  the  anterior  surface  (Fig.  454,  C),  the  former 

method  being  much  the  better,  as  it  inflicts 
little  damage  upon  the  muscles,  and  leaves,  in 
consequence,  a  more  useful  arm,  though  occa- 
sionally, because  of  the  nature  and  extent  of 
the  original  injury,  the  deltoid  has  been  so 
wounded  that  little  additional  violence  will  be 
done  it  in  forming  a  flap.  Generally  the  cut 
is  made  directly  down  to  the  bone  in  a  line 
from  the  middle  of  the  acromion  to  the  center 
of  the  deltoid  insertion,  separating  rather 
than  cutting  the  muscular  fibers,  though  it 
may  be  carried  from  the  inner  (Fig.  454,  A) 
or  outer  point  of  the  acromion  along  the  in- 
ternal or  external  border  of  the  deltoid. 

The  capsule  is  then  opened  and  the  soft 
parts  separated  from  the  tuberosities  and  the 
upper  part  of  the  shaft,  the  knife  being  kept 
close  upon  the  bone,  especial  care  being  taken 
to  turn  the  long  head  of  the  biceps  uninjured 
out  of  its  groove.  The  head  of  the  bone 
having  been  luxated  through  the  incision, 
division  is  made  with  the  saw  at  the  neces- 
sary level,  no  lower  down  than  is  absolutely  demanded,  in  order  that  the  likeli- 
hood of  the  occurrence  of  a  "dangle"  joint  may  be  reduced  to  a  minimum,  for 
although  a  "flail  "  arm  is  often  far  from  being  a  useless  one,  either  without  or 
with  the  aid  of  an  apparatus,  yet  if  recovery  can  be  secured  with  close  approx- 
imation of  the  upper  end  of  the  humerus  to  the  scapula,  it  is  much  better. 

The  operation  may  be  done  subperiosteally,  the  periosteum  being  divided 
longitudinally  and  then  transversely  at  the  level  of  the  section  of  the  bone, 
and  turned  aside,  and  the  tuberosities  chipped  off",  carrying  with  them  the  unin- 
jured muscular  insertions.  In  old  luxations,  as  the  vessels  are  pushed  back- 
ward and  inward,  the  incision  can  safely  be  made  along  the  border  of  the  coraco- 
brachialis  muscle. 

If  necessary,  though  such  is  seldom  the  case,  the  glenoid  fossa  may  be 
removed  by  saw  or  forceps,  the  attachment  of  the  long  head  of  the  biceps 
being,  if  possible,  preserved  by  separating  a  scale  of  bone  or  stripping  off 


Excision  of  the  Shoulder:  A,  vertical  in- 
cision of  Laiificnbcck  :  B,  incision  of 
Baudens.lhictcr.and  Oilier;  C,  Morel's 
incision  (after  Tillmanns). 


OPERATIONS  ON  BONES  AND  JOINTS. 


1143 


Fig.  455. 


the  periosteum.  The  ordinary  antiseptic  dressing  iiaving  ])Con  applied,  the 
parts  are  lioUl  in  place  by  a  bandage,  or,  better,  by  an  immobilizing  i)laster 
splint  or  casing,  carried  well  up  over  the  top  of  the  shoulder  and  retained 
by  a  bandage  passed  under  the  opposite  axilla. 

Elbow. — Resection  of  the  elbow  is  called  for  in  certain  cases  of  compound 
fracture,  gunshot  or  other,  of  tubercular  disease,  of  old  unreduced  luxation,  or 
of  bony  ankylosis.  It  may  be  done  in  various  ways,  all  or  nearly  all,  liowever, 
modifications  more  or  less  diverse  of  tiie  method  by  a  single  longitudinal  in- 
cision, central  or  lateral,  with  or  without  a  transverse 
incision  (Fig.  455) ;  or  of  that  by  two  lateral  incisions, 
with  a  connecting  cross-cut — H-shaped — the  former  being 
generally  preferred.  Cutting  down  upon  the  posterior  sur- 
face of  the  joint  in  the  median  line  from  a  point  a  couple 
of  inches  above  the  articulation  to  one  at  or  slightly 
below  the  line  of  junction  of  the  olecranon  with  the 
shaft,  or  along  the  outer  border  of  the  triceps  to  the  B- 
level  of  the  epicondyle,  and  then  downward  and  inward 
across  the  olecranon,  the  capsule  is  opened  and  the  soft 
parts  dissected  oft'  on  each  side  (subperiosteally,  if  pos- 
sible) until  the  condyles  have  been  well  uncovered,  special 
care  being  taken  to  save  uninjured  the  ulnar  nerve. 
This  lies  between  the  olecranon  and  the  internal  con- 
dyle, and  is  to  be  avoided  by  dissecting  close  to  the 
bone  in  this  situation.  After  flexion  of  the  forearm 
the  lower  end  of  the  humerus  is  cleared  (Fig.  456), 
pushed  out  through  the  wound,  and  sawn  off"  (Fig. 
457) ;  and  then  the  upper  ends  of  the  ulna  and  of 
the  radius  are  treated  in  like  manner.      Instead  of  Excision  of  the  Elbow:  a, 

T  ,.  ,,  (,,  ,        p  .-,  ■  T    1  1     median  vertical  incision ;  5, 

dissecting   the   soit   parts    irom   the   epicondyles    and    Listen's  r-incision  (after  Es- 

the  upper  edge  of  the  olecranon,  these  bony  surfaces    ™^'"'^^)- 

may  be  chiselled  off'  and  turned  aside  with  their  muscular  attachments  un- 


Fk;.  456. 


Excision  of  the  Elbow  :  the  clearing  of  the  humerus  (original). 

disturbed.     If  the  amount  of  bone  removed  is  so  great   that  a  movable 
joint  is  not  likely  to  be  secured,  the  sawn  surfaces  may  be  Avired  or  pinned 


11 II 


LV  AMi:ui('Ay  'n:x r-iiooK  of  srii<ii:i!Y 


tofjc'tlior.  or  a  sort  of  inortiso  and  tonon  mar  be  made  ln-twccn  the  nln.-i  ami 
the  liuiiierus. 

If"  tlicrc  lias  not  been  much  of  the  liones  excised,  restoration  of  the  func- 
tions of  the  elhow  to  a  "greater  or  less  extent  may  be  exjteeted,  so  conijdcte  at 
times  as  to  pei-niit  of  the  Imnd  liciuir  hiiil  upon  the  shnulder.       in  a  few  cases 

Vu..  4-)7. 


Excision  of  the  Elbow :  sawing  of  the  humerus  (after  Farabeuf ). 


in  which  years  after  the  resection  an  examination  of  the  elbow  has  been  made^ 
there  have  been  found  to  be  present  bony  down-growths  from  the  sides  of  the 
humerus,  embracing  between  them  and  buttressing  the  upper  end  of  the  ulna 
and  radius,  much  as  the  malleoli  do  the  astragalus. 

When  the  portion  excised  has  been  considerable,  unless  close  approximation, 
is  made  and  maintained  a  flail-like  condition  of  the  arm  will  be  produced,  capa- 
ble, however,  of  being  greatly  improved  by  the  use  of  proper  prothetic  appa- 
ratus. At  the  completion  of  the  operation  immobilization  should  be  made, 
readily  and  fully  effected  by  plaster  of  Paris,  and  maintained  for  six,  eight,  or 
more  weeks  if  ankylosis  is  sought  for  (always,  of  course,  at  a  right  angle,  or  a 
little  less,  never  in  extension) ;  but  if  motion  is  aimed  at,  passive  movements 
should  be  commenced  by  the  end  of  the  second  Aveek.  When  done  in  the 
hope  of  bony  ankylosis,  care  should  be  taken  that  as  much  of  the  periosteum 
as  possible  is  preserved  in  the  area  of  the  future  joint. 

At  times  in  these  cases  simple  osteotomy,  linear  or  trochleiform.  will  relieve 
the  ^lifliculty,  but  there  is  always  danger  that  such  operation  will  be  followe<l 
by  fusion  of  the  bones  in  spite  of  earlv  and  metho<lical  passive  motion. 

Old  unreduced  luxations  may  be  treated  by  complete  or  partial  excision, 
access  to  the  joint  being  readily  had  through  an  incision  across  the  back  of  the 
joint  with  division  of  the  olecranon  at  its  base,  this  process  being  reflected  with 


OPERATIONS  ON  BONES  AND  JOINTS. 


1115 


the  soft  parts  and  later  replaced  and  wired.  Oftentimes,  after  subcutaneous  sec- 
tion of  the  olecranon,  reduction  of  tlie  luxation  can  he  effected,  passive  motion 
securing  a  lax  fibrous  attachment  of  the  separated  process  which  later  allows 
of  the  ordinary  movements  of  the  joint.  As  is  true  of  compound  fractures  of 
all  joints,  treatment  by  resection  after  this  injury  at  the  elbow  is  now  much 
less  frecjuently   reijuired  than  formerly. 

WiiiST. — Kesection  of  the  wrist  is  occasionally  done  because  of  extensive 
injury,  mainly  of  the  lower  end  of  the  bones  of  the  forearm.  Ordinarily,  how- 
ever, it  is  necessitated  by  tubercular  disease,  which  always  chiefly  aff'ects  the 
carpus.  The  best  method  of  operating  must  vary  according  as  the  excision  is 
for  injury  or  for  disease.  In  the  former  case  lateral  incisions  carried  but  a  little 
distance,  or  perhaps  not  at  all,  below  the  joint  level  will  give  ready  access  to 
the  bone  and  permit  of  easy  removal,  with  slight  danger  to  the  soft  parts. 

It  is  widely  different  with  the  operation  for  disease.  The  carpal  bones  can- 
not thus  be  readily  reached  nor  thoroughly  extirpated  without  serious  risk  to 
vessels  and  nerves.  One  of  three  methods  will  commonly  be  selected :  a  single 
long  dorsal  median  incision,  or  two  incisions  placed  laterally  over  the  back  of 
the  wrist,  or  a  transverse  straight  or  curved  division  of  the  structures  covering 
the  posterior  surface  of  the  carpus,  the  last  affording  readiest  access  to  the  dis- 
eased bones,  but  objectionable  because  of 
the  necessary  section  of  the  tendons — an 
objection,  however,  of  much  less  weight 
now  than  formerly,  since  after  their  suture 
early  and  functionally  perfect  repair  can  be 
secured. 

The  method  by  a  single  incision  will 
generally  be  preferred,  being  easier  of  exe- 
cution and  less  disturbing  to  the  tendons 
than  the  others.  A  very  convenient  form 
of  the  incision  consists  in  carrying  it  from 
the  middle  of  the  radial  border  of  the  meta- 
carpal bone  of  the  index  finger  upward  be- 
tween the  tendon  of  the  long  extensor  of 
the  thumb  and  that  of  the  extensor  indicis 

Fig.  459. 


Fig.  458. 


Excision  of  the  Wrist  by  OUier's  incision 
for  radial  side  (original). 


A.  Excision  of  First  Metacarpal  Bone;  B,  Excision  of 
MetiicariMi-iilialaiiseal  Joint  of  the  Thumb;  CC,  Excis- 
ion of  IiiH"r]ihalan,t;eal  .Joint  of  the  Thumb;  D,  Excision 
of  Metaearpii-jihalangeal  Joint  (original). 


to  the  dorsum  of  the  radius  between  the  extensor  indicis  and  the  short  radial 
extensor  of  the  wrist,  the  soft  parts  covering  the  carpus  being  carefully  lifted 
and  turned  aside,  subperiosteally  as  far  as  possible  (Fig.  458). 


lui; 


.4.Y  AMERICAN  TEXT-BOOK  OF  &UJiGEIiY 


Fjg.  400. 


In  excising  an  interphalanffeal  joint  a  lateral  incision  is  made  on  the  side 
of  the  joint  (Fig.  450.  C).  Tlie  lateral  ligament  is  divided,  and  the  bones 
protruded  and  i?awn.  Two  lateral  incisions  instead  of  one  may  be  used  (Fig. 
4ol),  C,  C). 

In    excising    a    metacarpo-phalangeal  joint   a   single    lateral    incision    is 
employed,  and  the  operation  is  done  as  in  the  above  case  (Fig.  4')9,  D  and  B). 
Fig.  4">0,  A^  also  shows  the  incision  for  resection  of  XheJirHt  metacarpal  hone. 
Ju'section  in  eontinuiti/  or  comph'te  removal  of  a  bone  of  the  upper  extrem- 
ity for  injury,  more  often  for  disease,  will  be  effected  in  the  ordinary  way,  as 
already   mentioned    in  treating    of   such  operations   in 
general,   care    being   taken    to   fasten   the   ends   firmly 
together  when  this  can  be  done,  and  to  preserve  the 
periosteum  as  far  as  practicable,  in  order  that  regener- 
ation may  take  place,  thus  lessening,  or  in  the  most  suc- 
cessful cases  preventing,  after-deformity. 

Hip. — Resection  of  the  head  of  the  femur  in  civil  life 
is  almost  always  required  because  of  tubercular  caries. 
It  is  ordinarily  done  through  an  incision  beginning  about 
midway  between  the  anterior  superior  iliac  spine  and 
the  trochanter,  and  continued  downAvard  around  the  tro- 
chanter or  across  its  outer  surface  along  the  outer  border 
of  the  thigh  for  a  sliort  distance,  the  knife  being  carried 
directly  to  the  bone  (Fig.  460).  Figs.  4G1  and  4Gi*  show 
other  incisions  for  excision  of  the  hip-joint.  The  cap- 
sule having  been  thoroughly  opened,  the  periosteum  is 
divided  transversely  at  the  level  of  bone-section,  and  as 
completely  as  possible  separated  from  the  femoral  neck,  the  muscular  attach- 


Excision  of  the  Hip-joint 
(Tillinanns). 


Fig.  461. 


Fig.  402. 


Excision  of  the  Hipj :  Luecke's  incision 
(original). 


Excision  of  the  Hip:  Langenbeck's  external  incision 
(original). 


ment  to  the  trochanters  being  severed,  or,  better,  the  bone-surfaces  which  secure 
them  being  chiselled  off,  or  the  whole  of  the  greater  trochanter  may  be  split 
off  and  turned  aside.  It  very  often  happens  that  the  condition  of  the  parts 
is  such  that  little  or  nothing  can  be  gained  by  an  attempt  at  preserving  the 


orKHATioys  o.v  jkjxf.s  axd  joints. 


11-17 


Fig.  4(io. 


periosteum,  and  iDuch  time  will  bo  saved  and  as  <rood  an  ultimate  result  secured 
by  omitting  it.  The  head  of  the  femur  is  then  forced  out  of  the  acetabulum  and 
the  diseased  bone  sawed  oft",  any  limited  portion 
of  affected  tissue  being  removed  by  gouge  and 
spoon  rather  than  by  a  second  sawing  at  a 
lower  level.  To  facilitate  (lraina<:e,  the  tro- 
chanter  major  is  generally  taken  away,  but 
in  most  of  the  cases  suitable  for  operation  this 
is  not  necessary.  If  the  acetabulum  is  dis- 
eased, it  should  be  thoroughly  scraped.  In- 
stead of  luxatinti;  the  head  and  then  dividing 
the  neck,  the  steps  may  be  reversed,  the  neck 
being  first  sawn  through  ;  but  the  operation 
thus  done,  as  a  rule,  is  not  so  easy  of  exe- 
cution. Moderate  extension  may  be  em- 
ployed after  the  operation.  As  soon  as 
the  wound  is  sufficiently  healed  the  patient 
should  be  gotten  up  on  crutches. 

By  a  few  surgeons  an  anterior  incision  is 
preferred  (Fig.  461),  the  knife  being  entered 
half  an  inch  below  the  anterior  superior  iliac 
spine  and  carried  downward  and  a  little  in- 
ward for  about  three  inches,  passing  between 
the  tensor  vaginae  and  glutei  muscles  on  the 
outer  side  and  the  sartorius  and  rectus  on  the 
inner.  If  the  operation  is  done  aseptically 
and  the  parts  protected  against  after-infection, 
primary  union  may  be  secured. 

Knee. — Resection  of  the  knee  is  done 
because  of  injury,  deformity,  ankylosis,  or 
especially  disease.  It  is  performed  in  seve- 
ral ways,  according  to  individual  preference 
and  the  facility  and  thoroughness  of  exposure 
of  the  joint  structures.  These  methods  are  a 
curved  incision  across  the  front  of  the  joint,  with  the  convexity  downward, 
passing  through  the  ligamentum  patelh^  (Fig-  463),  or  with  the  convexity 
upward  above  the  patella,  a  straight  transverse  incision  passing  through  the 
patella,  Avhich  is  sawn,  with  or  without  associated  short  longitudinal  incisions 
on  the  sides;  or  a  single  longitudinal  incision,  median  or  lateral,  a  method 
inapplicable  to  cases  of  disease. 

As  ordinarily  done,  the  curved  or  transverse  incision  is  made  from  condyle 
to  condyle,  opening  the  joint;  the  flap  containing  the  patella  is  turned  upward; 
the  limb  is  flexed,  the  crucial  and  lateral  ligaments  divided,  great  care  being 
used  to  avoid  wounding  the  popliteal  artery,  the  end  of  the  femur  is  thoroughly 
uncovered,  and  a  slice  of  necessary  thickness  sawn  off",  the  epiphyseal  line 
being,  if  possible,  preserved  in  children.  This  is  very  essential,  in  order 
that  the  ultimate  shortening  may  be  reduced  to  a  minimum,  as  the  chief 
growth  of  the  femur — and  the  point  of  greatest  growth  in  the  entire  body — 
is  at  its  lower  end.  The  saw  should  be  carried  in  a  slightly  oblique  direc- 
tion from  behind  forward  and  in  a  plane  parallel  to  that  of  the  epiphyseal 
line.  The  articulating  surface  of  the  tibia  is  then  to  be  in  like  manner 
removed,  all  diseased  soft  parts  being  cut  or  scraped  away.  The  patella, 
if  diseased,   as   is   usually  the    case,  should    be    removed ;  if  not  diseased. 


Incieion  for  Resection  of  the  Knee 
(MaeCormac). 


114S  AX  AMKRFtWN    TEXT-BOOK    OF  HURGFAIY. 

it  may  l»r  removed  or  left  as  preferred.  The  hone  surfaces  are  then 
apposed,  drainage-tuhcs  placed  in  position  from  side  to  side  or  ohliquely 
from  before  backward,  and  brought  out  through  counter-openings  on  the 
posterior  surface,  the  edges  of  the  incision  sutured,  the  parts  antiseptically 
dressed,    and    the    limb    immobilized    by    plaster    of    Taris    or    a    suitable 

Fig.  464. 


InterruiittHi  Splint  (modified  from  Esmarcli  mid  Kowulzig). 

bracketed  splint.  If  the  patella  has  been  sawn  through,  its  fragments 
should  be  wired,  or  held  together  by  stout  catgut  sutures  through  the  fascial 
enveloj^e.  The  femur  and  tibia  may  be  sutured  with  catgut  or  wire  or  fas- 
tened by  nails  or  dowels. 

Immobilization  should  be  maintained  for  two,  or  better  three,  months,  and 
a  posterior  splint  should  be  worn  for  many  months  longer,  that  firm  union 
in  the  position  of  nearly  full  extension  may  be  secured.  The  drainage-tubes 
should  be  removed  in  the  course  of  a  few  days,  as,  although  they  have  at 
times  been  left  for  many  weeks  without  harm,  it  is  likely  that  their  presence 
may  favor  the  formation  of  sinuses  which  may  become  tubercular  and  con- 
tribute to  the  production  of  an  unfavorable  result. 

Bony  ankylosis  -of  the  knee,  as  a  rule,  may  be  treated  by  osteotomy, 
linear  or  cuneiform,  rather  than  by  resection. 

In  operating  upon  old  luxations  partial  excision  of  the  end  of  the  femur 
may  usually  be  made. . 

It  is  at  this  articulation  that  erasion  is  most  frequently  done,  and  the 
relative  value  of  such  operation  as  compared  with  typical  resection  has  yet 
to  be  determined.  When  done  for  tubercular  disease,  an  excellent  method  is 
that  of  Miller  of  Edinburgh.  An  incision  is  made  below  the  patella,  deeply 
curved  downward  toward  the  tuberosity  of  the  tibia,  and  another  straight 
across  the  center  of  the  patella,  joining  the  ends  of  the  first.  The  upper 
flap  is  then  reflected  upward,  the  tendon  of  the  rectus  and  adjacent 
muscular  fibers  divided,  and  the  entire  anterior  portion  of  the  capsule, 
together  with  the  patella  and  an  elliptical  portion  of  skin,  stripped  downward 
and  removed  en  masse  by  cutting  through  the  ligamentum  patellae  and  the 
tibial  attachments.  The  remainder  of  the  joint  is  then  cleaned  uj)  and  the 
bones  resected. 

When  the  joint  lesion  is  great,  the  destruction  extensive,  and  the  gen- 
eral health  much  enfeebled,  especially  in  poor  patients  not  in  hospital, 
amputation  often  offers  a  much  better  chance  of  preserving  life,  and  should 
be  performed. 

Ankle. — For  the  resection-of  the  ankle-joint  many  operations  have  been 
devised  of  late  years — more  than  for  the  removal  of  any  other  articulation. 
The  methods  are  lateral,  postero-lateral,  and  posterior,  without  and  with  asso- 
ciated division  of  tendons  and  removal  of  the  astragalus. 

An  excellent  method  is  that  in  which  an  incision  over  the  inner  border  of 
the  fibula,  commencing  an  inch  and  a  half  or  two  inches  above  the  tip  of  the 


OPERATIONS  ON   BONES   AND  JOINTS. 


1140 


external  malleolus,  is  carried  to  and  a  little   in   front  of  the  malleolus,  and 
another  is  made  directly  backward  close  under  the  malleolus  to  the  external 


Fni.  405. 


\    i    ] 


Reseetion  of  Ankle-joint,  after  Langenbeck;  incision  over  the  lower  end  of  fibula  {a)  and  tibia  (6) 

(Tillmans). 

border  of  the  tendo  Achillis,  dividing  the  peroneal  tendons  (Fig.  467,  li).  The 
flap  thus  outlined  is  dissected  off"  the  lower  part  of  the  fibula,  and  the  malleolus 
sejiarated   with   chisel,   saw, 

or  cutting  forceps — removed  yiq.  460. 

if  diseased,  if  healthy  turned 
back  to  be  later  reunited. 
The  astragalus  is  then  freed 
from  its  attachments  and 
taken  away,  and  the  foot 
dislocated  "^  inward,  when 
ready  access  is  had  to  the 
lower  end  of  the  tibia,  which 
is  cut  away  to  such  extent 
as  is  necessary.  The  dis- 
eased tissues  about  the  joint 
are  easily  reached  and  re- 
moved,   and    by    extending  _ — 

the    orip-inal    incision     alons;    a,  Excision  of  Astragalus  (inner  incision) :   £,  Excision  of 
LUC    yjiiQ  ID  Ankle  (inner  incision)  (original). 

the  outer  border  ot  the  loot 
other  bones  of  the  tarsus, 
if  affected,  can  be  got  at 
and  taken  away.  The  sev- 
ered peroneal  tendons  are 
then  sutured,  drainage-tubes 
put  in,  counter-openings,  if 
thought  advisable,  being 
made  and  through  drain- 
age thus  secured,  gauze  and 
cotton  dressing  applied,  and 
the  leg  and  foot  placed  in  a 
splint  or  immobilized  with 
plaster.  Figs.  465,  466, 
and   467    show   the   various  _^.,^_  

incisions  for    excision  of  the   .-i,  Excisionof  Astragalus  f  outer  incision^:  5,  Exdsion  of  Ankle 
,  .  (outer  incision) ;  C,  Excision  of  Os  Calcis  (original). 

The  removal  of  the  as-  .    ,       ,.  ,   .•  i,      i 

tracralus  very  much  facilitates  the  extirpation  of  the  diseased  tissues,  hard 
and  soft,  and  lessens  but  little  if  at  all  the   later   functional  value  of  the 


Fig.  407. 


1150 


.l.V   AMI'JRICAX    TEXT-BOOK    OF  SUROKRY 


limb.  If  it  is  desired  to  save  uninjured  the  peroneal  tendons,  two  lateral 
incisions  may  be  made,  one  as  already  described,  the  other  (Fif^.  400.  .1) 
over  the  inner  malleolus  and  forward  internal  to  the  tendon  of  the  tiljialis 
anticus,  between  which  the  structures  in  front  of  the  joint  can  be  lifteil 
up,  chiselled,  or  scraped  out,  or  excised,  as  before,  after  reujoval  of  tjie 
external  malleolus  and  astragalus.  When  there  is  a  compound  luxation  of 
the  astragalus  a  formal  resection  will  not  ordinarily  be  required,  it  being 
usually  possible  to  take  away  the  bone  through  the  existing  wound  or  by 
enlarging  it. 

Resections  of  the  Foot. — Removals  of  the  tarsal  bones,  largely  atypical, 
may  be  made  through  lateral  incisions,  or,  better,  by  an  incision  across  the 
dorsum,  the  severed  tendons  being  later  sutured  or  allowed  to  make  attachment 
as  they  can  in  the  course  of  the  healing  of  the  wound,  the  former  procedure 
being  preferable.  It  has  lately  been  advised  to  split  the  foot  back  between 
the  third  and  fourth  metatarsals  to  the  middle  tarsal  joint,  and  thus  gain  access 
to  the  affected  parts.  The  essential  prerequisite  to  success  is  thorough  removal 
of  the  diseased  tissues,  and  the  end-result  of  complete  excisions  even  of  the 
entire  tarsus  or  of  its  anterior  segment  and  the  metatarsus  in  part  or  in  whole 
is  often  excellent,  the  functional  value  of  the  foot  being  but  little  impaired. 
Figs.  466  and  467  show  the  incisions  for  removal  of  the  astragalus,  and  Fig. 
467  shows  the  incision  for  removal  of  the  os  calcis. 

When  the  tarsus  is  largely  diseased,  and  especially  when  the  soft  parts  of 
the  heel  and  the  posterior  part  of  the  sole  have  been  destroyed  or  seriously 


Fig.  468 


Via.  4G9. 


Osteoplastic  Resection  of  the  Foot :  A,  B,  C,  skin  incisions  ;  D.  E 
and  F,  G,  points  at  which  the  bones  are  to  be  divided  ;  shaded 
parts  to  be  exsected  (original). 


Result   after  Osteoplastic    Resection 
of  the  Foot  (after  Farabeuf  >. 


damaged,  an  osteoplastic  operation  ("  Wladimiroff-Mikulicz  operation")  may 
be  done,  a  flap  of  the  posterior  tissues  from  the  level  of  the  malleoli  to  that  of 
the  scaphoid  tubercle  being  removed  (Fig.  468,  A,  B,  C),  the  articulating  end 
of  the  leg-bones  and  the  posterior  part  of  the  scaphoid  and  cuboid  sawn  through 
(Fig.  468,  DE,FG),  the  intervening  bone  excised,  the  foot  extended,  the 
sawn  surfaces  apposed,  and  the  edges  of  the  wound  sutured,  the  weight  of  the 
body  being  afterward  supjjorted  on  the  ends  of  the  metatarsal  bones,  and  the 
under  surfaces  of  the  toes  now  bent  at  a  right  angle  (Fig.  46l>).  Except  when 
there  is  extensive  ulceration  or  loss  of  substance  at  the  heel,  such  osteoplastic 
resection  has  no  advantage  over  a  large  atypical  tarsal  excision,  and  is  likely 
to  leave  a  less  useful  foot. 


AMPUTATIONS. 


1151 


Rejection  in  Continuity  of  Bones  of  the  Lower  Extremity. — Such 
an  operation  should  not  be  done  upon  the  femur,  because  of  the  strong  prob- 
ability of  non-union.      Upon  the 

tibia  or  fibula  it  is  more  likely  to  Fio.  470. 

be  followed  by  a  successful  re- 
sult, regeneration  of  the  bone  or 
compensatory  hypertrophy  of  the 
untouched  shaft  freiiuently  tak- 
ing place.  Care  must  be  exer- 
cised during  the  period  of  repair 
to  prevent  deviation  of  the  foot. 
Upon  a  metatarsal  or  phalangeal 
bone  of  the  foot,  as  upon  a  cor- 
responding one  of  the  hand,  it 
may  be  readily  and  successfully 
done,  the  necessary  incision  being 
made  over  the  inner  or  outer  side 
rather  than  the  middle,  to  avoid  injuring  the  extensor  tendon  (Fig.  473). 

When  in  the  hand  a  first  or  second  phalanx  cannot  be  subperiosteally 
removed,  the  distal  part  of  the  finger  should  be  allowed  to  drop  back,  the 
resulting  fibrous  union  often  becoming  short  and  firm  and  securing  a  useful 
finger,  failing  which-  amputation  can  be  done. 


Excision  of  First  Metatarsal  Bone  (original). 


CHAPTER    VI. 


AMPUTATIONS. 

Indications. — It  is  impossible  to  do  more  than  indicate  in  very  general 
terms  the  more  important  conditions  calling  for  amputation.  Injuries  of  similar 
degree  afiecting  the  upper  or  the  lower  extremity  call  for  difi"erent  treatment, 
because  of  the  much  greater  freedom  of  the  collateral  circulation  in  the  former, 
rendering  gangrene  less  probable.  Where  conservative  treatment  or  excision 
would  be  proper  in  the  upper  extremity,  amputation  would  be  called  for  in  the 
lower  limb.  A  broken  constitution  with  damaged  assimilative  and  eliminative 
organs,  as  in  the  aged,  in  alcoholics,  in  chronic  Bright's  disease,  or  when  tuber- 
culosis of  the  lungs  exists,  often  compels  the  sacrifice  of  the  limb.  Avulsion 
of  a  whole  or  part  of  an  extremity  of  course  requires  an  attempt  to  place  the 
remaining  portions  in  a  condition  to  heal  by  amputating  at  a  higher  point, 
or,  if  the  whole  limb  is  gone,  by  fashioning  flaps  out  of  what  remains  of  the 
soft  parts,  and  approximating  and  dressing  them. 

Compound  Fractures  and  Dislocations  are  the  most  common  accidents 
demanding  amputation.  Extensive  comminution  and  loss  of  bone  may  demand 
this  in  the  lower  extremity,  because  even  if  saved  the  limb  will  be  useless  as  a 
means  of  locomotion :  when  in  the  lower  limb  rupture  of  the  main  vessels  is 


1152  ^.V  AMERICAN  TEXT-BOOK  OF  SURGERY. 

added  to  this  condition,  amputation  is  indicated,  but  in  the  upper  limb  an 
attempt  should  bo  made  to  save  it  by  securin<^  the  vessel  in  the  wound.  In 
the  lower  extremity  secondary  lu'iiiorrha<fe  from  the  main  arter^^  after  compound 
fracture  usually  calls  for  amputation  ;  but  further  trial  of  conservative  treatment, 
after  arrest  of  the  bleeding  by  ligature,  is  in  exce[)tionally  favorable  cases  justi- 
fiable after  a  similar  accident  affecting  the  upper  extremity.  Great  laceration 
of  soft  parts,  with  extensive  loss  of  skin,  added  to  free  comminution  of  bone  and 
wounded  vessels,  always  demands  amputation  ;  extensive  flaying,  which  will  ren- 
der the  member  useless  if  saved,  sometimes  calls  for  its  removal ;  for  instance, 
destruction  of  the  skin  of  the  heel  and  sole  of  the  foot  will  result  in  a  cicatrix 
which  can  never  bear  the  weight  of  the  body,  and  extensive  burns  of  an  entire 
extremity  may  require  amputation.  Compound  fracture  involving  the  knee- 
joint  commonly  calls  for  amputation,  because  of  the  great  damage  to  the  soft 
parts.  Similar  injuries  to  the  ankle  may  admit  of  conservatism  if  the  parts 
can  be  rendered  aseptic  ;  or  if  the  soft  tissues  are  not  much  damaged,  ex- 
cision should  be  practised.  This  latter  rule  is  also  applicable  to  the  shoulder 
and  elbow,  but  bad  compound  fractures  of  the  wrist  require  amputation. 

Compound  dislocations  of  the  ankle,  elbow,  shoulder,  and  hip,  provided 
only  moderate  injury  has  been  inflicted  upon  the  soft  parts — where  conserva- 
tism is  not  indicated — should  be  treated  by  excision,  as  a  rule.  Owing  to  the 
frequent  damage  to  the  popliteal  vessels,  and  the  destruction  of  most  of  the 
vessels  capable  of  carrying  on  the  collateral  circulation,  amputation  is  the 
safest  course  in  compound  dislocations  of  the  knee. 

Lacerated  and  Contused  Wounds  inflicted  by  the  claws  or  the  teeth  of  wild 
animals,  and  the  extensive  shattering  of  bone  produced  by  gunshot  wounds, 
often  demand  amputation.  AVhile  Avounds  and  lacerations  of  arteries  rarely 
call  for  amputation  except  for  a  traumatic  or  diff"used  popliteal  aneurysm  or 
similar  conditions  of  the  deep  arteries  of  the  leg,  or  for  traumatic  aneurysm  of 
the  axillary,  it  is  often  required  for  secondary  hemorrhage  the  result  of  pre- 
vious wound  of  a  vessel  or  following  ligation  of  an  artery  in  its  continuity. 

Gangrene  the  result  of  frost-bite,  of  burns,  of  traumatism,  or  of  a  wound 
of  an  artery  or  of  its  gradual  occlusion  in  the  young,  demands  amputation  well 
above  the  limits  of  the  disease,  and  even  in  the  senile  form,  under  favorable 
circumstances,  amputation  of  the  leg  or  thigh  is  sometimes  proper.  The  stu- 
dent, however,  should  consult  the  section'on  this  disease  for  the  special  indi- 
cations for  and  against  operation. 

Many  destructive  diseases  of  the  hones  a,m\  joints,  where  extensive  implica- 
tion of  the  soft  tissues  exists,  demand  amputation. 

Malignayit  Tumors  of  the  extremities  are  best  treated  by  amputation  when 
they  affect  the  bones,  and  even  when  these  tumors  are  free  from  bony  attach- 
ments their  relations  to  other  important  structures  may  be  such  that  they  can- 
not otherwise  be  safely  removed.  In  this  case  the  whole  of  the  bone  involved 
should  be  removed  ;  that  is,  the  amputation  should  be  at  or  above  the  joint  on 
the  proximal  side  of  the  disease.  Very  rarely,  benign  growths  reaching  such 
a  size  as  to  render  life  burdensome  require  removal  of  the  limb;  or  by  their 
ulceration,  followed  by  profuse  discharges,  they  may  menace  the  patient's  life 
unless  removed. 

Tetanus,  with  the  modern  views  as  to  its  pathology,  cannot  be  considered 
an  indication  for  amputation. 

For  Deformities,  such  as  severe  neglected  club-foot,  limbs  rendered  useless 
by  cicatrices,  mal-union  of  fractures,  etc.,  amputation  is  sometimes  done  in  robust 
young  individuals,  but  these  are  usually  operations  of  complaisance,  not  of 
necessity. 


AM/'ITATKjXS.  11'>' 


INSTRUMKNTS. 
The  instruments  re(|uire.l  for  iun]mtations  are  those  to  arrest  hemor- 
rhac'e  ilurin<-  the  operation,  knives,  saws,  retractors,  cutting  bone  lorceps 
stro"ig  (lion^jaw)  forceps  to  liohl  a  bone  fragment,  tenacula,  artery  and 
hemostatic  forceps  to  secure  the  vessels,  needles  to  sew  up  the  Haps,  scis- 
sors, and  dissecting  forceps ;  in  addition,  capillary  or  tube  drains  must  be 
provided,  proper  dressings,  and  a  splint  to  fix  the  joint  above  the  segment 

amjjutated. 

ToURNiQrKT. — The  most  commonly  employed  tournniuet  at  the  present 
time  is  the  elastic  band  devised  by  Esmarch  \iu<h'  infra).  Petit's  was  em- 
ployed largely  for  many  years ;  it  consists  of  two  metal  plates  capaole  ot 
beim^  separated  bv  a  powerful  screw,  and  a  stout  strap  with  pad  and  buckle. 
Othei"  forms  of  instruments  have  been  devised  which  press  only  on  the  vessel 
and  at  a  point  directly  opposite—/,  e.  horseshoe  tourniquets,  Hoey's  clamp, 
and  Skey's  tourniciuet,  large  sizes  of  the  two  latter  being  used  to  control  the 

abdominal  aorta.  ,,,17  j 

EsM arch's  Apparatus. — This  consists  of  a  broad  rubber  bandage  and  a 
flattened  rubber  band  with  a  hook  at  one  end  and  a  few  links  of  chain  at  the 
other.  ApjjUcatioH.—'Yhe  bandage  is  put  on  firmly  from  below  upward, 
without  reverses,  as  high  as  is  desired,  when  the  band  is  carried  well  on  the 
stretch  around  the  limb  above,  but  close  to  the  last  turn  of  the  bandage,  and 
is  secured  with  the  hook  and  chain  or  by  tying  the  crossed  ends :  the  rubber 
bandacre  is  then  removed.  Do  not  draw  the  band  too  tight  nor  leave  it  on  too 
lonc^,  fest  paralysis  from  pressure  on  the  nerves  result ;  again,  never  allow 
the^member  to  be  decidedly  flexed  or  extended  after  its  application,  because 
tearing  of  the  muscles  may  result.  The  annoying  oozing  following  the  use 
of  the'^Esmarch  bandage  can  be  lessened  by  removing  it  as  promptly  as  pos- 
sible, thus  lessening  the  vaso-motor  paresis ;  by  maintaining  elevation  of  the 
part  combined  with  the  use  of  hot  water;  and  by  digital  compression  of  the 
main  artery  for  a  few  moments.  An  amputation  can  be  made  practically 
bloodless  without  the  Esmarch  bandage  by  elevation  of  the  limb  for  a  few 
minutes  just  before  operation,  bv  centripetal  massage  of  the  part,  and 
the  use  of  the  Esmarch  band  applied  on  the  full  stretch  so  that  the  main 
artery  is  at  once  compressed.  Thus,  apply  the  mid-part  of  a  portion  of 
the  stretched  band  suddenly  against  the  inner,  anterior  aspect  of  the  upper 
thigh,  quickly  encircling  the  limb  with  the  band  and  rapidly  passing  other 

tight  turns.  ,    •         •  1  i 

Amputating  Knives. — Modern  knives,  having  their  points  sharp  and 
double-edcred,  are  fitted  for  both  the  circular  and  the  transfixion  methods  of  ope- 
rating. A  breadth  of  from  three-  to  five-eighths  of  an  inch,  and  a  length  of 
from  six  to  nine  inches  of  cutting  edge,  are  proper  dimensions  for  the  blade. 
Double-edged,  sharp-pointed  knives  called  catlins  are  employed  by  some  ope- 
rators in  transfixion  operations  or  to  clear  the  interosseous  space,  but  the  point 
of  any  amputating  knife  will  do  for  this  latter  purpose.  One  metacarpal  knife 
with  a  three-and-a-half-inch  blade,  a  slender  bistoury  with  heavy  back,  and  a 
stout  scalpel  are  all  the  knives  absolutely  requisite. 

Saws. While  many  patterns  of  saws  have  been  proposed,  the  best  is 

the  ordinary  flat-bladed  one.  but  it  is  well  to  have  a  smaller  instrument  (meta- 
carpal saw)  with  movable  back. 

Cutting  Bone  Ft>RCEPS  are  necessary  to  remove  rough  or  splintered 
edf'es  which  may  be  left  by  the  saw  or  for  dividing  the  metacarpal  or  pha- 
langeal bones. 


11.04  J.v  AMr.nicAX  ri: XT- nook'  or  s('ii(;i:in\ 

Fergusson's  lion-jaw  forceps  are  useful  where  in  compound  fractures  only  a 
fragment  of  bone  is  left,  rendering  difficult  such  steadying  (jf  it  by  the  hand  as 
will  prevent  splintering  when  sawing,  or  when  retrenchment  of  bone  is  requisite 
because  the  flaps  have  been  cut  too  short. 

A  Tenaculum  and  Artery-,  or  Hemostatic  Forceps  are  required  to  secure 
the  vessels,  the  last  being  all  that  are  usually  rerjuisite,  except  where  a  vessel 
is  imbedded  in  naturally  dense  tissues  or  those  rendered  dense  by  inflammation, 
or  when  the  vascular  coats  will  not  hold  a  ligature ;  in  all  of  which  cjises  it  is 
often  necessary  to  take  up  with  the  vessel  some  of  the  surrounding  tissues  and 
include  them  in  the  ligature.  In  these  cases  the  tenaculum  is  the  best  instru- 
ment, or  a  ligature  may  be  carried  through  the  tissues  by  a  curved  needle  and 
tied. 

Lir.ATURES  are  made  of  silk,  catgut,  or  some  animal  tissue  of  a  size  propor- 
tioned to  the  vessels  to  be  tied,  properly  asepticized  and  secured  by  a  square  or 
reef  knot :  sometimes  it  is  desirable  to  use  the  surgeon's  knot,  secured  by  a 
second  half  knot,  when  including  a  mass  of  tissue  with  the  artery. 

The  Ri:tk ACTOR  consists  of  a  piece  of  muslin  or  of  several  thicknesses  of 
gauze,  six  or  eight  inches  wide,  rendered  thoroughly  aseptic,  and  torn  halfway 
up  into  two  or  three  tails.  The  latter  form  is  used  for  the  forearm  or  leg,  the 
center  tail  being  passed  through  the  interosseous  space,  the  outer  ones  being 
wound  around  the  bone  on  each  side,  crossed  over  the  soft  parts,  and.  with  the 
untorn  portion  similarly  disposed  on  the  other  side,  drawn  firmly  upward  by 
an  assistant.  Where  there  is  only  one  bone,  the  two  tails  are  made  to  embrace 
the  bone,  are  crossed,  and  then  held  as  above  directed. 

Sutures  may  be  of  wire,  when  they  must  be  twisted  and  cut  off,  and 
removed  by  a  reversal  of  the  process  ;  of  chromicized  catgut,  when  they  should 
be  introduced  in  the  form  of  interrupted  sutures,  tied  in  a  reef  knot ;  or,  best, 
of  silkworm  gut  or  silk,  employed  as  the  interrupted  suture,  the  stitches  being 
about  one-third  of  an  inch  apart. 

The  Needles  employed  to  pass  the  sutures  should  be  either  large,  long 
"saddlers'  needles."  or  ordinary  surgical  needles  with  only  their  extremities 
slightly  curved,  or  the  Hagedorn  needle.  The  best  needle-holder  for  the  latter 
is  Abbe's  with  the  spring  catch. 

Halsteds  "gut  wool  "  or  "antiseptic  wax  "'  for  controlling  undue  bleeding 
from  the  bone  should  be  ready.  The  best  formula  for  tlie  latter  is  Horsley's, 
viz.  :   beeswax  seven  parts,  almond  oil  one  part,  and  salicylic  acid  one  part. 

OPERATIVE  METHODS. 

These  are  all  modifications  (1)  of  the  ^''  circular  method  "  in  which  the  skin 
and  superficial  fascia,  being  divided  in  a  circular  manner,  are  dissected  up  for 
a  sufficient  distance,  the  muscles  cut  circularly  down  to  the  bone,  and  this  in 
turn  sawn  at  a  higher  point;  and  (2)  of  the  "'flop  method,''  in  which  a  cover- 
ing is  provided  for  the  bones  by  variously-shaped  "flaps  "  of  skin  and  fascia, 
or  of  muscle  in  addition. 

Circular  Operation. — After  shaving  and  antiseptic  cleansing,  hemor- 
rhage having  been  ])rovided  against  by  Esmarch's  band,  by  the  tourniquet,  or 
by  digital  ])ressure  on  the  artery,  the  patient's  limb  must  be  made  to  project 
over  the  edge  of  the  operating  table  or  bed,  and  the  floor  be  protected  from 
the  blood  by  an  old  blanket,  a  piece  of  oil-cloth,  or  a  bucket.  One  assistant's 
duty  should  bo  to  give  the  anesthetic,  another  must  attend  to  the  tourniquet,  a 
third  should  hold  and  manipulate  the  limb,  while  a  fourth  will  manage  the 
retractor,  assist  with  instruments,  etc.     The  instruments  should  be  arranged  in 


AMJ'l'TATlONS'. 


1155 


Circular  Amputation  ;  dissoctinj?  up  the  skiu-tlap  ( l-:smarch). 


proper  trays  orliiid  on  an  antiseptic  towel  conveniently  near  the  surgeon's  right 
hand  :   unless  the  operator  pj^  ^^j 

be  ambidextrous,  he  should 


stand  with  iiis  left  hand  to 
Avard  the  patient's  trunk. 
Drawing  the  skin  of  the 
limb  upward  with  the  left 
hand  and  stooping  slight- 
ly, a  long  knife  should  be 
carried  by  the  right  hand 
beneath  and  around  the 
limb,  so  that  its  back  pre- 
sents to  the  operator's  face 
with  its  point  drop])ed  well 

downward.   The  heel  being  i  .t      r    v    *v, 

firmly  pressed  against  the  skin,  the  knife  must  be  swept  around  the  limb,  the 
operator  gradually  rising  from  his  stooping  posture,  until  the  entire  circuit  ot 
the  member  has  been  made.  A  few  light  touches  of  the  knite  as  the  skin  is 
firmlv  pulled  up  will  suffice  to  obtain  enough  flap  for  a  thm  limb  ;  but  it  is 
usuailv  requisite  rapidly  to  dissect  up  and  reflect  a  cuft"  of  skinm  length  about 
half  the  diameter  of  tlie  member,  carefully  avoiding  scoring  the  subcutaneous 
fat  in  which  ramifv  the  cutaneous  vessels,  by  directing  the  knife  toward  the 
deeper  tissues.  A  "longitudinal  incision  must  often  be  made  on  one  side  ot  the 
cuff  to  admit  of  its  reflection  over  a  conical  part,  as  the  calf  or  a  muscular 

After  the  cuff  has  been  evenly  dissected  high  enough,  the  surgeon  must 
apply  the  long  knife  to  the  muscles  and  cut  them  as  before  with  a  circular 
sweep  of  the  knife  down  to  the  bone.  The  periosteum  must  be  divided  by  a 
circular  cut  and  forced  up  with  the  muscles,  either  by  the  finger  or  by  the 
handle  of  the  knife,  for  an  inch  or  more :  this  is  preferable  to  separating  the 
muscles  from  the  periosteum  up  to  the  point  where  the  bone  is  to  be  sawn,  in 
the  le<^  or  forearm,  where  tliere  are  two  bones,  the  interosseous  tissues  must  be 
divided  by  the  point  of  the  knife,  entered  first  in  front,  then  behind  rocking 
it  from  side  to  side,  or  by  a  scalpel  or  narrow  catlin  similarly  used.  Adjusting 
the  retractor  as  before  directed,  the  surgeon  must  force  up  the  soft  parts  in 
order  to  apply  the  saw  as  high  as  possible.  ,  .     ,  ^     ,       ,       -i    •. 

Holding  the  saw  firmly  and  steadying  its  edge  by  his  left  thumb-nail,  its 
ed<Te  must  be  drawn  firmlV  backward— from  heel  to  point— cutting  a  groove, 
wlRni  a  few  even  strokes  will  complete  the  division  of  the  bone  Theo- 
retically, the  saw  should  be  held  vertically  to  prevent  the  weight  of  the  limb 
from  breaking  the  bone  before  its  complete  division  ;  but  if  carefully  held  by  the 
assistant  so  as  neither  to  strain  the  unsawn  portion  nor  bind  the  saw,  the  divis- 
ion can  be  made  in  any  way  most  convenient  to  the  operator.  In  the  leg  it  is 
better  to  saw  through  the  fibula  before  the  tibia  is  completely  divided,  to  avoid 
strainintr  the  superior  tibio-fibular  joint;  and  the  radius  in  the  forearm,  as  it  is 
the  more  movable  of  the  two  bones.  As  soon  as  the  limb  is  removed,  all  ves- 
sels that  can  be  detected  are  to  be  taken  up  with  a  tenaculum  or  forceps  and 
tied  •  the  pressure  on  the  artery  is  then  to  be  relaxed,  and  any  bleeding  points 
are  to  be  caucrht  first  with  forceps,  and  then  every  bleeding  vessel,  whether 
artery  or  vein,  is  to  be  tied.  Cut  off  with  the  bone  forceps  any  uneven  por- 
tions of  bone,  draw  out  and  remove  with  the  scissors  all  large  nerves,  retrench 
projecting  tendons,  and  check  capillary  oozing  with  hot  aseptic  water.  If 
bleedincr  persists  from   the  bone,   and  the  vessel  cannot  be  plugged  with  a 


115G 


.l.Y    AMFJUCA.X    TEXT-HOOK    OF  ^VimERY. 


Fia.  472. 


piece  or  twisted  strand  of  catgut,  a  small  pellet  of  antiseptic  wax  fastened 
to  a  silk  ligature  must  be  pressed  on  the  spot :  this  can  be  brought  away 
by  the  ligature  along  the  track  of  the  drainage-tube  at  a  subsequent  dress- 
ing. This,  however,  is  an  expedient  rarely  demanded,  as  catgut  plugging 
or  sewing  of  the  periosteal  flaj>s  or  the  tissues  over  the  bone,  so  as  to  exert 
pressure,  is  better;  or  Ilalsted's  "gut  wool,"  or  Ilorsley's  "antiseptic  wax  " 
may  be  used.  Any  bleeding  periosteal  vessel  must  be  twisted,  or  tied  by  a 
catgut  thread  passed  by  a  small  curved  needle.  The  stump  being  now  dry, 
a  drainage-tube  should  be  placed  so  as  to  emerge  at  what  will  be  the  most 
dependent  angle,  and  the  skin  sutured  by  interrupted  silkworm  gut  or  silk 
stitches  so  as  to  form  a  vertical  or  a  horizontal  line :  an  antiseptic  dressing 
must  next  be  applied,  such  as  will  be  described  for  flap  operations,  and  a  splint 
bandaged  on  in  amputations  below  the  elbow  or  knee  to  keep  the  whole  limb 
at  rest ;  or  it  may  be  made  comfortable  on  a  pillow. 

Flap  Operations. — The  flaps  may  consist  of  skin  alone,  or  of  muscle  in 

addition.  When  the  latter  is  included, 
there  must  be  enough  skin  to  cover  the 
muscle,  enough  muscle  to  cover  the  bone, 
and  the  bone  must  be  sawn  above  the 
angle  of  junction  of  the  flaps.  The  flaps 
may  be  cut  from  without  inward  or  from 
within  outward.  The  latter  is  spoken 
of  as  transfixion. 

Siiujh'-flap  Operation. — This  is  ad- 
visable only  when  from  injury  or  disease 
the  tissues  on  one  side  are  unfit  to  use, 
while  on  the  other  they  are  sound.  The 
flap  must  be  somewhat  longer  than  the 
transverse  diameter  of  the  limb  at  the 
point  wliere  the  bone  is  to  be  sawn ; 
should  as  far  as  possible  be  rectangular 
in  outline ;  must  include  skin,  fascia,  and 
a  good  layer  of  muscle,  and  is  best  made 
by  cutting  from  the  skin  inward,  the  tis- 
sues on  the  opposite  side  of  the  extremity 
being  divided  transversely  or  by  an  in- 
cision slightly  convex  downward ;  and 
the  bone  cleaned  of  tlie  soft  parts,  and 
sawn  off"  at  least  one  inch  above  the  base 
of  the  flap,  as  directed  for  the  circular 
operation. 

Douhle-jiap  Operation  (Fig.  472). — In  addition  to  the  general  rules 
which  have  been  given  above,  the  following  directions  will  suflice,  ex- 
cept in  certain  instances  where  some  special  modifications — which  will  be 
described — become  requisite.  In  breadth  each  should  be  half  the  width  of 
the  member ;  in  length  they  may  be  equal,  or  one  may  be  longer  than  the 
other,  but  the  aggregate  length  must  be  somewhat  more  than  the  diameter  of 
the  limb  at  the  level  at  which  the  bone  is  to  be  sawn,  especially  in  operations 
for  disease,  where  the  muscles  will  not  at  once  retract  to  their  full  extent,  but 
may  do  so  to  an  unpleasant  degree  in  the  course  of  a  few  days.  They  may 
consist  of  skin  alone  or  of  muscle  also,  while  they  may  be  lateral,  antero-pos- 
terior,  or  antero-lateral.  While  cut  more  rapidly  by  the  transfixion  method, 
there  is  apt  to  be  a  redundance  of  muscle,  so  that  a  better  stump  can  be  made 


The  Flap  Method  by  Transfixion  (S(;'flillf>t). 


AMPUTATIONS. 


1157 


by  cutting  from  the  skin  iinvurd,  or  one  flap  may  thus  ho  made  while  the 
other  is  eut  by  transfixion.  The  advantage  of  inuscuh)-eutaneous  flaps  is 
that  by  buried  animal  sutures  all  s|)aces  may  be  effaced,  and  thus  all,  except 
perhaps  ca|)illary,  drainage  can  he  dispensed  with,  which  is  hardly  possible 
with  cutaneous  flaps  alone. 

Mixed  or  Modified  Circular  Method — i.  e.  flaps  of  skin  and  cir- 
cular of  muscles. — The  best  is  that  of  Syme,  in  which  two  semilunar  flaps 
are  dissected  up  a  short  distance  above  the  angles  of  juncture  of  the  Haps, 
the  remainder  of  the  operation  being  identical  with  the  circular  method 
(Fig.  478). 

Method  of  Closing  and  Dresshu/. — After  first  arresting  all  bleeding, 
if  the  patient's  condition  will  permit  of  prolonging  the  operation,  a  more 
ideal  result  will  be  obtained  by  sewing  the  periosteum  over  the  end  of  the 
bone  or  bones,  by  closing  the  sheaths  of  nerves  after  they  have  been  divided 
as  high  as  possible,  and  by  sewing  together  the  divided  ends  of  the  muscles. 
In  employing  this  method  it  is  essential  that  the  technique  be  consistently 
aseptic  throughout,  as  drainage  must  be  dispensed  Avith.  Finally,  the  skin 
must  be  united  by  interrupted  silk  or  chromicized  catgut  or  silkworm-gut 
sutures,  between  each  two  of  which  three  or  four  of  the  catgut  drainage- 

FiG.  473. 


Mixed  Method  :  skin-flaps  and  circular  through  muscles  (Esmarch). 

threads  should  pass.  These  are  kept  parallel  and  in  contact  with  one  another, 
cut  off  square,  and  kept  moist  by  «,  piece  of  protective  Avhich  shall  cover  in 
the  wound  and  extend  one  inch  beyond  the  cut  ends  of  the  drains.  Some 
surgeons  use  simply  a  rubber  drain-tube  for  a  day  or  two,  with  or  without 
capillary  drainage ;  suture  the  edges  of  the  flaps,  and  secure  apposition  of 
the  surfaces  of  the  flaps  by  deep  sutures  passed  through  and  through  or  by 
suitable  compression  by  pads  and  bandages.  Over  the  stump  a  voluminous 
mass  of  gauze,  Avith  sufficient  aseptic  cotton  or  wood-wool  to  absorb  the 
bloody  serum,  must  be  applied  and  bandaged  securely  in  place,  the  dressing 
extending  many  inches  above  the  extremity  of  the  stump  ;  for  instance,  well 
above  the  knee  for  an  amputation  at  the  middle  of  the  leg. 

Splints  are  indicated  for  amputations  below  the  elbow-,  knee-,  and  wrist- 
joints.  Should  no  hemorrhage,  great  rise  of  temperature,  undue  pain,  or 
soakage  of  discharges  through  the  bandages  demand  it,  such  a  dressing  in  an 
aseptic  operation  may  remain  undisturbed  for  from  tAvo  to  three  weeks,  when 
if  silk  thread  has  been  used  the  stitches  must  be  removed;  if  catgut  has  been 
employed,  it  may  have  disappeared ;  in  either  case  the  stump  will  usually  be 
found  soundly  healed.  When  it  is  doubtful  whether  asepticism  has  been 
secured,  two  short  rubber  drainage-tubes  must  be  introduced,  so  that  one 
emerges  at  each  angle  of  the  wound,  reaching  doAvn  to  the  bone,  cut  off 


1158  AN  AMERICAN    TEXT- HOOK    OF  SUIiaEliV. 

nearly  flush  witli  tlie  surface,  and  secured  by  a  safety-pin  or  stitcli  :  tliese 
must  be  removed  at  the  end  of  two  or  tliree  days  unless  re(|uired  for  a 
longer  period. 

Amputations  in  Continuity  and  in  (Juntkjuity. — The  first  term  is 
used  to  indicate  an  amputation  where  a  bone  is  sawn  tlirough,  wliile  an 
amputation  in  contiguity  is  synonymous  with  removal  of  a  limb  tlirough  a 
joint. 

After-treatment  and  Compijcations. — As  all  dressings  should  be 
conducted  on  aseptic  principles,  the  student  should  consult  the  section  devoted 
to  this  subject.  If  the  union  is  not  firm,  so  long  as  the  sutures  are  not  irri- 
tating the  parts  allow  them  to  remain.  Where  additional  support  is  needed, 
strips  of  aseptic  or  antiseptic  gauze  fixed  with  collodion  are  better  than  adhe- 
sive plaster;  but  if  this  latter  is  used,  interpose  a  few  layers  of  gauze  between 
them  and  the  line  of  union.  Spasm  and  retraction  of  the  muscles  must  be 
combated  by  firm  circular  bandaging,  adhesive  plaster,  stirrup-extension  by 
weight  and  pulley,  and  splints,  as  must  also  the  elevation  of  the  heel  some- 
times following  Chopart's  operation.  Antipyrine  internally  may  also  be 
used. 

Hemorrhage  may  occur  a  few  hours  after  operation  (consecutive  or  reac- 
tionary, from  small  vessels  overlooked,  because  not  bleeding,  during  shock), 
or  days  or  weeks  after  operation  from  imperfect  closure  or  giving  way  of 
arteries  (secondary  hemorrhage).  If  consecutive  and  slight,  firm  bandaging, 
elevation,  and  ice-bags  over  the  stump  should  be  tried.  If  these  measures 
fail,  or  if  it  is  evident  that  a  large  vessel  is  bleeding  when  union  has  not 
progressed  far,  the  flaps  must  be  opened  and  the  bleeding  points  secured  ; 
but  if  union  is  nearly  completed,  use  acupressure,  or,  better,  tie  the  vessel 
or  vessels  just  above  the  stump.  Painful  enlargements  of  the  nerves  must 
be  excised,  while  caries  and  necrosis  of  the  bones  re(iuire  the  same  treatment 
as  when  arising  from  other  causes,  except  that  reamputation  is  more  often 
appropriate  than  primary  amputation  would  be  for  bone  disease. 

Mortality. — Circumstances  vary  so  much  that  only  a  few  facts  are  beyond 
reasonable  dispute.  Age  influences  the  result:  thus,  operations  in  children  are 
usually  successful,  Avhile  the  reverse  holds  good  for  the  aged,  the  death-rate 
increasing  with  advancing  years.  Renal,  hepatic,  or  other  visceral  disease 
greatly  increases  the  danger,  as  do  bad  hygienic  surroundings.  Amputations 
for  injury  have  a  higher  death-rate  than  those  for  disease,  as  do  those  for 
malignant  disease  as  compared  with  operations  for  caries,  chronic  suppurative 
arthritis,  etc.;  moreover,  amputations  of  the  lower  limb  are  more  dangerous 
than  those  of  the  upper ;  again,  the  death-rate  for  the  thigh  is  nearly  twice  as 
great  as  for  removals  of  the  leg :  the  mortality  of  leg  amputations  is  much  greater 
than  that  of  amputations  of  the  forearm ;  and,  in  turn,  those  of  the  upper  arm 
are  more  dangerous  than  those  of  the  forearm.  Antiseptic  surgery  has  enor- 
mously diminished  the  mortality. 

Primary  Amputation  means  one  done  after  injury,  before  the  onset  of 
traumatic  fever  (if  shock  persists,  this  may  mean  after  the  lapse  of  even  so 
long  a  time  as  seventy-two  hours). 

Intermediary  operations  are  those  performed  during  the  acute  inflam- 
matory stage — /.  e.  from  two  to  four  weeks,  possibly  less ;  while  Secondary 
amputations  are  those  performed  after  the  subsidence  of  fever  and  the  establish- 
ment of  suppuration.  Amputations  for  accident  should  always,  when  possible, 
be  primary,  but  if  this  cannot  be  done,  wait  for  the  secondary  period  rather 
than  run  the  exceptional  risks  of  an  intermediary  operation. 


AMPUTATIONS. 


1159 


Fig.  474. 


Amputation  of  a  Phalanx  (after 
Esmarch). 


SPECIAL  AMPUTATIONS. 

Amputations  of  the  Fingers. — From  the  importance  of  the  hand,  and 
because  this  member  possesses  its  peculiar  powers  in  virtue  of  the  pos.sibility 
of  the  tip  of  each  digit  being  apposed  to  that  of  the  thumb,  it  is  of  paramount 
importance  to  presci-vc  even  small  ])ortions  of  a  phalanx,  especially  of  the  thumb. 

Amputation  through  a  Phalanx  can  be  done  by  two  square  ilaps  fash- 
ioned by  making  a  circular  cut  down  to  the  bone,  supplemented  by  two  vertical 
lateral  ones,  or  two  semilunar  flaps  may  be  employed;  the  bone  may  be  divided 
by  cutting  forceps  or  by  a  small  saw,  and  the  digital  arteries  on  each  side 
twisted  or  included  in  the  stitches  by  which  the  flaps  must  be  coa])tated ;  tlie 
other  fingers  and  the  wrist  must  be  kept  (juiet  on  a  si)lint  for  about  ten  days. 

Amputation  through  an  Interphalangeai  Joint  may  be  done  either 
by  a  single  palmar  flap  or  by  two  semilunar  flaps,  the  chief  point  to  be  re- 
membered being  that  the  joint  in  the  last  row 
of  phalanges  is  one-twelfth  of  an  inch  beyond 
the  most  projecting  part  of  the  knuckles  ;  that 
of  the  middle  row,  one-sixth  of  an  inch  beyond  ; 
and  that  of  the  metacarpo-phalangeal  joint, 
one-third  of  an  inch  beyond.  Use  a  narrow, 
sharp-pointed  bistoury  for  these  operations, 
and  cut  the  flaps  from  without  inw^ard,  after 
which  the  lateral  ligaments  must  be  divided, 
when  the  knife-edge  should  be  entered  on  the 
dorsal  aspect  of  the  joint,  passed  between  the 
bones,  and  made  to  cut  doAvnward  and  forward, 
severing  the  palmar  ligaments,  and  completing  the  disarticulation  (Fig.  474). 

Amputation  at  the  Metacarpo-phalangeal  Joints. — This  may  be 
done  by  double  lateral  flaps,  or  thus :  With  the  patient's  hand  pronated  make 
a  longitudinal  half-inch  cut  over  the  head  of  the  metacarpal  bone ;  carry  the 
knife  obliquely  from  the  lower  end  of  this  incision  down  on  one  side  to  the 
interdigital  web  across  the  base  of  the  finger  on  the  palmar  surface  and 
upward  on  the  other  side  to  the  longitudinal  cut,  dividing  the  tissues  down 
to  the  bone ;  cut  the  tendons  and  lateral  ligaments,  and  complete  the  dis- 
articulation. All  the  fingers  may  be  thus  separately  removed,  or  to  remove 
them  all  together  a  transverse  dorsal  incision  may  be  made,  disarticulation 
eff"ected,  and  a  palmar  flap  made  by  transfixion  from  within  outward, 
and  a  palmar  flap  made  from  within  outward. 

AMPUTATION   OF   THE    THUMB 

through  its  metacarpal  bone  (Fig.  475)  or  with  this  bone,  and  amputation 

of    the    little   finger   with 

its   metacarpal  bone,  can   be  F^*^'-  ^'^'^^ 

done    best   by    the    modified 

oval    method    given    for   the 

disarticulation    of    an    entire 

finger. 

AMPUTATION   OF   THE   META- 
CARPUS. 

Amputation  of  a  por- 
tion or  of  all  of  the  meta- 
carpus, with  or  without  por- 
tions of  the  carpus,  must 
usually  be   done  by  fashion- 


Amputation  of  the  Thumt)  through  the  Metacarpal  Bone 
(original). 


ll»i(> 


AN  A.VEJiJCAX   TPLXT-liOOK   OF  .SURGERY 


ing    tia}).s,    not    according    to   any   given    rule,    but    as   the    condition   of  the 
tissues  permits. 

AMPUTATION    AT   THE    WKIST. 

Til  is  mav  be  effected  bj  the  circular  method,  controlling  the  circulation 
through  the  brachial  artery.  Make  the  incision  from  one  inch  to  one  inch 
and  a  half  below  the  radio-carpal  joint,  reflect  the  Hap,  open  the  joint  from 
the  radial  side,  and,  having  disarticulated,  secure  the  vessels,  about  three  or 
four  in  number.  A  single  oval  or  rectangular  palmar  flap  cut  from  without 
inward  ni:iv  iiiso  be  em|)b>ved. 


AMPUTATION    OF   TH?:   FOREARM. 


The  circular  method  does  well  here,  but  antero-j)Osterior  musculo-cutaneous 
flaps  are  preferable  (Fig.  476),  best  made  by  cutting  from  without  inward, 


Fifi.  47«. 


Anii>ut.iti(>n  of  tin'  Forearm  (I5ryaiit). 

although  they  can  be  fashioned  by  transfixion :  retrenchment  of  tendons  is 
re(iuisite.  When  possible  saw  the  bones  above  the  attachments  of  the  pronator 
radii  teres  to  retain  the  power  of  pronation. 

AMPUTATION    AT   THE    ELBOW. 

Elliptu'iil  Method. — Semi-flex  the  arm  ;  enter  the  point  of  the  knife  about 
one  inch  below  the  inner  condyle,  carry  it  up  over  the  forearm  nearly  to  the 
joint  in  a  curve  with  the  concavity  upward,  thence  carry  the  curvilinear 
incision  downward,  passing  one  and  a  half  inches  below  the  external  condyle  ; 
forcibly  flex,  and  complete  the  incision  by  outlining  an  ellipse  with  the  con- 
vexity downward,  extending  at  its  lowest  point  about  three  inches  below  the 
tip  of  the  olecranon  :  reflect  the  skin  ;  divide  the  anterior  nniscles  half  an 
inch  below  the  joint;  disarticulate  this  from  the  outer  side,  cutting  the  ulnar 
nerve  well  above  the  joint ;  tie  the  brachial  or  radial  and  ulnar  vessels,  with 
a  few  smaller  branches ;  close  the  wound  transversely. 

The  F/ap  Method  of  Guerin. — Hold  the  forearm  semi-prone;  introduce 
the  knife  in  the  mid-forearm  line  one  inch  below  the  bend  of  the  elbow;  trans- 
fix by  skirting  around  the  radius  with  the  knife-point ;  cut  an  external  flap 
two  to  three  inches  long:  divide  the  tissues  on  the  opposite  side  of  the  joint 
by  a  curved  incision  carried  from  without  inwards,  convex  downward  ;  dis- 
articulate from  the  outer  siile :  close  the  wound  vertically  after  tying  the 
vessels. 

AMPUTATION    OF  THE    ARM. 

When  operating  near  the  shoulder  there  may  not  be  space  enough  to  apply 
the  tourniijuet.  but  by  maintaining  the  arm  at  a  right  angle  the  compress  can 
be  applied  over  the  axillary  artery  so  as  to  press  this  against  the  prominent 
head  of  the  humerus,  the  tourniquet  plate  being  placed  over  the  acromion  pro- 
cess ;  again,  compression  of  the  subclavian  against  the  first  rib  can  be  effected 
by  an  assistant  with  a  padded  key,  or  by  the  use  of  Keen's  method  by  a  com- 


AMPUTATIONS. 


n«)i 


Fro.  477. 


press  above  the  clavicle,  held  in  place  by  an  Esmarch  bandage  passed  alter- 
nately  between   the   thighs   and    in 
the  opposite  axilla. 

While  the  (.'ircular  nicthod  does 
well  in  innjditatioii  of  tho  arm,  the 
double  antero-posterior  flap 
is  the  better  operation,  this  being 
ione  either  by  transfixion  or  by 
cutting  from  without  inward  (Fig. 
477).  As  the  l»iceps  contracts  moic 
than  the  triceps,  the  anterior  ila]) 
should  be  the  longer  of  the  two, 
and  the  bone  must  be  especially 
cleaned  behind  by  a  few  extra 
touches  of  the  knife :  the  brachial 
artery,  the  superior  profunda,  and  a  varying  number  of  smaller  vessels  require 
ligature.  If  the  location  of  the  disease  or  injury  prevents  the  formation  of 
antero-posterior  flaps  variously  disposed,  single  or  double  flaps  can  be  made. 


Amputatiiiii  (if  the  Arm  (Bryant). 


Fig.  478. 


AMPUTATION  AT  THE  SHOULDER. 

The  Oval  or  Larrey's  Method  (Fig.  478). — Control  the  circulation  by 
compressing  the  subclavian  against  the  first  rib,  or  as  above;  enter  the  point  of  a 

medium-sized  knife  below  and  just  anterior  to  the  tip 
of  the  acromion  process,  making  a  three-inch  longi- 
tudinal cut;  from  just  below  the  middle  of  this  make, 
first  in  front,  then  behind,  slightly  curved  lateral 
incisions  with  their  convexities  downward,  extend- 
ing respectively  to  where  the  anterior  and  posterior 
axillary  folds  end  in  the  arm  tissues ;  rapidly  loosen 
the  edges  of  the  wound ;  while  the  bone  is  rotated 
outward,  forcibly  sweep  the  point  of  the  knife  be- 
neath the  acromion  process  across  the  capsule,  divid- 
ing it,  the  long  head  of  the  biceps,  and  the  subscap- 
ular muscle ;  then  forcibly  rotate  in,  cutting  the  infra- 
and  supraspinatus  and  teres  minor  muscles ;  finally, 
pass  the  knife  behind  the  head  and  neck  of  the 
bone,  and  while  an  assistant  grasps  the  flap  contain- 
ing the  vessels  behind  the  knife,  remove  the  limb  by 
cutting  from  within  outward,  so  as  to  connect  the 
two  lateral  incisions  by  a  transverse  one ;  tie  the  brachial  and  subscapular 
arteries,  the  former  occupying  the  first  muscular  interspace  behind  the  anterior 
axillary  fold :  suture  the  sides  of  the  oval  together,  so  that  a  linear  wound 
remains. 

Dupuytren's  Method. — Taking  the  same  precautions  against  hemor- 
rhage, with  the  patients  arm  well  extended  from  the  body  grasp  the  deltoid 
with  the  left  hand;  transfix,  traversing  the  joint  with  the  knife  entered  one 
inch  in  front  of  the  acromion  process  and  emerging  at  the  posterior  axillary 
fold,  and  form  a  large  deltoid  flap  by  cutting  downward,  backward,  and  out- 
ward ;  turn  this  aside ;  disarticulate  by  dividing  the  muscles  rendered  tense  by 
outward  and  inward  rotation  ;  slip  the  knife  behind  the  bone  and  cut  a  short 
inner  flap  from  within  outward,  an  assistant  grasping  the  flap  behind  the  blade 
to  control  the  artery  ;  secure  the  vessels  and  suture  the  wound. 


Larrey's  Amputation  at  the 
Shoulder-joint  (after Stim- 
son). 


IK; -J 


l.V    AMKIilCAy    TEXT-JIOOK  Of  S(  /.'(, /:/:)'. 


Wyeth's  Bloodless  Method.— See  tliat  tlie  shoulder  jn-ojects  .sliglitly 
bevonci  the  edge  uf  the  taldc  :  j.hiee  the  arra  at  a  right  angle  with  the  body  ; 
introduce  one  long  steel  {>in — a  twelve-inch  mattress  needle  will  do — through 
the  pectoralis  major  tendon  (Fig.  479) — /.<'..  the  anterior  axillary  foM,  enter- 
ing it  somewhat  to  the  thoracic  side  of  the  middle  of  the  fold  :  bring  the  point 
out  one  inch  internal  to  the  tip  of  the  acromion  process,  and  guard  it  with  a 
sterilized  cork.      Pass  a  second  pin  through  the  tendon  of  the  latissimus  dorsi 


Aminitation  at  Shoulder-joint 


arked  by  a  black 


muscle — i.  e.,  the  posterior  axillary  fold,  a  little  internal  to  the  middle  of  this- 
fold,  causing  the  point  to  emerge  posteriorly  one  inch  internal  to  the  tip  of  the 
acnnninH  process  ;  guard  the  point  with  a  sterilized  cork  :  tightly  wind  around 
the  axilla  and  shoulder,  internal  to  the  pins,  a  piece  of  black-rubber  tubing 
one-half  inch  in  diameter :  according  to  the  muscular  development  of  the 
patient  two  or  three  turns  may  be  made  :  disarticulate  by  any  of  the  approved 
methods ;  secure  the  main  vessels  and  any  small  ones  visible ;  remove  the  tub- 
ing and  pins :  secure  temporarily  all  bleeding  points  with  forceps  and  tie  them 
off;  complete  as  directed  for  each  special  method. 

Caution. — It  is  essential  that  both  pins  emerge  one  inch  internal  to  the  tip 
of  the  acromion:  otherwise,  when  the  humerus  is  disarticulated,  the  tulting 
tends  to  slip  down,  thus  drawing  the  flaps  together,  when  the  vessels  nuiy 
retract,  severe  hemorrhage  then  occurrincj,  necessitating  ligation  of  the  sub- 
clavian  artery  or  removal  of  the  tube  to  secure  the  vessels  in  the  wound,  this 
latter  only  being  possible  of  execution  after  severe  loss  of  blood. 

AMPUTATIONS  ABOVE  THE  SHOULDER. 

The  flaps  must  be  fashioned  as  the  condition  of  parts  left  by  injury  or  dis- 
ease will  allow ;  the  easiest  plan  is  to  disarticulate  the  arm  first,  tie  the  axillary 
vessels,  expose  the  scapula  by  a  T-incision,  the  transverse  arm  of  the  T 
roughly  corresponding  to  the  spine  of  the  scapula',  detach  it  from  the  thoracic 
wall  by  cutting  from  below  upward,  and  separate  it  from  the  clavicle  or 
divide  this  bone  with  a  saw  or  forceps. 


A.U/'l  /A  y/o.vx. 


1 1  <i;i 


i-Ki.  J  so. 


I.NThMtSC  \l'l   l.(i-T||u|!  ACie  A  M  ITT  A  I  I"  •  \  (  |{  i;.M(»VA  1,  n|t   Till:  WlluLK  I'l-l'KH 

ExTKii.MiTv),  I'M),  Hkkckk's  Mktiiok  ( Ki;,'.  4«0).— Iffli.-  (-..iiditions  <1<.  not 
forbid,  a|)|)ly  an  K>in:iirli  liaii(la;4('  tit  the  ii|i))t'r  fx- 
troiiiity  as  lar  as  the  lower  border  uf  the  axilla; 
make  an  incision  extending  fnttn  the  inner  extremity 
of  the  ehiviele  outward  to  the  toped"  the  sliouhler; 
iineover  and  resect  the  niiddh'  half  of  the  clavicle, 
thus  exposin;^  the  subclavian  vessels,  uhich  must 
next  l)e  tied — both  artery  and  vein  :  it  is  better  as  a 
rule  to  tie  the  artery  first  bv  two  ligatures,  each  about 
one  inch  apart;  divide  the  vessels  Itetween  the  liga- 
tures ;  cut  the  axillary  plexus  with  the  scissors; 
commence  a  second  incision  at  the  center  of  the  first, 
carryinir  the  knife  directly  across  the  anterior  part 
of  the  axilla  and  inner  arm  to  the  inferior  angle  of 
the  scapula;  from  the  outer  extremity  of  the  first 
incision  over  the  clavicle  carry  the  knife  posteriorly 
across  the  dorsum  of  the  scajjula  to  its  inferior  an<!;le, 
joining  the  termination  of  the  second  incision; 
reflect  the  posterior  flap  thus  made  ;  divide  all  muscular  and  ligamentous 
attachments;  secure  all  bleeding  points,  and  suture  the  flaps. 


Kcninviil  i»f  the  Whole  I'pper 
Kxtifinity  (Berserj. 


AMPUTATIONS  OF  THE  TOES. 

These  should  not  be  removed  through  a  phalanx,  interphalangeal  disarticu- 
lation being  preferable.  y  .    ,^, 

Amputations  througfn  the  Interphalan- 
geal Joints. — Open  the  joint  transversely  from 
above,  making  an  incision  slightly  distal  to  the 
joint,  disarticulate  by  dividing  the  lateral  liga- 
ments, and  shave  off  a  ])lantar  flap  by  cutting 
from  within  outwar<l. 

Amputation  at  the  Metatarso-phalan- 
geal  Joint. — This  can  be  done  either  by  lateral 
flaps  or  by  the  modified  oval,  remembering  that 
the  joint  is  higher  than  it  seems,  because  the 
web  between  the  toes  is  about  halfway  between 
this  joint  and  the  extremity  of  the  toe.  Make  a 
longitudinal  incision,  commencing  on  the  dorsal  /i.  nisnrtifuiati,, nor  the  second  pim- 

'^  1  •     1         f  -11  1  •  lanx  of  II  Toe  l)v  the  racket  or  oval  in- 

SUriace    two-thirds    OI     an    inch    above    the    artlC-      eision:  iJ.  disarticulation  of  the  ^reat 
1    .■  IT  ii__  -liii  t<x>  bv  the  oval  incision  (original  I. 

ulation ;   pass   oblujuely   down  one  sine  to  the 

web,  across  the  base  of  the  toe  on  the  plantar  surface,  and  up  on  the  opposite 
side  to  the  starting-point :  dissect  u))  the  ])lantar  flap,  and  disarticulate  during 
forcible  flexion  by  dividing  tendons,  lateral  and  other  ligaments.  The  oval 
method  (Fig.  481)  may  also  be  used  for  both  these  last  amputations. 

Amputation  of  the  Toes  may  be  done  by  opening  the  joints  by  an 
incision  extending  across  the  dorsum  of  the  foot  convex  downward,  dividing 
the  tendons,  disarticulating,  slipping  the  knife  behind  the  Ixmes.  and  shaving 
off  one  large  plantar  flap. 

Amputation  of  the  Great  or  Little  Toe  with  its  Metatarsal  Bone 
can  be  done  by  the  oval  method,  the  preliminary  longitudinal  incision  curving 
somewhat  upward  over  the  base  of  the  metatarsal  bone  to  give  more  room.  Two 
or  more  toes  with  their  metatarsals  mav  also  be  removed  bv  the  same  method. 


(M 


I.V    AMEIi/CAN    TEXT-BOOK    OF  SUlKiEllY 


coimiicnciiig  the  line  of  incision  half  an  inch  above  the  tarso-nietatarsnl  joints. 
and  carrving  it  so  as  to  embrace  tlie  toes  to  l)e  removed. 

AMPUTATION  TIIHOUJH  Till:  MHTATAUSUS. 
Cut  from  within  outward  by  transfixion  a  short  dorsal  flap  slightly  convex 
downward,  and  a  long  plantar  one  ;  free  these;  saw  the  bones  across  ;  suture 
so  as  to  make  the  line  of  union  on  the  dorsum  of  the  foot. 

AMPUTATION  THROU({H  THE  TARSO-METATARSAL  .JOINTS. 
Hey's  Operation. — Make  an  incision  commencing  on  the  outer  side  of  tlie 
tuberosity  of  the  fifth  metatarsal  bone  at  its  upper  end,  carry  it  down  to  the  line 

*       ,^.,  of  the  nietatarso-phalangeal  joints,  thence  across  the 

tio.  482.  ,  1        '        1         1  X!      n  1  xi      • 

sole  convex  downward,  and  hnally  up  along  the  inner 

side  of  the  foot  to  the  tuberosity  of  the  scaphoid  br)iK' ; 
connect  the  two  extremities  of  this  incision  by  a  dorsal 
one.  also  convex  doAvnward;  dissect  up  both  flaps,  the 
sole  resting  on  the  operator's  palm  ;  disarticulate  the 
four  outer  metatarsals,  and  saw  across  the  internal 
cuneiform  bone.  The  more  common  plan  is  to  disar- 
ticulate the  first,  third,  fourth,  and  fifth  metatarsals, 
and  saw  across  the  base  of  the  second  metatarsal. 

Lisfranc's  Operation  (Fig.  482). — For  the  right 
side  grasp  the  front  of  the  foot  with  the  left  thumb  on 
the  base  of  the  fifth  metatarsal  bone,  and  the  forefinger 
about  half  an  inch  in  front  of  the  tuberosity  of  the 
scaphoid  bone  ;  make  an  incision,  convex  downward, 
cutting  to  the  bones  between  these  two  points ;  reflect 
the  flap  slightly ;  disarticulate  first  the  three  outer 
metatarsals,  then  the  first,  and  finally  the  second,  by 
cutting  upward  between  its  base  and  the  internal  cu- 
neiform for  about  half  an  inch  (the  cowp  de  main. 
Figs.  483,  484) ;  repeat  this  procedure  on  the  outer 
dotted  liue'shows'tiie'piantar  sidc,  and  Complete  the  separation  by  a  transverse  cut, 
incision)  (after  GuurinV  dividing  the  ligaments  between  the  middle  cuneiform 

and  the  base  of  the  metatarsal  bone.     The  disarticulation  of  all  the  bones  is 


Lisfranc's      Amjmtation      (tlie 


Fig.  483. 


Ki.;.  484. 


The  Coup  de  Main  in  Lisfranc's  Amputation  :  first 
step  (after  Guerin). 


The  Coup  de  Main  in  Lisfranc's  Amputation  :  second 
step  (after  Gu(Jrin). 


greatly  facilitated  by  forcibly  depressing  the  front  of  the  foot.  Finally,  pass 
the  knife  behind  the  bones  and  shave  off"  a  long  plantar  flap,  longer  on  its 
inner  side. 


AMP  VTA  TIOXS. 


1165 


Chopart's  Aiuputation  :  .1, 
line  of  disarticnilatiim ; 
B,  the  dorsal,  and  C,  the 
plantar  incisions. 


AMPUTATION  AT  THE  MEDlO-TAKSAL  JOINT. 

Chopart's  Operation  (Ki;;.  485). — As  now  pcrforuied,  grasp  the  foot  so 
tliiit  the  tliimib  and  fori'liii^aT  (according'  to  the  side)  are 
Kifi.  48o.  rcspectivelv  alxmt  half  an  inch  behind  the  tuberosity  of 

the  scaphoid  and  midway  between  the  base  of  the  fifth 
metatarsal  and  the  outer  malleolus,  the  sole  thus  resting 
on  the  operator's  palm  ;  make  a  dorsal  incision,  curved 
downward  between  these  points;  divide  the  extensor 
tendons  ;  forcibly  de])ress  the  anterior  part  of  the  foot ; 
disarticulate  by  dividing  the  ligaments,  uniting  the 
scaphoid  with  the  astragalus  and  the  cuboid  with  the 
OS  calcis  ;  slip  the  knife  behind  and  then  under  the  bones, 
shaving  ott"  a  long  plantar  Hap,  longer  on  its  inner  side. 

AMITTATIONS  AT  THE  ANKLE. 

Syme's  Amputation  (Fig.  486). — Hold  the  foot 
at  right  angles  to  the  leg;  enter  the  point  of  a  short 
straight    knife    below    the 
center  of  the  external  mal-  Fig.  48G. 

leolus,  and  cut  straight 
across  the  sole  to  a  corre- 
sponding point  on  the  other 
side — not  to  the  tip  of  the 
internal  malleolus;  dissect 
the  tissues  of  the  sole  back 
of  the  OS  calcis,  keeping  close  to  the  bone,  until 
the  point  of  the  heel  is  turned,  and  then  cutting 
the  tendo  Achillis ;  unite  the  extremities  of  the 
first  incision  by  a  transverse  one  across  the 
articulation;  open  the  joint;  divide  the  lateral  ligaments  and  complete  the 
disarticulation ;  finally,  clear  the  tibia  and  fibula  and  saAV  off  the  malleoli, 
including  a  small  slice  of  the  articular  surface  of  the  tibia :  pass  a  drainage- 
tube  through  an  opening  made  at  the  thinnest  portion  of  the  flap  posteriorly  ; 
tie  the  anterior  and  pos- 
terior tibial  vessels. 

Pirogoff's  Ampu- 
tation (Fig.  487).— 
Make  a  plantar  incision 
obliquely  forward  from 
the  tip  of  one  malleolus 
to  that  of  the  other, 
extending  down  to  the 
bone;  dissect  back  half 
an  inch  :  unite  the  ex- 
tremities of  the  first 
cut  by  a  second  dorsal 
one  convex  anteriorly, 
exposing  the  ankle- 
joint;  disarticulate; 
slip  a  saw  back  of  the 
astragalus   and    divide 


Syme's  Amputation  of  the  Foot 
(after  E.smarch). 


Fig.  487, 


rirdfjoll  .s  Amputation  :  sawing  the  os  calcis  (Wyeth). 


the  OS  calcis  obliquely  in  the  line  of  the  first  incision;  remove  the  ends  of  the 
tibia  and  fibula ;  secure  vessels ;  suture  the  -svound  so  that  the  sawn  bones  are 


11  n<; 


I  X   A  MKIifC. I  .V    'I'KXT- lUtOh'    OF   Sf  1!<;  EJi  y 


in  contact,  and  hold  thcni  there  by  two  broad  strij)s  of  adhesive  phister,  crossing 
tlie  end  of  the  stump  at  ri;^ht  angles  over  the  dressing;  secure  the  limb  on  a 
posterior  splint. 

AMPUTATION   OF  THE  LEG.' 

The  modified  circular  is  the  best  for  the  lower  third,^while  the  double  ante- 
ro-posterior  flap  method,  the  anterior  one  being  the 
longer,  or  S^dillot's,  is  better  for  the  middle  and  upper 
portions. 

S^dillot's  Method  (Fig.  488).— Make  a  short  lon- 
gitudinal skin  incision  along  the  inner  edge  of  the  tibia; 
draw  the  tissues  to  the  fibular  side,  so  that  a  narrow, 
long  knife  can  be  passed  to  the  outer  side  of  the  tibia 
and  fibula,  transfixing  the  calf  muscles;  cut  a  broad, 
rounded  flap  by  a  sawing  motion  ;  divide  the  tissues 
on  the  inner  side  of  the  limb  by  an  incision  convex 
downward;  clear  the  bones  by  a  circular  cut;  divide 
the  interosseous  membrane ;  force  the  .soft  parts  up 
so  as  to  expose  the  bones  one  inch  above  the  angle  of 
the  flaps,  Avhere  they  must  be  sawn.  The  anterior  and 
posterior  ti))ial  and  ])eroneal  arteries,  with  two  or  three 
smaller  branches,  Avill  require  ligature :  the  line  of 
union  will  be  vertical,  one  angle  being  dependent  and 
well  fitted  for  drainage.  In  all  leg  amputations 
removing  half  an  inch  more  of  the  fibula  than  of 
the  tibia  makes  a  better  stump.  The  tibia  should  be 
first  sawn  for  an  inch  obliquely  from  above  downward 
and  backward,  and  then  by  a  fresh  cut  transversely. 
This  bevels  the  sharp  tibial  crest,  which  otherwise 
sMiiiots  Method  (Wyeth).      might  perforate  the  flap. 

AMPUTATION    OF    THE    KNEE-.JOINT. 

Flap  Method. — Cut  a  long  anterior  quadrilateral  cutaneous  flap  with 
rounded  corners  bv  commencing;  near  the  back  of  one  tuberosity 
of  the  tibia  and  extending  to  the  other,  passing  from  one  to  three 
inches  below  the  tubercle  of  the  tibia,  according  to  the  length 
of  the  posterior  flaps  ;  dissect  this  up  until  the  ligamentum  jiatelljfi 
is  reached ;  divide  this ;  forcibly  flex  the  knee ;  cut  the  lateral 
and  crucial  ligaments;  slip  the  knife  behind  the  joint  and  cut 
outAvard,  forming  a  short,  s<|uare  musculo-cutaneous  posterior  flap. 
Unly  the  j)opliteal  and  a  few  small  vessels  will  reciuire  ligature. 
Lateral  Flap  Method  (Fig.  489).— Stephen  Smith's 
Operation. — With  a  large  scalpel  commence  an  incision  one  inch 
below  the  tuberosity  of  the  tibia ;  curve  it  downward  and  back- 
ward to  the  back  of  the  leg,  thence  upward  to  the  middle  of  the 
popliteal  space;  repeat  this  on  the  other  side;  raise  the  flaps, 
including  everything  down  to  the  bone,  until  the  joint  is  reached; 
divide  the  patellar  and  lateral  ligaments  and  complete  the  disar- 

Fiap  Mitbod     ticulation  ;   the  line  of  union  is  longitudinally  median  behind  the 

snuth*"^^^"     condyles  of  the  femur. 

'  See  page  1171  for  point  of  election  for  :iiiii)iitatioii  of  tlie  leg,  umier  tlie  lii-ading  "Arti- 
ficial Limbs." 

''■  .See  page  11.5')  for  "circular  metiiod"  (Fig.  471),  page  1156  i  Fig.  472i  for  "single-flap" 
operations,  :ind  page  1157  (Fig.  473)  for  "mixed  method." 


J. 1/ /'/'/'.  I  rinys. 


Hi; 


AMPUTATION  ABOVE  THE  KNEE. 

This  may  be  done  by  either  of  the  inothofls  advised,  by  sawing  off  more 
or  less  of  the  condyhjid  end  of  the  femur,  but  the  antero-posterior  Hap  method 
is  the  better. 

Garden's  Operation. — 'I'his  is  done  by  dissectin;^  up  a  large  rounded 
anterior  cutaneous  thip,  dividing  the  tissues  behind  by  a  transverse  incision, 
and  cutting  the  muscles  in  a  similar  manner  down  to  the  femur  in  front  above 
the  patella,  which  is  drawn  downward  by  flexing  the  knee ;  complete  the  ope- 
ratiim  by  sawing  tlirough  the  base  of  the  condyles. 

Gritti's  Operation. — In  tiiis  a  rectangular  flap  is  raised  from  tlie  front 
of  the  leg  and  knee,  leaving  the  patella  in  s/fii,  a  shorter  posterior  one  fash- 
ioned, the  femur  sawn  across  above  the  condyles,  the  cartilaginous  surface  of 
the  patella  removed  by  a  small  saw.  and  the  two  freshened  osseous  surfaces 
maintaiiie<l  in  apposition. 


AMPl'TATION  OF  THE   THIGH.' 

At  the  lower  tFiird  cut  from  without  inward  an  anterior  semilunar  flap  in 
length  rather  more  than  one-half  the  diameter  of  the  limb  at  the  point  where  tin- 
bone  is  tobesawn,andin  width  half  the 

circumference:  dissect  this  up,  includ-  I''i<'-  -^'JO. 

ing  everything  down  to  the  bone  (Fig. 
490) ;  reelect  the  flap,  and,  passing  the 
knife  behind  the  femur,  cut  downward 
and  backward,  forming  a  posterior 
semilunar  Ha))  fully  equalling  the  an- 
terior in  length,  since  the  posterior 
thigh  muscles  will  retract  more  than 
the  anterior,  and  thus  will  bring 
the  cicatrix  behind  the  end  of  the 
bone  ;  clear  the  bone  by  a  few  cir- 
cular cuts  of  the  knife  ;  force  the 
tissues,  including  the  periosteum,  up 
with  the  knife-handle,  and  saw  the 
bone  an  inch  and  a  half  above  the 
angles  of  junction  of  the  flaps.  Seven  or  eight  vessels  will  require  ligature, 
]ierhaps  more. 

Middle  and  Upper  Thirds. — In  either  situation  the  same  operation  is  to 
be  recommended,  as  a  rule  cutting  both  flaps  from  without  inward,  not  by 
transfixion,  lest  they  be  too  bulky,  the  posterior  muscles  being  cut  longer  than 
the  anterior  to  allow  for  retraction.  The  modified  circular  operation  is  also 
well  ada))ted  for  operations  at  these  points.  In  high  thigh  amputations  there 
is  oftentimes  no  rooiu  either  for  the  tourni({uet  or  for  Esraarchs  tube  :  in  such 
case  recourse  must  be  had  to  either  Wyeth's  method,  digital  compression  of 
the  femoral  against  the  brim  of  the  pelvis,  the  abdominal  tournicjuet,  or 
Macewen's  method  of  controlling  the  circulation  through  the  abdominal  aorta 
(Fig.  494). 

Amputation  through  the  Trochanters,  as  being  less  dangerous  than 
exarticulation  at  the  hip,  may  be  performed  for  injury  or  even  for  malignant 
di.sease.  in  which  latter  case,  if  on  section  the  bone  proves  to  be  involved, 
the  remaining  fragment  can  be  dissected  out  of  the  joint. 

'  For  point  of  election,  see  Artificial  Limbs,  p.  1171. 


.\inpulatioii  of  the  Thigh  (Bryant) 


1168 


Ay   AMERICAN    TEXT-llOOK    OF   SVRCERY. 


AMPUTATION    AT  TIIK   IIIP-.TOINT. 
Before  an  amputation  at  the  liip-joint.  as  in  some  other  similarly  serious 
operations,  it  is  well  to  envelop  the  patient's  body  and  the  other  three  limbs 


Ki<i.  49). 


Wyeth's  Bloodless  Amputation  at  the  Hip-joint :  The  pins  and  rubber  tubing  applied :  circular  and 
longitudinal  incisions  for  skin-flap. 

with  raw  cotton  secured  by  bandages,  so  as  to  diminish  shock  by  preventing 
the  loss  of  body  heat. 

Fig.  492. 


Wyeth's  Bloodless  Amputation  at  the  Hip-joint :  Cuff  of  skin  and  subcutaneous  fat  turned  back,  muscles 
divided  at  level  of  small  trochanter,  bone  partly  stripped,  and  large  vessels  exposed  for  dcligation. 


Of  the  many  methods  of  performing  this  amputation  (over  forty-five  have 
been  described)  only  a  few  will  be  given. 


AMPUTATIONS. 


IKIi) 


Modified  Circular. — Tliis  is  useful  when  a  tumor  involves  tlie  muscles 
higli  u)).  Cut  sliort  antero-posterior  skiii-tia|ts;  make  a  circular  cut  of  the 
muscles  at  the  joint-level  and  disarticulate:  after  the  Haps  have  been  reflected 
the  femoral  vessels  can  he  tied,  if  desired,  before  they  are  divided  by  the  cir- 
cular sweep  through  the  muscles.  Macewen's  method  (p.  1170)  of  compress- 
ing the  abdominal  aorta  or  digital  compression  of  the  aorta  through  an  ab- 
dominal incision,  or  some  other  means  for  controlling  the  circulation,  must 
of  course  be  emj)loyed  if  the  artery  is  not  to  be  tied  until  after  the  anterior 
skin-llaj)  has  been  i'eliecte(l. 

Wyeth's  Bloodless  Method  of  Amputating  at  the  Hip-joint. — With 
the  hip  well  over  the  edge  of  the  table,  if  the  condition  of  the  limb  allows  it, 
apply  an  Esmarch  bandage  as  high  as  possible;  enter  the  point  of  a  steel 
mattress  needle,  three-sixteenths  of  an  inch  in  diameter  at  its  base  and  one 
foot  long,  one  inch  below  and  slightly  to  the  inner  side  of  the  anterior  supe- 
rior iliac  spine,  carrying  the  needle  through  the  tissues,  so  that  the  point  will 
emerge  directly  opposite  to  and  about  three  inches  from  the  point  of  entrance; 

Fk;.  493. 


Listen's  Amputation  at  the  Hip-joint  (Wyeth). 

pass  a  second  needle  an  inch  below  the  level  of  the  crotch  internally  to  the 
saphenous  opening,  through  the  adductors,  so  that  the  point  will  come  out  about 
an  inch  below  the  tuber  ischii  (Fig.  491);  cover  the  needle-points  with  corks; 
pass  a  long  piece  of  half-inch  black — ?'.  e.  pure — rubber  tubing,  on  the  stretch, 
tightly  five  or  six  times  around  the  thigh  above  the  fixation  needles,  and  tie 
or  clamp  it ;  remove  the  Esmarch  bandage ;  six  inches  below  the  tourni(juet 
make  a  circular  skin  incision  down  to  the  deep  fascia;  this  is  joined  by  a  lon- 
gitudinal incision  commencing  at  the  tubing  and  passing  over  the  trochanter 
major;  reflect  the  cellulo-cutaneous  cuff  to  the  level  of  the  trochanter  minor; 
by  a  circular  sweep  of  the  knife  divide  all  the  muscles  at  the  same  level  (Fig. 
492) ;  remove  the  soft  tissues  from  the  bone  for  about  four  inches  downward  so 
as  to  reach  the  vessels  ;  do  not  saw  off  the  bone,  but  keep  the  entire  limb  for  use 
as  a  lever  in  dislodging  the  head  of  the  bone  ;  secure  all  visible  vessels  ;  loosen 
the  rubber  tourniquet  and  tie  all  bleeding  points;  divide  all  the  muscular 
attachments  of  the  upper  portion  of  the  femur,  always  keeping  close  to  the 
bone  ;  expose  the  capsular  ligament  and  divide  it  in  its  circumference.  Forci- 
74 


117>) 


J.V    AMJ:JiJ(A.\    TKXT-llOOK    OF   SL  lidKUY 


blc  ek'Viitiuii,  abdiic-tion,  and  adduction  of  the  tlii^di  ])ermit  tlic  entrance  of  air 
into  the  socket  and  at  tlie  same  time  rupture  the  liffamentum  teres,  and  the 
disarticulation  is  thus  easily  and  rapidly  efl'ectiMl.  Secure  any  vessels  cut  by 
the  last  incisions,  and  coaptate  the  flaps  vertically.  To  obviate  the  danger  of 
infection  from  urine  and  feces,  especially  in  women,  place  the  drain  well 
externally  and  seal  the  inner  end  of  the  Avound  with  gauze  or  cotton  and  iodo- 
form collodion. 

Antero-posterior  Flap  Operations. — Liston's  Operation. — With  a 
ten-  or  twelve-inch  blade  transli.x  by  eiitciing  the  jioinl  niid\say  l)el\\een  the  ante- 
rior superior  iliac  spinous  process  and  the  trochanter  major ;  graze  the  front  of 

the  joint,  emerging  in  front  of 
I'K'-  ^''^-  the  tuber  ischii,  carefully  avoid 

wounding  the  genitals  or  o))po- 
site  thigh,  and  i-apidly  cut  an 
oval  flaj)  al)out  five  inches  long 
(Fig.  498);  let  an  assistant  re- 
flect this  ;  open  the  capsule  with 
the  limb  strongly  rotated  out- 
ward ;  cut  the  ligamentum  teres ; 
slip  the  knife  behind  the  hea<l 
of  the  femur,  dividing  the  rest 
of  the  capsule ;  have  the  femur 
rotated  somewhat  inward,  and, 
cutting  obli(|uely  downward  and 
backward,  form  a  posterior  flap 
('(jualling  in  length  the  anterior 
one;  as  each  flaj)  is  cut  an  as- 
sistant should  sei/.e  it  and  com- 
press the  whole  surface  with  a 
folded  towel  to  control  hemor- 
rhage. The  femoral,  the  pro- 
funda, the  comes  nervi  ischiad- 
ici,  with  the  gluteal  and  sciatic 
and  numerous  l)ranches.  includ- 
ing some  of  those  of  the  obtu- 
rator artery,  will  require  liga- 
ture. 

Guthrie's  Method. — With 
a  four-inch   blade   cut    a   semi- 
lunar posterior  flap,  commencing 
a    little    above    the    trochanter 
major,  and  passing  in  a  curve 
doAvnward  across  the  back   of 
the  limb  to  a  point  just  in  front 
of  the  tuberosity  of  the  ischium:  map  out  a  similar  anterior  flaf) ;   divide  the 
jtosterior  muscles  and  then  the  anterior  obliquely  from  l)elow  u])ward   until 
the  joint  is  reached;   then  disarticulate. 

Lateral  Flap  Method. — Larrey's  Operation. — This  will  be  described, 
not  because  superior  to  the  others,  but  because  the  injury  or  tumor  for  which 
operation  is  recjuired  may  necessitate  lateral  flaps.  Expose  and  tie  the  common 
femoral  vessels  just  l)eneath  TV)U])art's  ligament;  transfix  Avith  a  knife  entered 
in  the  incision  perpendicularly  between  the  muscles  inserted  into  the  trochanter 
minor  and  the  contiguous  under  suriace  of  the  femur,  and  cut  a  short  internal 


Macewen's  Method  for  Compression  of  the  Abdominal 
Aorta  (original). 


AMPl'TATIOAS.  1171 

Hup  by  directing  the  knife  oblicjuely  downwind  :ind  inward,  whieli  should  be 
retiected  by  an  assistant ;  Ireely  incise  the  capsule  as  the  femur  is  forcibly 
abducted:  divide  the  lignientuni  teres:  slip  the  knife  between  the  head  of  the 
femur  and  the  acetabulum  and  cut  a  postero-external  rounded  lla]»  by  an  incis- 
ion directed  downward  and  backward;  ])ressure  with  a  towel  and  the  hand 
must  control  bleeding  until  catch  forceps  can  be  applied  to  the  bleedinji;  jtoints. 
Hemorrhage  in  Hip-joint  Amputations. — As  the  chief  immediate 
danger  in  hip-joint  amputation  is  that  of  hemorrhage,  it  is  important  to  under- 
stand hoAV  to  apply  the  abdominal  tourniquet  unless  Wyeth's  method  be 
emi)loyed.  As  this  is  one  of  the  most  efficient  means,  so  it  is  also  attended 
with  some  danger  if  applied  with  too  much  force.  The  bowels  nmst  be  well 
emptied  by  a  cathartic  and  an  enema,  and  got  out  of  the  way  by  gently  rolling 
the  patient  upon  the  right  side  before  applying  the  ])ad.  'I'iie  ])ad  should 
then  be  adjusted,  with  a  soft  sponge  interposed  between  it  and  the  skin  a 
little  to  the  left  of  the  umbilicus:  but  as  the  aorta  may  be  median,  it  is  bet- 
ter to  feel  for  the  pulsation  of  the  vessel  r;ither  than  to  rely  upon  any  arbi- 
trary rule:  either  I'ancoast  s  (a  large  Skev's  tourniijuet)  or  Listers  (a  large 
Hoey's  clamp)  may  be  used,  the  pad  being  screwed  down  only  hard  enough 
to  control  pulsation  in  the  iliac;  and  not  a  moment  should  be  lost  in  putting 
catch  forceps  on  every  oozing  point  after  ligating  the  main  vessels,  so  that  the 
tourniquet  may  be  promptly  loosened.  With  a  thin  patient  digital  compression 
of  the  aorta  may  be  effected,  while  a  firm  pincushion  secured  over  the  vessel 
by  a  few  turns  of  an  Esmarch  bandage  makes  a  good  improvised  tourni(juet, 
the  chief  objection  to  this  being  that  it  interferes  unduly  with  respiration. 
An  Esmarch  bandage  applied  uj)  to  the  lower  limits  of  the  tumor  or  injury  and 
allowed  to  remain  during  the  operation  is  invaluable,  because  it  drives  into 
the  circulation,  and  thus  saves,  all  the  blood  contained  in  the  limb.  Macewen 
has  effectively  controlled  the  abdominal  aorta  by  throwing  the  weight  of  the 
body  on  the  aorta  through  the  closed  right  hand  (Fig.  494)  placed  a  little  to 
the  left  of  the  middle  line,  the  knuckles  of  the  index  finger  just  touching  the 
upper  border  of  the  umbilicus.  With  the  left  hand  the  arrest  of  the  blood- 
current  is  ascertained  by  feeling  the  femoral  at  the  brim  of  the  pelvis.  Only 
enough  weight  to  arrest  the  femoral  pulse  is  required.  If  the  patient  vomits 
or  coughs,  the  pressure  must  be  increased,  lest  the  hand  be  lifted  from  the 
aorta  by  the  abdominal  muscles. 

ARTIFICIAL  LIMBS. 

As  it  is  not  possible  for  all  patients  who  lose  limbs  to  obtain  artificial  ones, 
many  of  the  methods  of  amputating  described  will  still  be  practised  :  but  Avhile 
it  is  true  that  owing  to  the  inefficiency  of  prothetic  apparatus  for  the  upper 
extremity  all  that  can  possibly  be  saved  should  be  here  conserved,  in  the 
lower  limb  an  amputation  at  the  junction  of  the  middle  and  lower  thirds  of 
the  thigh,  or  one  at  the  same  point  of  the  leg,  renders  artificial  progression  far 
easier  than  is  possible  after  knee-  or  ankle-joint  amputations  or  partial  ampu- 
tations of  the  foot,  and  should  always  be  adopted  if  possible. 

The  attempt  to  supply  lost  portions  of  limbs  dates  back  to  about  the  begin- 
ning of  the  sixteenth  century,  and  the  present  ''box-"  or  "peg-leg  "  is  essen- 
tially that  described  by  Ambroise  Pare. 

Artificial  Arms. — The  simplest  form  of  apparatus  for  amputations  beloiv 
the  shoulder  consists  of  a  leather  socket  accurately  fitting  and  ensheathing  the 
stump  for  several  inches,  secured  to  the  part  and  to  the  body  by  proper  straps ; 
by  means  of  light  internal  and  external  steel  rods  jointed  at  the  elboAV,  and  a 


117J  j.v  AMKL'ic.w  ri:xr-ii<j<jK  or  sf/,'(;/:/n: 

coiicf.ileJ  CD^ijred  wheel  ami  ratcjitt  manij)ulate«l  b>-  the  other  hand,  movenieiit 
with  fixation  at  any  desired  angle  can  be  obtained  ;  at  a  point  corresponding 
to  the  wrist  is  secured  a  wooden  block  with  central  iron  socket,  into  which  a 
knife,  fork,  show-hand,  or  iron  hook  can  be  screwed.  With  the  latter  a  man 
can  use  the  spade,  drive.  an<l  indeed  make  a  living  by  light  manual  labor. 

A  similar  a})paratus  with  the  socket  fitting  what  remains  of  the  forearm, 
and  secured  by  a  broad  laced  band  or  straps  above  the  elbow,  serves  an  e.xcel- 
li.*nt  purpose  for  umjmtation  below  the  elbow.  When  a  cheaper  arm  for  ampu- 
tation above  the  elbow  is  desired,  and  flexion  at  the  joint  can  be  dispensed 
with,  a  raw-hide  moulded  apparatus,  curved  according  to  Biggs's  suggestion, 
and  stiffened  by  two  lateral  steel  bands,  fitted  of  course  with  the  same  terminal 
wooden  block  and  screw  socket,  both  looks  well  and  enables  the  patient  to  work 
with  consideraldc  ease. 

Many  pages  could  be  devoted  to  the  consideration  of  the  more  complex 
artificial  limbs,  but  the  attempt  will  be  made  here  only  to  describe  a  few  typi- 
cal ajiparatns.  while  those  desiring  more  explicit  information  in  the  English 
language  are  referred  to  special  treatises  on  this  subject. 

The  power  by  which  the  anificial  member  is  moved,  if  the  amputation  be 
above  the  elbow,  is  often  communicated  by  cords  passing  from  the  other  arm, 
but  by  Graefe  s  plan,  which  is  employed  in  a  modified  way  to-day,  spontaneous 
movement  is  effected  by  springs  or  catgut  strings  secured  to  a  corset  embracing 
the  shoulder  and  thorax,  by  the  action  of  the  shoulder  and  trunk  muscles,  un- 
aided by  the  other  hand,  even  in  amputations  of  the  arm  proper.  Where  the 
thumb  remains,  but  tlie  rest  of  the  hand  down  to  the  metacarpus  has  been 
removed,  the  best  results  are  to  be  obtained  by  an  artificial  hand  with 
immovable,  partly-flexed  fingers  secured  by  a  moulded  leather  socket  fitting 
over  the  carpus  and  secured  to  the  forearm. 

For  amputation  through  the  forearm  the  following  apparatus  of  Van  Peter- 
son, although  old.  is  one  of  the  best :  A  sheath  of  light  wood  enclosing  the 
stump  is  secured  to  the  arm  by  two  padded  leather  bands  connected  by  vertical 
straps ;  the  hand,  movable  at  the  wrist  in  flexion  and  extension,  has  the  fin- 
gers kept  constantly  flexed,  with  the  thumb  apposed  to  the  tip  of  the  fore- 
finger by  springs;  from  the  encircling  band  just  above  the  elbow  is  a  strap 
connected  with  a  cord  passing  around  a  concealed  pulley  near  the  wrist,  so  that 
when  the  arm  is  extended  to  seize  an  object  the  fingers  are  also  extended, 
while  when  the  forearm  is  flexed  to  bring  the  object  forward,  the  fingers  close 
by  virtue  of  springs,  grasping  the  object.  The  efficiency  of  this  apparatus  is 
in  proportion  to  the  length  and  strength  of  the  forearm  stump 

The  loss  of  the  arm  at  or  above  the  elbow  is  also  best  remedied  by  Van 
Peterson's  adaptation  of  Graefe's  ideas.  This  apparatus  consists  of  an  articu- 
lated arm.  forearm,  carpus,  and  phalanges,  the  stump  being  received  into  a 
socket  which  is  secured  to  the  shoulder  and  chest  by  a  *'  corset  of  that  sort 
which  readily  transmits  to  the  artificial  arm  all  the  movements  which  are 
made  by  the  stump  if  he  brings  it  forward,  backward,  upward,  or  downward." 
Three  catgut  cords  are  fastened  to  the  corset — one  back  of  the  sound  shoulder, 
one  beneath  the  armpit  on  the  side  of  amputation,  and  one  near  the  shoulder 
of  the  same  side.  These  are  so  disposed  that  when  the  stump  is  drawn  forward 
the  traction  flexes  the  forearm  :  when  it  is  carried  back,  the  forearm  is  extended 
and  carried  away  from  the  body,  in  which  position  the  fingers — held  flexed  by 
springs — are  opened.  To  seize  anything,  the  patient  need  only  carry  the 
hand  thus  opened  to  the  object,  and  gently  draw  the  stump  toward  the  body, 
when  the  springs  will  close  the  fingers  upon,  say  a  cup,  which  can  now  be  car- 
ried to  the  mouth  by  bringing  the  stump  forward,  this  motion  flexing  the  fore- 


AMi'i  lA  rioxs.  117;> 

nnii  iiiul  l)nn_iring  the  liand  to  its  (k'stination.      The  anus  of  Charrierc.  Mathieu, 
aiui  InH'hard  art^far  inferior  in  usi-fiilness  to  that  of  Van  Peterson. 

Artificial  Leus. —  For  jtavtial  (imjnitntiaus  of  flu-  foot  a  nietallic  sole, 
somewhat  elastic  at  its  fore  part,  with  a  raised  niariiin  around  tlie  In-el,  should 
be  secured  to  two  light  lateral  steel  splints  extending  to  just  below  the  knee, 
jointed  opposite  the  ankle,  and  held  in  proper  relation  with  one  another  and 
the  leg  by  two  transverse  padded  seuiicircular  metallic  bands,  to  which  straps 
are  att'iiched  in  front  so  as  to  secure  the  apparatus  to  the  leg.  A  hollow  wooden 
or  moulded  raw-hide  foot  may  be  used  to  fill  out  the  boot  in  front. 

Bechard's  modification  of  Martins  apparatus— for  the  description  of  which 
there  is  not  space — is  the  best  for  the  average  C/iopart  ntump.  For  a  Syme 
or  subastragaloid  amputation  the  simplest  apparatus  is  a  laced  leather  boot-leg 
stiffened  by  lateral  steel  supports,  with  a  heel  composed  of  thick  cork  lined 
with  chamois  leather. 

For  amputations  beloiv  the  knee  the  peg  or  bucket  leg  employed  since  the 
time  of  Pare  may  be  used,  consisting  of  a  stout  wooden  peg  with  an  expanded 
lower  extremity, "^attached  by  the  other  end  to  a  socket  composed  of  a  conical 
piece  of  lisht  wood,  with  two  lateral  splints  embracing  the  thigh,  the  inner  of 
which  should  extend  onlv  to  the  middle  of  the  thigh,  while  the  external  reaches 
to  the  iliac  crest  and  is  fastened  around  the  pelvis  by  a  padded  belt:  a  strap 
passed  around  the  lower  part  of  the  thigh  holds  the  inner  short  splint  to  the 
outer.     The  front  of  the  flexed  knee  rests  upon  a  cushion  between  the  two 

splints.  ■     •  7 

When  selecting  a  more  elaborate  apparatus  certain  general  principles  must 
be  kept  in  mind— viz.  no  pressure  must  be  made  on  the  end  of  the  stump;  the 
points  of  support  must  be  the  thigh,  the  circumference  of  the  leg,  the  inferior 
border  of  the  patella,  the  tuberosities  of  the  tibia,  and  the  tuberosity  of  the 
ischium,  one  or  all,  according  to  the  point  at  which  the  limb  has  been  removed 
or  as  the  special  requirements  of  the  case  demand ;  moreover,  where  an  arti- 
ficial knee-joint  is  required  the  center  of  motion  must  be  behind  the  long  axis 
of  the  lower  extremity,  and  it  is  essential  that  the  foot  shall  be  capable  of  ever- 
sion  and  inversion  as\vell  as  of  flexion  and  extension,  so  that  the  whole  surface 
of  the  bottom  of  the  foot  can  rest  upon  the  ground  whatever  may  be  the  direction 
of  the  artificial  limb.  Probably  the  best  leg  is  that  of  Bly  of  Rochester,  con- 
sisting of  a  nroper  socket  and  bearings  with  the  center  of  movement  of  the  knee- 
joint  "posterior  to  the  axis  of  the  limb,  a  foot  with  a  metatarso-phalangeal  joint, 
and  a  tibio-tarsal  articulation  formed  by  a  glass  ball  enclosed  in  a  vulcanized 
rubber  sac,  with  four  adjustable  rubber  muscles,  which  enable  all  the  normal 
movements  of  the  foot  to  take  place,  while  the  eccentric  position  of  the  knee- 
joint  does  away  with  the  necessity  of  any  thigh  extensor  when  the  limb  has 
been  removed  above  the  knee.  The  artificial  limb  of  Myops  may  perhaps 
serve  a  better  purpose  when  the  amputation  has  been  made  just  above  the 
tibio-tarsal  articulation,  being  constructed  on  the  same  principles  as  that  of 
Bly,  but  employing  spiral  springs  instead  of  compressed  rubber  for  muscles. 
Marks's  rubber^foot,  constructed  of  a  light  piece  of  wood  imbedded  in  a  mass 
of  rubber  of  the  shape  of  the  foot,  is  immovably  connected  with  the  leg,  but 
the  rubber,  by  virtue  of  its  elasticity,  is  said  to  accommodate  itself  to  all  sur- 
faces, thus  compensating  for  the  absence  of  the  movements  of  the  tibio-tarsal 
joint.  . 

After  amputations  at  the  knee-joint,  both  in  the  peg  leg  and  in  the  more 
elaborate  substitutes,  the  end  of  the  stump— as  in  Hudson's  limb— must  rest 
upon  the  distal  extremity  of  the  thigh  armor.  This  in  Hudson's  apparatus 
consists  of  a  concavo-convex  posterior  splint  laced  on  the  thigh,  with  a  lower 


1171  .l.V    AMIJncAX    TEXT-naoK    OF   SUHGKRY. 

extreraity  modelled  so  as  to  represent  the  femoral  condyles,  which- is  secured 
hv  proper  bolts  and  joints  to  a  metal  surface  on  the  le<;  section  resemblinjr  the 
articular  surfaces  of  the  licad  of  the  tibia.  Artificial  ligaments  and  muscles 
favor  the  natural   knee  movements. 

Sufficient  has  been  already  incidentally  said  about  artififial  limbs  for  //////// 
amputations,  except  that  the  support  ought  to  be  taken  from  the  tuberosity  of 
the  ischium,  the  gluteal  region,  and  the  pelvis,  and  not  through  the  medium  of 
the  thigh  armor,  which  will  sooner  or  later  create  trouble  with  the  stump. 

Prothetic  a|ij>aratuses  for  hip-joint  amputations  are  so  rarely  required,  and 
are  in  general  so  unsatisfactory,  that  only  a  few  words  need  be  devoted  to  the 
general  principles  involved  in  their  construction,  the  student  being  referred  for 
further  details  to  Watson  on  Amputations  and  tlieir  Complications.  (Acknow- 
ledgment is  here  made  to  this  source  for  many  of  the  foregoing  facts.) 

Pelvic  armor,  moulded  to  the  gluteal  and  iliac  regions  on  the  side  of  ampu- 
tation and  on  as  much  of  the  opposite  side  of  the  pelvis  as  can  be  utilized,  and 
bearing  upon  the  tuberosity  of  the  ischium,  must  be  firmly  secured  by  circum- 
pelvic  strajis  supported  by  suspenders:  the  artificial  hip-  and  knee-joints  can 
flex  only  in  the  sitting  position,  this  movement  being  permitted  by  the  with- 
drawal of  bolts  which  are  movable  at  will  by  means  of  a  strap.  The  usual 
means  of  progression  is  by  undulatory  movement  of  the  body,  projecting  the 
limb  by  a  swing  similar  to  that  employed  by  the  hemiplegic,  although  a  strap 
passing  from  the  foot,  secured  over  the  front  of  the  knee  and  obliquely  encir- 
cling the  shoulder  of  the  sound  side  and  thorax,  may  be  employed  to  impart 
additional  movement  to  the  limb  by  the  action  of  the  opposite  shoulder  mus- 
cles :  it  hardly  again  needs  mention  that  during  progression  the  artificial  knee- 
and  hip-joints  must  be  rigid ;  a  cane  or  even  a  crutch  is  usually  needed. 


MINOR    SrRGERY.  1175 

CHAPTER    VII. 

MINOR  SURGERY. 
I.— SURGICAL  DRESSINGS. 

Any  surgical  wound-dressing  should  be  absorbent,  to  admit  of  the  ready 
impregnation^^  ith  medicinal  substances  and  to  absorb  discharges.  The  sub- 
stances in  most  common  use  are  absorbent  cotton,  gauze,  lint,  tow,  oakum, 
jute,  wood-wool,  moss,  peat,  and  })ine  sawdust. 

Lint,  in  the  form  of  "patent  lint,"  is  well  adapted  for  wet  dressings  and  for 
spread  cerates;  domestic  lint  is  prepared  from  old  linen,  boiled  in  a  weak  alkaline 
solution,  freed  from  this  bv  washing,  dried,  and  scraped  on  one  side  with  a  knife ; 
this  latter  i)rocedurc  may  be  dispensed  with .  Paper  lint  is  moderately  absorbent, 
and  can  be  used  with  fair  satisfaction  for  the  apidication  of  wet  dressings  over 
unbroken  surfaces.  Absorbent  gauze  is  ordinary  cheese-cloth  from  which  all 
rrreasy  material  has  been  removed  by  boiling  in  a  weak  alkaline  solution  (r^  g. 
washing  soda  or  soft  soap),  thoroughly  rinsing  out  in  pure  water,  and  <lrymg. 
It  can  readily  be  impregnated  with  any  medicinal  agent,  and  freely  absorbs  dis- 
charcre^  Tow,  unless  rendered  aseptic,  should  only  be  used  outside  other  dress- 
ings as  an  absorbent  or  to  pad  splints;  the  same  remark  is  applicable  to  oakum, 
jute  and  the  substance  now  to  be  considered.  Absorbent  cotton,  made  by  a 
process  similar  to  that  for  preparing  gauze,  is  an  exceedingly  useful  material, 
readily  rendered  antiseptic  by  impregnating  it  with  antiseptics  in  solution  or  m 
fine  powder ;  it  can  also  be  used  for  wet  dressings.  3Ioss,  long-fibred  such  as 
abounds  in  the  far  South,  cleansed  and  baked,  is  an  excellent  outside  dressing, 
as  is  wood-ivool,  peat,  or  ;;me?  saivdust  sewn  up  in  bags  of  proper  size,  feo  tar 
as  possible,  all  these  substances,  even  when  made  antiseptic  by  germicidal 
drugs,  should  be  previously  rendered  aseptic  by  proper  heating. 

Practically  speaking,  gauze  rendered  sterile  by  steam  in  the  modern 
pressure  sterilizer,  the  antiseptic  gauze  prepared  with  corrosive  sublimate 
or  carbolic  acid,  the  sterile  or  medicated  cotton,  and  the  sublimated  wood- 
wool, prepared  in  sheets,  are  the  dressings  chiefly  used  in  this  country. 

For  various  mechanical  purposes  surgical  dressings  are  used  m  the  form  of 
compresses,  firm  masses  of  different  sizes  and  shapes,  oblong,  square,  cylindri- 
cal graduated,  etc.,  made  by  folding  up  lint  or  muslin.  Graduated  compresses 
ma'y1)e  either  pyramidal  or  wedge-shaped,  and  are  formed  by  superimposing  one 
upon  another,  in  proper  relation,  a  series  of  square  or  oblong  compresses  of 
aradually  diminishing  size.  A  square  of  lint  or  muslin  cut  from  the  angles 
Toward  its  center  forms  a  Maltese  cross  well  adapted  for  snugly  applying  a 
dressing  over  a  projection,  as  a  stump.  Pledgets  are  compresses  formed  of 
cotton,%ow,  oakum,  etc.,  in  which  the  fibers  are  pulled  longitudinally  until 
most  are  parallel,  the  ends  folded  and  tucked  in,  and  then  formed  by  pressure 
of  the  hands  into  various  shapes :  they  are  used  externally  to  other  dressings  to 
absorb  discharges  or  to  exert  compression.  Tents  are  small  cylinders  or  cones 
made  by  rolling  strips  of  gauze  or  lint  or  by  twisting  masses  of  oakum  into 
the  required  shape :  they  are  occasionally  used  to  keep  wounds  open  to  per- 
mit serum  or  pus  to  escape.  If  wet  dressings  are  employed,  especially  where 
warmth  is  desired,  some  covering  impervious  to  heat  and  moisture  must  be 
used,  such  as  "  rubber  dam,"  oiled  silk,  paper  passed  through  melted  wax  or 
paraffin,  or  even  stout  paper  thoroughly  greased. 


llTfJ  AN   AMERICAN    TEX  I- HOOK    OF   SL'IKiFJiY. 

11.   HANDAiiKS. 

RoLLKH  Bandaoks  (Platos  XXXIV  to  XXXVII)  consist  of  strips  of 
muslin,  preferably  unbleaclied  or  gauze,  varying  from  one  inch  to  four  inches 
in  width  and  from  one  to  twelve  yards  in  length,  which  are  rolle(l  up 
from  one  end  so  as  to  form  cylindrical  masses  or  ''  single-headed  "  rollers, 
or  are  rolled  from  both  ends,  constituting  "  double-headed  "  rollers. 
Bandages  are  rolled  either  by  the  hand  or  with  some  kind  of  bandage- 
roller.  To  roll  by  hand,  fold  one  end  for  two  or  three  inches  sev- 
eral times  upon  itself,  then,  forming  this  portion  into  a  small  mass, 
roll  the  bandage  up  upon  the  thigh  until  a  small  cvlinder  is  formed.  Next 
seize  this  between  the  thumb  and  forefinger  of  the  left  hand,  the  unrolled 
portion  firmly  held  between  the  extended  right  forefinger  and  thumb,  keeping 
up  moderate  traction  so  as  to  tighten  the  cylinder,  which  is  formed  by  first 
supinating  the  left  hand,  then,  loosening  the  grip,  pronating  the  same  hand  to 
gain  a  fresh  hold,  so  that  by  supinating  again  the  cylinder  will  be  rolled  around 
its  long  axis  from  right  to  left:  this  rotation  is  kept  up  by  a  series  of  move- 
ments of  supination  and  ))ronation,  the  remaining  fingers  of  the  left  hand  aid- 
ing in  the  revolution  of  the  cylinder,  while  the  extended  right  forefinger  and 
thumb  revolve  partly  around  the  cylinder.  A  single-headed  roller  consists  of 
an  initial  or  free  end,  a  terminal  one — i.  e.  that  in  the  center  of  the  roll — and 
a  body,  the  portion  between  the  two  extremities.  In  applying  a  single-headed 
roller  hold  it  between  the  thumb  and  fingers  of  one  hand,  pressing  it  firmly 
into  the  palm  by  the  fingers,  and  always  place  the  external  surface  of  the  free 
end  on  the  part  to  be  bandaged,  to  prevent  its  sudden  unrolling:  retain  it  there 
by  pressure  of  the  fingers  of  the  other  hand  until  it  can  be  fixed  by  one  or  two 
circular  turns.  All  bandages  must  lie  smoothly  and  flat,  each  edge  exercis- 
ing the  same  pressure  ;  otherwise  excoriation  of  the  skin  or  interference  with 
the  circulation  may  result.  The  tui-ns  of  a  roller  applied  to  a  cylindrical 
part  may  pass  in  a  circular  manner,  each  turn  exactly  covering  the  ]»receding 
ones  [circular  bandage). 

If  the  part  be  covered  by  causing  the  turns  to  ascend  moi-e  or  less  rapidly 
in  a  spiral  manner,  each  turn  overlapping  the  preceding  one  about  one-third,  the 
result  is  a  s/}ir(fl  handai/c.  In  most  limbs  the  attempt  to  cover  with  a  spiral  will 
result  in  only  one  edge  of  the  bandage  being  in  contact  with  the  part,  the  other 
standing  freely  off.  To  obviate  this,  adopt  the  following  mananiver :  hold  the 
spiral  turn  just  made  with  the  fingers  of  the  left  hand  on  the  upper  surface 
of  the  limb,  then  with  the  roller  held  in  the  supinated  right  hand,  four  to  eight 
inches  being  unwound  so  as  to  form  a  dependent  loop,  pronate  the  hand  ;  carry 
the  bandage  loosely  beneath  the  limb  until  the  opposite  side  is  reached,  when  by 
gentle,  gradual  traction  the  reversed  turn  will  snugly  apply  itself  to  the  part: 
this  is  called  a  "reversed  turn"  or  "making  a  reverse,"  and,  combined  with 
the  spiral  turns,  "a  spiral  reversed  handafje.''  The  secret  of  success  is  to 
make  the  loop  of  bandage  turn  over  without  the  slightest  traction,  this  being 
made  only  when  the  opposite  side  of  the  limb  is  reached. 

When  a  projecting  point  is  to  be  covered — the  elbow,  for  instance — a  series 
of  figure-of-8  turns,  applied  alternately  above  and  below,  will  best  secure  this 
end,  each  overlapping  its  neighboring  turn  by  one-third  of  its  width.  Such 
regions  as  the  groin,  axilla,  shoulder,  and  breast  can  be  best  covered  by  what 
are  essentially  figure-of-8  turns,  each  succeeding  one  ascending  from  below 
upward,  overlapping  by  one-third,  foi'ming  a  figure  like  "  the  leaves  of  an  ear 
of  corn,"  one  member  of  the  figure-of-8  encircling  the  thigh,  for  instance,  the 
next  the  pelvis,  the  next  the  thigh  and  groin,  and  so  on  :  this  bandage  i-s 
called  a  spica. 


BANDAGES. 


Plate  XXXIV. 


Fig.  1.— Spiral  reversed  of  tlie  npi>er  extremity. 


Fio.2.— The  gauntlet. 


Fig.  3. — Spica  of  the  thumb. 


-.Spiral  reversed  of  the  lower  ex- 
tremity. 


Fig.  4.— The  demi-gauntlet. 


Fig.  6. — Method  of  covering  the  heel. 


MINOR  srnaiinv.  1177 

T>an(la<xos  placed  on  the  cxtreiiiitics  sliould  he  ui)])lied  more  h)0.sely  as  they 
advance  (■n)ni  heh>\v  upward,  especially  if  the  lind)  he  flexed,  in  order  not  to 
interfere  with  the  circulation.  Until  experience  teaches  the  surj^eon  how 
firmly  turns  of  a  handa«^e  can  witii  safety  he  drawn,  they  should  l)e  ai)plicd 
loosely  rather  than  tightly.  When  used  to  retain  dressin<,'s  or  splints,  a  num- 
ber of  moderately  firm  turns,  passing  and  repassing  over  one  another,  will 
secure  better  fixation  than  a  single  layer  drawn  dangerously  tight.  All  firmly- 
applied  dressings  of  the  extremities  should  leave  the  fingers  and  toes  exposed  : 
the  patients  should  be  seen  within  a  few  iiours,  when,  if  the  jiarts  do  not  feel 
easy,  or  if  a  duskiness  of  the  exposed  portions  is  seen,  or  nundjness  of  the  fingers 
or  toes  is  complained  of,  the  dressings  should  be  loosened.  If  a  pin  secures 
the  end  of  a  bandage,  it  should  be  introduced  point  downward.  In  bandaging 
the  arm  to  the  chest,  etc.  a  pad  must  be  interposed  to  prevent  chafing.  Skin 
must  never  be  in  contact  with  skin. 

The  special  methods  of  applying  certain  bandages  will  now  be  given  in 
detail,  by  modifications  of  which  any  form  of  di-essing  may  be  devised. 

Spiral  Reversed  Bandage  of  the  Upper  Extremity. — AVitli  the  initial 
end  of  a  roller  eight  yards  long,  take  two  circular  turns  around  the  Avrist ;  pas& 
thence  obliquely  across  the  back  of  the  hand  to  the  extremities  of  the  fingers ; 
ascend  the  hand  by  three  or  more  spiral  turns  to  the  metacarpo-phalangeal 
joint  of  the  thumb;  cover  this  and  the  wrist  by  figure-of-8  turns,  and  ascend 
the  forearm  by  spiral  turns,  adding  reverses  when  requisite  until  the  elbow  is 
reached,  Avhen,  if  the  joint  is  to  be  flexed,  it  must  be  covered  in  Avith  figure-of- 
8  turns,  after  which  continue  the  spiral  or  spiral  reversed  turns  up  the  arm 
(Plate  XXXIV,  Fig.  1). 

Spiral  of  the  Fingers. — By  two  circular  turns  around  the  wrist  fix  the 
initial  end  of  a  roller  one  inch  wide  and  one  and  a  half  yards  long ;  pass 
obliquely  across  the  back  of  the  hand  to  the  root  of  the  finger ;  descend  to  its 
tip  by  very  oblique  turns,  whence  the  bandage  must  ascend  by  a  series  of  spiral 
reverses ;  "secure  by  splitting  the  bandage  for  a  few  inches  and  tying  the  ends 
around  the  root  of  the  finger,  or  ascend  to  the  wrist  by  a  spiral  turn,  terminat- 
ing by  a  circular  turn.  All  the  fingers  may  be  thus  bandaged  in  succession, 
the  hand  finally  being  covered  in  bv  a  series  of  figure-of-8  turns,  forming  the 
gauntlet  (Plate'XXXIV,  Fig.  2). 

The  Spica  of  the  Thumb  is  started  by  a  circular  turn  around  the  wrist, 
and  a  second  turn  follows  to  hold  the  first  in  position.  It  then  sweeps  across 
the  back  of  the  hand  and  the  back  of  the  metacarpo-phalangeal  articulation 
under  the  middle  phalangeal  joint  to  the  upper  surface  of  the  last  phalanx  of 
the  thumb  :  several  ascending  spiral  turns  are  now  made,  and  the  ball  of  the 
thumb  is  then  covered  by  a  series  of  ascending  figure-of-8  turns.  The  spica 
of  the  thumb  is  used  to  retain  splints  and  dressings  or  to  arrest  hemorrhage  by 
pressure  (Plate  XXXIV,  Fig.  3). 

The  Demi-gauntlet  has  but  a  limited  field  of  usefulness,  and,  as  it  leaves 
the  fingers  free,  it  must  not  be  tightly  applied.  It  is  used  to  retain  dressings 
on  either  the  dorsum  or  palm.  If  we  desire  particularly  to  cover  the  palm, 
that  portion  of  the  hand  is  turned  up,  or  if  the  dorsum,  that  part  is  made 
superior.  Take  two  circular  turns  around  the  wrist ;  sweep  to  the  root  of 
either  the  thumb  or  little  finger ;  pass  it  around  the  base  of  the  extremity 
and  return  to  the  wrist,  and  so  progressively  bandage  each  finger,  and  finally 
run  a  series  of  ascending  figure-of-8  turns,  including  the  hand  and  wrist, 
from  the  roots  of  the  fingers  (Plate  XXXIV,  Fig.  4). 

Spiral  Reversed  Bandage  of  the  Lower  Extremity. — With  the  tip 
of  the  patient's  heel  on  the  surgeon's  knee  or  properly  supported  by  an  assist- 


117S  j.v  AMEiiirAX  TKXT-iinoK  OF  srinnim'. 

.int.  Hx  the  initial  extremity  of  a  roller  seven  yards  Ion;,'  and  two  and  a  lialf  or 
three  inches  wide  by  circular  turns  just  above  the  malleoli ;  descend  obliijuely 
over  the  dorsum,  under  the  sole,  and  back  to  the  dorsum  of  the  foot,  up  which 
the  bandage  must  pass  by  several  spiral  turns,  covering  in  the  instep :  when| 
this  is  reached,  pass  the  bandage  under  the  point  of  the  heel,  thence  to  thej 
dorsum,  then  down  beneath  the  sole,  then  along  the  outer  surface  of  the  heel, 
next  around  the  heel  above  its  point  to  reach  the  instep,  whence,  passing  to 
the  sole,  a  turn  is  made  around  and  above  the  point  of  the  heel  on  the  inner 
side,  again  to  pass  to  the  instep,  when  the  roller  must  be  carried  by  spiral  and 
reversed  turns  up  to  the  knee.  There  it  is  finished  off  by  a  few  circular  turns. 
If  it  is  desired  to  extend  the  dressing  above  the  knee,  this  must  be  covered  by 
figure-of-8  turns  of  a  second  roller,  and  the  thigh  ascended  by  spiral  and 
reversed  turns.  When  the  heel  does  not  require  covering,  the  turns  beneath 
and  around  the  point  of  the  heel  must  be  omitted  (Plate  XXXIV,  Fig.  5). 

The  method  of  covering  the  heel  is  shown  in  Plate  XXXIV,  Fig.  6. 

The  Spica  of  the  Instep  starts  by  a  circular  turn  around  the  ankle,  fol- 
lowed by  a  second  turn  to  hold  the  first ;  the  roller  now  sweeps  across  the 
instep  to  the  root  of  the  toes  under  the  sole  of  the  foot,  and  ascends  for  a  dis- 
tance by  several  spiral  or  spiral  reversed  turns.  From  the  instep  a  turn  is  made 
across  the  point  of  the  heel,  another  somewhat  higher  and  another  somewhat 
lower  to  catch  the  free  edge,  and  the  bandage  is  ascended  by  figure-of-8  turns 
around  the  ankle  and  instep  (Plate  XXXV,  Fig.  1). 

The  Crossed  or  Figure-of-8  of  One  or  Both  Eyes. — Place  the  initial 
extremity  of  a  two-inch  roller  five  yards  long  on  one  temple  ;  make  two  circu- 
lar turns  around  the  forehead  and  occiput  from  right  to  left  for  the  right  eye; 
I'eaching  the  occiput,  pass  from  under  the  right  ear  up  over  the  right  eye,  across 
the  opposite  temple,  down  to  the  occiput ;  then,  repeating  two  or  more  of  these 
oblique  turns,  finish  off  with  a  circular  turn  around  the  forehead.  If  both 
eyes  are  to  be  covered,  proceed  as  before  until  the  third  oblique  turn  over  the 
right  eye  has  reached  the  left  parietal  protuberance,  when,  instead  of  descend- 
ing to  the  nape  of  the  neck,  pass  around  the  forehead,  down  over  the  root  of 
the  nose,  the  left  eye,  left  cheek,  under  the  same  ear  to  the  nape  of  the  neck, 
thence  to  the  right  parietal  protuberance,  down  again  over  the  left  eye,  and, 
making  two  more  similar  turns,  finish  off  with  a  few  circular  turns  around  the 
forehead  (Plate  XXXV,  Fig.  2). 

Barton's  Bandage,  or  Figure-of-8,  of  the  Jaw. — Place  the  initial 
extremity  of  a  roller  two  inches  wide  and  five  yards  long  on  the  nape  of  the 
neck  just  beneath  the  inion ;  pass  over  the  right  parietal  bone  to  the  vertex, 
down  over  the  left  temple  to  the  chin,  beneath  this  up  the  right  side  of  the 
face  and  right  temple  to  the  vertex,  down  over  the  left  parietal  bone  to  the 
starting-point  at  the  nape  of  the  neck,  thence  around  the  right  side  of  and 
along  the  jaw  to  the  chin,  across  the  front  of  which  the  bandage  must  pass 
back  to  the  nape  of  the  neck  :  a  repetition  of  these  turns,  with  pins  at  their 
points  of  intersection,  completes  the  dressing  (Plate  XXXV,  Fig.  3). 

The  Gibson  Bandage  starts  with  three  vertical  turns  around  the  head  and 
jaw  and  in  front  of  the  ears.  Just  above  the  level  of  the  ear,  after  the  three 
vertical  turns  have  been  made,  the  bandage  is  reversed  and  carried  three  times 
horizontally  around  the  head  and  forehead.  As  the  bandage  reaches  the  occi- 
put after  completing  the  third  horizontal  turn,  it  drops  to  the  base  of  the  skull, 
and  is  run  forward  below  the  ear  and  around  the  chin  back  to  the  opposite  side 
of  the  head  and  neck  to  the  starting-point.  Three  of  these  neck-and-jaw 
turns  are  made.  On  completing  the  third  turn  the  bandage  is  reversed  and 
carried  from  the  occiput  to  the  forehead  over  the  vertex,  and  fastened  with  a 


BANDAGES. 


Plate  XXXV. 


Fig.  1.— Spica  of  the  instep. 


^^   ^.^^_^^^^^ 

^^^A  ^-^Ski   ^^H 

Flu.  2.— Cruh.Mjd  ur  lif,'urc  ul-s  ul  buUi  eyes. 


Fk;.  ;;. — Barton's  bandage,  or  ngure-of-8 
of  the  jaw. 


Fig.  4. — Gibson's  bandage. 


Fig.  5.— Oblique  or  crossed  bandage  of  the 
angle  of  the  jaw. 


Fig.  6.— Spica  of  the  groin. 


MIXO  n   s  r/.v ,'  /.;/.'  > '.  J  I  7 «) 

])iii.  Pins  are  now  introdiiccd  at  |»i»ints  where  the  turns  cross  each  other. 
This  bandaj^e  is  used  in  fracture  or  dislocation  of  the  jaw  (IMate  XXXV, 
Fig.  4). 

The  Oi$i-iQUE  or  Cuosskd  Handacjk  ok  tjik  Anclk  of  tiik  Jaw  is  started 
by  a  circuhir  around  tlie  forehead,  and  a  second  turn  to  hold  the  first,  running 
toward  the  affected  si<le.  After  the  completion  of  the  second  turn  the  bandage 
is  carried  around  the  head  to  the  base  of  the  skull,  passes  forward  to  tlie  opposite 
side,  and  is  carried  under  the  ear  and  Tinder  the  jaw  to  the  front  of  the  ear  of 
the  injured  side.  A  series  of  advancing  turns  are  now^  made,  in  front  of  the 
ear  of  the  injured  side  and  back  of  the  ear  of  the  sound  side,  until  the  parts 
are  sufficiently  covered.  The  bandage  is  ended  by  carrying  the  last  turn  under 
the  ear  of  the  injured  side  to  below  the  occiput  on  the  opposite  side,  and  then 
by  a  circular  around  the  forehead  and  occiput  (Plate  XXXV,  Fig.  5). 

This  bandage  is  used  with  a  compress  in  fractures  of  or  near  the  angle  of 
the  lower  jaw,  and  for  retaining  dressings  on  the  chin,  side  of  the  face,  and 
vault  of  the  cranium.  It  is  a  useful  dressing,  but  is  tight  and  uncomfortable, 
and  it  makes  so  much  pressure  on  the  throat  as  to  be  rather  unsafe  for  young 
children  or  to  apply  to  a  person  not  entirely  recovered  from  an  anesthetic. 

The  Spica  of  the  Groin  or  Figure-of-8  of  the  Pelvis  and  Thigh. — 
With  a  three-inch  roller  ten  yards  long  make  two  circular  turns  around  the 
pelvis,  passing  from  right  to  left,  and  from  before  backward  if  for  the  right 
groin,  and  the  reverse  if  for  the  left.  Reaching  the  front  of  the  right  groin, 
pass  over  the  inner  side  of  the  thigh,  beneath  and  around  it  to  reach  the  groin, 
whence  the  bandage,  crossing  the  first  turn,  ascends  to  the  ilium  of  the  oppo- 
site side;  beneath  the  back  around  the  pelvis  to  the  right  groin  as  before,  each 
turn  ascending  the  thigh  and  covering  one-third  of  the  previous  one  until  by 
their  repetition  the  roller  is  exhausted.  With  a  longer  bandage  by  passing 
every  other  turn  around  the  opposite  instead  of  the  same  thigh  a  spica  of  both 
groins  may  be  applied  (Plate  XXXV,  Fig.  6). 

Spica  of  the  Shoulder. — Start  a  two-and-a-half-inch  roller  by  one  or 
two  spiral  reversed  turns  around  the  upper  arm,  then  pass  up  from  behind  over 
the  shoulder,  over  the  front  of  the  chest,  beneath  the  opposite  axilla,  across 
the  back,  over  to  the  front  of  the  arm,  around  which  it  must  w  ind  to  pass  from 
over  the  back  of  the  shoulder  to  the  front  of  the  chest,  the  successive  turns 
advancing  from  below  upward  (Plate  XXXVI,  Fig.  1). 

Figure-of-8  Bandages  of  both  Shoulders  (Plate  XXXVI,  Fig.  2),  of 
one  or  both  Breasts  (Plate  XXXVI,  Fig.  3),  of  the  Neck  and  Axilla  (Plate 
XXXVI,  Fig.  4),  of  the  Ankle  (Plate  XXXVI,  Fig.  5),  or  of  the  Elbow 
(Plate  XXXVI,  Fig.  (3),  convey  in  their  names  the  method  of  application,  the 
only  advice  requisite  being  to  fix  the  initial  end  by  circular  turns  around  the 
arm,  leg  or  chest. 

Velpeau's  Bandage. — Place  the  palm  of  the  hand  of  the  injured  arm  on 
the  shoulder  of  the  sound  side,  with  padding  between  the  arm  and  the  chests 
wall  to  prevent  chafing ;  place  the  initial  extremity  of  a  two-and-a-half-inch 
roller  ten  yards  loiig  under  the  axilla  of  the  sound  side,  pass  up  over  the  back, 
over  the  clavicle,  down  the  front  and  outside  of  the  arm,  under  the  outside  of 
the  elbow,  up  over  the  chest  to  the  sound  axilla;  repeat  the  first  turn,  but  on 
reaching  the  sound  axilla  the  second  time,  pass  around  the  chest  and  over  the 
injured  arm  to  the  same  axilla,  then  make  a  turn  over  the  clavicle  and  arm, 
then  a  circular,  the  turns  (tseendiiKj  spica-Avise :  pin  the  points  of  intersection 
of  the  turns  (Plate  XXXVII,  Fig!  1). 

The  Desault  Bandage  consists  of  three  rollers,  a  pad,  and  a  sling.  The 
first  roller  is  to  be  applied  while  the  arm  of  the  injured  side  is  extended  at 


IISO  .l.V   AMKUK'Ay    TEXr-IlOOK    OF   SJlidKIlY. 

right  angles  to  the  body.  A  wodgc-sliaped  pad  with  the  base  up  is  inserted 
into  the  axilla,  and  this  first  bandage  holds  the  pad.  It  is  applied  by  ascend- 
ing spiral  turns  around  the  chest,  and  is  listened  by  carrying  the  roller  obliquely 
across  the  front  of  the  chest,  over  the  sound  shoulder,  under  the  a.xilla.  over 
the  shoulder  across  the  back  to  the  pad.  obli(juely  over  the  lower  portion  of  the 
chest  to  opposite  the  lower  portion  f»f  the  pad.  and  then  ascending  spiral  turns 
are  made  to  a  level  with  the  top  of  the  jnid  (Plate  XXXA^II,  Fig.  '!). 

The  arm  is  now  brought  to  the  side  over  the  pad.  This  pad  is  the  fulcrum, 
the  arm  is  the  lever,  and  the  second  roller  of  Desault  is  the  force  to  correct  the 
inwanl  displacement  of  the  fracture  of  the  clavicle.  The  second  roller  of 
Desault  holds  the  arm  to  the  side  by  a  series  of  ascending  spiral  turns,  includ- 
ing the  arm  and  chest,  starting  just  above  the  elbow  and  terminating  just 
below  the  shoulder  of  the  injured  side  (Plate  XXXVII.  Fig.  8). 

The  third  roller  corrects  the  downward  and  forward  displacement  from  a 
fractured  clavicle.  It  starts  in  the  axilla  of  the  sound  side  anteriorly,  runs  to 
the  top  of  the  shoulder  of  the  injured  side,  down  the  back  of  the  arm  to  the 
elbow,  and  from  this  to  the  point  of  origin.  The  roller  is  now  carrie<l  backward 
under  the  axilla  of  the  sound  side,  runs  across  the  back  to  the  shoulder  of  the 
injured  side,  down  the  front  of  the  arm  to  the  elbow,  and  from  this  point  across 
the  back  to  the  point  of  origin.  These  turns  give  us  two  triangles,  an  anterior 
and  a  posterior.  Remembering  that  the  third  roller  of  Desault  starts  in  the 
axilla  of  the  sound  side  anteriorly,  its  formula  is :  from  axilla  to  shoulder, 
from  shoulder  to  elbow,  from  elbow  to  axilla,  pass  to  the  back  ;  and  again 
from  axilla  to  shoulder,  from  shoulder  to  elbow,  from  elbow  to  axilla  (Plate 
XXXVII.  Fig.  4). 

After  the  application  of  the  third  roller  the  hand  is  hung  in  a  sling. 

Recurrent  B.\ndage  of  the  Head. — Fix  the  initial  extremity  of  a  six- 
yard  roller,  two  inches  wide,  by  circular  turns  parallel  to  the  supraorbital  ridge. 
When  the  middle  of  the  forehead  is  reached,  reverse,  hold  the  reverse  with 
a  finger  of  the  left  hand,  carry  the  bandage  over  the  sagittal  suture  to  the 
occiput,  reverse  here ;  let  an  assistant  hold  the  turn,  carry  back  the  roller 
obliquely  to  the  forehead,  reverse,  hold,  carry  back  to  the  occiput,  repeating 
these  turns,  covering  in  one-third  of  each  preceding  one  until  the  left  half  of 
the  head  is  covered  from  above  downward  to  the  circular  turns ;  then  cover 
in  the  right  side  by  similar  turns,  fixing  all  by  circular  turns  and  careful  pin- 
ning (Plate  XXXVII.  Fig.  o).  The  same  bandage  can  be  applied  by  a  double- 
beaded  roller,  the  body  placed  over  the  occiput  or  forehead,  circular  turns  made, 
and  then  the  recurrent  turns  by  one  head  of  the  roller  while  the  other  is  con- 
tinued in  a  circular  manner,  fixing  each  recurrent  turn  as  it  is  made. 

Recurrent  Bandage  of  Stumps. — This  should  be  applied  with  a  single- 
headed  roller  of  proper  width  precisely  as  for  a  recurrent  of  the  head,  com- 
mencing by  circular  turns  a  few  inches  above  the  end  of  the  stump,  followed  by 
the  recurrent  turns  covering  the  stump,  and  finishing  off"  bv  circular  turns 
(Plate  XXXVII.  Fig.  6). 

T-Bandages. — These  consist  of  a  strip  of  muslin  long  enough  to  encircle 
the  part  once  or  twice,  to  the  middle  of  which  a  second  shorter  strip,  or  some- 
times two  strips,  are  secured  at  a  right  angle  :  when  one  cross-strip  is  employed, 
the  bandage  is  called  a  single  T.  when  two,  a  double  T. 

Double  T  of  the  Perineu.m. — Pass  the  transverse  portion  around  the 
body  just  above  the  iliac  crests,  with  the  vertical  strips  at  the  mid-point  behind  : 
tie  or  pin  ;  then  bring  one  vertical  strip  over  the  dressings  between  one  thigh 
and  the  genitals,  and  the  other  between  the  opposite  thigh  and  the  genitals,^ 
securing  both  to  the  transverse  portion.     A  single  or  a  double  T-bandage  may 


BANDAGES. 


Plate  XXXVI. 


Fig.  1.— Spica  uf  ihc  sliuuldur. 


Fig.  2.— Posterior  flgure-of-8  of  both  shoulders. 


Fig.  3.— Figure-of-8  of  one  breast. 


Fig.  4.— Fiffure-of-8  of  neck  and  axilla. 


Fig.  5.— Figure-of-8  of  the  ankle. 


Fig.  6.— Figure-of-8  of  the  elbow. 


MI.\<>n    SURGERY.  ll.Sl 

be  employed  to  retain  dressings  on  the  head,  the  transverse  portion  passing 
around  the  eranial  vault,  the  other  passed  over  the  dressings,  boieath  the 
transverse  strip,  back  again  to  it,  and  there  pinned :  a  wide  vertical  piece,  for 
instance,  may  be  used  to  cover  in  an  ear. 

Four-tailed  Bandage. — This  is  useful  to  retain  dressings  on  the  chin, 
etc.,  and  is  made  of  a  strip  of  muslin  three  to  four  inches  wide,  long  enough  to 
encircle  the  part  and  overlap  somewhat ;  turn  down  the  middle  of  each  end 
toward  the  center.  In  ajyplying  it  to  the  chin,  for  instance,  place  the  body  of 
the  bandage  over  the  point  of  the  chin,  pass  the  anterior  or  upper  pair  of  tails 
over  the  front  of  the  chin,  beneath  the  ears  to  the  nape  of  the  neck,  and  secure 
them;  then  bring  the  other  tails  up  beneath  the  chin  to  the  back  part  of  the 
vertex  ;  tic  or  pin. 

Handkekchief  Bandages. — These  consist  of  large  handkerchiefs  or  pieces 
of  muslin  about  three-fourths  of  a  yard  square,  one  of  which,  folded  once,  forms 
an  oblong ;  its  diagonal  angles  being  brought  together,  a  triangle;  by  folding 
a  triangle  from  its  summit  to  its  base,  a  cravat  is  formed  ;  while  a  cravat  twisted 
is  a  cord.  It  would  require  many  pages  to  describe  all  temporary  or  permanent 
handkerchief  bandages,  and  but  three  Avill  be  explained,  premising  that  in 
applying  all  forms  the  body  of  a  cravat  and  the  base  of  the  triangle  correspond 
to  the  initial  end  of  a  roller  bandage. 

Fronto-occipital  Triangle. — Place  the  base  on  the  forehead ;  carry  the 
apex  over  the  vertex,  letting  it  drop  below  the  occiput ;  bring  the  lateral  angles 
around  the  head  over  the  apex  of  the  triangle  crossing  them  at  the  occiput 
until  they  reach  the  temples  or  the  forehead ;  pin  or  tie :  the  summit  is  then 
to  be  turned  up  and  pinned  behind  to  the  body  of  the  handkerchief.  A  hand 
or  a  stump  can  be  dressed  in  a  similar  manner. 

Fronto-occipito-labial  Cravat. — Place  the  body  on  the  forehead,  carry 
the  ends  to  the  occiput,  and  cross  them,  bringing  them  forward  to  each  side  of 
the  lip  and  pin,  or  first  pass  one  end  through  a  slit  in  the  other. 

Figures-of-8,  serving  a  similar  purpose  to  that  of  Barton's  bandage  of  the 
jaw,  or  similar  figures  of  the  neck  and  armpit,  the  shoulders,  the  chest,  sus- 
pensories of  the  breast  or  of  the  testicle,  can  be  devised  by  using  more  than 
one  triangle  or  cravat. 

III.  Fixed  Dressings. — Such  substances  as  glue  and  zinc  oxide,  glue 
and  chalk,  paraffin,  dextrin,  and  starch  have  all  been  employed,  but  the  appli- 
cation of  plaster  of  Paris  and  silicate  of  sodium  alone  will  be  described,  the 
former  being  the  one  almost  universally  employed. 

Plaster  of  Paris. — This  must  be  of  good  quality  (dental  plaster  is  the 
best),  recently  calcined,  and  may  be  applied  in  one  of  two  ways :  Bandages, 
pieces  of  blanket  or  strips  of  other  materials,  are  passed  through  a  watery 
mixture  of  plaster  of  the  consistency  of  cream,  loosely  rolled,  and  rapidly 
applied  to  the  part,  or  the  li(iuid  plaster  may  be  smeared  over  a  bandage  pre- 
viously applied.  Unless  employed  in  the  form  of  one  or  more  thicknesses 
of  old  blanket,  cut  into  the  shape  of  the  re(|uired  splints  and  soaked  in  the 
li(iuid  plaster,  this  method  is  undesirable. 

Almost  universally,  some  loose  texture,  as  cheese-cloth,  cross-barred  muslin, 
mosquito  netting,  or,  preferably,  crinoline,  is  cut  into  strips  of  a  Avidth  proper 
for  the  part  (two  to  three  inches),  and  the  meshes  filled  by  rubbing  in  dry  plas- 
ter with  the  hand  as  it  is  loosely  rolled  up.  Wrapped  in  w^axed  paper  and  kept 
in  a  warm,  dry  place,  these  rollers  will  be  serviceable  for  some  time,  but  are  best 
prepared  just  before  using.  Various  special  apparatuses  have  been  devised  for 
preparing  and  rolling  plaster  bandages,  but  the  hand  will  do  equally  well. 

Mode  of  Application. — Cover  the  part  with  a  woollen  stocking,  a  flannel 


lisLi  A\  AMi:i!i<\\.\   ri:xr-r,()Oh'  oi'  sri:<;i:i:y. 

roUiT  baiida^ic,  <n'  a  knit  uiidervest,  act'ordiiig  to  the  part,  liimicrse  a  rolk-r 
emhvi.se  in  a  basin  of  warm  water,  and  when  all  air-bubble.s  have  cca-^ed  t<> 
escape  take  out,  S(jiieeze  with  the  hand,  and  iipply  as  any  roller  bandage,  but 
mori'  .sA^'^///,  smoothing  the  turns  with  the  other  hand  as  they  are  made :  three 
or  four  thiekne.sses  of  bandage  are  usually  sutficient.  When  the  first  bandage 
is  taken  out  of  the  water,  put  in  another.  A  little  drv  plaster  may  })e  used 
to  strengthen  the  dressing,  sprinkled  over  the  e.xterior  and  smootlied  down 
with  the  wet  hands  as  it  sets.  A  little  mucilage,  glue,  or  stale  beer  will  delay 
setting,  while  a  little  table  salt  or  alum  will  hasten  the  process,  which  unas- 
sisted takes  from  ten  to  thirty  minutes.  Some  one  of  the  plaster  shears  or 
Hunter's  saw  is  the  best  instrument  for  the  removal  of  plaster  dressings,  but 
a  stout  knife — a  pruning-knife  is  the  best — will  do,  while  painting  a  strip 
of  the  dressing  with  dilute  hydrochloric  acid  will  soften  it  so  that  an  ordinary 
knife  or  shears  will  divide  it. 

SiLiCATE-OF-SoDA  DRESSING. — After  protecting  the  part  in  the  same  way 
as  when  applying  a  plaster  dressing,  bandage  the  limb  loosely  (because  if  un- 
washed the  bandages  will  shrink,  thus  constricting  the  parts)  with  ordinary 
wet  muslin  rollers,  painting  each  layer  thickly  with  the  silicate  :  from  four  to 
six  layers  of  bandage  will  suflice.  Ordinary  cheese-clotii  folded  in  several 
thicknesses  and  soaked  in  the  sodium  silicate  can  be  more  expeditiously 
ajiplied.  As  water  softens  this  material,  the  dressing  is  easily  removed.  The 
disadvantage  of  the  silicate  dressing  is  that  it  refjuires  many  hours  to  dry 
thoroughly,  and  that  it  becomes  softened  by  discharges  or  wet  dressings. 

IV.  Rubefacients. — These  are  agents  which  revulse  by  causing  congestion 
of  the  skin  :  a  few  teaspoonfuls  of  oil  of  turpentine  sprinkled  over  a  piece  of 
flannel  wrung  out  of  hot  water,  applied  to  the  skin  and  covered  with  oiled  silk 
or  dry  flannel,  form  the  turpentine  stupe :  twenty  minutes  is  the  maximum 
for  this  application.  Mustard  flour  (the  black  being  the  stronger),  mixed 
"with  tepitl  water  into  a  paste,  spread  thinly  on  a  piece  of  muslin  or  paper,  and 
covered  with  jjauze  or  thin  cambric,  is  an  excellent  counter-irritant.  Few 
skins  will  bear  pure  black  mustard  for  more  than  ten  minutes.  Diluted  one- 
half  with  wheat  or  corn  flour,  twenty  minutes  should  be  the  maximum  of  appli- 
cation, because  blistering  must  be  {^voided,  that  produced  by  mustard  being 
specially  painful.  After  removing  a  mustard  plaster,  greased  lint  should  be 
applied.  A  mustard  fnot-hafJi  consists  of  one  or  two  tablespoonfuls  of  pure 
mustard  in  a  bucket  two-thirds  full  of  water  at  105°  F. :  the  feet  may  be  kept 
in  this  for  about  twenty  minutes,  a  blanket  being  thrown  around  the  limbs 
and  including  the  bucket  to  retain  the  heat.  Revulsives  must  be  used  with 
caution  in  cases  of  shock  or  coma,  lest  impaired  vitality  or  sensation  to  pain 
result  in  extensive  sloughing  of  the  skin. 

V.  Vesicants  are  agents  which  cause  a  more  permanent  congestion  of  the 
skin  by  producing  inflammation,  terminating  in  a  serous  effusion,  elevating 
the  cuticle  into  vesicles  or  blisters.  Rapid  vesication  can  be  effected  by  the 
strong  acjua  ammoni?e  of  the  Pharmacopeia,  by  wetting  with  it  a  piece  of  lint 
of  the  desired  size  and  covering  with  oiled  silk  ;  or  by  a  suitably  shaped  iron 
(knife-blade,  etc.)  heated  in  boiling  water.  Spanish  flif  in  the  form  of  can- 
tharidal  cerate  or  collodion  is  the  vesicant  most  often  used,  the  cerate  being 
spread  thinly  on  a  piece  of  adhesive  plaster,  leaving  a  margin  of  from  one- 
half  to  three-fourths  of  an  inch,  which  will  serve  to  retain  the  blister  in  posi- 
tion. The  skin  must  be  well  cleansed  before  its  application:  six  to  eight 
hours  will  usually  suffice  to  produce  incipient  vesication,  when  removal  of  the 
blister  and  the  application  of  a  poultice  for  a  few  hours  will  cause  the  "  filling 
up  of  the  blister."     If  no  further  effect  is  desired,  the  serum  should  be  drained 


BANDAGES. 


Plate  XXXVIT. 


Fig.  1.— Velpeau's  baiulatje. 


Fig.  2.— Desault's  bandage,  first  roller. 


Fig.  3. — Desault's  bandage,  second  roller. 


Fig.  4.— Desault's  bandage,  third  roller. 


Fig.  5.— Recurrent  bandage  of  the  head. 


Fig.  6.— Recurrent  bandage  of  stumps. 


MINOR   SURGERY.  1183 

oft"  by  ii  puiicturc  at  tlie  most  (lc'j>ou(lc'nt  point,  and  an  ointnient  of  oxide  <)f 
zinc  be  applied  :  but  if  a  more  persistent  irritation  is  requisite,  tiie  cuticle 
must  be  removed  and  the  surface  kept  covered  with  some  in-itating  ointment, 
as  compound  resin  cerate.  Cantharidal  collodion,  when  of  good  quality,  will 
vesicate  if  painted  on  in  several  layers,  but  as  found  in  the  shops  is  an  uncer- 
tain remedy.  Blisters  must  be  cautiously  employed  in  either  the  aged  or  the 
voung,  and  especially  in  those  suflfering  from  any  low  form  of  disease. 

VI.  The  Actual  Cautery  is  used  in  the  form  of  variously-shaped  irons 
(hatchet-edged,  round,  or  olivary)  fitted  into  wooden  handles  and  heated  in  a 
charcoal  furnace.  As  a  counter-irritant  the  iron  should  be  heated  only  to  a  dull 
red  heat,  and  be  ((uickly  drawn  in  parallel  lines,  about  one  inch  apart,  over  the 
skin,  avoiding  all  bony"  prominences:  compresses  wet  with  aseptic  cold  water 
or  with  some  antiseptic  lotion  may  then  be  applied. 

The  Paquelin.  Thermo-cmitery  \^  a  convenient  form.  It  consists  of  hollow 
platinum  cauteries  and  a  handle  covered  with  wood ;  a  benzole  reservoir;  a 
pair  of  rubber  bulbs,  like  those  for  a  hand-spray  apparatus,  connected  by  a 
tube  with  the  reservoir ;  a  long  rubber  tube  to  connect  the  cautery  handle 
also  with  the  reservoir ;  and  a  spirit-lamp  with  attached  blowpipe.  Screwing 
on  the  desired  point,  the  tube  from  the  reservoir  is  slipped  over  the  handle,  the 
point  is  heated  in  the  lamp,  is  removed  from  the  flame,  and  by  compressing  the 
bulbs — previously  connected  with  the  reservoir — benzole  vapor  is -forced  into 
the  point,  which  will  heat  up,  and  can  be  maintained  at  any  temperature  by  the 
rapidity  with  which  the  bulb  is  worked :  if  the  point  will  not  heat  with  the 
simple  "flame,  attach  the  bulbs  to  the  blowpipe  on  the  lamp,  and,  compressing 
them,  heat  the  cautery  to  a  bright-red  heat,  and  then  connect  with  the  reser- 
voir and  proceed  as  before  directed. 

VII.  Bloodletting. — Local  depletion  is  effected  by  scarification,  punc- 
ture, cupping,  and  leeching. 

Scarification  consists  in  numerous  small,  parallel  incisions  made  in  the 
long  axis  of  the  limb  or  part  with  a  sharp-pointed  knife,  which,  depleting  the 
capillaries  of  such  parts  as  inflamed  skin,  the  tongue,  the  tonsils,  or  the  con- 
junctiva, is  often  beneficial ;  the  length  and  depth  of  the  incisions  must  vary 
with  the  part.     When  employed  to  relieve  tension  of  skin  or  fascia,  by  dis- 

posing  them  as  in  the  subjoined  diagram,  the  maximum  of  yield- 

_r-_-^2—  ing  will  be  obtained  by  the  minimum  of  cutting.  The  flow  of 
-^' blood  can  be  encouraged  by  warm  aseptic  fomentations,  or.  if  ex- 
cessive, packing  with  aseptic  gauze  will  check  the  flow.  Puncture  is -dinodi- 
fication,  as  when,  for  instance,  a  narrow  bistoury  is  plunged  into  an  inflamed 
testicle  to  relieve  tension. 

Cupping  may  be  dri/  or  wet.  Dry  Cupping  consists  in  employing  an 
exhausted  receiver  over  the  integument,  whereby  congestion  of  the  included 
skin  is  effected  and  sometimes  serum  is  effused.  When  cupping-glasses  with  a 
suction-pump  are  employed,  the  glasses  must  be  firmly  held  in  position  and 
the  air  exhausted ;  but  small  tumblers  or  wineglasses  will  do.  In  using  them, 
moisten  their  interiors  with  a  little  alcohol  or  whiskey,  light  this,  and  at  once 
apply,  holding  firmly  over  the  part :  as  the  contained  air  cools  the  glass  will 
"  suck,"  owing  to  contraction  of  the  air.  Always  remove  cups  either  by  open- 
ing the  stopcock  or  by  tilting  them  while  pressing  down  the  skin  on  one  side. 

"  Wet  Cupping.— Having  congested  the  skin  by  a  dry  cup,  make  parallel 
incisions  with  a  lancet  point,  or  apply  the  spring  scarificator  set  to  such  a 
depth  as  only  to  cut  through  the  true  skin ;  spring  the  lancets,  set,  reapply 


1184  ^I^V    AMA'Ji'/CAX    TEXT-nOOK    OF  SURGERY. 

at  right  angles,  and  spring  again,  and  at  once  apply  a  cup  :  tlio  second  cutting 
is  not  always  necessary,  and  adds  to  the  inevitable  scarring.  When  the  cups 
have  ceased  to  fill  remove  them,  empty,  apply,  and  exliaust  again ;  when 
enough  blood  has  been  drawn,  wash  the  parts  with  some  mild  antiseptic  solu- 
tion and  cover  with  dry  aseptic  or  antiseptic  compresses. 

Lekching. — Two  varieties  of  leech  are  employed:  the  American,  capable 
of  withdrawing  one  dram  of  blood,  and  the  European  or  Swedish,  abstract- 
'\xi(T  about  half  an  ounce;  but  warm  fomentations  after  the  animals  have 
dropped  off  will  in  both  instances  increase  the  amount.  Method  of  Applica- 
tion,— Select  the  most  vigorous,  remove  them  from  the  water,  in  which  they 
should  be  kept  one  hour  before  using,  dry  in  a  soft  warm  cloth,  and  apply  to 
the  part,  previously  shaved  if  necessary  and  thoroughly  cleansed  with  warm 
water  and  soap.  A  few  drops  of  blood  placed  on  the  part  or  smearing  it  with 
milk  will  induce  the  leeches  to  take  hold.  By  a  cone  of  paper  a  single  leech 
can  be  confined  to  one  part,  as  the  canthus  of  the  eye,  while  for  the  cervix 
uteri  a  cylindrical  speculum  must  be  employed.  When  a  number  are  used  on 
external  parts,  they  may  be  confined  beneath  a  tumbler :  if  only  one  or  two 
are  needed,  they  can  be*  taken  one  at  a  time  between  the  thumb  and  forefinger 
and  held  to  the  part  until  they  bite.  Such  parts  as  the  eyelids  or  the  scrotum 
should  never  be  leeched,  nor  should  the  inflamed  area  itself,  but  only  the  cir- 
cumjacent tissues.  Never  pull  off  a  leech,  but  sprinkle  salt  on  it  if  slow  to 
drop  off:  injecting  a  solution  of  salt  will  serve  a  similar  purpose  in  the  vagina. 
Pressure  usually  checks  all  oozing,  but  if  it  should  fail  to  do  so.  touching  with 
a  pointed  stick  of  nitrate  of  silver  or  with  a  red-hot  knitting  needle,  or  pass- 
ing a  fine  cambric  needle  beneath  the  wound  and  throwing  a  figure-of-8  thread 
around  it.  will  check  the  bleeding.  The  artificial  leech  may  be  employed,  but 
is  uncertain  in  action  and  produces  raised,  rounded  scars. 

Venesection,  or  Phlebotomy. — All  the  advantages,  with  none  of  the 
risks,  of  arteriotomy,  or  of  bleeding  from  the  jugular  vein,  can  be  effected  by 
opening  a  vein  in  the  arm  :  and  this  operation  alone  will  be  described.  Ren- 
dering the  parts  and  instruments  thoroughly  aseptic  (for  septic  phlebitis  is  the 
only  thing  to  be  dreaded  after  phlebotomy),  make  a  few  moderately  firm  turns 
of  a  narrow  bandage  or  of  a  tape  around  the  middle  of  the  arm  ;  fi.x  the  me- 
dian cephalic  vein  with  the  left  thumb,  and  with  a  lancet  or  a  sharp-pointed 
bistoury  open  the  vein  obliquely  to  its  long  axis :  few  practitioners  possess  a 
spring  lancet,  and  if  used  on  the  median  basilic  vein  it  may  wound  the  sub- 
jacent brachial  artery.  If  the  vein  does  not  become  prominent,  make  the 
patient  firmly  grasp  a  stick  or  merely  close  the  hand  forcibly  ;  alternate  open- 
ing and  closing  of  the  hand  will  promote  the  flow  after  opening  the  vein. 
Having  obtained  the  requisite  effects  as  indicated  by  the  pulse,  remove  the 
tape,  apply  a  dry  aseptic  compress,  and,  securing  this  by  a  few  figure-of-8 
turns  of  bandage  around  the  elbow,  place  the  arm  at  rest.  The  more  rapidly 
the  blood  is  abstracted,  the  less  will  be  required  to  lower  the  force  of  the  cir- 
culation, so  that  the  sitting  or  standing  posture  is  desirable  where  marked 
effects  are  required  and  but  little   blood  can  be  spared. 

A'lII.  Artificial  Respiration. — Sylvester's,  being  that  most  generally 
applicable,  will  alone  be  described :  Lay  the  patient  on  a  level  surfjice ;  clear 
the  pharynx  of  all  mucus,  etc.  ;  keep  the  tongue  drawn  forward  by  forceps  or  a 
suture  ;  secure  it  to  the  lower  jaw  or  let  an  assistant  hold  it  out;  remove  all 
constricting  clothing  from  the  chest  and  abdomen  ;  support  the  head  and  shoul- 
ders slightly  by  a  folded-up  coat.  Kneeling  or  standing  behind  the  patient, 
grasp  the  forearms  near  the  fully-flexed  elbows ;  firmly  compress  the  lower  part 


MINOR  suii<ii:ny.  1185 

of  the  tlidiMX  fur  ;i  few  seconds  by  pressirif;  the  patient's  elbows  against  the 
front  of  the  chest;  then  sweep  the  arms  outward  and  upward  alongside  of  the 
head  until  the  hands  touch,  pulling  firndy  upward  for  a  few,.seconds  to  secure 
thorough  elevation  of  the  thoracic  walls  {inspiration) ;  then  bring  the  arms 
with  flexed  elbows  down  against  the  sides  and  lower  part  of  the  chest,  firmly 
compressing  it  as  before,  thus  imitating  expiration.  l^e[)eat  these  procedures 
from  twelve  to  fifteen  times  a  minute  until  voluntary  respiration  reconmiences, 
when  the  movements  must  be  eontinueil  to  reinforce  the  natural  effort  so  long 
as  nature  is  unequal  to  assume  all  the  labor.  The  efforts  at  resuscitation  must 
not  be  abandoned  for  an  hour  or  more,  meanwhile  employing  dry  warmth, 
warm  frictions  to  the  surface,  and  stimulants  hypodernuitically,  by  the  rectum, 
or  by  the  mouth  when  swallowing  becomes  possible ;  carefully  watch  for  sec- 
ondary apnea,  and  promptly  resume  artificial  respiration  if  it  supervenes. 
Fell's  method  of  forced  artificial  respiration  is  described  on  page  1096. 

IX.  Transfusion  and  Hypodermoclysis  with  Normal  Salt  Solu- 
tion.— Mikulicz  has  shown  that  in  profuse  hemorrhages  the  collapse  is  due 
to  the  diminution  of  the  arteria!  pressure,  and  that  if  a  solution  is  injected 
into  the  body,  which  is  of  the  same  chemical  composition  as  the  serum  of  the 

7k;.  495. 


Or 


Collin's  Transfusion  Apparatus. 

blood,  the  solution  will  raise  arterial  pressure.     The  saline  solution  which  is 
used  is  as  follows  : 

Sodii  chloridi,  1  dram  ; 

Sodii  bicarb.,  15  grs.  ; 

Aquaj  destill.,  2  pints. 

Calcium  chloride,  grm.  0.25  (grains  4) ; 

Potassium  chloride,  grm.  0.1     (grains  1^); 

Sodium  chloride,  grm.  9.0    (grains  135) ; 

Sterilized  water,  1000  c.cm.  (1  quart). 

Or  in  an  emergency  1  dram  of  common  salt  to  a  pint  of  sterilized  water. 

This  solution  can  be  injected  subcutaneously  into  the  cellular  tissue  of 
the  body,  notably  over  the  abdomen,  under  the  breasts,  or  in  the  axillae  (hypo- 
dermoclysis), with  a  carefully-disinfected  funnel  and  five  or  six  feet  of  rub- 
ber tubing,  or  a  similarly  disinfected  fountain  syringe  and  a  needle  of  large 
75 


1186 


.-l.V    AMKRlCAy    TEXT- HOOK    OF   S {/.'(; KJi' y 


size  or  an  aspirator  needle.      A  pint  or  more  lias  been  introduce*!.      The  skin 
is  to  be  rubbed  constantly  to  help  the  diffusion  of  the  solution. 

For  tmnfffufiio)!.  the  apparatus  of  Collin  (Fi<j:.  4'.t5).  or  a  most  carefully 
disinfected  syringe  or  funnel  connected  with  a  hypodermatic  needle  by  dis- 
infected rubber  tubing,  may  be  used.  After  preparing  the  parts  as  for  any 
other  operation,  a  vein  at  the  bend  of  the  elbow  is  laid  bare  and  three  cat<:ut 
liiratures  placed  under  it.  The  needle  is  introduced  into  the  vein  and  held 
in  place  by  the  middle  litrature.  r)ne  or  more  pints  of  the  solution  at  Ux.b'^ 
F.  are  then  slowlv  introduced.  The  needle  is  then  withdrawn,  the  middle 
ligature  removed,  and  the  upper  and  lower  ligatures  tieil  and  cut  short.  The 
wound  is  then  closed  and  dressed  as  usual.  During  transfusion  great  care 
must  be  taken  to  prevent  entrance  of  air — e.  g.,  by  keeping  the  funnel  con- 
stantly full. 

X.  Aspiration. — The  usual  form  of  aspirator  (Potain's.  Fig.  4!»6)  consists  of 
a  hollow  needle  with  a  lateral  eye  (or  trocar  and  canula  with  plunger  to  clear  it  if 

Fir,.  496. 


Aspirator  and  Injector. 

I 

blocked)  :  of  a  stopcock  and  joints,  to  which  on  one  side  is  attached  the  needle 
and  on  the  other  a  long  rubber  tube  having  a  short  piece  of  glass  tubing  inter- 
posed near  the  needle  end ;  of  a  rubber  cork  with  two  stopcocked  tubes,  one  for 
the  tube  connecting  with  the  needle,  the  other  for  the  short  tubing  connecting 
with  the  pump ;  finally,  a  wide-mouthed  bottle  must  be  provided. 

Operation. — Having  arranged  the  instrument  as  directed,  secure  the  cork 
in  the  bottle,  turn  off  the  stopcock  on  the  side  next  the  needle,  and  open  that 
on  the  pump  side ;  exhaust  the  bottle,  turn  off  the  exhaust  cock,  introduce  the 
needle  until  the  lateral  eye  is  buried  ;  then,  turning  the  cock  on  the  needle  side 
of  the  vacuum,  pass  the  needle  onward  until  the  pus  or  serum  appears  in  the 
segment  of  glass  tubing.  When  the  reservoir  is  filled,  turn  the  cock  on  the 
needle  side,  remove  the  cork,  empty,  replace  the  cork,  form  a  new  vacuum,  and 
proceed  as  at  first :  should  the  needle  become  blocked,  a  few  strokes  of  the 
pump  will  clear  it.  If  a  trocar  is  to  be  used,  screwing  the  canula  on  in  place 
of  the  needle,  the  trocar,  with  its  properly-packed  joint  to  render  the  canula 
air-tight,  is  to  be  introduced,  and  the  same  connections  made  as  before,  but  the 
instrument  must  be  thrust  into  the  cavity  and  the  trocar  withdrawn  until  the 
stopcock  back  of  the  canula  can  be  turned  off.  then  the  cock  between  the  can- 
ula tubing  and  the  vacuum  is  to  be  turned  on.     If  the  canula  becomes  blocked, 


Mixoh'  s nun: in'.  ii.s7 

introduce  the  appropriate  ])lun>!;er,  tiii'ii  on  tlie  eaiiula  stopcock — the  trocar 
having  been  withdrawn — remove  the  phmger  iind  turn  off  the  canula  cock,  all 
with  the  vacuum  connected.  When  tlie  packed  joint  for  both  trocar  and 
plunger  fits  into  the  connecting  joint,  a  groove  on  each  instrument  informs  the 
operator  when  it  has  been  sufficiently  pulled  out  to  enable  the  stopcock  to  be 
turned  off;  when  the  packed  joint  belongs  to  each  trocar  or  plunger,  these 
instruments  can  be  withdrawn  only  to  a  certain  point,  which  will  allow  the 
stopcock  to  be  turned.  After  the  canula  or  the  needle  has  been  withdrawn 
the  little  puncture  must  be  sealed  with   collodion  or  plaster. 

XI,  Hypodermatic  Injections. — These  are  made  with  a  syringe  contain- 
ing about  thirty  minims  and  having  an  adjustable  hollow  needle  jioint,  the  cylin- 
der being  of  metal,  glass,  or  hard  rubber.  When  not  in  use  a  fine  wire  should 
be  kept  in  the  needle,  which  must  always  be  cleansed  and  dried  after  using, 
while  the  cap  should  be  adjusted  over  the  end  of  the  syringe  to  prevent  the 
packing  of  the  piston  from  drying  :  if  iodine  is  employed,  gold  or  platinum 
points,  instead  of  steel,  and  a  hard  rubber  syringe  should   be  used. 

Operation. — As  perfect  asepticism  is  essential,  it  is  better  to  boil  the  needle 
in  a  little  water  in  a  spoon.  Then  draw  up  about  twenty  minims  of  the  water 
into  the  syringe  and  empty  this  into  the  spoon,  having  thrown  out  any  of  the 
water  left  after  having  removed  the  needle ;  drop  into  the  fluid  the  powdered 
drug  or  compressed  pellet  (as  it  is  most  commonly  prepared  for  liypodermatic 
use),  aid  its  solution  by  stirring  with  the  end  of  the  syringe ;  then  charge  the 
instrument,  attach  the  needle,  and,  holding  it  point  upward,  that  all  air  may 
rise  to  the  top,  slowdy  force  up  the  piston  until  the  air  is  expelled,  as  shown 
by  the  escape  of  a  drop  of  fluid  from  the  needle.  While  strychnine  and  ergot 
are  usually  thrown  into  the  muscles,  morphia,  atropine,  and  brandy  are  to  be 
injected  into  the  subcutaneous  cellular  tissue. 

There  are  two  Avays  of  introducing  the  needle — one  by  pinching  up  a  fold 
of  skin  free  from  veins  (usually  over  the  outer  anterior  surface  of  the  forearm 
or  thigh)  between  the  thumb  and  first  two  fingers  of  one  hand,  while  with  the 
other  the  needle  is  quickly  thrust  into  the  cellular  tissue  parallel  with  the  fold : 
the  other  method,  far  less  painful,  is  to  select  an  avascular  portion  of  the  skin, 
render  it  tense  by  the  thumb  and  finger  of  one  hand,  and  quickly  drive  the 
needle  so  obliquely  through  the  integument  as  to  reach  the  cellular  tissue, 
which  it  must  penetrate — introduced  in  either  way — for  about  three-fourths  of 
an  inch  ;  the  fluid  must  next  be  slowly  injected,  the  needle  withdrawn,  and  the 
puncture  compressed  for  a  few  moments  by  one  finger,  while  with  another  gen- 
tle friction  is  exercised  over  the  projection  formed  by  the  fluid,  to  diffuse  it  over 
a  larger  area. 

XII.  Vaccination. — This  should  be  done  immediately  after  birth  if  expos- 
ure to  variola  has  occurred  or  if  an  epidemic  of  that  disease  is  prevalent ;  but 
about  three  months  is  the  preferable  age.  Infjints  suffering  from  any  slight  ail- 
ment or  from  any  form  of  skin  affection  should  first  be  cured  of  such  diseases. 
Humanized  virus  in  the  form  of  lymph  taken  from  a  typical  vesicle  on  a  healtJiy 
infant  and  of  healthy  parentage  at  the  eighth  or  ninth  day  of  the  disease  (arm- 
to-arm  vaccination) ;  carefully  pulverized  fragments  of  dried  human  scab  of 
such  a  child  free  from  all  blood  or  pus,  ground  up  between  two  clean  glass  plates 
and  mixed  to  a  creamy  consistence  with  tepid  water ;  and  bovine  or  aiiimal 
virus — i.  e.  the  lymph  from  the  eight-day-old  vesicle  of  the  inoculated  natural 
vaccine  disease  on  the  udders  of  young  heifei's,  allowed  to  dry  on  quills  or  ivory 
points, — are  all  employed,  but  the  safest  plan  is  to  use  only  bovine  virus. 


118s  AX  j.v/./.'/r.i.y  rr.xr-iiooK  or  scua i:i!V. 

Operatiii)!. — I'rcpart'  tlie  skin  as  tor  any  otlicr  ojteration.  Witli  an  asep- 
tic lancet,  the  skin  over  the  insertion  of  the  deltoid  muscle,  or.  better,  on 
the  leg,  being  rendered  tense  by  the  thumb  and  fingers  of  one  hand,  carefully 
scrape  away  the  epitlu^liuni  over  at  least  two  small  surfaces  of  skin  about 
one  eighth  of  an  inch  square  until  a  slight  bloody  serous  oozing  occurs,  and 
then  with  the  lancet  cover  these  spots  with  the  drieil  scab  reduced  to  a  creamy 
consistence  as  just  described,  or  thoroughly  rub  them  with  the  (juill  or  ivory 
point  charged  with  bovine  virus  previously  dipped  in  tepid  water  :  any  of 
these  methods  is  rendered  more  certain  by  tattooing  the  lymph  into  the 
abraded  surface  by  the  lancet  or  ivory  point.  A  more  rapid  and  equally 
effective  plan  is  to  make  with  the  lancet  or  the  previously  moistened  ivory 
point  three  or  four  short  parallel  scratches  very  close  together,  crossing 
these  with  others  similarly  disposed,  and  then  applying  the  lymph  as 
directed.  Arm-to-arm  vaccination  can  be  done  by  puncturing  the  vesicle 
on  the  eighth  day  with  the  lancet  point,  and  then  entering  the  instru- 
ment obliquely  well  into  the  cutis  at  one  or  more  points.  The  exuded 
blood  and  serum  must  be  allowed  to  dry  thoroughly  before  replacing 
the  clothing.  The  parts  should  be  constantly  protected  by  an  aseptic 
dressing  until  the  inflammation  has  subsided  and  the  crust  is  dry.  Ex- 
posure to  cold  and  dampness  must  also  be  avoided.  The  indications  for 
revaccination  can  be  found  in  medical  treatises,  the  operation  being  like 
the  primary  one. 

XIII.  Electricity. — This  is  used  in  the  form  of  the  in dueed  current  (farad- 
ism)  to  exercise  and  improve  the  nutrition  of  muscles,  and  in  the  form  of  the  coji- 
stant  current  (galvanism)  along  the  course  of  nerve-trunks  to  excite  their  con- 
ducting power  or  act  as  a  sedative  in  neuralgia :  and  the  same  current  is  used 
to  induce  chemical  decomposition  (electrolysis)  or  to  cauterize  and  destroy  tissue 
by  heating  an  encircling  wire  or  a  galvanic  knife.  Franklinic  or  static  elec- 
tricity is  also  occasionally  used.  For  electrolysis  a  galvanic  battery  of  thirty 
or  more  medium-sized  cells  is  required,  with  needle  electrodes  insulated  except 
near  their  points.  The  operation  consists  in  introducing  into  the  aneurysm  or 
tumor  two  needles  a  short  distance  apart,  each  connected  with  a  pole  of  the 
battery ;  then,  commencing  w  ith  a  weak  current,  this  must  be  cautiously 
increased,  the  sitting  lasting  from  a  half-hour  to  one  hour,  after  which  the 
needles  are  to  be  removed  and  the  punctures  sealed  by  collodion. 

XIV.  Galvano-caitery. — This  requires  a  battery  of  a  few  large  elements 
closely  coupled,  and  various  curettes,  knives,  and  ^craseurs  fitting  into  an  insu- 
lated handle.  The  chief  advantage  of  this  form  of  cautery  is  the  po.ssibility 
of  placing  the  instrument  in  position  ivkile  cold,  and  then  heating  it.  Where 
hemorrhage  is  undesirable,  a  dull  red  heat  should  be  maintained,  for  at  a  white 
heat  the  tissues  are  divided  as  if  with  a  knife  and  bleeding  follows.  When 
the  ecraseur  is  used,  needles  must  be  passed  at  right  angles  through  the  healthy 
tissues,  the  platinum  wire  placed  behind  these,  and  the  wire — at  a  dull  red 
heat — slowly  tightened. 

XA'.  Massage. — This  is  employed  to  stimulate  the  circulation  in  the  part 
mechanically,  to  loosen  tissues  bound  down  by  adhesions,  to  diffuse  inflammatory 
exuilaies  over  a  wider  area,  thus  favoring  their  absorption,  and  to  change  the 
rate  of  the  circulation  to  a  point  compatible  with  rapid  absorption  and  normal 
nutrition.  Four  distinct  varieties  of  manipulation  are  found  to  be  most  gen- 
erally useful:   viz.  rubbing  or  stroking;    kneading;  tapping  or  percussion; 


MiMtL'  s(  n<;i:in'.  11x9 

piis^ive  and  active  inuvcnients.  Strokimj  coii^iists  in  ;j:;(.'nti(.'  rubbing  dii-ected 
from  the  periphery  upward,  commencing  the  process  above  the  inflamed  part 
and  continuing  it  over  tlic  diseased  area;  the  pressure  at  first  light,  but  finally 
firmer,  will  force  the  exudates  into  the  tissues  above,  which  have  been  emptied 
by  the  prejjaratory  rubbing.  KncaiJiiKj  means  rubbing  the  part  circularly 
with  the  pulps  of  the  fingers  and  the  thumb  or  the  palm  of  the  hand,  and  is 
best  combined  with  pinching  up  of  the  skin  or  muscles  singly  or  together  and 
gently  rolling  them  between  the  fingers  and  palm.  PercuHHian  is  effected  by 
tap]iing  the  surface  over  the  diseased  part  with  the  tips  of  all  the  fingers  held 
on  a  level,  or  with  the  ulnar  side  of  the  hands,  or,  after  covering  the  part  with 
a  towel,  three  parallel  }>ieces  of  stiff"  rul)ber  tubing  fixed  in  a  handle  (a  muscle- 
beater)  may  be  employed,  gently  striking  the  part  transversely  to  its  long 
axis.  Passive  movements  should  be  made  at  the  close  of  each  sitting  if  a  joint 
is  concerned.  Massage  is  sometimes  advisable  twice  daily,  but  often  once  a 
day  or  every  other  day  is  better;  each  sitting  may  last  from  fifteen  minutes 
to  one  hour. 

XVI.  Clinical  Thermometers, — The  best  are  straight  self-registering 
instruments,  generally  graduated  in  this  country  on  the  tube  in  degrees  and 
fractions  of  degrees  of  the  Fahrenheit  scale.  Only  "certified"  thermometers 
should  be  used.  These  have  been  tested  as  to  their  accuracy,  and  a  certificate 
of  the  error  comes  with  each.  No  good  thermometer  ought  to  vary  more  than 
■^°.  To  use  one,  the  register  must  be  shaken  below  95°  by  Jiohling  the 
instrument  bulb  downward  and  swinging  it  sharply  at  arm's  length,  or,  holding 
it  in  the  same  manner  with  one  hand,  jar  it  down  by  striking  the  lower  side 
of  the  hand  grasping  it  against  the  wrist  of  the  other  hand :  the  bulb  must 
now  be  placed  beneath  the  patient's  tongue  with  the  lips  gently  closed  over 
the  stem,  observing  that  this  is  directed  upward,  or  in  the  axilla,  the  arm 
being  brought  up  and  across  the  chest  to  maintain  apposition  of  the  axillary 
surfaces  with  the  bulb.  The  instrument  must  ordinarily  be  retained  about 
five  minutes,  but  one-,  two-,  and  three-minute  thermometers  are  now  made. 
The  same  thermometer  should  always  be  used,  and  for  the  same  length  of  time, 
in  any  given  case.  Carefully  cleanse  the  thermometer  in  water  or  with  some 
disinfectant  immediately  after  removing,  es])ecially  if  it  has  been  in  the  mouth, 
the  vagina,  or  the  rectum,  where  it  is  sometimes  placed. 

Thermometers  should  not  be  used  in  the  mouth  in  young  children,  in  the 
insane,  or  in  delirious  patients,  lest  they  bite  them  and  injure  their  mouths 
with  the  fragments  of  glass. 

Surface  thermometers,  the  bulbs  of  which  are  spiral  or  coiled,  are  some- 
times employed  for  noting  the  diff'erence  in  temperature  of  corresponding  parts 
of  the  body,  but  the  ordinary  clinical  thermometer,  held  in  place  by  a  grooved 
cork,  or  covered  with  a  layer  of  absorbent  cotton,  by  the  ends  of  which  it  is 
held  in  position  by  the  examiner's  fingers  applied  at  some  distance,  will  often 
suffice. 

XVII.  Applications  of  Heat  and  Cold. — Dry  heat  may  be  applied  by 
means  of  hot-Avater  bags,  hot  sand-  or  salt-bags,  heated  bricks,  or  bottles  or 
cans  filled  with  hot  water:  again,  by  coils  of  block-tin  pipes  arranged  as  caps 
for  the  head  or  flat  pads,  a  constant  current  of  water  at  any  temperature  can  be 
employed.  Always  interpose  one  or  more  layers  of  flannel  or  clothing  between 
the  skin  and  the  heated  applications,  exercising  great  care  lest  the  heat  be  too 
great  or  leakage  occur,  because  in  either  event  serious  burning  or  scalding  may 
result.     Old  hot-water  bags  should  not  be  used,  lest  they  burst.     Moist  heat  is 


lino  .LV  .i.i//;/.'/r.i.v  Ti.xr-iiooh'  (H'  srn<;i:in'. 

emplovoil  iu  tlio  funn  of  fonK'ntations  as  described  below  ;  or  by  hot  affusion 
or  the  douche — that  is  to  say.  pourinjT  it  from  a  height  ;  or,  finally,  by  l»ot 
baths.  When  moist  heat  is  to  be  applied  to  a  joint,  the  best  way  is  to  extend 
the  limb  and  wrap  the  joint  witii  a  lonii  Hannel  bandage  ten  or  twelve  inches 
wiile.  This  is  j>assed  four  or  five  times  around  the  joint,  the  end  han<^ini^ 
down  into  a  slop-jar  or  bucket  to  carry  off  the  water.  Very  hot  water  may 
then  be  poured  over  the  flannel  from  a  tablespoon  or  cup.  the  part  beinj;  thus 
kept  continuously  at  as  high  a  temperature  as  can  be  borne. 

Prolonged  {hot)  Baths  may  be  of  service  in  shock  Avhere  the  injury  will 
admit  of  this,  which  is  seldom.  Locally,  as  for  a  sprained  ankle,  the  tem- 
perature must  be  as  hi<;h  as  can  be  borne,  and  kept  up  for  half  an  hour  or 
more  by  adding  freshly-heated  water.  As  a  substitute  for  the  relaxation  bet- 
ter effected  by  anesthesia,  a  general  warm  bath,  prolonged  until  faintness  is 
induced,  may  be  employed  in  strangulated  hernia,  while  a  warm  hip-bath  often 
proves  of  value  in  cystitis,  vaginitis,  and  in  retention  of  urine,  when  the 
patient  should  endeavor  to  pass  his  urine  while  in  the  bath. 

Poultices  are  much  less  freijuently  employed  than  formerly.  While  they 
mav  still  be  used  occasionally  when  the  skin  is  unbroken,  if  there  is  any 
lesion  of  the  skin  antiseptic  fomkxtations  of  gauze  moistened  with  a  hot 
antiseptic  solution,  covered  with  rubber  dam,  and  kept  warm  by  a  hot-water 
bag,  should  be  used  instead,  and  in  fact  are  always  to  be  preferred. 

JJrf/  cold,  applied  by  means  of  crushed  ice  in  bladders  or  rubber  bags,  or 
ice-water  passed  through  coils  of  tubing,  is  an  important  agent :  several  yards 
of  small  rubber  tubing  coiled  around  and  secured  to  a  night-cap,  one  end  of 
the  tubing  being  connected  with  an  ice-water  receptacle  above  and  by  the 
other  emptying  into  a  vessel  below,  is  a  good  substitute  for  the  metallic  coils, 
while  mats  for  the  abdomen  and  other  parts  can  also  be  similarly  made.  Moist 
cold  may  be  applied  by  compresses  wet  in  ice-water,  by  irrigation,  or  by  cold 
affusions.  Irrigation  can  readily  be  carried  on  by  a  constant  current  of  water 
conveyed  from  an  elevated  receptacle  by  the  capillary  attraction  of  a  few  nar- 
row strips  of  lint,  gauze,  or  lampwick  extending  from  the  reservoir  to  a  moist- 
ened clotb  covering  the  diseased  area.  The  alternate  affusion  or  douche  of 
hot  and  cold  water,  poured  from  a  height,  is  often  serviceable  by  improving 
the  sluggish  circulation  in  chronic  joint  affections,thus  favoring  the  absorption 
of  exudates. 

XA^III.  Adhesive  Plaster  is  cut  or  torn  of  appropriate  width.  Rubber 
adhesive  plaster  does  not  require  heat  to  make  it  adhere,  but  the  old  form  of  plas- 
ter does.  "When  used  to  coaptate  wounds,  one  end  is  fixed  a  short  distance  from 
one  side  of  the  wound:  the  strip  is  firmly  drawn  across  the  wound,  more  or  less 
ataright  angle  to  it,  while  the  fingers  on  the  opposite  side  exercise  counter- 
pressure  :  the  free  extremity  must  then  be  applied.  Intervals  must  be  left 
between  the  strips  for  the  escape  of  discharges,  except  when  strapping  ulcers, 
where  each  strip  should  overlap  its  fellow  by  one-third.  When  removing  strips 
of  adhesive  plaster  always  loosen  both  ends,  and  draw  them  equally  toward  the 
line  of  the  wound,  thus  removing  them  without  straining  the  union. 

XIX.  CoLLODiOX  may  be  used  to  seal  a  puncture,  either  by' merely  paint- 
ing it  on  or  by  the  application  of  a  morsel  of  absorbent  cotton  soaked  with  it. 
By  fixing  one  end  of  a  strip  of  gauze  or  a  long  shred  of  absorbent  cotton  by 
collodion  on  one  side  of  a  wound  it  may  be  drawn  together,  the  free  end  being 
similarly  fixed  on  the  opposite  side :  this  is  excellent  for  scalp  and  face 
wounds. 


USE    or    Tin:    RONTGKN    RAYS   IN  SURGIUIY.  HDl 

XX.   Ointments  sliould  bo  spread  with  a  spatula  or  table  knifo  in  a  thin 
layer  upon  lint  or  muslin,  nicked  liero  and  there  to  give  exit  to  discharges. 


CHAPTER    VIII. 

THE  USE  OF  THE  X   OR  RONTGEN  RAYS  IN  SURGERY. 

Thk  llontgen  method  is,  of  course,  in  its  infancy.  It  has,  however, 
reached  already  a  degree  of  usefulness  that  makes  it  obvious  that  the  neces- 
sary apparatus  will  be  an  essential  part  of  the  surgical  outfit  of  all  hospitals, 
and  will  be  employed  constantly  in  a  variety  of  cases.  Those  to  which  the 
method  can  now  be  applied  with  advantage  may  be  summarized  as  follo\ys, 
emphasis  being  placed  on  the  fact  that  what  is  written  to-day  may  require 
revision  or  reversal  tomorrow;  so  rapidly  are  improvements  and  discoveries 
taking  place : 

1.  Foreign  Bodies  Imbedded  in  any  of  the  Tissues  of  tine  Body. 
— This  is  at  once  the  most  obvious  and  the  simplest  application  of  the  skia- 
graph to  surgery.  Hundreds  of  cases  have  already  been  reported.  Bullets, 
fragments  of  metal  or  of  glass,  needles,  etc.  are  easily  found,  and  even  if 
they  are  lodged  in  bone  the  varying  density  of  the  shadows  cast  by  sub- 
stances of  different  permeability  or  of  different  chemical  constitution  will  serve 
to  define  and  locate  them.  It  is  desirable,  if  the  foreign  body  be  in  a  locality 
containing  important  surgical  structures,  that  skiagraphs  be  made  from  at 
least  two  view-points,  so  that  the  depth  from  the  surface  and  the  exact  rela- 
tions of  such  body  can  be  determined  by  measurement.  A  single  skiagraph 
of  a  piece  of  steel  in  the  arm,  for  example,  taken  from  the  front  shows 
merely  its  relation  to  the  inner  or  outer  edge  of  the  arm,  not  at  all  its 
depth.  A  second  view  taken  laterally  would  make  the  approximal  situation 
evident. 

Various  methods  based  on  mathematical  principles  have  been  devised 
Avhich,  when  employed  with  sufficiently  accurate  apparatus,  make  the  precise 
localization  of  even  minute  foreign  bodies  possible. 

2.  Foreign  Bodies  in  Certain  of  thie  Organs  and  Viscera  are 
likely  to  be  discovered  and  located  with  a  degree  of  accuracy  that  will  vary 
with  the  region  or  structure  involved  and  with  the  thickness  of  the  enclosing 
tissues.  It  is  obvious  that  extension  of  the  method  to  the  location  of  such 
bodies  in  the  trachea,  bronchi,  and  other  portions  of  the  air-passages  is  sure 
to  come  Avith  further  improvements  in  technique.  In  the  digestive  tract — 
except,  perhaps,  the  first  third  of  the  oesophagus — the  difficulties  are  greater ; 
but  the  presence  or  absence  of  foreign  bodies  can  doubtless  be  determined, 
although  below  the  stomach  it  is  questionable  whether  any  definite  informa- 
tion as  to  exact  situation  can  be  obtained.  In  many  cases,  however,  especi- 
ally in  children,  it  is  a  matter  of  grave  doubt  as  to  whether  or  not  some 
foreign  body  has  been  swallowed.  As  the  most  uncertain  cases  occur  in  the 
youngest  children,  and  as  the  ease  of  skiagraphy  of  the  whole  body  is  in 
direct  proportion  to  the  thinness  and  softness  of  the  tissues,  we  may  expect 
in  )ust  these  cases  to  get  the  exact  information  which  is  so  often  lacking  in 
the  history  given  by  anxious  parents  or  nurses.      White  has  removed  by  gas- 


1192  A  A  AMi.iiicAX   rr.xr-nooK  or  scuaKin'. 

trotoiny  from  the  thoracic  portion  of  the  (esoph;i«!;us  of  a  chihl  two  years  and 
five  months  of  age  a  "jackstone,'"  which  liad  heen  impacted  there  for  twelve 
days  and  which  was  detected  and  located  by  this  method  (JM.  XXWIII.). 

Manv  cases  have  already  been  reported  of  tiie  detection  and  removal  of 
bullets  from  within  the  cranium,  while  the  detection,  localization,  and  re- 
moval of  fragments  of  metal  from  the  eye  are  of  freipient  oecurreiice. 

3.  Foreign  Bodies  Formed  within  the  Organism  Itself  include 
chiefly  gall-stones  and  renal,  vesical,   and  prostatic  calculi. 

Gall-stones  skiagraphed  without  the  body  cast  very  faint  shadows  :  cal- 
culi of  oxalate  of  lime,  of  i)hos])hate  of  lime,  and  of  triple  phosphate  cast 
shadows  as  dense  as  those  of  bone  or  metal  ;  uric  acid  calculi  cast  easily- 
recogni/able  but  somewhat  fainter  shadows. 

Kecent  improvements  in  apparatus  and  technique  have  made  discovery 
of  most  of  these  calculi  possible.  Gall-stones  have  and  probably  will  evade 
detection,  as  they  are  surrounded  by  the  bile  and  liver,  both  of  which  are  as 
opaque  as  these  calculi.  The  yiresence  or  absence  of  renal  and  vesical  cal- 
culi can,  however,  be  absolutely  demonstrated.  The  Kfintgen  discharge  from 
a  low  vacuum  or  "  soft  "  tube  will  differentiate  between  the  less  dense  tissues. 
It  has  been  found  possible  to  jienetrate  the  lumbar  region  and  differentiate 
between  the  kidney  shadow  and  surrounding  structures.  Where  such  detail 
is  possible  it  is  absolutely  certain  that  no  calculus,  no  matter  what  its  density, 
can  escape  detection.  Where  no  calculus  is  visible  in  a  negative  having  such 
detail  it  is  certain  that  none  is  present.  The  negative  as  well  as  the  ])0sitive 
diagnosis  can  therefore  be  relied  upon. 

4.  Inflammatory  Swellings  and  New  Growths  (except  Avhen  l)ony) 
have  not  yet  been  shown  to  offer  any  sj)ecia]  features  diagnosticating  them 
from  normal  structures.  Bony  tumors  can  plainly  be  seen,  and  as  the 
method  improves  it  is  to  be  expected  that  intracranial  and  intraspinal 
osteomata  may  be  discovered  and  located,  and  possibly  even  jx-riosteal  thick- 
enings due  to' tubercular,  syphilitic,  or  pyogenic  infection.  Dead  bone  has 
frequently  been  differentiated  from  living  bone  and  the  approxinuite  outline 
of  the  diseased  area  shown,  while  sequestra  can  be  detected  in  the  cavities  in 
which  they  lie.     Abscess  in  bone  can  be  made  out  perfectly. 

Comparison  of  the  normal  limb  Avith  that  which  is  the  subject  of  tuber- 
cular or  other  chronic  bone-disease  w  ill  often  reveal  the  full  extent  of  the 
latter  better  than  any  other  method  of  exploration,  and  in  a  recent  case  led 
to  the  perform n nee  of  an  amputation  through  the  hip-joint  instead  of  through 
the  upper  third  of  the  femur,  the  condition  found  abundantly  justifying  the 
procedure. 

5.  Fractures  and  Dislocations  (PI.  XXXIX.)  at  present  ofter  the 
greatest  field  for  the  e very-day  use  of  the  Riintgen  method.  It  is  impossible 
at  this  time  to  present  exhaustively  the  conditions  under  which  it  should  inva- 
riably be  used,  or  to  separate  them  from  those  in  which  it  is  a  matter  of 
interest  rather  than  of  necessity.  But  it  is  safe  to  say  that  it  will  be 
■wise  to   employ  it,  when  possible : 

{a)  In  all  fractures  in  or  about  joints,  either  as  a  preliminary  to  the 
reduction  of  deformity  or  as  evidence  that  such  reduction  has  been  accom- 
plished. These  fractures  are,  for  unavoidable  reasons,  often  followed  by 
some  limitation  of  motion  and  a  more  or  less  imperfect  functional  result. 
They  have  therefore  on  innumerable  occasions  been  the  basis  for  suits  for 
malpractice.  It  will  be  both  a  satisfaction  and  a  safeguard  for  the  surgeon 
if  he  can  see  that  his  work  has  been  accomplished  properly,  and  can  retain 
definite  evidence  of  that  fact. 


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USE    OF    THE    l.'OXTdKy    HAYS    /\   .vrAV/A'A' )'.  lii)3 

{b)  In  doubtful  cases  or  cases  supposed  to  be  of  great  rarity  it  will  be 
of  inestimable  value,  both  as  aidiny;  diay-nosis  and  as  demonstratinir  and 
recording  the  conditions  present. 

((')  In  cases  of  old  injury  in  Avhich,  as  so  frequently  hajjjiens,  no  reliable 
clinical  history  is  obtainable  and  no  accurate  diagnosis  can  possibly  be  made 
by  the  ordinary  methods. 

((/)  In  cases  of  ununited  fracture,  both  to  show  the  exact  position  and 
relation  of  tlie  fragments  prior  to  operation,  the  presence  or  absence  of  inter- 
posing structures,  etc.,  and  also  to  show  after  operation  the  degree  of  efficacy 
of  the  wire,  or  of  the  peg  or  screw,  or  of  the  splint  or  other  retaining  appa- 
ratus. AVe  may  freciuently  determine  in  such  cases  whether  or  not  open  oper- 
ation is  needed,  union  often  being  obtainable,  where  the  fragments  can  be 
brought  into  good  position  and  nothing  is  interposed,  by  mere  friction  and 
the  reapplication  of  the  splint  or  other  dressing. 

6.  In  cases  of  excision  of  joints  at  the  time  when — for  example,  in  the 
knee — it  is  desirable  to  demonstrate  that  bony  union  has  been  obtained, 
and  in  the  elbow  that  it  has  been  avoided. 

7.  In  cases  of  deformity  of  all  sorts  affecting  the  bones,  their  epiphyses 
or  dia])hyses,  and  requiring  careful  investigation  before  surgical  interference 
is  declined  or  advised. 

8.  In  many  obscure  cases  of  the  type  of  metatarsalgia,  in  which  the 
demonstration  of  the  cause  of  the  nerve-pain  and  the  indications  for  surgical 
treatment  are  etiually  clear  and  convincing. 

The  Apparatus. — The  most  practical  form  of  apparatus  and  the  method 
of  using  it  employed  at  present  are  described  as  folloAvs  by  Dr.  Leonard, 
skiagrapher  to  the  hospital : 

The  apparatus  consists  of  four  parts.  The  first  is  a  storage  battery  of 
from  four  to  twelve  cells,  arranged  to  give  an  electromotive  force  of  from 
eight  to  twelve  volts.  By  combining  the  cells  in  series  or  in  multiple  arc 
varying  amounts  of  amperage  and  voltage  can  be  secured,  according  to  the 
needs  of  the  coil  employed.  The  second  part  of  the  apparatus  is  a  current- 
inferrupter.  The  best  type  is  represented  by  the  automatic  electro-magnetic 
vibrator  running  on  a  shunt  circuit  of  the  main  current  by  a  separate  electro- 
magnet. The  vibrator  should  be  so  constructed  that  the  ratio  between  the 
make  and  the  break  in  the  main  current  can  be  varied  at  will,  as  well  as  the 
number  of  interruptions.  The  contact-points  of  the  interrupter  where  the 
break  is  made  in  the  current  are  made  of  thick  pieces  of  platinum,  and  on 
either  side  are  attached  the  terminals  of  a  variable  condenser,  to  take  uj)  the 
extra  current  due  to  the  self-induction  in  the  coil,  and  thus  help  t(j  make  the 
break  more  sudden.  The  third  part  consists  of  an  inductorium  of  the  Ruhm- 
korff  type,  the  primary  coil  of  which  is  attached  to  the  interrupted  battery- 
circuit.  A  coil  to  do  efficient  .r-ray  work  shoidd  be  capable  of  giving  a 
''  fat "  spark  of  at  least  eight  inches,  while  twelve  or  fifteen  inches  are  proba- 
bly a  better  length.  The  length  of  the  spark  is  not  the  only  essential.  Its 
efficiency  is  dependent  upon  its  volume  or  amperage,  which  is  recognizable 
by  the  "fat"  quality,  which  makes  the  spark  look  yellow  and  smoky,  as  if 
fat  were  burning.  This  quality  of  amperage  in  a  secondary  spark  is  needed 
in  ;c-ray  work,  for  without  it  it  is  impossible  to  produce  a  sufficient  volume 
of  low  vacuum  discharge  to  penetrate  masses  of  tissue,  as  the  lumbar  and 
pelvic  regions. 

Before  undertaking  to  use  an  .I'-ray  tube  the  student  should  acquire  com- 
plete control  of  the  coil  he  is  using,  for  unless  the  coil  is  perfectly  adjusted 
and  mastered  the  greatest  efficacy  cannot  be  secured  from  the  tube.     When- 


II!)  I  .i.v  A  y/:/:/(A.\   THxr-iiook'  of  sunaKRY. 

over  the ro  if*  any  (leticiency  in  the  (juality  of  the  work  prodiiccil  hy  the  tiil)e 
the  coil  shoiihl  be  tested  by  itself  to  see  tiiat  it  is  in  jierfect  condition. 

The  /to>if(/i'n  Ray  Tahr. — The  necessity  of  prodncing  shar]dy-defined 
sluidows  in  the  adaptation  of  the  Kdntgen  rays  to  surgical  diagnosis  lias  de- 
veloped a  type  of  tube  that  is  innch  more  eilicient  than  the  Crookes'  tube  of 
the  type  studied  by  Hilntgen.  It  Avas  noticed  at  an  early  jieriod  that  as  the 
tube  was  employed  its  resistance  to  the  passage  of  the  current  gradually  in- 
creased till  it  became  impossible  to  pass  the  current  through  it,  and  it  became 
necessary  to  re-exhaust  it. 

Careful  study  of  the  qualities  of  the  discharge  fioni  the  tube  during  the 
progressive  raising  of  the  vacuum  shows  that  there  was  an  equal  variation  in 
the  penetrating  power  of  the  discharge.  The  low  vacuum  or  "soft"'  tube 
was  found  to  be  capable  of  differentiating  between  the  less  opaque  structures, 
while  the  power  of  penetration  was  found  to  increase  with  the  vacuum,  and 
the  higher  the  vacuum  which  can  be  overcome  by  the  energy  of  the  second- 
ary current  the  greater  will  be  the  penetration. 

Penetration  is  not,  however,  of  the  greatest  value  ;  the  property  of  differ- 
entiating between  all  ranges  of  densities  is  of  greater  value.  Differentiation 
between  the  lesser  as  well  as  the  greater  densities  is  essential  to  the  future 
development  of  this  method  of  diagnosis.  In  order,  therefore,  that  a  tube 
should  be  most  useful  for  diagnostic  purposes,  it  should  be  capable  of  pro- 
ducing and  maintaining  for  any  desired  length  of  time  any  of  the  various 
(jualities  of  the  RiJntgen  ray  that  the  operator  may  desire  to  employ. 

The  self-regulating.  a:-ray  tube  seems,  at  present,  to  fulfil  most  nearly 
these  requirements,  as  it  can  be  made  to  produce  any  quality  of  Rlintgen 
discharge  whenever  the  operator  desires.  It  consists  of  two  parts — the  main 
bulb  and  an  auxiliarv  bulb,  containing  a  regulating  device  that  is  connected 
with  a  shunt-circuit  outside  the  tube.  The  main  bulb  is  exhausted  to  about 
one-millionth  of  an  atmosphere  and  has  within  it  two  terminals,  the  kathode 
or  negative  pole  and  the  anode  or  posi*^ive.  The  kathode  is  a  concave  alum- 
inum disc  of  such  radius  of  curvature  that  the  discharge  from  its  concave 
surface  is  focussed  upon  the  surface  of  a  platinum  plate  which  forms  the 
anode.  This  anode  plate  is  inclined  at  an  angle  of  about  fifty  degrees.  The 
Rbntgen  rays  originate  on  its  surface  at  the  focal  point  of  the  kathode  dis- 
charge, and  its  inclination  permits  them  to  be  cast  out  at  one  side.  The 
rays  radiate  in  all  directions  in  straight  lines  from  their  point  of  origin.  The 
shadow  of  any  body  skiagraphcd  is  thus  cast  by  a  bundle  of  rectilinear 
divergent  rays.  The  image  is  thus  always  larger  than  the  original  object, 
and  the  parts  farthest  from  the  perpendicular  rays  in  the  center  of  the 
bundle  are  more  or  less  distorted.  These  facts  should  be  always  remembered, 
for  in  order  to  get  least  distortion  in  the  part  to  be  studied  it  should  be 
placed  directly   beneath  the  focal   point  on   the  jdatinum   anode. 

The  auxiliary  bulb  contains  a  second  kathode  that  heats  a  salt  contained 
in  a  conical  bulb  opposite  it,  and  thus  drives  off'  a  gas  that  lowers  the  vacuum 
in  the  main  bulb.  The  action  of  this  auxiliary  kathode  is  governed  by  a 
gap  in  a  shunt-circuit  outside  the  main  tube.  When  the  resistance  of  the 
main  bulb  is  greater  than  the  shunt-circuit  containing  the  air-gap  and  the 
auxiliary  kathode,  the  current  |)asses  through  the  shunt-circuit  and  heats  the 
regulating  tube  till  the  resistances  are  e((ualized  or  the  main  ])ulb  is  slightly 
lower,  when  the  r-rays  are  again  produced  in  it. 

To  judge  whether  a  tube  is  working  properly,  the  ((uality  of  the  current 
that  is  energizing  it  must  be  considered.  When  Avorking  regularly  the  tube 
should  have  an   apple-green   color,  while   the  platinum  anode  should  be  red 


o 


0} 

;?; 

c 

w 

H 

o 
a 


1 


USE    or    THE    RONTGEN   HA  VS    IN  SURGERY.  1  H>5 

hot,  with  a  white-heat  spot  at  the  center.  Cure  should  be  taken,  however, 
not  to  overheat  a  low  or  "  soft "  tube,  or  the  platinum  may  be  punctured.  A 
tube  .should  never  be  allowed  to  go  so  low  that  a  pur])le  color  is  seen  about 
the  kathode. 

Thi'  PIioto;/ni/>/it'r  Plat>\ — The  photographic  plate  employed  may  be  of 
any  make,  and  should  be  wrapped  in  light-proof  black-an<l-nrange  pai)er. 
The  specially  prepared  a;-ray  plates  seem,  however,  to  give  better  results,  and 
come  conveniently  wrapped  in  light-proof  envelopes,  which  protect  them 
from  ordinary  light  while  permitting  the  perfect  action  of  the  a:-rays.  The 
plate  is  placed  with  the  .sensitive  side  next  the  i)art  to  ))e  skiagraphed,  pro- 
tected in  warm  weather  by  waxed-paper,  and  may  be  conveniently  held  in 
place  by  a  gauze  bandage  to  prevent  motion  and  a  consequent  loss  of  defini- 
tion. 

The  intensity  and  chemical  effect  of  the  rays  seem  to  be  governed  by 
the  law  of  inverse  squares,  so  that  an  exposure  at  double  the  distance  must 
at  least  be  quadrupled  if  the  same  density  in  the  negative  is  desired.  The 
tube  is  placed  on  the  o])posite  side  of  the  part  to  be  skiagraphed.  Thus  the 
shadow  of  the  part  is  cast  upon  the  plate,  the  differentiation  in  density  de- 
pending on  the  relative  opacity  of  the  various  tissues  to  the  rays.  The  tube 
should  always  be  at  least  twelve  inches  from  the  plate.  At  this  distance  the 
length  of  tlie  exposure  varies  from  one  to  fifteen  minutes,  according  to  the 
condition  of  the  tube,  the  quality  of  the  current  energizing  it,  and  the  result 
that  it  is  desired  to  produce. 

The  Fluoroserrpe. — The  fluoroscope  is  made  to  protect  the  eyes  from  ordi- 
nary light  while  observing  the  shadows  cast  upon  the  fiuoroscopic  screen  by 
the  more  opaque  tissues.  The  screen  is  an  opaque  cardboard,  upon  which  is 
a  fluorescent  salt,  as  calcium  tungstate  or  barium  platino-cyanide,  which  has 
the  property  of  fluorescing  or  glowing  wlien  acted  upon  by  the  .r-rays. 
The  fluoroscope  is  a  necessity  Avith  every  outfit.  Its  chief  value  consists  in 
detecting  abnormal  motion,  although  it  may  be  employed  to  detect  foreign 
bodies  and  even  to  locate  them  Avhen  used  Avith  a  localizing  tube. 

Rontgen-ray  Dermatitis. — Some  time  after  the  introduction  of  the  Ront- 
gen  rays  into  surgical  diagnosis  it  Avas  found  that  under  certain  circum- 
stances' a  dermatitis  Avas  produced,  which  Avas  erroneously  described  as  a 
burn  caused  by  the  :c-rays.  For  a  long  time  the  exact  conditions  'that 
would  produce  "it,  its  pathology,  and  the  method  of  protecting  patients  from 
it  Avere  unknoAvn.  Investigations  by  experienced  pathologists  have  proved 
that  this  lesion  is  not  a  true  burn,  but  a  dermatitis  which  probably  results 
from  the  devitalizing  action  of  the  currents  of  electricity  that  escape  into  the 
air  about  the  tube.  At  least  this  much  has  been  established  :  when  these 
currents  are  eliminated  no  "  burns  '"  can  be  produced.  They  are  readily 
eliminated  by  introducing  between  the  tube  and  the  patient  a  .sheet  of  thin 
aluminum  or  gold  leaf  spread  on  a  card,  and  connected  to  the  earth  by  a 
•'•grounding  "  Avire,  Avhich  in  practice  can  be  conA^eniently  attached  to  a  gas-, 
water-,  or  steam-pipe.  Care,  however,  should  ahvays  be  taken  in  operating 
under  new  conditions  till  the  phenomena  connected  with  this  dermatitis  are 
all  knoAvn. 
% 


INDEX. 


Auuk's  l)(ivv>tiiii<,'  operation,  TIT) 
Al)doineii,  (•<.)iii|ires.sioii  of,  in  olistriictioii,  7ol 
contusions  of,  711,  TliH 
diseases  and  injuries  of,  701 
cnterectomy  in  wounds  of,  709 
gnnsliot  wounds  of,  702 
incised  wounds  of,  701 
lacerated  wounds  of,  701 
laparotomy  in  punctured  wounds  of,  70o 
uon-penetratinsi  wounds  of,  701 
omental  graftiutj  in  wounds  of,  710 
penetrating  wounds  of,  7Ul,  702 

symptoms  of,  704 
punctured  wounds  of,  702 
stab  wounds  of,  702 
wounds  of,  701 

searcii  fur  perforations  in,  708 

treatment  after  operation,  710 
Abdominal  aorta,  ligation  of,  1123 
cavitv,  irrigation  of,  710 
drainage,  710.  1014 
hysterectomy,  1007 
section,  734,"  1007,  1012.  1037,  1049 

ablation  of  uterine  appendages  by.  1037 

adhesions  found  in,  1013 

after-treatment  in,  1013 

arrest  of  hemorrhage  in,  1013 

cleansing  of  peritoneal  cavity  in,  1014 

closure  and  dressing  of  abdominal  wound 
in,   1015 

for  diseases  of  female  generative  organs, 
1012 

drainage  in,  710 

incision  for,  1012 

for  intestinal  obstruction   from  adhesions 
and  angulation,   1016 

position  of  patient  in,  1012 

preparation  of  patient  in,  1012 
Abortion  after  syphilis,  181,  190 
Abscess,  acute,  44 
of  antrum,  610 
of  bone,  chronic,  275 
of  brain,  533 

treatment  of,  536 
of  breast,  chronic,  1055 
Brodie's,  47,  275 
cerebellar,  534.  540 
cerebral.  533,  538 

from  ear  disease,  538 
cold,  45,  77 
dorsal,  569 
extra  dural.  533,  541 
follicular.  S99 

treatment  of,  917 
of  gums,  i)S2 
hepatic,  47 

from  hip-joint  disease,  393,  394 
of  hip-joint,  opening  of,  397 


Abscess  of  iliac  fo.ssa,  767 

iscliio-rectal,  79(»,  801 

of  jaw,  6.S2 

of  larynx,  617 

of  liver,  47,  782 

lumbar,  46,  569 
treatment  of,  573 

of  lympbatic  glands,  47 

marginal,  HOI 

mediiLstinal.  649 

metastatic,  60,  63 

of  neck,  47,  653 

of  nose,  590 

of  palate,  695 

palmar,  47,  338 

of  pancreas,  788 

perinephric,  47.  845 

perinephritic,  47,  844 

perityphlitic,  47,  762 

peri-uretlirai,  899 
treatment  of,  917 

of  prostate,  917 

psoas,  46.  569 

treatment  of,  573 

of  rectum,  801 

retro-piiaryngeal,  47,  569,  691 
treatment  of,  573.  692 

of  scalp,  509 

of  space  of  Retzius,  47 

spinal,  569 

treatment  of,  573 

of  spleen,  789 

subdiapliragmatic,  of  subphrenic.  47 

subdural,  532 

of  the  teeth.  683 

vulvovaginal,  920 
A.  C.  E.  mixture,  1100 
Acetabulum,  fracture  of,  321 
Acinous  carcinoma,  211 
Acne,  syphilitic,  161 
Acromegaly,  281 
.Vcromion  process,  fracture  of,  309 
Actinomycosis,  137,  655 

iodid  of  potassium  in,  139 
Actual  cautery,  1183 
.\cu pressure,  255 
.Vcupuncture  in  aneurysm,  245 
Adams'  operation,  1138 
Adenitis,  467,  470 

syphilitic,  155,  156 

tubercular,  80 
Adenocystoma  of  breast,  1059 
Adeno-fibroma  of  breast,  105^ 
Adenoma  of  breast,  1059 

malignant,  of  corporeal  endometriiun.  1025 

of  nose,  607 
Adenomata,  209 
Adeno-sarcoma  of  breast,  1059 

1197 


Jilts 


JNDJ'LX. 


Aillii'-sivc  iMtlannnatiiin,  18 

l)laster,    111)0 

!,trii)s,  102 
Al-robir  hinit-riii,  2 
AfTC  relation  of,  to  operation,  1074 
Ajjnew's  operation  for  webl»e<i  fingers,  350 

splint,  .'527 
Apraphia,  4t>S,  o4f. 
Air,  enlranee  of,  into  veins,  1072 

filtered,  reetal  insufflation  of,  730 
Air-eiisliions,  1090 
Air-passaijes,  foreign  bodies  in,  *i25 

surgery  of.  aS*.) 
Alcoholic,   intoxication,  differential    diagnosis 

of,  513 
Alexia,  498,  546 
Alexins,  S'2 
Allis  on  the  hip,  457 
Alopecia,  157 

AiiKvba  coli  in  liver  abscess,  783 
Anii)iill;o,  1049 
Amputation,  1 151 

for  aneurysm,  '245 

at  ani<le,  1165 

in  ankle-joint  disease,  401 

of  arm,  1160 

Berger's,  1163 

(ardcn's,  1107 

C'hopart's,  1165 

circular  method,  1154 

after  compound   fractures  and  dislocations, 
1151 

in  conliiruity,  1158 

in  continuity,  1158 

for  deformities,  1152 

double-flap  operation,  1156 

Dupuytren's,  at  shoulder,  1161 

at  elbow,  1160 

in  elbow-joint  disease,  403 

of  fingers,  1159 

flap  method,  1156 

of  forearm,  1160 

for  gangrene,  1152 

of  great  toe  with  its  metatarsal  bone,  1163 

Gritti's,  1167 

after  gunshot  wounds,  120 

hemorrhage  after,  1158 

Key's,  1164 

at  hip-joint,  1168 
Guthrie's,  1170 
Larrey's,  1170 
Listoii's,  1170 
Wyeth's  bloodless,  1169 

indications  for,  1151 

through  interphalangeal  joint,  1159 

through  interphalangeal  joints  of  toes,  1163 

interseapulo-thoracic,  1 163 

above  knee,  1167 

at  knee-joint,  1166 

for  knee-joint  disease,  400 

Larrev's,  at  shoulder,  1161 

of  leg!  1166 
Lisfranc's,  1164 

of  little    finger   with    its   metacarpal    bone, 
1159 

of  little  toe  with  its  metatarsal  lx)ne,  1163 

for  malii;nant  tumors,  1152 

at  medio-tarsal  joint,  1165 

at  metacarpophalangeal  joint,  1159 
at  metacarpus,  1159 


Am|tutation  at  metatarso-phalangeal  joini,  1163 

through  metatarsus,  llti4 

mixed  method,  1 157 

mortidity  after,  1158 

f)f  jienis,  9(»4 

tiirough  a  |)halanx,  1159 

PirogoH's,  1165 

Sedillot's,  1166 

above  shoulder,  1162 

at  shoulder,  1 161 

single-flap  operation,  1156 

special  forms  of,  1159 

Stephen  .Smith's,  1166 

iSyme's,  1165 

through  tarso-metatarsal  joint,  1164 

for  tetanus,  1152 

of  thigh,  1167 

of  thumb,  1159 

of  toes,  1 1 63 

through  the  trochanters,  1167 

of  entire  upper  extremity,  1163 

after  wounds,  lacerated  and  contused,  1152 

at  wrist,  1160 
Amussat's  operation  (colostomy),  732 
Anaerobic  bacteria,  2 
Anastomosis,  intestinal,  736 

without  rings,  741 
Anatomical  tubercle,  77 

Anderson's  method  of  tendon-lengthening,  335 
Anel's  operation  in  aneurvsm,  242 
Anesthesia,  1071,  1092 

areas  of,  369 

in  deformities  of  chest,  1073 

local,  1100 
Anesthetic,  choice  of,  1100 
Anesthetics,   accidents   during    administration 
of,   1099 

history  of,  1092 

mortal itv  from,  1099 
Anestile,  I'lOl 
Aneurysm,  229 

acupuncture  in,  245 

amputation  for.  245 

Anel's  operation  for.  242 

Antyllus's  operation  for,  242 

arterio-venous,  248 

axillary,  250 

brachial,  251 

Brasdor's  ()j)eration  for,  243 

carotid,  249 

causes  of,  234 

circumscribed  false  sacculated,  2:!2 

cirsoid,  233,  503 

coagulating  injections  in,  245 

component  parts  of,  232 

compression  in,  239 

advantages  over  ligation,  244 

diagnosis  of,  237 

diffuse  false  sacculated,  232 

digital  pressure  for,  241 

dissecting,  232 

duration  ol",  23S 

Esmarch's  iiandage  in,  241 

extirpation  of,  245 

false  sacculated,  232 

femoral,  251 

flexion  of  joint  in,  241 

foreign  bodies  introduced  into  sac  in,  244 

fusiform,  231,  238 

galvano-puncture  in,  245 


INDEX. 


1199 


Aneiirvsni,  Hiintoriiin  operation  for.  'l\'-\ 

idiopathic,  'I'M 

iliai-.  li.")! 

instniiDoiital  coinpri'ssinn  in,  21U 

Macfwi-n's  method  in,  'J-lfJ 

nianipiilation  in,  24-'> 

lUH'.ile,  1114 

popliteal,  'J-")l 

pressure  upon  orj^ans  by,  2;'.4 

sacoMJated,  'IWl 

.septicemia  and  pyemia  in,    'I'.W 

sifjns  and  symjitonis  ot'.  "io-j 

spiiy>,Mno<rrapiiic  judse-tracings  in,  23() 

spontaneous  cnre  of,  233 

subclavian,  ^l^^i) 

traumatic,  24() 

treatment  of,  238 

true  sacculated,  232 

tubulated,  231 

varicose,  248 

Wardrop's  operation  for,  244 
.\neurysinal  hernia,  232 

sac,  contractility  of,  240 

varix,  247 
Angioleucitis.     See  Lymphangitis,  466 
Angioniata,  202 

cavernous,  228 

of  nose,  607 

plexiform,  228 
Angular  gyrus,  497 
Ankle,  amputations  at,   1165 

excision  of,  1148 
Ankle-joint  disease,  400 

osteoplastic  resection  in,  401,  1150 
Wladiinirofi'-Mikulicz  operation  for,  401, 
1150 

tuberculosis  of,  400 
Ankylosis,  418 

in  liii) -joint  disease,  395 

of  jaw,  686 

Esmarch's  operation  for,  686 

after  knee-joint  disease,  400 

l)artial,  419 
Anthrax,  83,  128 

bacillus  of,  10 

carbuncle,  129 

cedenia,  129 
Antisepsis,  1076 
Antiseptic  method,  1077 

wax,  Horsleys,  1154 
Antiseptics,  1077 
Antrum,  abscess  of,  610 

of  High  more,  610 

tumors  of,  611 
Antyllus,  method  of,  in  aneurysm,  242 
Anuria,  841 
Anus,  artificial,  734 

fissure  of,  49,  800 

imperforate,  790 

])rolapse  of,  797 

pruritus  of,  799 
Aorta,  abdominal,  ligation  of,  1123 
Aphasia,  497 

amnesic,  546 

sensory,  546 
Apophysis,  separation  of,  283 
Apoplexy,  differential  diagnosis  of,  513 
Appendicitis,  759 

bacterial  causes  of,  761 

bacterium  coli  commune  in,  701 


Appendicitis,  catarrhal,  7f'il 
ciironic  relapsing,  768 
iliagnosis  of,  764 
etiology  of,  760 
exciting  causes  of,  760 
fecal  concretions  in,  761 
foreign  bodies  in,  761 
McBurney's  j)lan  of  incising  abdominal  wall 

in,  766 
micro-organisms  in,  761 
olijiterans,  768 
pathology  of,  762 
surgical  treatment  of,  766 
symptoms  of,  763 
Appendix  vermiformis,  anatomy  of,  760 

inflannnation  of,  759 
Apraxia,  49.S,  546 
Arachnitis,  530 
Ardor  urinaj,  897 
Argyll-Robertson  puiiil,  535,  note. 
Arm,  amputation  of,  1160 
bandages  for,  1177 
cerebral  center  for,  497 
Arms,  artificial,  1171 
Arrow-wounds,  121 
Arterial  varix,  230,  503 
Arteries,  atheroma  of,  229 
calcification  of,  229 
contusecL  wounds  of,  257 
gunshot  wounds  of,  257 
healing  of,  33 
incised  wounds  of,  257 
inflammation  of,  228 
lacerated  wounds  of,  257 
ligation  of,  1113 

for  hemorrhage,  254,  255 
punctured  wounds  of,  257 
rupture  of  coats  of,  258 
special,  ligation  of,  1115 
torsion  of,  for  hemorrhage,  255 
wounds  of,  257 
Arteritis,  228 

Artery,    axillary,    collateral    circulation    after 
ligation  of,  1121 
ligation  of,  1121  « 

wounds  of,  260 
brachial,  collateral  circulation  after  ligation 
of,  1122 
ligation  of,  1121 
carotid,  collateral   circulation  after  ligation 
of,  1116 
common,  ligation  of.  1115 
external,  ligation  of,  1117 
internal,  ligation  of,  1117 
wounds  of,  260 
of  cerebral  hemorrhage,  514 
circmnflex  ilii,  ligation  of,  1127 
dorsalis  pedis,  ligation  of,  1131 
epigastric,  deep,  ligation  of,  1127 
facial,  ligation  of,  1118 

femoral,  collateral  circulation  after  ligation 
of,   1129 
ligation  of,  1128 
wounds  of,  261 
gluteal,  ligation  of,  1125 
iliac,  conunon,  ligation  of,  1124' 

external,  collateral  circulation  after  liga- 
tion of,  1127 
ligation  of,  1126 
internal,  ligation  of,  1125 


12(J0 


jyOEX. 


Artery,  innnininate,  litjalion  of,  1I1"> 

inter^<>^ital,  lieiiic>rilia;,'u  from,  2(jl 
ii^ntioii  of,  1 1-."> 

internal  niaimnarv,  lieiuorrliage  from,  2fil 
ligation  of,  I'VIO 

lingual,  ligation  of,  lllS 

niiiiille  meningeal,  hemorrhage  from,  'A\ 
ligation  of,  51G 

peroneal,  ligation  of,  1130 

p0|>liteal,  ligation  of,  WIS} 
\vi. mills  of,  2(31 

pudic,  internal,  ligation  of,  112(5 

radial,  collateral  circulation  after  ligation, 
of,  1122 
ligation  of,  1 122 

rupture  of  in  fracture.  292 

sciatic,  ligation  of,  112(5 

subclavian,  collateral  circulation  after  liL'a- 
tion  of,  1120 
ligiitiou  of.  1119 
woimds  of,  26(J 

temporal,  ligation  of,  1119 

terminal,  59 

thyroid,  inferior,  ligation  of,  1120 
superior,  ligation  of,  1118 

tibial,  anterior,  ligation  of,  1130 
jiosterior,  ligation  of,  1129 

ulnar,  ligation  of,  1122 

vertebral,  ligation  of,  1120 
wounds  of,  2fi0 
Arthrectomv,  1134 
Arthritis,  386,  388 

chronic  rheumatoid,  409 

deformans,  409 

deformitv  in,  389 

forms  <.f,"388 

gonorrhceal,  407 

gouty,  409 

infective,  406 

neuropathic.  413 

post-gonorrheal,  407,  903 

rheumatic,  408 

septic,  405 

of  temporo-maxillary  articulation,  685 

tubercular,  388 

urethral,  407 
Artificiid  arms,  1171 

legs.  1173 

limbs.  1171 

respiration,  1184 

forced,  in  poisoning  bv  ether  and  chloro- 
form, 10H(5 
Ascites,  1046 

tubercular.  778 
Asepsis,  1076 
Aseptic  fever,  34 

methods,  1077 
Asphyxia.  1095.  1184 
Aspiration.  1 186 

of  hip-j(jini,  397 

in  joint-tuberculosis,  388 

use  of,  in  paracentesis  thoracis,  639 
Assistants,  preparation  of  for  operation,  1077 
Asterion,  491 

Asthenic  inflammation,  18 
Astratralus.  removal  of,  355 
Atheroma,  229 
Atony  of  bladder,  858 
Atrophv  of  bone,  276 

of  breast,  1053 


Atrophy  of  muscle,  336 

Aveling's  transfusion  apparatus.  1185 

P>A<lM,i:.s,   1 

of  anthrax,  lo,  128 
of  glanders,  9,  135 
of  malignant  odema,  9,  125 
mallei,  9,  135 
of  noma,  9 
of  jKscudo-iidema,  9 
pvocvaneus,  7 
of  syphilis,  9 
of  tetanus.  8,  70 
of  tubercle,  8,  74 
Hack,  injuries  of,  575 

sprains  of,  575 
I'acteria,  1 
aerobic.  2 
anaerobic,  2 
of  dental  caries,  iiN7 
efTect  of  temperature  on,  3 
facultative,  2 

number  injected  or  dose  of,  7 
obligate,  li 
pathogenic,  2 
pyogenic,  2 
saprogenic,  2 
saprophytic,  2 
Bactericidal  drugs,  4 
Balanitis,  897 

treatment  of  916 
Balano-posthitis,  S98 

treatment  of,  916 
Baldness  from  syphilis,  157 
Ball's  operation  for  radical  cure  of  hernia.  8l4 
Bandage,  Barton'.s,  1178 
circular,  1176 

crossed,  of  angle  of  jaw,  1179 
demi-gauntlet,  1177 
Desault's,  1 199 
double  T  of  perineum,  1180 
figure-of-8,  1176,  117s,  1179 

of  ankle,  1179 

of  elbow,  1179 

of  both  eyes,  1178 

of  the  jaw,  1178 

of  neck  and  axilla,  1179 

of  pelvis  and  thigh,  1179 

of  shoulders,  1179 
four-tailed,  1181 
fronto-occipital  triangle,  1181 
fronto-occipito-labial  cravat,  1181 
Gibson's,  1178 
handkerchief.  1181 
oblique,  of  ant;le  of  jaw,  1179 
recurrent,  of  head,  ll80 

of  stump,  1180 
spica,  1176 

of  groin,  1 179 

of  instep,  1178 

of  shftulder,  1179 

of  thumb.  1 177 
spiral,  1176 

of  fingers,  1177 

reversed,  1176 

of  lower  extremity,  1177 
of  upper  extremitv,  1177 

T,  1180 

\'elpeau's.  1 179 
Bandages,  1176 


INDEX. 


12U1 


Barker's  operation  for  fractured  patella,  328 
for  radical  cure  of  hernia,  81,") 
for  transverse  fracture  of  patella,  328 
Bartholin's  j;land,  inHainniation  of,  969 

retention-cyst  of,  971 
Barton's  dressing,  319 
Basedow's  disease,  062 
Basion,  491 

Bassini's  operation  for  radical  cure  of  femoral 
hernia,  SIT 
of  inguinal  hernia,  815 
Baths,  hot,  proloni^ed,  1190 
Baiun's  method  of  stretching  facial  nerves,  383 
Bed  after  operation,  1088 
Bed-rests,  1090 
Bedsores,  48,  54 
Bee-stings,  126 
Bellocq's  canula,  602 
Berger's  amputation,  1163 
Bichat,  fissure  of,  491 

Bichloride  of  mercury  as  an  antiseptic,  1077 
Bigelow's  evacuator,  878 

operation   (lithola[)axy),  876 
Bilharzia  luvniatobia,  854 
Biliary  calculus,  obstruction  from,  749 
Bites  of  lips,  668 

and  stings  of  insects  and  reptiles,  126 
Bladder,  absence  of,  851 

atony  of,  858 

attention  to,  after  an  operation,  1089 

congenital  deformities  of,  851 

diseases  and  injuries  of,  851 

exstrophy  of,  851 

fibromata  of,  886 

fibro-myxomata  of,  886 

hernia  of,  851 

inflammation  of,  883 

injuries  of,  856 

papillomata  of,  886 

rupture  of,  857 

stone  in,  860 

tumors  of,  885 

wounds  of,  856 
Bladders,  supernumerary,  851 
Blennorrhagia.     See  Gonorrhea,  895 
Blennorrhagics,  912 
Blisters,  1182 
Blood,  changes  of,  in  inflammation,  12 

extravasation  of,  in  inflammation.  12 

poisoning.     See  Septicemia  and  Pyemia. 

transfusion  of,  1185 
Blood-plaques,  14 
Blood-vessels,  changes  of,  in  inflammation,  11 

diseases  of,  224 

wounds  of,  260 
Bloodless  tissues,  regeneration  in,  30 
Bloodletting,  1183 
Bodies,  foreign,     i^ee  Foreign  bodies. 

loose,  in  joints,  421 
Boil,  476 

Boiling  water,  effect  of,  on  bacteria,  4 
Bonds  splint,  319 
Bone,  abscess  of,  chronic,  275 

atrophy  of,  276 

chips,  decalcified,  1112 

chondromata  of,  279 

fibromata  of,  278 

fissure  of,  283 

inflammations  of,  chronic,  271 
septic,  266 

76 


Bone,  overgrowth  of,  275 

regeneration  of,  31 

replacement  of,  after  trepiiining,  501 

sarcomata  of,  280 

Senn's  decalcified  plates,  736,  737 

separation  of  splinter  of,  283 

tul)ercn]osis  of,  79,  272 

tumors  of,  277 
malignant,  280 
Bone-grafting,  1112 
Bones  and  joints,  operations  on,  1132 

jdastic  operations  on,  1112 

syphilis  of,  167,  184,  277 
Bonnet's  wire  cuirass,  396 
Bony  tumors,  200 
Bougies  a  bnnlr,  928 

filiform  whalebone,  893 

oesophageal,  697 
Bowel.     See  Intestine. 
Bow-legs,  352 

Brachial  plexus,  exposure  of,  384 
Brain,  abscess  of,  533 
treatment  of,  536 

compression  of,  512 

concussion  of,  510 

diseases  from  ear  disease,  537 

electrode,  501 

faradization   of,  for  recognizing  motor  cen- 
ters, 500 

foreign  bodies  in,  528 

gunshot  wounds  of,  525 

removal  of  the  ball  in,  526 

laceration  of,  510 

limits  of  operative  procedure  on,  502 

and  membranes,  traumatic  inflammation  of, 
530 

motor  areas  of,  497 

punctured  wounds  of,  521 

secondary  operations  on,  502 

topography  of,  491 

treatment  of,  after  operation,  501 

tumors,  544 

diagnosis  of,  from  abscess,  547 
differential  diagnosis  of,  535 
prognosis  of,  548 
symptoms  of,  545 
treatment  of,  550 

wounds  of,  524 
Branchial  arches,  664 

clefts,  G51,  664 

cvsts,  651 

folds  and  clefts,  651,  664 
Breast,  abscess  of,  chronic,  1055 

adeno-cystoma  of,  1059 

adeno-fibroma  of,  1058 

adenoma  of,  1058 

adeno-sarcoma  of,  1059 

amputation  of,  1065 

atrophy  of,  1053 

cancer  of,  1061 

carcinoma  of,  1061 
encephaloid,  1061 
scirrhous,  1062 

atrophic  or  withering,  1063 
soft,  1064 

chancre  of,  148 

congenital  malformations  of,  1050 

contusions  of,  1069 

cvsto-sarcoma  of,  1061 

cysts  of,  1068 


1202 


INDEX. 


Bre.i.^t,  diseases  of,  1052 

diseases  and  injuries  of,  1049 

livpertrophy  of,  1053 

inHaiiiiiiation  of,  1053 

niak',  diseaises  of,  1070 
iiillaiiiiiiation  of,  1070 
tumors  of,  1070 

neurotic  conditions  of,  1052 

sarcoma  of,  1060 

surgical  anatomy  of,  1049 

syphilis  of,  1057 

tuberculosis  of,  1057 

tumors  of,  1057 

wounds  of,  1069 
Bregma,  491 

Bridle  (linear)  stricture,  926 
Broad  ligament,  hematoiua  of,  1033 
surgerv  of,  1032 
tumors  of.  1048 
Broca,  points  of  skull  named  by,  491 
Broca's  center  for  speech,  497 
Brodie's  abscess,  47,  275 
Brokaw's  rings,  737 
Bronchial  tubes,  foreign  bodies  in,  625 
Bronchocele,  660 
Bronchotomy,  627 
Browne's,  Buckston,  tampon,  872 
Brush  burn.  112 
Bryant's  triangle,  323 
Bubo,  gonorrheal,  900 
in  female,  920 
treatment  of,  917 

syphilitic,  ditlerential  diagnosis  of,  156 
Buboes,  chancroidal,  156 

syphilitic,  155 
Bubonic  plague,  83 
Buck's  extension,  296 
Bullet  probes,  117,  526 
Bunion.  345 
Burn,  brush,  112 
Burns,  477 

of  larynx  and  trachea,  627 

and  scalds,  deformities  from,  670 
Burs.-e,  aflections  of,  343 
Bursitis,  344 
Button  suture,  1085 

Cachexia,  cancerous,  210 

strumipriva,  662 
Cadaverin,  2 
Caxal  hernia,  817 
Calcification  of  artery,  229 
Calculus,  biliary,  obstruction  from,  749 
of  prostate,  948 
renal,  838 
salivary,  658,  675 
vesical,  860 

in  children,  operations  for,  879 

failure  in  detection  of,  865 

in  females,  882 

operative  treatment  of,  867 

preparatory   treatment   for  operation 

868 
prophylaxis  of,  866 
size  of,  865 
sounding  for,  864 
symptoms  of,  862 
treatment  of,  st;6 
varieties  of,  861 
in  Wharton's  duct,  659 


Callosities,  480 

Callus,  external,  31,  291 

exuberant  and  painful,  292 

intermediate,  31 

internal,  31 

provisional,  31 
Cancer  of  breast,  1061 

chimney  sweeps',  960 

en  cubage,  1065 

juice,  211 

melanotic,  205 
Cancerous  cachexia,  210 

ulcers  of  skin,  488 
Cancrum  oris,  55,  671 
Caiiula,  Belloc(i's,  602 
Capillaries,  changes  of,  in  inflammation,  11 
Caput  succedaneum,  508 
Carbolic  acid  as  an  antiseptic,  1077 
Carbuncle,  46,  477 

anthrax,  129 
Carcinoma,  acinous  or  spheroidal-celled,  211 

of  bre;ist,  1061 
encephaloid,  1064 

Ilalsted's  method  of  treatment,  1067 
mortality  of,  1065 
scirrhous,  1062 

retraction  of  nipple  in,  1062 
soft,  1064 

of  cervix  uteri,  1017 

diagnosis  of,  213 

encephaloid,  212 

epithelial,  213 

extension  of,  212 

hard  spheroidal-celled,  211 

of  intestine,  756 

of  jaws,  685 

of  larynx,  differential  diagnosis  of,  172 

medullary,  212 

of  pancreas,  789 

of  pharynx,  692 

of  rectum,  805 

scirrhous,  211 

of  skin,  488 

soft  spheroidal-celled,  212 

of  stomach,  716 

of  testicle.  950 

encephaloid,  differential  diagnosis  of,  173 

of  tongue,  677 

of  tonsils,  691 

treatment,  215 

of  uterus,  1017 

palliative   treatment   of    advanced    cases, 
1024 
Carcinomata,  210 
Carden's  amputation,  1189 
Carditis,  traumatic,  223 
Caries.  264 

of  bones  of  skull,  505 

dental,  686 

dry,  78,  271 

fungous,  271 

necrotic,  265 

sicca,  76,  271 
CarrKid  triangle,  inferior,  1116 

superior.  1116 
Cartilages,  floating,  421 

.semilunar,  dislocations  of,  459 
displacement  of,  422 
Cartilaginous  tumors,  199 
Caruncle  of  urethra,  971 


INDEX. 


1203 


( 'aseoiis  degeneration,  7o 
Castration,  9o'2 

for  hypertrophy  of  prostate,  944 
Catarrii,  atrophic  nasal,  59fi,  59!' 

nasal,  COO 

hypertrophic  and  atrophic,  ■"iQG 

of  lirethra,  90") 
treatment  of,  914 
Catsnt,  108-J 
Catheter  en  chemise,  870 

fever,  893 

(Joulev's  tunnelled,  893 
Catheterlsm,  889 
Catheterization,  859 
Causal}j;ia,  574 
Cautery,  actual,  1183 

galvano-,  1 188 
Cell-division,  direct,  29 

indirect,  29 
Cell-nests,  213  • 

Cells,  exudation,  27 

formative,  27 

wandering,  12 
Cellulitis  of  neck,  652 

pelvic,  1032 

phlegmonous,  67 
Center,  cerebral,  for  arm,  497 

for  elbow,  497 

for  face,  497 

for  hand,  497 

for  liearing,  498 

for  leg,  497 

for  mental  processes,  497 

for  mouth  and  larynx,  497 

for  shoulder,  497 

for  smell,  498 

for  speech,  497 

for  trunk,  497 

for  vision,  497 
Cephalhematoma,  219,  508 
Cephalic  tetanus,  71 
Cerebellar  abscess,  540 
Cerebellitis,  530 
Cerebral  abscess  from  ear  disease,  538 

center.     See  Center,  cerebral. 

hemorrhage,  artery  of,  514 

injuries,  differential  diagnosis  of,  513 

irritability,  512 

operations,  color  of  brain  in,  500 
opening  of  dura  in,  500 
technique  of,  498 

syphilis,  170 
Cerebritis,  530 
Cerebro-spinal   fluid  from  ear  in  fractures 

base  of  skull,  522 
Cervical  plexus,  exposure  of,  384 
Cervix  uteri,  carcinoma  of,  1017 
treatment  of,  1019 
hypertrophy  of,  982 
lacerations  of,  983 
Cesarean  section,  985 
Chalk-stones,  409 
Chancre,  142 

of  breast,  148 

diagnosis  of,  145 

diflerential  diagnosis  of,  148 

extra-genital,  144 

of  hairy  scalp,  146 

of  hands,  147 

hard  or  Hunterian,  142 


of 


("hancre,  laliial,  differential  diagnosis  of,  146 

prognosis  of,  151 

soft  (jr  chancroid,  154 

subpreputial,  diflerential  diagnosis  of,  150 

of  tongue,  147 

of  tonsil,  147 

treatment  of,  151 

uretiual,  diflerential  diagnosis  of,  150 
(  haiicroid,  154 

treatment  of,  155 
Chapped  lips,  668 
Charbon,  128 
Charcot's  disease,  413 

Cheeks  and  lips,  malformations  and  deformi- 
ties of,  664 
Cheese-cloth  for  dressings,  1082 
Cheiloplasty,  ()70 
Chetuotaxis,  13 
Chest,  contusions  of,  (546 

injuries  and  diseases  of,  637 

injuries,  complication  of,  648 
sequelae  of,  648 

non-penetrating  wounds  of,  647 

penetrating  wounds  of,  647 
hemorrhage  in,  647 

wounds  of,  647 
Chiene's  method  for  fixing  Bolandic  fissure, 

492 
Chilblain,  480 

Chimney-sweeps'  cancer,  960 
Chloride-of-ethyl  spray,  1101 
Chloroform,  1094 

and  ether,  rules  for  giving,  1098 

poisoning  from,  1096 
Cholecystectomy,  785 
Cholecyst-enterostomy,  787 
Cholecystotomy,  786 
Choledochotomy,  788 
Chondritis,  618 
Chondroma  of  bone,  279 
Chondromata,  199 
Chopart's  amputation,  1165 
Chordee,  897 

treatment  of,  909 
Chylocele,  470  , 
Chyluria,  470 
Cicatrices  of  neck,  653 

tumors  of,  484 
Circulation,  collateral.     See  Arlei-y. 
Circumcision,  962 

Clamp  and  cautery  for  internal  piles,  796 
Clap  (gonorrhea),  895 
Clavus,  481 
Claw-hand,  339,  372 
Cleft  palate,  664,  692 

production  of,  664 
Clement's  operation  for  hare-lip,  666 
Cloaca,  269 
Club-foot,  353 

hysterical,  357 

shoes,  355 
Club-hand,  349 
Coagulation-necrosis,  19 
Cocaine  hydrochlorate,  dangers  of,  1101 

as  a  local  anesthetic,  1101 
Coeliotomy,  734 
Cold  abscess,  cocci  in,  7 

constitutional  effects  of,  480 

sores,  668 

in  synovitis,  387 


1204 


INDEX. 


Colli,  use  of,  1190 

Collateral  circulation.     See  Artery. 

Colics' y  law  in  syphilis,  178 

Collodion,  1190" 

Colon,  distention  of,  with  fluids,  730 

Colostomy,  732 

iliac  or  inguinal,  732,  733,  734 
Colotoniy,  732 
Columnar  epitheliomata,  seats  of  predilection 

of.  215 
Coma,  diagnosis  of  forms  of,  513 
Come<lo,  475 

Complications  after  operation,  1091 
Compound  fractures.     See  Fractures. 
Compresses,  1175 
Compression  of  abdomen,  731 

for  aneurysm,  239 
advantages  of,  over  ligation,  244 

of  brain,  512 

of  spinal  cord,  578 
Concretions  of  tonsils,  690 
Concussion  of  brain,  510 

of  spinal  cord,  577 
Conditions  to  which  neurectasy  is  applicable, 

379 
Condylomata,  208 

syphilitic,  183 
Coiidy's  fluid,  682 
Congenital  defects  of  diaphragm,  649 

deformities  of  bladder,  851 
of  jaws,  682 
of  palate,  692 
of  testicles,  949 

fistulic  of  neck,  652 

malformation  of  breast,  1050 
of  pharynx,  689 
of  rectum,  790 

sacral  tumor,  561 
Congestion  in  inflammation,  13 
Constant  current.  1188 
Contractures,  347 

from  burns  and  scalds,  347,  479 

of  muscle,  335 
Contre-coup,  fractures  by,  489 

injuries  of  brain  by,  510        ^ 
Contusions,  87 

of  breast,  1069 

of  chest,  646 

and  compression  of  nerves,  366 

of  head,  510 

of  intestines,  728 

involving  thoracic  viscera,  646 

of  larynx,  624 

of  neck,  653 

of  parotid  gland,  657 

of  spinal  cord,  577 

of  stomach,  7ll 
Cooper,  mesenteric  hernia  of,  834 
Corn,  481 

Cornu  cutaneum,  482 
Corpuscle,  the  third,  14 

Corpuscles,  white,  numerical  increase  of,  in  in- 
flammation, 14 
Coryza,  acute,  591 

syphilitic,  182 
Cotton,  absorbent,  1175 
Cowperitis,  900 

treatment  of,  917 
(!owper's  glands,  inflammation  of,  900 
Cracked  lips,  668 


Cracked-pot  sound  in  fissured  fracture  of  skull 

and  hydrocephalus,  519 
Craniotabes,  86 
Crepitus,  290 
Cripp's  splint,  298 
Croupous  inflammation,  19 
Crusta  phlogistica,  14 
C'ryptorchidism,  949 
Cuneus,  497 
Cupping,  dry,  1183 

wet,  1 183 
Curettage  of  endometriun),  989 
Curvature  of  spine,  angular,  567 
anterior,  566 
lateral,  563 
posterior,  565 
Cut  throat,  624 
Cynanche  tonsillaris,  689 
Cvrtometer,  Horslev's,  494 

■  Wilson's,  494 
Cystic  dilatation  of  Stenson's  duct,  658 

testicle,  951 
Cystitis,  883,  901 

treatment  of,  884,  917 
Cystocele,  811,851,972,  981 
Cystomata,  217,  1039 
Cystoscope,  Leiter's,  886 
Cystotomy,  perineal,  868 

suprapubic,  873 
Cysts,  atheromatous,  217 
'blood-,  219 

branchial,  651 

of  breast,  1068 

compound  proliferous,  219 

congenital,  219 

dermoid,  219,  560,  789,  971,  1041 

extravasation,  218 

exudation,  217 

of  gland  of  Bartholin,  971 

hydatid,  220 

intrathoracic,  645 

of  jaw,  dentigerous,  684 
lower,  684 
multilocular,  684 

of  kidnev,  847 
hydatid,  848 

of  lip,  669 

of  liver,  780,  782 

of  mesentery,  780 

mucous,  218 

of  neck,  651 

of  new  formation,  218 

of  omentum,  779 

ovarian,  1042 

of  ovary,  1042 
dermoid,  1041 

of  pancreas,  788 

papillomatous,  within  oophoron,  1042 

parasitic,  220 

paroophoritic,  1041 

parovarian,  1042 

proliferous  mammary,  1059 

retention,  217 

sebaceous,  217,  475 

simple  or  serous,  218 

of  spine,  dermoid,  560 

of  spleen,  789 

sublingual,  675 

of  submaxillary  gland,  659 

of  vulva,  dermoid,  971 


INDEX. 


1205 


Cysts  of  vulva,  sebaceous,  971 
Czeriiy-Lenibert  suture,  709,  745 
Czerny's  method  of  tendon  suture,  343 

Dactylitis,  syphilitic,  170,  186 
Death,  causes  of,  after  operation,  1091 
Decubitus,  48,  54 
Deformities,  amputation  for,  1152 

(if  chest,  anesthesia  in,  1073 

congenital,  351,  G51,  682,  692,  851,  949 

of  jaws,  684 

of  nose,  589 

of  palate,  692 

of  spine,  558 
Deformity  in  arthritis,  389 

in  fractures,  28!) 

silver-fork,  318 
Degeneration,  reactions  of,  359 
Delirium  nervosum,  37 

traumatic,  37 

tremens,  38,  293 
after  fracture,  293 
Demarcation,  line  of,  53 
Dental  caries,  686 

periostitis,  686 
Dentigerous  cysts  of  jaw,  684 
Dermatitis  venenata,  475 
Dermoid  cysts.     See  CijMs,  dei-moid. 
Desault's  bandage,  1179 
Development,  arrested,  trephining  for,  556 
Diapedesis  of  leucocytes,  12 
Diaphragm,  congenital  defects  of,  649 

hernia  of.     See  Hernia. 

paralysis  of,  649 

rupture  of,  650 

surgical  affections  of,  649 

wounds  of,  650 
Didot's  operation  for  webbed  fingers,  350 
Digestive  tract,  surgery  of,  664 
Dilatation  of  stomach,  715,  716 

of  urethra,  928 
Diplococci,  1 

Disease,  relation  of,  to  operation,  1074 
Disinfection  of  field  of  operation,  1076 

of  hands,  1078 

of  instruments,  1079 
Dislocations,   accidents    during    reduction 
429 

after-treatment  of,  430 

of  astragalus,  461 

attitude  of  limb  in,  426 

bilateral,  423 

of  carpal  bones,  449 

carpo-metacarpal,  449 

causes  of,  424 

of  clavicle,  433 

of  coccyx,  451 

complicated,  423 

complications  of,  312,  425 

congenital,  423,  430 

of  costal  cartilages,  433 

deformity  in,  426 

double,  423 

of  elbow,  443 

etiology  of,  424 

of  femur,  451 

of  fibula,  460 

of  foot,  461 

habitual,  443 

of  hip,  451 


of. 


Dislocations  of  hi|>,  complications  of,  45(1 
compouixl,  456 

congenital,  430 
after  typhoid,  452 

fractures  in  reduction  of,  456 

pathological,  457 

unreduced,  treatment  of,  457 
of  humerus,  436 

with  fracture,  442 

McBurney's  method  of  treatment,  442 

habitual,  443 
incomplete,  423 
of  lower  jaw,  432 
of  knee,  458 

of  laryngeal  cartilages,  625 
measurements  in,  427 
mechanism  of,  424 
methods  of  reduction  of,  428 
mobility  in,  427 
by  muscular  action,  424 
nomenclature  of,  423 
old,  reduction  of,  429 
partial,  423 
of  patella,  459 
pathological,  423 
pathology  of  recent,  425 
of  pelvis,  451 

predisposing  causes  of,  424 
of  radio-ulnar  joint,  lower,  448 
of  radius  above,  447 

by  elongation,  448 

and  ulna,  divergent,  447 
reduction  of,  by  manipulation,  428 
repair  after,  425 
of  ribs,  433 

of  semilunar  cartilages,  459 
shortening  in,  427 
of  shoulder,  436 

complications  of,  441 

compound,  441 

fractures  with,  441 

luxatio  erecta,  440 

old,  unreduced,  treatment  of,  443 

reduction  of,  by  Kocher's  method,  438 

treatment  of,  438 

vascular  and  nerve  injuries  in,  442 
of  spine,  587 
spontaneous,  423,  431 

in  fevers,  431 
of  sternum,  432 
subastragaloid,  461 
symptoms  of,  426 
of  tarsus  and  metatarsus,  462 
of  thumb  and  fingers,  449 
traumatic,  423 
treatment  of,  427 
of  ulna  alone,  447 
unreduced,  426 
of  vertebrie,  587 
of  wrist,  448 
Dissection  wounds,  123 
Diverticula  of  pharynx,  689 
Double  inclined  plane,  296 
Douche,  alternate,  hot  and  cold,  1190 
Drainage,  102, 1083 

of  abdominal  cavity,  710 
Dressing,  plaster-of- Paris,  1181 
silicate-of-soda,  1181 
wounds,  dry  method  of,  1087 
Dressings,  103,  1082 


1206 


INDEX. 


Dressings,  changes  of,  103,  1090 
Hxed, 1181 
renewal  of,  1092 
Dry  cold,  1190 
heat.  11S9 

method  of  dressing  wounds,  1087 
of  Landerer,  1083 
Dugas'  sign,  437 

Dupuvtren's     amputation     at    shoulder-joint, 
1161 
contraction  of  fingers,  348 
splint,  332 
I)ural  separator,  Horsley's,  499 
Dura  mater,  fungus  of,  50G 

loss  of,  tilled  in  by  pericranium,  502 
opening  of,  in  cerebral  operations,  499 
Dysesthesia,  regions  of,  369 

£ab,  cerebro-spinal  fluid  from,  in  fracture  of, 
base  of  skull,  522 

disease  causing  meningitis,  538 
cerebral  abscess  from,  538 

suppurative  disease  of,   causing  brain  dis- 
ease, 537 

syphilis  of,  184 
Ecchvmosis,  87 

Echinococci,  220,  781,  848,  1068 
Ecthyma,  syphilitic,  161 
Effusions,  pleuritic,  637 
Elbow,  cerebral  center  for,  497 
Elbow-joint  disease,  402 

tuberculosis  of  402 
Election,  triangle  of,  1115 
Electric  injuries,  122 
Electricity,  1188 
Electrode,  double,  for  brain,  501 
Electrolysis,  1188 

in  uterine  fibro-myomata,  1006 
Elephantiasis  arabum,  472 

of  scrotum,  960 

of  vulva,  972 
Elytrorrhaphy,  981 
Embolism,  58,  292 

fat,  96,  292 
Embolus,  58 
Embryonic  tissue,  26 
Emphysema,  647,  648 

of  neck,  655 

surgical,  of  nose,  612 
Empyema,  47,  638 

of  frontal  sinus,  609 

idiopathic  forms  of,  638 

surgical  treatment  of,  638 

traumatic,  638 
Encephalitis,  530 

operative  interference  in,  531 
Encephalocele,  506 
Encephaloid  carcinoma,  212 

of  breast,  1064 
Enchondroma  of  jaws,  684 

of  nose,  608 

of  testicle,  951 
Enchondromata,  199 
Endarteritis,  228 

Endocanalicular  mammary  tumor,  1059 
Endometritis,  987 
Endometrium,  curettage  of,  989 
Endotheliomata,  208 
Enterectomy,  709,  744 

in  wounds  of  abdomen,  709 


Enterocele,  811 

I)artial,  821 
Entero-epiplocele,  811 
Entero-llthiasis,  749 
Enterorrhai)liy,  744 
Enterostomy,  731 
Enterotomy,  732 
Epiblastic  tumors,  210 
Epidermic  pearls,  213 
Epidermis,  regeneration  of,  30 
Epididymitis,  902,  949 

treatment  of,  919 
Epilepsy,  550 

focal,  554 

general,  555 

Jacksonian,  552 

non-traumatic,  552 

removal  of  cortical  center  in,  551 

traumatic,  550 

trephining  for,  551,  553,  554 
Epiphysis  of  femur,  separation  of,  325 

lower,  of  humerus,  separation  of,  315 

separation  of,  284,  311,  315,  325 

upper,  of  humerus,  separation  of,  311 
Epiphysitis,  267 

acute,  267 
Epiplocele,  811 
Epispadias,  962 
Epistaxis,  601 

Epithelial  carcinomata,  213 
Epithelioma,  213,  487 

columnar,  215 

columnar-celled,  215 

of  jaws,  685 

of  lip,  214,  668 

of  penis,  963 

of  scrotum,  960 

of  skull,  506 

squamous-celled,  213 

of  tongue,  166,  677 
Epulis,  683 
Equinia,  135 
Erasion,  1133 

in  ankle-joint  disease,  401 

in  elbow-joint  disease,  403 

of  joint,  391 

for  knee-joint  disease,  400 

in  wrist-joint  disease,  403 
Erectile  tumors,  202 
Erethistic  granulations,  28 
Ergot  in  uterine  fibro-myomata,  1005 
Erysipelas,  66 

curative  influence  of,  69 

facial,  68 

of  mucous  membranes,  68 

neonatorum,  68 

phlegmonous,  68 

streptococcus  of,  7,  66 

after  wounds,  107 
Erysipeloid,  467 
Erythema,  syphilitic,  158 
Esmarcli's  apparatus,  1153 

bandage  in  aneurysm,  241 

operation  for  ankylosis  of  jaw,  686 

powder,  1065 
Esthiomene,  970 
Estlander's  operation,  47,  641 
Ether,  1092 

administration  of,  1093 

and  chloroform,  rules  for  giving,  1098 


INDEX. 


1207 


Ether,  contraindication  to  use  of,  as  an  anes- 
thetic, 1093 

poisoning  iVoni,  1096 

voniitinf,',  10S9 
J:thnioi<l.ii  ceils,  f)09 
Ethvl  cliloride,  1101 
Eucaine,  1103 
Evacuation  of  sti>inach,  730 
Evacuator  of  Higelow,  S78 
Examination  of  patient  before  operation,  1073 
Excision.     See  Iit;gection,  1142 
Excurvation  of  spine,  563,  565 
Exostoses,  277,  505 

of  nose,  607 
Exploratory  puncture,  969 
Exstr()f)l>y  of  bladder,  851 
Extension  apparatus,  296 
Extravasation  of  urine,  935 
Exudation  cells,  27 

Eace,  cerebral  center  for,  497 
Facies  ovariana,  1044 
Facultative  bacteria,  2 
Fallopian  tube,  fibro -rayomata  of,  1048 
inliainmation  of,  1025 
papilloniata  of,  1048 
surgerv  of,  1025 
tumors  of,  1029. 
malignant,  1048 
False  passages,  892,  934 
Faradic  electricity,  1188 
Faradization  of   brain,   in   recognizing  motor 

centers,  500 
Farcy,  135 
Fat  embolism,  296 
Fatty  tumors,  198 
of  scalp,  503 
Faucial  tonsils,  598 
Fecal  fistula,  770 

impaction,  750,  800 

obstruction,  750 
Feces,  rectal  impaction  of,  800 
Felon,  47,  340 
Femoral  canal,  828 

hernia.     See  Hernia,  femoral. 

ring,  828 
Femur,  osteotomy  through  neck  of,  1138 
through  shaft  of,  1138 

separation  of  epiphysis  of,  325 
Fever,  aseptic,  34 

blisters,  668 

catheter,  893 

hectic,  36 

secondary,  36 

septic,  35 

suppurative,  34-36 

surgical,  34 
scarlet,  37 

traumatic,  35 

malignant  group  of,  34 

urethral,  37,  893 

urinary,  893 
Fevers,  spontaneous  dislocations  in,  431 
Fibrinous  inflammation,  18 
Fibroblasts,  30 
Fibroma  of  bladder,  886 

of  bone,  278 

of  jaws,  684 

of  "uterus,  1003 
Fibromata,  197 


Fil)ro-myomata,  uterine,  1003 
electrolysis  in,  1006 
ergot  in,  1005 

extirpation   through    abdominal    incision, 
1007 
through  vagina,  1000 
removal  l)y  f)i)('ratiou,   1006 

of  uterine  appendages  for,  1006 
sul)mucous,  1003 
sul)serous,  1003 
treatment  of,  1005 
Fibro-myxomata  of  bladder,  886 
Fibrous  tumors,  197 
Field  of  operation,  disinfection  of,  1076 
Filaria  sanguinis  hominis,  471 
Filiform  wliaiel)oue  Itougies,  893 
Fingers,  Dupuvtren's  contraction  of,  348 

webbed,  349 
First  intention,  liealing  by,  25 
Fissure  of  anus,  49,  800 
of  Bichat,  491 
of  bone,  283 

of  cheek,  congenital,  665 
intraparietal,  497 
median,  491 

of  lower  lip,  670 
of  nose,  590 
ofEolando,  491 

Chiene's  method  of  fixing,  492 
of  Sylvius,  496 
Fistula,  51,  801 
in  ano,  801 

and  phthisis,  803 
tubercular,  78 
blind,  802 
complete,  802 
of  neck,  652 
fecal,_  770 
gastric,  718 
incomplete,  802 
milk,  1055 
of  neck,  652 
of  parotid  gland,  657 
of  pharynx,  689 
recto-urethral,  804 
recto-vaginal,  804,  980 
recto-vesical,  803 
salivary,  657 
of  Stenson's  duct,  657 
ureteral,  850,  1023 
urethral,  936 
vesico-vaginal,  977 
Fixed  dressings,  1181 
Flail-joint  after  excision  of  head  of  humerus, 

402 
Flat-foot,  357 

Flexion  of  joint  in  aneurysm,  241 
Floating  cartilages,  421 
kidnev,  836 
liver,  784 
Fluhrer's  aluminium  probe,  526 
Focal  epilepsy,  554 
Foetal  tumors,  561 
Follicular  abscess,  899 
treatment  of,  917 
Fomentations,  antiseptic,  1190 
Food  and  drink  after  an  operation,  1089 
Foot,  perforating  ulcer  of,  486 
Foot-drop,  374 
Forcible  correction  in  Pott's  disease,  575 


1208 


INDEX. 


Foreign  bodies  in  air-paRsages,  625 

in  brain.  o'iS 

in  frontiil  sinuses,  G09 

in  nose,  fiOS 

in  cesopliagns,  69S 

in  j)eritoneuni,  773 

in  rectum,  799 

in  stomach,  713 

of  tongue,  674 

in  vagina,  981 
I'^ormaldehyde  sterilization,  1080 
Formative  cells,  27 
Fossa  iiaviiMilaris,  stricture  of,  932 
Fracture  or  Fractures,  282 
of  acetabulum,  321 
of  acromion  process,  309 
ambulant  treatment  of,  296 
of  astragalus,  333 
of  atlas  and  axis,  583 
Barton  s,  320 
box,  294 

of  calcaneum,  333 
of  clavicle,  30G 
of  coccvx,  321 
Col  less,  318 
comminuted,  285 
complete,  283 

complications  and  consequences  of,  291,  312 
compound,  276,  283 

treatment  of,  298,  299 
of  coracoid  process,  309 
of  coronoid  process,  316 
of  costal  cartilages,  306 
with  crushing,  286 
deformity  in,  289 
delayed  union  of,  300 
dentate,  283 
by  depression,  283 
by  direct  violence,  285,  289 
with  dislocations  of  shoulder,  441 

of  hip,  456 
displacements  in,  287 
just  above  elbow,  after-treatment  of,  316 
of  external  malleolus,  332 
extracapsular,  285 
faulty  union  of,  303 
of  femur,  321 

extracapsular,  321 

intracapsular,  321 

lower  end  of,  325 

neck  of.  321 

ill  reducing  hip  dislocations,  456 

shaft  of,  324 
fissured,  283 
of  foot,  333 
of  forearm,  317 

frequency  of,  in  different  bones,  282 
of  glenoid  fossa,  rim  of,  310 
green-stick,  283 
gunshot,  287 
of  hip,  322 

measurements  in,  322 
of  humerus,  310 

with  dislocation  of  bead,  312 

lower  end  of,  313 

shaft  of,  31. S 

upper  end  of,  310 
of  hyoid  bone,  305 
of  ilium,  321 
immediate  causes  of,  288 


Fracture  or  Fractures,  impacted,  285,  310,  322 
incom]>lete,  283 
bv  indirect  violence,  285,  289 
intercondyloid,  284,  313,  325 
intra-articular,  284 
intracapsular,  285 
of  ischium,  321 
of  larvnx,  625 
of  leg,'  329 

lower  end  of,  330 

upper  end  of,  329 
longitudinal,  283 
of  lower  jaw,  304 
of  metacarpal  bone,  320 
of  metatarsal  bones,  333 
mobility  in,  427 

abnormal,  290 
multiple,  285 

by  muscular  action,  285,  289 
of  nasal  bones,  303 
oblique,  283 
of  olecranon,  316 
of  patella,  326 

operative  measures  for,  327 

subcutaneous  suture  for,  328 
pathological,  282 
of  pelvis,  320 
of  penis,  962 

permanent  dressings  for,  293 
of  phalanges,  320 
Pott's,  330 

predisposing  causes  of,  288 
of  pubes,  321 
of  radius,  lower  end  of,  318 

shaft  of,  317 

and  ulna,  316 

upper  end  of,  317 
reduction  or  setting  of,  293 
repair  of,  290 
of  ribs,  305 
of  sacrum,  321 
of  scapula,  309 
simple,  282 
of  skull,  518 

base  of,  522 

compound,  521 

by  contre-coup  or  counter-stroke,  489 

fissured,  of  vault  of,  519 

inner  table  of,  519 

punctured,  521 
of  base  of,  522 

rules  for  trephining  in,  520 

vault  of,  519 
of  spine,  579 
spontaneous,  282 

in  cancer,  212 
of  sternum,  305 

of  superior  maxilla  and  malar  bones,  303 
symptoms  of,  289 
toothed,   283 
transverse,  283 
treatment  of,  293 
T-shaped.  284 
of  ulna,  shaft  of,  317 
ununited,  282,  300 

treatment  of,  302 
varieties  of,  282 
of  vertebrae,  579 
V-shaped,  283 
Fraenum  linguae,  shortness  of,  672 


INDEX. 


1209 


Fragilitas  ossium,  277 
Fratiklinic  electricity,  1188 
Fruiiklinism,  1188 

Frontal  sinus,  cystic  dilatation  of,  609 
dropsy  of,  009 
empyenui  of,  609 
tumors  of,  609 
sinuses,  foreif^n  bodies  in,  609 
inHamniation  of,  609 
injuries  of,  608 
sulcus,  inferior,  496 
superior,  496 
Frost-bite,  479 

gangrene  from,  55 
Fungus  cerebri,  o28 
of  dura  mater,  506 
hi^matodes,  212,  655 
Fiirbringer's    method   of   disinfecting  hands, 

1078 
Furuncle,  46 

Galactocele,  218,  1068 
Gallbladder,  distention  of,  784 

rupture  of,  785 
Gall-stones,  784 

intestinal  obstruction  from,  749 
Galvanic  electricity,  1188 
Galvano-cautery,  1188 
Gal vano- puncture  iti  aneurysm,  245 
Ganglion,  341 

compound,  340 
Gangrene,  21,  52 

amputation  for,  1152 

dry,  52 

embolic,  60 

ergot  causing,  55 

after  fracture,  293 

from  frost-bite,  55 

hospital,  57 

idiopathic,  53 

of  lungs,  643 

moist,  53 

neuropathic,  55 

of  penis,  963 

senile,  53 

symmetrical,  55 

traumatic,  localized,  54 
spreading,  54 

treatment  of,  55 

after  wounds,  107 
Gangrenous  emphysema,  125 

inflammation,  19 

intestine,  824 
Gant's  operation,  1138 
Gartner's  duct,  1040 
Gasserian  ganglion,  removal  of,  364,  381 
Gastrectomy,  727 
Gastric  fistula,  718 
Gastrocele,  811 
Gastro-enterostomy,  724 

Gastro-intestinal  tract,  disturbances  of,  in  he- 
reditary syphilis,  189 
Gastrorrhaphy,  719 
Gastrostomy,  719 

Witzel's  method  of  performing,  721 
Gastrotomy,  718 

and  digital  exploration  of  oesophagus,  700 

for  foreign  bodies  in  stomach,  713 
Gauze,  absorbent,  1082,  1175 

antiseptic,  1082 


Gauze,  bichloride,  1082 
iodoform,  1082 
sublimate,  1082 
(ielatiniform  or  gelatinoid  degeneration,  389 
Generative  organs,  female,  anatomy  of,  965 
methods  of  examination  of,  967 
surgery  of,  965 
Genitourinary  disease,  diagnosis  of,  852 
frequency  of  micturition  in,  853 
hematuria  in,  853 
pain  in,  852 
tract,  male,  surgery  of,  835 
tuberculosis  of,  78 
Genu  valgum,  351,  1136 

varum,  352 
Gibson's  bandage,  1178 
Girdner's  telephonic  probe,  528 
Glabella,  491 

(iiand,  prostate.     See  Prostate  gland. 
Glanders,  84,  135 

bacillus  of,  9,  135 
Glands  of  Hartliolin,  inflammation  of,  969 
retention-cyst  of,  971 
lymphatic,  inflanunation  of,  466 

sarcoma  of,  474 
salivary,  657 
tubercular,  of  neck,  655 
Glandular  tumors,  209 
Gleet,  906 

treatment  of,  915 
Glioma,  205 
Glossitis,  acute,  676 

mercurial,  676 
Glover's  suture,  1084 
Goitre,  660 

exophthalmic,  662 
operative  procedures  for,  661 
strumitis  in,  660 
treatment  of,  661 
Gonion,  491 
Gonococcus,  7,  896 
Gonorrhea,  895 
abortive,  904 
ardor  urinse  in,  897 
bubo  in,  900 
catarrhal,  903 

complications  of,  903 
chronic,  905 

treatment  of,  914 
in  the  female,  920 

treatment  of,  923 
incubation  interval,  896 
irritative,  904 
lymphangitis  in,  900 
subacute,  903 

symptoms  and  complications  of  first  stage, 
897 
of  second  stage,  899 
of  third  stage,  902 
treatment  of,  907 

urethral  injections  for  early  stage  of,  910 
of  uterus,  923 
treatment  of,  925 
Gonorrheal  arthritis,  407 
bubo,  in  female,  920 

treatment  of,  917 

conjunctivitis,  904 

treatment  of,  920 

ophthalmia,  904 

treatment  of,  919 


1210 


jyiJEX. 


Gononlical  rlieiiniatism,  407,  877 

treatment  of,  '.Ult 
(ioulev's  tunnelled  catheter,  893 
(iout,  rlieuinatie,  409 
(Toutv  arthritis,  409 
(iranulation  and  Granulations,  28 
erethistic,  28 
healing  by,  27 
-tissue,  2t) 
Grannlomata,  infectious,  of  neck,  655 
Gravel,  838 
ti raves'  disease,  662 
Grilled  hand,  339 
Grittis  amputation,  1167 
Guaiacol  in  treatment  of  local  tuberculosis,  656 

pain,  1103 
Gum-boil,  682 
Gumma,  cerebral,  170 
of  tongue,  677 

diflerential  diagnosis  of,  166 
Gumniata,  163 
Gummatous  osteo-myelitis,  168 

osteo-periostitis,  168 
Gums,  abscess  of,  682 
Gunpowder  grains  in  skin,  121 
Gunshot  wounds,  112 

of  abdomen,  702 

of  brain,  525 

of  the  head,  525 

of  joints,  416 

of  spleen,  789 

of  stomach,  712 
Guthrie's  amputation  at  hip-joint,  1170 
Gyrus,  angular,  497 
supramarginal,  497 

Hallux  varcs,  357 

Halsted's  method  in  carcinoma  of  breast,  1067 

Hammer-finger,  358 

Hammer-toe,  358 

Hand,  cerebral  center  for,  497 

Handkerchief  bandages,  1181 

Hands,  disinfection  of,  1078 

Hare-lip,  604 

Hartley's  operation  on  the  Gasserian  ganglion, 

382 
Head,  contusions  of,  510 

diseases  and  injuries  of,  489 

gunshot  wounds  of,  525 
Headache,  inveterate,  trephining  for,  555 
Healing  of  arteries,  33 

under  a  blood-clot,  29,  1087 

by  first  intention,  25 

by  granulation,  27 

by  second  intention,  27 

of  subcutaneous  wounds,  29 

by  third  intention,  28 

of  wounds,  25 
Hearing,  cerebral  center  for,  498 
Heart,  diseases  of,  221 

injuries  of,  222 

and  lungs,  examination  of,  before  operation, 
1073 

over-distention  of,  221 

rupture  of,  222 

tapping  the  cavitv  of,  221 

wo\mds  of,  222.  22:; 

cause  of  sudden  death  in,  223 
Heat  as  an  antiseptic,  1077 

and  cold,  ajiplications  of,  1189 


Heat,  dry,  1189 

eHect  of,  on  sjwres,  4 

moist,  11.S9 
Heath's  method  of  removal  of  entire  tongue, 

680 
Hectic  fever,  36 

state,  394 
Hematocele,  058 

intraperitoneal,  1033 

pelvic,  1033 

pudendal,  9t)9 
Hematomata,  87,  219 

of  broad  ligament,  1033 

vulva-,  969 
Ilematomyelia,  578 
Hematosalpinx,  1026 
Hematuria  in  genitourinary  disease,  853 
Hemianopsia,  546 
Hemophilia,  256,  1073 
Hemorrhage,  91,  252,  1071 

abdominal,  laparotomy  for,  707 

in  abdominal  section,  arrest  of,  1013 

after  amputation,  1158 

after-treatment  of,  256 

arrest  of,  99 

in  penetrating  wounds  of  chest,  648 

arterial,  252 

into  brain-substance,  517 

capillary,  252 

cerebral,  artery  of,  513 

in  cerebral  operations,  500 

consecutive,  252 

constitutional,  253 

diagnosis  of,  254 

extradural,  514 

extrameduilary,  of  spine,  578 

in  hip-joint  amputations,  1171 

from  intercostal  artery,  261 

intermediary,  252 

from  internal  mammary  artery,  261 

intracranial,  514 

intramedullary,  of  spine,  579 

ligation  in,  255 

local,  treatment  of,  254 

from  middle  meningeal  artery,  514 

in  operations  on  liver,  784 

from  pachymeningitis  interna,  517 

parenchymatous,  252 

primary,  252 

reactionary,  252 

secondary,  253 

spinal,  578 

spontaneous,  arrest  of,  253 

subdural,  516 

from  tooth  socket,  688 

torsion  in,  255 

transfusion  after,  254 

treatment  of,  rules  for  256 

in  \iranoplasty,  695 

venous,  252 

symptoms  of,  261 

in  woiuids  of  abdomen,  707 
Hemorrhagic  diathesis,  1073 

inHammatif)n,  19 
Hemorrhoids,  792 

external,  794 

internal,  795 
Hemothorax,  639 
Hepatopexy,  784 
Hereditary  syphilis,  176 


INDEX. 


1211 


Hiri'ditarv    sypliilis,    disttirliances    of    jjaslro- 

intestiiial    trat't  in,   IS'J 
IIiTiua,  SIO 
anatomy  ul",  SI  1 

Hassini's  method  of  radical  cure,  .SI"),  S17 
of  bladder,  S')! 
ciecal,  811,  817 
cerebri,  G'JS 

conjienital,  radical  cure  of,  S17 
of  diaphragm,  8o3 
diaphragmatic,  8o.> 
encysted,  8*2(1 
femoral,  S'JS 

into  foramen  of  Winslow,  833 
into  funicular  j)rocess,  826 
incarcerated,  818 
infantile,  82(> 
inflamed,  819 
inguinal,  825 

treatment  of,  828 
irreducible,  818 
ischiatic,  832 
Littr^'s,  821 
lumbar,  832  ^ 
of  lung,  648 
of  muscle,  334 
obturator,  832 
ovarian,  1034 

palliative  treatment  of,  812 
perineal,  832 
properitoneal,  833 
radical  cure  of,  831 
retroperitoneal,  834 
Richter's,  821 
sigmoid,  818 
strangulated,  819 
umbilical,  830 
ventral,  831 
Herniotomy,  823 

in  femoral  hernia,  829 
in  inguinal  hernia,  828 
in  umbilical  hernia,  831 
Herpes  of  lips,  668 
Hesselbach's  triangle,  825 
Heterologous  tumors,  194 
Hey's  amputation,  1163 
Highmore,  antrum  of,  610 
Hip-joint  abscess,  aspiration  of,  397 
opening  of,  397 
disease,  391 

abscess  from,  393,  394 
ankylosis  in,  395 
deposition  of  bacilli  in,  392 
first  stage,  392 
osteotomy  for,  1137 
prognosis  of,  395 
second  stage,  392 
stage  of  lengthening,  392 

of  shortening,  393 
symptoms  of  first  stage,  392 
of  second  stage,  392 
of  third  stage,  393 
terminations  of,  395 
treatment  of,  395 
tuberculosis  of,  391 
Hodgen's  splint,  299 
Hodgkin's  disease,  474,  657 
Holla's  operation,  437 
Hollow  foot,  356 
Homologous  tumors,  194 


Hopkins'  rongeur  forceps,  499 
Horns,  482 

of  scalp,  503 
Horny  growths  of  lips,  669 
Horseshoe  kidney,  841 
Horsley's  antiseptic  wax,  1154 
cyrtometer,  494 
dural  separator,  499 
Hospital  gangrene,  9 
Housemaid's  knee,  344 
Howship's  lacuna-,  2<)4 

Humerus,  separation  of  upper  epiphysis  of,  311 
Hunterian  oj)eration  for  aneurysm,  243 
Hutchinson's  teeth,  187,  6S7 
li (iter's  mctliod  of  reaching  the  facial  nerve,  38:1^ 
Hydatids,  220,  780,  848,  1068 
Hvdrartlirosis,  388 
Hydrated  testicle,  951 
Hydrenceplialocele,  506 
Hydrocele,  955 
encysted,  956 
incision  of,  958 
infantile,  956 
injection  of,  956,  957 
of  neck,  congenital,  651 
of  round  ligament,  1048 
of  spermatic  cord,  827,  958 
symptoms  of,  956 
tapping  of,  956 
treatment  of,  956 
Hydrocephalus,  507 

Hydrogen  gas  in  intestinal   perforation,    /06, 
70S,  728 
rectal  insufflation  of,  706,  730 
peroxide  as  an  antiseptic,  1077 
test  in  intestinal  contusions  and  lacerations, 
728 
Hydronaphtol  as  an  antiseptic,  1077 
Hydronephrosis,  843 
Hydrophobia,  84,  131 
Hydrops  articuli,  388 
Hydrorrhachis,  559 
Hydrosalpinx,  1026 
Hygroma  of  neck,  651 
Hymen,  976 
Hyperostosis  of  jaw,  684 
Hvpertrophv  of  bones  of  skull,  505 
of  breast,"  1053 
of  cervix  uteri,  982 
of  lips,  669 
of  muscle,  336 
of  nails,  483 
of  prostate,  940 
scars,  484 
of  tonsils,  690 
Hvpnotic  suggestion  in  hysterical  joints,  415 
Hypoblastic  tumors,  210 
Hypodermatic  injections,  1187 
Hypodermoclysis,  95,  1185 
Hypospadias,  960 
Hysterectomy,  abdominal,  1007 
Cesarean,  985 
supravaginal,  partial,  1007 

total.  1010 
vaginal,  1019 
Hysteria,  traumatic,  577 
Hysterical  club-foot,  357 

joints,  413 
Hysteropexy,  997 
Hysterorrhaphy,  986 


1212 


INDEX. 


IciioRors  pus,  41 

Ileo-oolostoiiiy,  738 

lli:ic  fossa,  circumscribed  alwcess  of,  7<>7 

Iiiipai'tiou,  fecal,  800 

Imperforate  aims,  7!)0 

rectum,  790 
Impetigo,  sypliililic,  161 
Implantation,  lateral,  of  intestine,  74ri 
Impotence,  953 

pseudo-,  9")3 
Incision,  length  of,  1083 
Inclineil  jilanes,  1091 
Incontinence  of  retention,  581,  95ti 

of  urine,  856 

after  fractures  of  the  spine,  581 
Incurvation  of  spine,  563-566 
Indian  method  of  rhinoplasty,  613 
Inditierent  cells,  26 
Induced  current,  1188 
Infarction,  59 
Infection,  bio-chemical,  123 

mixed.  123 
Inflammation,  10 

adhesive,  18 

asthenic,  18 

of  bone,  chronic,  271 

of  breast,  1 053 

cardinal  symptoms  of,  10 

chronic,  20 

congestion  in,   13 

croupous.  19 

diet  in.  25 

of  Fallopian  tubes,  1025 

fibrinous,   18 

of  frontal  sinuses,  609 

gangrenous,  19 

hemorrhagic,  19 

interstitial,  18 

of  joints,  388 

of  lips,  668 

of  male  breast,  1070 

of  nerve,  360 

of  nipple,  1051 

of  ovary,  1035 

parenchymatous,  18 

of  penis,  963 

phlegmonous,  19 

of  scalp,  503 

septic,  of  bone,  266 

serous,  18 

sthenic,  18 

suppurative,  19 

terminations  of,  20 

treatment  of,  constitutional,  23 
local,  21 

of  uterus,  987 

of  vagina,  980 

varieties  of,  18 

vascular  changes  in,  11 

of  veins,  224 

of  vulva,  969 

after  wounds,  106 
Ingrowing  toe-nail,  483 
Inion,  491 

Injections,  coagulating,  in  aneurysm,  245 
hypodermatic,  1187 

of  rectum,  730 

urethral,     in     earlv     stage     of    gonorrhea, 
910 
Insanity,  post-operative,  38 


Insanity,  trephining  for,  555 
Insect-bites  and  stings,  126 
Instruments,  disinfection  of,  1079 
Intestinal  anastomosis,  736 
without  rings,  741 
canal,  tuberculosis  of,  78 
concretions,  obstruction  from,  750 
fistula,  770 
obstruction,  729 
acute,  748 

from  adhesions  and  angulations,  1016 
adynamic,  759 
after-treatment  of,  747 
anatomico-pathological  forms  of,  748 
from  ascarides,  750 
chronic,  748,  749 
from  concretions,  750 
direct  treatment  of,  from  strangulation  by 
band,  diverticulum,   flexion  or  adhe- 
sion of  intestines,  746 
from  gall-stones,  749 
from  intussusception,  751 
operative  treatment  of,  719,  730 
surgical  resources  in  treatment  of,  730 
perforation,  after  tvphoid,  hydrogen  gas  in, 

706,  708,  709 
stenosis,  non-malignant,  755 
tract,  syphilis  of,  172 
tumors,  756 
Intestine  and  Intestines,  carcinoma  of,  756 
cicatricial  stenosis  of,  755 
congenital  stenosis  of,  755 
contusion  of,  728 
diseases  and  injuries  of,  728 
exclusion  of,  747 
flexions  and  adhesions  of,  753 
gangrene  of,  60 
invagination  of,  751 
lateral  implantation  of,  736,  746 
puncture  of,  731 
rupture  of,  728 
sarcoma  of,  756 
strangulation     bv     bands     or     diverticula, 

756 
suturing  of  wounds  of,  709 
to  trace  up  or  down,  724 
woinids  of,  728 
Intracanalicular  mammary  tumor,  1059 
Intra  parietal  fissure,  497 
Intrathoracic  cysts,  645 

tumors,  644 
Intubation  of  larynx,  632 

in  syphilitic  stenosis  of  larynx,  532 
Intussusception,  751 
Intussusceptum,  751 
Intussuscipiens,  751 
Invagination  of  bowels,  751 
Involucrum,  269 
Involution  cysts  of  breast,  1069 
Iodoform  as  an  antiseptic,  1077 
gauze,  1082 

in  treatment  of  cold  abscess,  46 
Iritis,  svphilitic,  183 
Irrigation,  1083,  1190 
of  abdominal  cavity,  710 
of  stomach,  730 
Irritability,  cerebral,  512 
I  schio- rectal  abscess,  790,  801 
chronic,  801 
fossa,  790 


INDEX. 


1213 


Jacksonian  epilepsy,  552 
Jaw  and  Jaws,  abscess  of,  682 
acqiiireil  derurinilies  of,  082 
ankylosis  of,  GSG 

Ksniarch's  operation  for,  686 
oareinonia  of,  685 
closure  of,  686 

congenital  deformities  of,  682 
dentigerous  cysts  of,  684 
diseases  of,  682 
enchondroina  of,  684 
epithelioma  of,  685 
fibroma  of,  684 
hyperostosis  of,  684 
lower,  cysts  of,  684 
uniltilocular  cysts  of,  684 
necrosis  of,  683 
osteomata  of,  685 
phosphorous  necrosis  of,  683 
sarcoma  of,  685 
tumors  of,  684 
Johnson's  modified  Durham's  trachea-tube,  630 
Joints,  anatomical  construction  of,  385 
ankylosis  of,  418 

partial,  419 
erasion  of,  391 
excision  of,  391 
gunshot  wounds  of,  416 
hysterical,  413 
inflammations  of,  386,  388 
loose  bodies  in,  421 
neuralgia  of,  415 
stiffness  of,  after  fractures,  292 
•surgery  of,  385 
tuberculosis  of,  80,  388 

aspiration  in,  391 

rest  in,  390 

treatment  of,  390 
wounds  and  injuries  of,  415 

Karyokinesis,  29 
Keen's  operation  blank,  735 
rongeur  forceps,  487 
trachea-tube,  630 
Kelly's  method  of  disinfecting  hands,  1079 

rectal  tubes,  792 
Keloid,  484 
Keratitis,  187 

interstitial,  187 
Kidney,  cysts  of,  847 
diseases  of,  835 
floating,   836 
hydatid  cysts  of,  848 
injuries  of,  848 
sarcoma  of,  848 
stone  in,  838 
surgical  anatomy  of,  835 

nephrectomy  in,  844 
tuberculosis  of,  847 
tumors  of,  848 
wounds  of,  848 
Knee,  turning  of,  in  or  out,  353 
Knee-jerk,  561,  note 
Knee-joint  disease,  398 
amputation  for,  400 
ankylosis  after,  399 
erasion  for,  400 
excision  for,  400 
non-operative  treatment  of,  399 
operative  treatment  for,  400 


Knee-joint  disease,  subluxation  in,  399 
terminations  of,  399 
tuiierculosis  of,  398 
Knee-splint  of  Sayre,  398 
Knock-knee,  351 
Kobelt's  tubes,  1040,  1041 
Kocher's  method  of  reduction  of  shoulder  dis- 
locations, 438 
operation  for  removal  of  entire  tongue,  6H0 
for  hernia,  816 
Koch's    tuberculin    in   tubercular    lymphoma, 

656 
Kraske's  operation,  807 
Kronlein's  method,  48 
Kussmaul's  tube,  730 
Kyphosis,  86,  553,  565 

Labia.     See  Vvlm. 
Laceration  of  brain,  510 

of  the  cervix  uteri,  983 
Lambda,  491 
Laminectomy,  585 
Landerer's  dry  method,  1083 
Langenbeck's   method   of  treating  aneurysm, 

238 
Laparotomy.     See  Abdominal  section. 
for  abdominal  hemorrhage,  707 
closure  of  external  incision  in,  710 
in  punctured  wound  of  abdomen,  704,  707 
Laplace's  forceps,  739,  740 
Larrey's  amputation  at  hip-joint,  1170 

at  shoulder-joint,  1161 
Laryngectomy,  635 
partial,  637 
unilateral,  637 
Laryngitis,  615 

sicca,  616 
Laryngotomy,  627 

thyroid,  622 
Laryngo-tracheotomy,  628 
Larynx,  abscess  of,  617 
benign  tumors  of,  621 
burns  and  scalds  of,  627 
cancer  of,  differential  diagnosis  of,  172 
cerebral  center  for,  497 
contusions  of,  624 
dislocation  of  cartilages  of,  625 
fractures  of,  625 
incised  wounds  of,  624 
intubation  of,  632 
malignant  tumors  of,  623 
cedema  of,  616 

phthisis  of,  differential  diagnosis  of,  172 
syphilis  of,  189,  619 
'  differential  diagnosis  of,  172 
and  trachea,  diseases  and  injuries  of,  615 
congenital  deformities  and  defects  of,  615 
strictures  of,  619 
treatment  of  Avounds  of,  624 
tuberculosis  of,  620 
tumors  of,  621 
ulcers  of,  618 

wounds  and  injuries  of,  624 
Lateral  implantation  of  intestine,  746 
Lavage  of  stomach,  730 
Lawn  tennis  arm,  334 

leg,  334 
Leeching,  1184 
Leg,  artificial,  1173 
cerebral  center  for,  497 


J  21 4 


INDEX. 


Leio-mvoma,  202 
Leiter's  cystoscope,  886 

tubes  in  nviiovitis,  887 
I.enibert's  .siilniv,  74") 
Lei  lilt  iiL'^is  (issitmi,  505,  684 
Lepra,  655 
Leptinneningitis,  530 
Leptotlirix  hueealis,  787 
Lessor's  triangle,  1118 
Leiicoeytes,  function  of,  16 
Leucoeytosis,  18 
LeuconiaVnes,  2 
Leucnrrliea,  ".•S7 
I^evis's  splint,  819 

ligament,  roinid,  hydrocele  of,  1048 
Lifjation,  255 

of  arteries,  1113.'   See -.4r/eri/. 
Ligature  of  arteries,  1113.     See  Arlerij. 

for  internal  piles,  796 
Ligatures.  lOSl 

material  and  disinfection,  1081 
Lightning-stroke,  479 
Lint,  1175 
Lip,  cysts  of,  669 

epithelioma  of,  668 

na»vi  of,  669 
Lipomata,  198 

of  neck,  657 

of  spermatic  cord,  958 

of  spine,  560 
Lips,  affections  of,  668 

bites  of,  668 

chapped,  668 

cracked,  668 

herpes  of,  668 

horny  growths  of,  669 

hypertrophy  of,  669 

inHanimation  of,  668 

tumors  of,  668 

wounds  of,  669 
Lisfranc's  amputation,  1164 
Liston's  amputation  at  hip-joint,  1170 
Litholapaxy,  876 

in  children,  880 
Lithotomy,  lateral,  868 

median,  873 

perineal,  868 

suprapubic,  868,  873 
Lithotrites,  876,  877 
Littre's  hernia,  821 
Liver,  abscess  of,  47,  782 
amoeba  coli  in,  783 

dermoid  cysts  of,  782 

disease  and  injuries  of,  780 

floating,  784 

hydatid  cysta  of,  780 

resections  of  portions  of,  784 

rupture  of,  783 

simple  (;ysts  of,  782 

syphilis  of,  184 

tumors  of,  782 

wounds  of,  783 
Lockjaw,  70 

Loose  bodies  in  joints,  421 
Lordosis,  86,  563,  566 

compeaisatory,  567 
Lorenz's  operation,  431 
Loreta's  operation,  722 
Ludwig's  angina,  653 
Lumbar  abscess,  44,  569 


Lumbar  abscess,  treatment  of,  573 

puncture,  508 
Lum|iy  jaw,  18S 
Lung,  hernia  of,  648 

rupture  of,  646 

surgery  of,  643 
Lungs,  gangrene  of,  648 

injuries  and  diseases  of,  637 
Lupus,  76,  78,  485,  504 

exedens,  76 

hypertrophicus,  76 

of  pharynx,  78 

of  skin,  76 

and  syphilis,  ditlerential  diagnosis  of,  485 

of  tonsil,  78 

of  velum,  78 

vulgaris,  76,  163 

differential  diagnosis  of,  163 

vulva?,  970 
Luxatio  erecta,  440 
Luxation.     See  Dislocation, 
Lymph,  26 

Koch's,  85 
Lymphadenitis,  469 
Lymphadenoma,  473 
Lymphangiectasis,  470 
Lymj)hangionia,  470 
Lymphangitis,  466 

in  gonorrhea,  900 

from  gonorrhea,  treatment  of,  917 

reticular,  467 

tubular,  467 
Lymphatic  cysts  of  breast,  1069 

glands,  abscess  of,  47  * 

inflammation  of,  466 
tuberculosis  of,  80 
Lymphatics,  diseases  and  injuries  of,  463 
Lymphcedema,  472,  972 

of  vulva,  972 
Lymphoma,  malignant,  474 

of  neck,  657 
Lymphorrhagia,  470 
Lymphorrhea,  470 
Lympho-sarcoma,  205,  474 

malignant,  657 
Lyssa,  131 

Macewen'.s    method    of    amputating    upper 
third  of  thigh,  1167 
in  aneurysm,  246 
of  compressing  the  aorta,  1171 

operation  for  radical  cure  of  hernia,  814 

snpracondyloid  osteotomy,  1136 
Macrocheilia,  471,  667 
Macroglossia,  471,  673 
Macrophages,  16 
Macropluigocytes,  16 
Macrostoma,  670 
Malacosteon,  276 
Malgaigne's  hooks,  327 

operation  for  hare-lip,  666 
Malignant  disease.     See   Carcinoma   and   Sar- 

COllUi. 

growths,  protozoa  in,  195 

psorospermije  in,  195 
(edema,  125 

bacillus  of,  9 
pustule,  129 
Mallein,  84 
Mai  perforant,  48,  486 


iM)i:x. 


1215 


Maltese  cross,  1 175 
Mamma,  irritable,  1056 

tubereiilosis  of,  78 
Mamma',  absence  of,  10")  1 

supernumerary,  1051 
Manunary  gland.     See  Breast. 
Mammitis,  1058 
Manipulation  in  aneurysm,  245 

in  rediutiou  of  dislocations,  428 
Marginal  abscesses,  801 
Marjolin's  ulcer,  214 
Massage,  1188 

abdominal,  731 
Mastication,  noisy,  685 
Mastitis,  1053 

chronic  cirrhotic,  1050 
Mastoid  disease,  ditierential  diagnosis  of,  535 

diseases  of,  535,  538 
Mannsell's  method,  742 
Maxillary  sinus,  610 
Maydl's  operation,  732 
Mayer's  dressing  for  Thiersch's  skin-grafting, 

1110 
McBurney's  point,  763 
Measurements  in  fractures  of  hip,  322 
Meatotomy,  932 

Meatus,  urinary,  stricture  of,  932 
Meckel's  cartilage,  6.51 

diverticulum,  754,  790  (Fig.  323) 
ganglion,  removal  of,  364,  380 
Median  fissure,  491 
Mediastinal  abscess,  649 
Mediastinum,  posterior,  645 
Medullary  carcinoma,  212 
Melanosis,  205 
Melanotic  cancer,  205 
Melon-seed  bodies,  80,  339 
Meningeal   artery,  middle,  hemorrhage  from, 

514 
Meningitis,  530 

from  aural  disease,  538 
differential  diagnosis  of,  535 
operative  interference  in,  532 
Meningocele,  cerebral,  506 

spinal,  559 
Meningo-myelocele,  559 
Mental  processes,  cerebral  center  for,  497 

state  of  patient,  1073 
Mercurial  glossitis,  672 

stomatitis,  672 
Mercury,  bichloride  of,  as  an  antiseptic,  1077 

biniodide  of,  as  an  antiseptic,  1077 
Mesarteritis,  228 

Mesenteric  hernia  of  Cooper,  834 
Mesentery,  cysts  of,  780 

injuries  and  diseases  of,  772 
tumors  of,  780 
Metastatic  abscesses,  60,  62 
Microbes,  1 
Micrococcus,  1 
Micro-organisms,  1 
Microphages,  16 
Micro-phagocytes,  16 
Microstoma,  670 
Micturition,    frequency    of,    in    genito-urinary 

disease,  853 
Mikulicz's  osteoplastic  resection,  401,  1150 
Milium,  475 

Milk  cysts  of  breast,  1068 
fistulae,  1055 


Milk,  sinuses,  1049 

Milzbrand,  128 

Mind  blindness,  546 

Miner's  elbow,  344 

Minor  surgery,  1175 

Mirault's  operation  for  liare-lip,  667 

Mixed  infection,  45 

Mixter's  operation  on  fifth  nerve,  382 

Moles  of  scalp,  503 

Mollities  o.ssium,  276 

Molluscum  contagiosum,  475 

epitheliale,  475 
Monorchidism,  949 
Morbus  coxic,  391 

coxarius,  391 
Mortality  from  anesthetics,  1098 

of  carcinoma  of  breast,  1066 
Morton's  fluid,  507 
Mother's  mark,  228,  504 
Motor  areas  of  brain,  497 
Mouth,  cerebral  center  for,  497 

closure  of,  670 

diseases  and  injuries  of,  664 

malformations  of,  670 
Mucous  membrane,  transplantation  of,  1111 
tuberculosis  of,  77 

membranes,  erysipelas  of,  68 

papules,  183 

patches,  159,  183 

tubercles,  208 

tumors,  201 
Mumps,  657 
Murphy  button,  739 
Muscle,  atrophy  of,  336 

contractures  of,  335 

diseases  and  injuries  of,  333 

hernia  of,  334 

hypertrophy  of,  336 

ossification  of,  337 

plastic  operations  in,  1111 

rupture  of,  334 

syphilis  of,  167 

tuberculosis  of,  77 

tumors  of,  337 
wounds  of,  337 
Muscle-grafting,  1111 
Muscular  fiber,  striped,  regeneration  of,  30 
Mustard  foot-bath,  1182 

plasters,  1182 
Myalgia,  334 
Myornata,  202 

of  uterus,  1003 
Myomectomy,  1007 
Myositis,  334 

afrigore,  335 

ossificans,  337 

rheumatic,  335 
Myxcedema,  662 
Myxomata,  201 

N^vi  of  lips,  669 

of  tongue,  674 
Na^vus,  227,  504 

verrucosus,  482 
Nail,  hypertrophy  of,  483 

inflammation  of  matrix  of,  483 

ingrowing,  49,  483 
Nails,  diseases  of,  483 

polypi,  605 
Nasion,  491 


iL'lt] 


jyi)i:x. 


Xaso-pkarvngeal  p<^>lvp,  S07 
Navel.     S«»e  Umbiliau. 
Necessity,  triangle  of,  1116 
Neck,  abscess  of,  658 
cellulitis  of.  652 
cicatrices  of,  653 
coDgenital  tistula  of,  652 

hydrocele  of,  651 
contusions  of,  653 
cysts  of,  651 

diseases  and  injuries  of,  651 
emphysema  of,  654 
fistulre  of,  653 
hygromata  of.  651 
infectious  granulomata  of,  655 
injuries  of.  651 
lipomata  of,  657 
open  wounds  of,  654 
syphilis  of.  655 

tuberculosis  of  lymph-glands  of,  655 
tumors  of,  655 
wounds  of,  654 
wr^•-.     See  Torticollis. 
Necrosis,  264,  269 
of  bones  of  skull,  505 
of jaw,  683 
of  palate,  695 
phosphorous,  of  jaw,  683 
Necrotic  caries,  265 
Necrotomy,  osteoplastic,  272 
N^laton's'line,  323 

prol)e.  117 
Neoplasms.     See  Tumors. 
Nephralgia,  837 
Nephrectomy,  841 

in  surgical  kidney,  844 
Nephritis,  interstitial,  842 

suppurative,  842,  843 
Nephro-lithotomy,  840 
Nepliropexy,  836 
Nophrorrhaphy,  836 
Nerve  or  Nerves,  centers,  syphilis  of,  188 
cohesion  of,  378 

contusions  and  compressions  of,  366 
facial,  diagnosis  of  lesions  of,  370 
fifth,  diagnosis  of  lesions  of,  370 

methods  of  reaching,  377 
grafting,  376,  377,  1111 
great  sciatic,  diagnosis  of  lesions  of,  374 

exposure  of,  384 
inflammation  of,  360 
injuries,  prognosis  of,  374 

remote  eflects  following,  treatment  of,  374 
lingual,  stretching  <(r  eisection  of,  383 
median,  diagnosis  of  lesions  of,  372 

e.x[>osure  of.  373 
musculo-spiral,  diagnosis  of  lesions  of,  373 

exposure  of,  384 
operations  on,  376 
plastic  operations  on,  1111 
pneumogastric,  diagnosis  of  lesions  of,  371 
of  posterior  cervical  muscles,  division  of,  for 

wry-neck.  3'<-i 
radial,  diagnosis  of  lesions  of,  373 

exposure  of.  384 
recurrent  larvngeal,  diagnosis  of  lesions  of, 

371 
special,  diagnosis  of  lesions  of,  370 
spinal  accessory,  exposure  of,  384 
stretching,  377 


Nerve  or  Nerves,  supraorbital,  exposure  of,  379 

surgery  of,  359 

suture,  376 

syphilis  of,  188 

tibial,  ex|)fi6ure  of,  385 

tissue,  regeneration  of,  31 

tumors  of.  202,  366 

ulnar,  diagnf>sis  of  lesions  of,  371 
exjKjsure  of,  384 

wounds  of,  367 

and  injuries  of,  366 
treatment  of,  374 
Nervous  syphilis,  170 
Neuralgia,  361 

of  brachial  plexus,  surgical  treatment  of,  364 

of  joints.  415 

of  scars,  surgical  treatment  of,  364 

of  spine,  562 

of  stumps  and  scars,  363 

treatment  of,  364 
Neurasthenic  sequel*  of  spinal  sprains.  577 
Neurectasy,  377 

conditions  to  which  it  is  applicable,  379 
Neurectomy,  379 
Neuritis,  360 
Neuromata,  365 
Neurotomy,  379 
Nipple  and  areola,  1049 

diseases  of,  1051 

inflammation  of,  1051 
Nipples  retracted,  1051 

supernumerary,  1048 
Nitrous  oxide  gas,  1048 
Nodes,  syphilitic,  168 
Noma.  55,  969 

bacilli  in,  9 
Nose,  abscess  of,  590 

adenomata  of,  607 

angeiomata  of,  607 

asymmetry  of.  590 

atrophic  catarrh  of,  599 

catarrh  of,  600 

deformities  of,  5S9 

enchondromata  of,  606 

exostoses  and  osteomata  of,  607 

fissures  of,  590 

foreign  lx>dies  in,  603 

hypertrophic  and  atrophic  catarrh  of,  596 

injuries  of,  603 

parasites  in,  604 

plugging  of,  602 

polypi  of,  605 

restoration  of,  612 

rhinoliths  in,  604 

septum  of,  diseases  and  displacements  of,  590 

surgery  of,  589 

surgical  emphysema  of,  612 

tumors  of.  607 

ulcers  of,  600 

wounds  of,  612 
Nose-bleed.  603 
Nostrils,  deformities  of,  589 
Nurse,  preparation  of,  for  operation,  1077 


Obeliox,  491 
Obligate  bacteria,  2 
Obliterating  appendicitis, 
Obstniction,  fecal,  750 
intestinal.  729 
acute,  743 


r68 


INDEX. 


1217 


Obstnutioii,  intestinal,  adyiiiiinic,  7J0 
arter-lrealinent  of,  747 
lioni  ascariiles,  750 
chronic,  741) 
from  concretions,  750 
from  gal  I -stones,  749 
operative  treatment  of.  730 
in   stran^Milation    by    hand,    diverticnlnni, 
tlexion,  or  adiiesion  of  intestines,  di- 
rect treatment  of,  746 
surgical  treatment  of,  730 
Odontumes,  C88 

O'Dwyer's  intubation  instruments,  632 
(Edema,  antlirax,  I'iU 

of  hirynx,  616 
Gi^sophageal  bougies,  687 
CEsophagectomy,  700 
tEsophagoscope,  700 
(Esophagotomy,  697 
CEsopliagus,  dilatation  of,  696 
diseases  and  injuries  of,  695 
foreign  bodies  in,  69S 

gastrotomy  and  digital  exploration  of,  700 
malformations  of,  695 
operations  on,  699 
sacculation  of,  696 
stricture  of,  696 
wounds  of,  698 
Ointments,  1191  ' 

Omental  grafting  in  abdominal  wounds,  700 
Omentum,  cysts  of,  779 
diseases  of,  779 
injuries  and  diseases  of,  772 
tumors  of,  780 
Omphalectomy,  831 
Onychia,  483  ' 
maligna,  4S3 
syphilitic,  160 
Oophorectomy,  1037 
Oophoron,  1040,  1041 

papillomatous  cysts  within,  1042 
Operation  cases,  after-treatment  of,  1088 
Operations,  dangers  common  to  all,  1071 
dangers,  special,  in,  1072 
preparation  for,  1076 
Operative  surgery,  general  principles  of,  1071 
Operculum,  496 
Ophryon,  491 
Ophthalmia,  gonorrheal,  904 

treatment  of. 
Opisthotonos,  70 

Opium-poisoning,  differential  diagnosis  of,  51: 
Orchitis,  949 

syphilitic,  173,  950 

differential  diagnosis  of,  173 
tubercular,  173,  950 
Orrhotherapy,  81 
Orthopedic  surgery,  346 
Osseous  system,  surgery  of,  262 

tumorsi^  200 
Ossification  of  muscle,  337 
Osteitis  of  bones  of  skull,  505 
rarefying,  264 
simple  acute,  266 

syphilitic,  differential  diagnosis  of,  169 
tubercular,  differential  diagnosis  of,  169 
Osteo-arthritis,  410 
Osteoblasts,  32 

Osteoclasis  in  genu  valgum,  353 
Osteoclasts,  32 
77 


Osteo-malacia,  378 
Osteomata,  200 
of  Jaws,  6S5 
of  nose,  607 
Osteo-myelitis,  264 
gummatous,  168 
tubercular,  79 
Osteoperiostitis,  263 
gummatous,  16S 

non-speiiiic,  differential  diagnosis  of,  180 
syphilitic,  168 

diflereiitial  diagnosis  of,  186 
Osteoplastic  necrotomy,  272 
resection  of  foot,  401,  1150 
of  skull,  499 
(Jsteoporosis,  264 
<  )steo-sarconia,   280 
Osteo-sclerosis,  264,  265 
Osteotomy,  1135 

for  ankylosis  of  hip-joint,  398,  1137 
(cuneiform)  for  talipes,  355 
for  deformity  after  coxalgia,  398,  1137 
for  genu  valgum,  352,  353,  1136 
through  neck  of  fenmr,  1138 
supracopdyloid,  1136 
Otitis  media,  catarrhal,  1087 

chronic  purulent,  intracranial  sequela;  of, 
525 
Ovarian  cyst,  1042 

diagnosis  of,  1045 
inflammation  of,  1044 
rupture  of,  1045 
suppuration  of,  1044 
torsion  of  pedicle  of,  1044 
cystomata,  1039 
dermoids,  1041 
hernia,  1034 
tumors,  1039 
Ovaries,  surgery  of,  1034 

and  tubes,  removal  of,  1037 
Ovariotomy,  1047 

technique  of,  1047 
Ovaritis,  1035 
Ovary,  cysts  of,  1042 
dermoid  cysts  of,  1041 
inflammation  of,  1035 
prolapse  of,  1034        " 
tumors  of,  solid,  1048 
Oxaluria,  838 
Ozena,  592 

PACHYMENINGXTIiS,  530 

internal  hemorrhage  from,  517 
Paget's  disease,  1051 

relation  of  psorosperms  to,  1052 
Pain  in  genito-urinary  disease,  852 
Painful  subcutaneous  tubercle,  366 
Palate,  abscess  of,  695 

cleft,  692 

congenital  deformities  of,  692 

necrosis  of,  695 

tumors  of,  695 

ulceration  of,  695 
Palmar  abscess,  47 

arches,  ligation  of,  1122 

fascia,  contraction  of,  348 
Palpation,  bimanual,  968 
Panaris,  47,  339 
Pancreas,  abscess  of,  788 

cancer  of,  789 


1218 


L\j)i:x. 


Pancreas,  cv.sts  of,  7S8 

diseases  and  injuries  of,  780 
wounds  of,  78S 
Pannous  synovitis,  oilO 
I'apilloina  neurotieuin,  482 
Papilloniata,  *J(»S 

of  bladder,  88(1 

of  Kallopian  tube,  1048 

of  tongue,  t!74 

of  vulva,  971 
Papillomatous  cysts  within  tlie  oophoron,  1042 
Pa(pielin's  thernio-cautery,  lls.'i 
Paracentesis,  <i89 

abdominis,  779 

auriculi,  221 

pericardii,  222 

thoracis,  ().S9 
Paralysis  of  bladtler,  858 

of  bowels,  759 

muscular,  335,  355,  368 

from  nerve  injuries,  370  et  seq. 

persistent,  after  fractures,  292 
Parametritis,  1032 
Paraphimosis,  899 

treatment  of,  910 
Paratoloid,  81 
Paratyphlitis,  760 
Parenchymatous  inflammation,  18 
Paresthesia,  region  of,  369 
Parietal  lobule,  superior,  497 
Park's  tlivided  trachea-tube,  630 
Paronychia,  340 
Paroophoritic  cvsts,  1041 
Paroophoron,  1040,  1041 
Parotid  gland,  contusions  of,  657 
cystic  dilatation  of,  658 
fistula;  of,  657 
tumors  of,  658 
wounds  of,  657 
Parotitis,  657 

suppurative,  658 
Parovarian  cysts,  1042 
Parovarium, 'l040,  1041 
Patella,  fracture  of,  treatment  of,  32G 
Pathogenic  bacteria,  2 
Patient,  examination  of,  before  operation,  1073 

hygienic  conditions  surrounding,  1075 

management  of,  before  operation,  1075 

mental  state  of,  before  operation,  1073 

preparation  of,  1076 
Pedicle  in  hysterectomy,  treatment  of,  1008 

of  ovarian  cyst,  torsion  of,  1044 
Pelvic  abscess,  1026 

cellulitis,  1032 
Pemphigus,  182 
Penis,  an)pntation  of,  964 

diseiises  and  injuries  of,  960 

epithelioma  of,  963 

fracture  of,  962 

gangrene  of,  963 

inflammation  of,  963 

and  urethra,  relative  sizes  of,  928 

wounds  of,  962 
Perforating  ulcer  of  foot,  48,  486 

of  nasal  septum,  593 
Perforations,  intestinal,  search  for,  708 
Periarteritis,  228 
Pericarditis,  traumatic,  223 
Pericardium,  diseases  of,  221 

efliision  into,  222 


Pericardium,  incision  and  drainage  of,  222 

injuries  of,  222 
Perichondritis,  (118 
Perineal  lithotomy,  868 

section,  937 
Perineoplasty,  973 
I'erinephric  abscess,  47,  845 
Perinephritic  abscess,  47,  844 
I'erineidiritis,  844 
Perineum,  rupture  of,  972 
complete,  972,  975 
concealed,  972,  974 
incomplete,  972 
repair  of,  973 

surgery  of,  972 
Periostitis  aibuminosa,  268 

of  bones  of  skull,  505 

dental,  687 
Pcri])hlel)itis,  225 
Peritoneal  cavity,  toilet  of,  747 
Peritoneum,  foreign  bodies  in,  773 

injuries  and  diseases  of,  772 

wounds  of,  773 
Peritonitis,  773 

adhesive  tubercular,  778 

appendicular,  760 

librino- plastic,  774 

plastic,  773 

saline  cathartics  in,  710 

septic,  774 

suppurative,  775 

treatment  of,  776 

tubercular,  777 
Perityphlitic  abscess,  47,  762 
Perityphlitis,  47,  760 
I'eri-urethral  abscess,  899 

treatment  of,  917 
Pernio,  480 
Pes  cavus,  356 

planus,  357 
Peteisen's  rectal  colpeurynter,  875 
Petil's  tourniquet,  1153 

triangle,  832 
Phagedena,  154 
Phagocytes,  3,  16 
Phagocytosis,  16 
Pharyngeal  tonsil,  598 
Pharynx,  afTections  of,  689 

carcinoma  of,  692 

congenital  malformations  of,  689 

diverticula  from,  689 

fistuhe  ot;  689 

lupus  of,  78 

tumors  of,  692 
Phimosis,  898,  962 

treatment  of,  916 
Phlebitis.  224 
Phleboliths,  226 
Phlclmtomy,  1184 
Phlegmonous  inflammation,  19 
Phosphalic  urine,  837 
Phos|)horus  necrosis  of  jaw,  683 
Phthisis  and  fistula  in  ano,  803 

of  larynx,  differential  diagnosis  of,  172 
Piles,  792 

bleeding,  795 

external,  794 

internal,  795 
Pirogofl's  amputation,  1165 
Placenta,  syphilis  of,  180 


INDEX. 


1219 


Phuiter,  adhesive,  1190 
breeches,  HIHJ 
splint,  2'.»0 
Plaster  of-Paris  bandage,  295 
dressing,  1181 
splints,  294 
in  synovitis,  387,  388 
Plastic  operations  on  bones,  1112 
on  muscles,  1111 
on  nerves,  1111 
surgery,  1104 
Pledgets,  1175 

Pleura,  injuries  and  diseases  of,  637 
Pleuritic  efliisions,  637 

operative  treatment  of,  639 
Plexus,  brachial,  exposure  of,  384 

cervical,  exposure  of,  384 
Pneumatocele,  503 
Pneuniectomy,  643 
Pneuniocele,  648 
Pneumotouiy,  643 
Polydactylism,  350 
Polypus,  nasal,  605 
nasopharyngeal,  607 
of  rectum,  805 
Port-wine  mark,  228,  504 
Potassium  permanganate  and  oxalic  acid  for 

disinfecting  hands,  1079 
Pott's  disease  of  spine,  79 
treatment  of,  569 
fracture,  330 
Poultices,  1190 
Powder  in  skin,  121 
Precentral  sulcus,  496 
Pregnancy,  extra- uterine,  1029 
Preparation  of  patient  for  operation,  1076 
of  surgeon,  assistants,  and  nurse  for  opera- 
tion, 1077 
Prepuce,  899,  916,  962 
Pressure,  digital,  for  aneurysm,  241 
Primary  syphilis,  142 
Probe,  Fluhrer's  aluminium,  526 
^selaton's,  117 

telephonic,  of  Girdner,  117,  528 
Procidentia  uteri,  972,  999 
Proctectomy,  806 
Proctotomy,  810 
Prolapse  of  anus,  797 
of  ovary,  1034 
of  rectum,  797 
of  uterus,  999 
of  vagina,  981 
Proliferation  of  cells,  15 
Prostatectomy,  943 
Prostate  gland,  anatomy  of,  939 
atrophy  of,  940 
calculus  of,  948 
diseases  of,  939 
hypertrophy  of,  940 
diagnosis  of,  942 
double  castration  for,  944 
pathology  of,  940 
symptoms  of,  942 
treatment  of,  942 

castration  in,  944 
Wiiite's  operation  for,  944 
injuries  of,  940 

malignant  disease  of,  942,  948 
tubercle  of,  947 
wounds  of,  940 


Prostatic  abscess,  917 
Prostatitis,  900,  947 

acute,  947 

chronic,  treatment  of,  918 

follicular,  acute,  907,  947 
chronic,  947 
treatment  of,  918 

gouty,  948 

parenchymatous,  947 

treatment  of,  917 

tul)ercular,  947 
Prostato-cystitis,  treatment  of,  917 
Prostatorrhea,  907 
Pruritus  ani,  799 

of  vulva,  970 
Psammoma,  205 
Pseudarthrosis,  300 
Pseudo-impotence,  953 
Pseudo-leukemia,  474 
Pseudo-oedema,  bacillus,  9 
Pseudopodia,  12 
Psoas  abscess,  46,  569 
treatment  of,  573 
Pterion,  491 
Ptomaines,  2 

in  traumatic  gangrene,  9 
Ptyalism,  672 
Pudendal  liematocele,  969 
Puncture,  1205 

of  bladder,  856 

exploratory,  949 

lumbar,  508 

of  subarachnoid  space,  507 
Pupil,  Argyll-Robertson,  535,  note 
Purulent  infiltration,  42 
Pus,  41 

blue,  41 

ichorous,  41 

sanious,  41 

tubercular,  76 
Pus-corpuscles,  41 
Pustule,  malignant,  128 
Putrescin,  2 

Pyelitis,  suppurative,  842 
Pyelonephritis,  842 
Pyemia,  63 

in  aneurj'sm,  234 

after  fractures,  293 

and  thrombosis  of  lateral  sinus,  541 
Pylorectomy,  725 
Pyloroplasty,  723 

Pylorus,  cicatricial  stricture  of,  digital  divul- 
sion  of,  723 

excision  of,  725 
Pyocyanine,  7 
Pyogenic  bacteria,  2 

cocci,  6 

membrane,  45 
Pyo-nephrosis,  842 
Pyosalpinx,  1026 
Pyothorax,  638 

Quilled  suture,  1085 
Quilted  suture,  1086 
Quinsy,  689 

Rabies,  84,  131 

Railroad  injuries  of  spine,  576 

Ranula,  218,  674 

Ray  fungus,  137 


1220 


INDEX. 


Kayiiaud's  disease,  55 
Keactions  i)f  degeneration,   35!) 
Keetal  oolpeurynler,   .^75 

insiilUatiou    oi  hydrgen  gas  (jr  filtered  air, 
730 
Rectocele,  1»72,  981 
Recto-urethral  fistnla-,  803 
Recto-vaginal  fistula,  804,  980 
Recto-vesical  fistula,  803 
Rectum,  abscess  of,  801 

cancer  of,  805 
diagnosis  of,  806 

condylomata  of,  183 

congenital  malformations  of,  790 

examination  of,  792 

excision  ot",  SOG 

foreign  bodies  in,  799 

imi)erforate,  790 

injuries  and  diseases  of,  789 

ojjening  into  bladder,  790 

polypus  of,  805 

prolapse  of,  797 

sarcoma  of,  805 

stricture  of,  809 

surgical  anatomy  of,  789 

syphilitic  ulceration  of,  804 

tubercular  ulceration  of,  804 

tumors  of,  805 

villous  growths  of,  805 

warty  growths  of,  805 

wounds  of,  799 
Reef  knot,  255 

Reflex,  definition  of,  561,  note 
Reid's  base  line,  540 
Relation    of   psorosperms  to   Paget's  disease, 

1052 
Relaxation  suture,  1086 
Renal  absc§ss,  642 

calculus,  838 

fistula,  846 

hemorrhage,  849 
Rei)air,  the  process  of,  25 
Resection,  1132 

of  ankle,  1148 

atypical,  1133 

of  bones  of  lower  extremity,  1150 
of  upper  extremity,  1145 

of  clavicle,  1141 

in  contiguitv,  1133 

of  foot,  1150 

formal  or  typical,  1133 

after  gunshot  wounds,  120 

of  hip,  1146 

informal  or  atypical,  1133 

intermediary,  1133 

of  interphalangeal  joint,  1146 

of  jaw,  lower,  1140 
upper,  1138 

of  knee,  1147 

of  liver,  portions  of,  784 

of  metacarpo-phalangeal  joint,  1146 

osteoplastic,  1133 
of  foot,  1150 
of  skull,  499 

primary,  1155 

of  ribs,  642 

of  scapula,  1141 

secondary,  1133 

of  shoulder,  1142 

of  wrist,  1145 


Residual  urine,  859 

Resolution,  20 

Respiratory  organs,  surgery  of,  589 

tract,  syphilis  of,  172 
Rest  in  joint-tuberculosis,  390 

after  operations,  1088 
Retention  cyst  of  gland  of  Bartholin,  971 

of  urine,  855 

treatment  of,  917 
Retraction  of  nipple  in  carcinoma,  1062 
Retractor  for  amputation,  1154 
Retro-i)eritoneal  tumors  and  cysts,  757 
Retro-pharyngeal  abscess,  509,  691 
treatment  of,  573 

tumors,  692 
Reverdin's  method  of  skin-grafting,  1107 
Rhalido-myoma,  202 
Rhachitis,  85,  185,  276 
Rheumatic  arthritis,  408 

of    the    temporo-maxillary    articulation, 
685 

gout,  409 

myositis,  335 
Rheumatism,  gonorrheal,  407,  903 
treatment  of,  919 

muscular,  335 
Rheumatoid  arthritis,  chronic,  409 
Rhigolene  spray,  1101 
Rhinoliths,  604 
Rhinophyma,  590 
Rhinoplasty,  612 
Rhinoscleroma,  590 
Rhiziform  bodies,  80,  339 
Rice  bodies,  80,  339 
Richter's  hernia,  821 
Rickets,  85,  276 

difierential  diagnosis  of,  185 
Rings,  Brockaw's,  737 

Senn's  707,  738 
Robb  and  Cihrisky's  bacteriological  study  of 

sutures,  1082 
Rodent  ulcer,  214,  487 
Rolando,  fissure  of,  491 

Chiene's  method  of  fixing,  492 
Rongeur  forceps,  499,  505 
Rontgen  (X)  rays,  use  of,  in  surgery,  1191 
Roseola,  syphilitic,  158 
Rose's  operation   on  the  Gasserian   ganglion, 

381 
Round  ligament,  hydrocele  of,  1048 

shortening  of,  996 
Rubefacients,  1182 
Rupia,  162 
Rupture,  810 

of  bladder,  857 

of  diaphragm,  650 

of  gall-bladder,  785 

of  intestines,  728 

of  liver,  783 

of  lung,  64(> 

of  muscle,  334 

of  ovarian  cyst,  1042 

of  perineum,  972 

of  sphincter  ani,  972 

of  spleen,  789 

of  stomach,  711 

of  tendon,  342 

of  urethra,  893 

of  uterus,  984 
Rydygier's  operation,  808 


JMu:x. 


1221 


Sat,  lionual,  Sll 

Sacral  tumor,  congenital,  ofil 

SatTo-iliac  joint  disease,  403 

tiiiiermlosis  of,  -lO.S 
Saline  cat liartirs  in  peritonitis.  710 

transfusion,  95,  11 S5 
Salivary  concretions  or  calculi,  doS,  G75  • 

list  M lie,  ()')7 

Inlands,  657 
Salivation,  ti72 
Salpini^itis,  \(\2.h 

Salt  solution,  transfusion  of,  9o,  11  So 
Sanious  pns,  41 

Saphenous  vein,  internal,  varix  of,  226 
Sapreinia,  (it),  61 
Saprogenic  l)acteria,  2 
Saprophytic  bacteria,  2 
Sarcocele,  syphilitic,  950 
Sarcoma  and  Sarcomata,  202 

alveolar,  205 

bacillus  i>rodigiosus  in,  treatment  of,  207 

of  bone,  280 

of  bones  of  skull,  506 

of  breast,  1060 

diagnosis  of,  207 

giant-celled,  205 

of  intestine,  756 

of  jaws,  685 

of  "kidney,  848    " 

of  lymphatic  glands,  474 

lymph 0-,  205 

melanotic,  205 

myeloid,  205 

nest-celled,  205 

prognosis  of,  207 

of  rectum,  805 

round-celled,  204 

of  skin,  488 

spindle-celled,  205 

subperiosteal,  206 

of  testicle,  951 

of  tonsils,  691 

toxins  of  erysipelas  in  treatment  of,  207 

treatment  of,  207 

of  uterus,  1025 
Suyres  dressing  for  fracture  of  clavicle,  308 

jacket,  571 

knee-splint,  398 
Scalds,  477 

of  larynx  and  trachea,  627 
Scalp,  abscesses  of,  509 

diseases  involving,  503 

fatty  tumors  of,  503 

horns  of,  503 

inflammation  of,  503 

moles  of,  503 

sebaceous  tumors  of,  503 

tumors  of,  503 

warts  of,  503 

wounds  of,  509 
Scaritication,  1183 
Scars,  hypertrophied,  505 

neuralgia  of,  363 
Schede's  operation,  642 
Schleich's  method  for  local  anaesthesia,  1102 
Sciatica,  363 

surgical  treatment  of,  364 
Scirrhous  carcinoma  of  breast,  1062 

carcinomata,  211 
Scirrhus,  atrophic,  211 


Scirrlni-i,  atrophic,  of  breast,  1062 

duration  of  life  in,  21 1 

of  testicle,  951 

withering.  211 
of  brea.st,  1063 
Scoliosis,  86,  563 
Scrofuloderma,,  77 
Scrofulous  abscess,  45,  77 
Scrotum,  diseases  of,  959 

elephantiasis  of,  960 

epithelioma  of,  960 

fcdema  of,  959 
Scurvy,  72 

Sebaceous  cysts,  217,  475 
of  scalp,  503 
of  vulva,  971 
Second  intention,  healing  by,  27 
Section,  abdominal.     See  Abdominal  section. 
S^dillot's  amputation,  1166 

method  of  removal  of  tongue,  681 
Senn's  bone  chips,  1112 

decalcified -bone  plate,  737,  738 

hydrogen  test,  706,  708,  728 
Separation  of  lower  epiphysis  of  humerus,  315 
Sepsin,  2 
Septic  infection,  60,  61 

inflammations  of  bone,  266 

intoxication,  3,  60 
Septicemia,  60 

in  aneurysm,  234 

after  fractures,  293 

temperature  of,  61 
Septum,  nasal,  deviation  of,  593 

perforating  ulcer  of,  593 
Sequestra,  269 
Sequestrotomy,  270 
Sequestrum,  269 
Serous  inflammation,  18 
Serpent-bites,  126 

Serum-therapy,  81.     See  Orrhotherapy.  ' 
Sex,  relation  of,  to  operations,  1074 
Shock,  92,  1071 

Shoulder,  cerebral  center  for,  497 
Shoulder-joint  disease,  401 
excision  in,  402 

tuberculosis  of,  401 
Silicate-of-soda  dressing,  1182 
Silk,  1081 
Silkworm  gut,  1081 
Silver-fork  deformity,  318 
Simple  ulcer  of  tongue,  679 
Sinus,  51 

cavernous,  thrombosis  of,  542 

frontal,  diseases  and  injuries  of,  608 

lateral,  pyemia  and  thrombosis  of,  541 

maxillary,  610 

petrosal,  thrombosis  of,  542 

sphenoidal,  609 
Sinuses  of  brain,  wounds  of,  517 
Skin,  carcinoma  of,  488 

malignant  di.seases  of,  487 

sarcoma  of,  488 

surgical  diseases  of,  475 

tuberci.ilosis  of,  76 
Skin-grafting,  Krause's  method,  1110 

Reverdin's  method,  1107 

Thiersch's  method,  1109 
Skull,  atrophy  of  bones  of,  505 

caries  of  bones  of,  505 

epithelioma  of,  506 


1222 


iyi)EX. 


Skull,  hvpertrophv  of  bones  of,  505 

necrosis  of  bones  of,  505 

osteitis  of  bones  of,  505 

periostitis  of  bones  of,  505 

points  named  by  Broca  in,  491 

sarcoma  of  bones  of,  506 

tumors  of,  506 
Sloughs,  54 

Smell,  cerebral  center  for,  498 
Smith,  Nathan  R.,  anterior  splint  of,  298 

Stephen,  amputation  of,  1166 
Snake-bites,  84,  126 
Sounding  for  urinarv  calculus,  864 
Spanish  flv,  1182 
Speech,  Broca's  center  for,  497 
Spermatic  cord,  diseases  of,  958 
hydrocele  of,  difbsed,  958 

encysted,  959 
lipomata  of,  958 

malignant  growths  of,  primary,  958 
Spermatorrhea,  953 
Sphenoidal  sinus,  609 
Sphincter  ani,  rupture  of,  972 
Sphincterismus,  798 
Spina  bifida,  558 
Spinal  cord,  compression  of,  578 
concussion  of,  577 
contusion  of,  577 
theca,  tapping  of,  570 
tumors  of,  561 
wounds  of,  578 

hemorrhage,  578 

jacket,  599 

meningocele,  559 

tumors,  560 
Spine,  access  of,  567,  569 

abscesses  of,  treatment  of,  573 

congenital  deformities  of,  558 

curvature  of  anterior,  566 
lateral,  563 
posterior,  565 

curvatures  of,  563 

dermoid  cysts  of,  560 

excurvation  of,  563,  565 

extramedullary  hemorrhage  of,  578 

incurvation  of,  563,  566 

intramedullary  hemorrhage  of,  579 

lipomata  of,  560 

neuralgia  of,  562 

Pott's  disease  of.  566 

sprains  of,  576 

surgery  of,  557 

tuberculosis  of,  566 

tumors  of,  560 
Spirillum,  1 
Spleen,  abscess  of,  789 

cysts  of,  789 

gunshot  wound  of,  789 

injuries  and  diseases  of,  789 

rupture  of,  789 

stabs  of,  789 

syphilis  of,  188 

tumors  of,  789 
Splenectomy,  789 
Splint,  plaster,  296 
Splinter  of  bone,  separation  of,  283 
Splints,  1091 

Gooch's  flexible  wooden,  294 

moulded,  294 

plaster-of-Paris,  294 


Splints,  wire-gauze,  294 

wooden,  294 
Spondylitis,  566 

deformans,  566 
S{H)nges,  1079 
SjMjres,  2 

effect  of  heat  on,  4 
Sprain,  416,  423,  576 

of  back,  576 
Sputa,  tubercle  bacilli  in,  5 
Squint.     See  Strabismus. 
Stab  wounds  of  abdomen,  702 
of  spleen,  789 
of  stomach,  712 
Staphylococci,  1,  8 
Staphylococcus  epidermis  albus,  1085,  1090 

pyogenes  albus,  6 
aureus,  6 
citreus,  6 

serum,  83 
Staphylorrhaphy,  693 
Static  electricity,  1188 
Stay-knot  of  Ballance  and  Edmunds.  33 
Stenosis,  cicatricial,  of  stomach,  715 

of  intestine,  non-malignant,  755 
Stenson's  duct,  cystic  dilatation  of,  658 

fistulae  of,  657 
Stephanion,  491 
Sterility,  953 

Sterilization,  methods  of  1077 
Sthenic  inflammation,  18 
Stomach,  carcinoma  of,  716 

cicatricial  stenosis  of,  715 

contusions  of,  711 

dilatation  of,  715,  716 

diseases  and  injuries  of,  711 

evacuation  of,  730 

foreign  bodies  in,  713 

gunshot  wounds  of,  712 

irrigation  of,  730 

lavage  of,  730 

operations  on,  718 

rupture  of,  711 

stab  wounds  of,  712 

suturing  of  wounds  of,  709 

ulcer  of,  713 

wounds  of,  711 
Stomatitis.  671 

mercurial,  672 
Stone  in  the  bladder.     See  CcUadus,  urinary. 
Strangulated  heniia,  819 

abdominal  section  in,  824 
after-treatment  of,  823 
diagnosis  of,  821 
symptoms  of,  820 
treatment  of,  822 
Strangulation   of  intestine  by  bands  or  diver- 
ticula, 754 

local  changes  from,  in  hernia,  820 

mechanism  of,  in  hernia,  819 

reduction  after,  822 
Streptococci,  1,  S3 
Streptococcus  erysipelatis,  7,  66 

pyogenes,  6 
Stricture  of  larynx  and  trachea,  619 

of  oesophagus,  696 

of  pylorus,  cicatricial,  digital  divulsioo  of,  722 

of  rectum,  809 

of  ureter,  851 

of  urethra.  926 


INDEX. 


1223 


Struma,  660 

Strumitis  iu  goitri-,  660 

Strumous  uUi-r  of  palate,  695 

Stumps,  neuralgia  of,  H63 

Suliararhnoiil  space,  puncture  of,  507 

Subclavian  artorv.  Keen's  metliod  of  compress- 

inp,  1160 __ 
Sublingual  cysts,  675 

gland,  659 
Subluxations,  423 

iu  knee-joint  disease,  399 
Submaxillary  angina,  infectious,  653 

gland,  diseases  of,  659 
Sulcus,  frontal,  inferior,  496 
superior,  4yt) 
precentral,  496 
vertical,  490 
Supernumerary  breasts,  1050 

digits,  350 
Suppuration,  36 

acute,  treatment  of,  26 
witb  bacteria,  7 
after  wounds,  107 
Suppurative  inflammation,  19 
Supramarginal  gyrus,  497 
Suprameatal  triangle,  539 
Suprapubic  cystotomy,  873 

lithotomy,  873 
Surgeon,  preparation  of,  for  operation,  1077 
Surgical  fever,  34 

kidney,  nephrectomy  in,  844 
scarlet  fever,  37 
Suspension  apparatus,  1091 
Suture  and  Sutures,  102,  1081 
buried,  1086 
button,  1085 
continuous,  1084 
Czemy-Lembert,  709,  745 
glover's,  1084 
interrupted,  1084 
Lembert,  709,  745 
of  nerve,  primary,  376 

secondary,  377 
quilled,  1085 
quilted,  1086 
relaxation,  1086 
secondary,  1086 
subcutaneous,  1086 
of  tendon,  342 
twisted,  1085 
Suturing,  methods  of,  1084 
Swedish  turnip  plaster,  737 
Sylvius,  fissure  of,  496 
Syme's  amputation,  1165 
Symphyseotomy,  986 
Symphysis,  pubic,  separation  of,  320 
Synchronous  operations,  1074 
Syndactylism,  349 
Synechia,  590 
Synovitis,  386 
pannous,  390 

plaster  of  Paris  in,  387,  388 
tubercular,  80 
urethral,  903 
Syphilides,  157 
palmar,  16© 
papular,  158 
papulo-squamous,  160 
plantar,  160 
pustular.  161 


Syphilides,  tubercular,  162 

differential  diagnosis  of,  163 
Svphilis,  139 
"bacillus  of,  9,  139 
of  bone,  167,  184,277 
of  breast,  1057 
cerebral,  170 

diagnosis  of,  171 
of  ear,  184 
general,  157 
hereditary,  176 
diiU-reiitial  diagnosis  of  osseous  lesions  of, 

1S5 
intermediate  period  of,  184 
pathology  and  symptoms  of,  180 
primary  stage  of,  181 
secondary  stage  of,  181 
treatment  of,  192 
inherited,  diagnosis  of,  189 

prognosis  of,  189 
intermediate  period,  141 
of  intestinal  tract,  172 
of  larynx,  189,  619 

differential  diagnosis  of,  172 
of  liver,  184 

mercurial  inunction  in,  175 
methods  of  transmission  of,  141 
of  mouth,  tertiary,  165 
of  muscles,  167 
of  neck,  655 

of  nerve-centers  and  nerves,  188 
of  nervous  system,  170 
period  of  primary  incubation,  140,  141 
of  primary  symptoms,  141 
of  secondary  incubation,  141 
of  secondary  symptoms,  141 
of  tertiary  symptoms,  141 
primary,  142 
of  respiratory  tract,  172 
secondary,  157 
of  spleen,  188 
of  teeth,  187 
of  testicles,  173,  189 
transmissibility  of,  177 

to  child,  179 
treatment  of,  174 
vapor  baths  of  mercury  in,  155 
Syphilitic  buboes,  155 
"orchitis.  950 

differential  diagnosis  of,  173 
osteojaeriostitis,  168 

diflferential  diagnosis  of,  186 
sarcocele,  950 
teeth,  687 

ulcers  of  palate,  695 

of  rectum,  804 

of  tongue,  676 

Syphilodermata,  157 

Syringo-myelia,  559 

Syringo-myelocele,  559 

Tabetic  arthropathy,  413 
Tagliacotian  method  of  rhinoplasty,  613 
Talipes,  353 

calcaneus,  353,  356 

congenital.  354 

equino-varus,  354 

equinus,  353 

non-congenital,  355 

valgus,  353,  356 


1224 


jyjiKX. 


TalijH^  variiis  iio3 
Tapping.     See  Ptuncfnttstis. 
Taxis,  822 

aUli^iuinnl,  731 

when  conlraindicated,  S22 

in  femoral  hernia,  strangulated.  829 

in  inguinal  liernia,  strangulatetl,  828 

methcHi  oi  }^>erforming,  S22 

in  un)bilic:il  ht-rnia,  strangulated,  831 
Teeth,  diseases  of,  t>86 

extraction  of,  687 

Hutihinson's,  187 

irre<.MiIarities  of,  6SS 

syphilitic.  1S7 
Telangiectasis.  227 

Tenn)oro-niaxilL'ir_v  articulation,    arthritis  of. 
685 
diseases  of,  685 
Tendon,  reflex,  561,  note 

lengthening  of.  '^mo 

regeneration  of.  31 

rupture  of.  342 
Tendon-sheaths,  tuberculosis  of,  80.  339 
Tendon-suture,  342 
Tendons,  dise.nses  and  injuries  of,  338 

displacement  of,  342 

wounds  of.  342 
Teno-svnovitis.  338 

chronic  tubercular,  339 

for  talii>es  equino-varus,  355 
Tents,  1175 
Teratomata,  216 
Testicle  and  Testicles,  carcinoma  of,  950 

iencephaloid>,   diflerential    diagnosis    of. 
173 

congenital  deformities  of,  949 

cystic,  951 

dise.ises  of.  949 

enchondroraa  of,  951 
V  hydrateil  951 

inflammation  of.  949 

malignant  disease  of,  950 

retaineil.  949 

sarcoma  of.  951 

scirrhus  of.  951 

syphilis  of,  173,  189 

tuberculosis  of,  78,  950 

undescended.  949 
Tetanus,  70 

acute,  70 

after  fractures.  293 

amputation  lor.  1152 

antitoxin.  72,  S3 

bacillus  of,  8.  70 

cephalic,  71 

hydrophobicus  71 

neonatorum,  71 

traumatic,  70 
Tetanv.  71 
Theciti.*.  338 

Thermocautery,  r.-npielin's.  1183 
Thermometers,  cliniad.  1189 
Thieriichs  niethotl  of  skin-grafting,  1109 

solution.  7o7 
Thomas's  long  splint,  396 
Thoracic  duct,  rupture  of,  463 
wound  of,  466 

viscera,  contusions  involving,  646 
Thoracoplasty,  641 
Thoracotomv,  640 


ThromlK>-phlebitis.  226 
Throml>osis,  58 

of  cavernous  sinus,  542 

of  i>etrosal  sinus,  542 

and  pyemia  of  lateral  sinus,  541 

white,  59 
Thrombus,  58 

white,  cure  of  aneurysm  by,  246 
Thyroid  IkhIv,  659 

laryngotomy,  622 

tumors  of.  6(i3 
Thyroidea  ima  artery,  629 
Thyroidectomy.  661 
Thyroiditis,  659 
Thyrotomy,  622 
Tic  convulsif.  362 
I      douloureux.  362 
Toe-nail,  ingrowing.  483 
Toilet  of  {>eritoneal  cavity,  747 
Tongue,  cancer  of.  677 

chancre  of.  147 

epithelioma  of.  165.  214,  215,  677 

loreign  bodies  in,  674 

gummata  of,  165,  677 

malformations  of.  672 

mucous  tubercles  of,  677 

nsevi  of.  674 

oj^>erations  on,  679 

papillomata  of,  674 

parenchymatous  int^ammation  of,  676 

removal  of,  entire,  679 
partial,  679 

swallowing  of,  672 

syphilis  of,  165,  676,  678 

tuberculosis  of,  77,  677 

tumoi^  of,  674 

ulcer  of,  tubercular.  677 

ulcerations  of.  diagnosis  from  chancre.  147 

warty  tumors  of,  673 

wounds  of.  673 
Tongue-tie,  672 

Tonsil  and  Tonsils,  calcareous  concretions  of. 
690 

carcinoma  of.  691 

caseous  concretions  of,  690 

chancre  of,  147 

faucial.  59$ 

hy|»erirophy  of  690 

lingual,  598 

lupus  of.  78 

malignant  tumors  of,  removal  of.  691 

pharyngeal,  598 

san-oma  of,  691 

tumors  of.  malignant,  691 
Tonsillitis,  689 
Tooth,  hemorrhage  after  extraction  of,  683 

tumors,  688 
Toothache,  688 
Tophi.  409 
Torsion,  2-55 

of  pedicle  t)f  ovarian  cyst,  1044 
Torticollis,  346 
Tourniquet  of  Petit,  1153 
Toxemia,  60 
Toxic  infection.  3 
Toxins,  2 
Trachea,  burns  and  scalds  of,  627 

tumors  of,  623 
Trachea -tubes,  630 
Trachelocele,  624 


INDEX. 


1225 


Tiacheotomy,  627,  628 

at'ter-treatiuent  of,  G31 

in  traotiire  of  larynx,  625 
Transfnsion  ol"  salt  solntion,  254,  1185 
Transmission  of  liereditary  syphilis,  177 

of  niii-robic  disease,  3 

of  syphilis,  141 
Traumatic  anenrysm,  240 

delirium,  37 

epilepsy,  550 

fevei-,  34 

gangrene,  53 
ptomaines  in,  9 

hysteria,  577 
Trendelonhurg's  position,  736,  1008 

operation  for  varicose  veins,  227 
Trephining  for  arrested  development,  556 

for  cerebral  abscess,  536 

in  fracture  of  skull,  rules  for,  520 

for  insanity  and  other  mental  disturbances, 
555" 

for  inveterate  headache,  555 
Triangle,  carotid,  inferior,  1116 
superior,  1115 

of  election,  1115 

Lesser's,  1118 

of  necessity,  1116 

supramental,  539 
Trismus,  71 

nascentium,  71 
Trunk,  cerebral  center  for,  497 
Truss,  812 

how  to  measure  for,  813 
Tubal  pregnancy,  1029 
diagnosis  of,  1031 
treatment  of,  1031 
Tubercle,  anatomical,  75 

bacillus  of,  74 

miliary,  74 

painful  subcutaneous,  366 
Tubercles,  mucous,  208 
Tubercular  arthritis,  388 

ascites,  778 

fistula,  78 

osteo-myelitis,  79 

peritonitis,  777 
adhesive,  778 

synovitis,  80 

ulcer  of  tongue,  677,  678 

ulceration  of  rectum,  804 
Tuberculin,  84,  656 
Tuberculosis,  74 

of  ankle-joint,  400 

of  bone,  79,  272 

of  breast,  78,  1057 

of  elbow-joint,  402 

of  genito-urinary  tract,  78 

of  hip-joint,  391 

of  intestinal  canal,  78 

of  joints,  80,  388 
diagnosis  of,  389 
prognosis  of,  390 
treatment  of,  390 

of  kidney,  847 

of  knee-joint,  398 

of  larynx,  620 

of  lymphatic  glands,  80 
of  neck,  6-53 

®f  mucous  membranes,  77 

of  muscles,  77 


Tuberculosis  of  panniculus  adiposus,  77 

of  sacro  iliac  joint,  403 

of  shoulder-joint,  401 

of  skin,  76 

of  the  spine,  79,  556 

of  tendon-sheaths,  80,  339 

of  testicle,  78 

of  tongue,  77,  077 

verrucosa,  77 

of  the  vertebrie,  79,  566 

of  vulva,  970 

of  wrist-joint,  403 
Tubes  and  ovaries,  removal  of,  1037 
TiiiliieU's  method  in  aneurysm,  238 
Tumor  albus,  80 
Tumors,  194 

of  antrum,  611 

of  bladder,  885 

of  bone,  277 

of  brain,  diagnosis  of,  547 
diflerential  diagnosis  of,  535 
prognosis  of,  548 
treatment  of,  550 

of  breast,  1057 

of  broad  ligament,  1048" 

cartilaginous,  199 

causes  of,  194 

of  cicatrices,  484 

classification  of,  196 

diagnosis  of,  196 

epiblastic  and  hypoblastic,  210 

erectile,  202 

of  Fallopian  tube,  1029 
malignant,  1048 

fatty,  198 
of  scalp,  503 

fibrous,  197 

fcetal,  561 

of  frontal  sinus,  609 

glandular,  202 

growth  of,  195 

intestinal,  756 

intracranial,  544 

intrathoracic,  644 

of  jaws,  684 

of  kidney,  solid,  848 

of  larynx,  621 

of  lips,  668 

of  liver,  782 

malignant,  amputations  for,  1152 

of  mesentery,  780 

mesoblaslic  or  connective-tissue,  197 

mucous,  201 

of  muscle,  337 

muscular,  202 

of  neck,  655 

of  nerves,  365 

of  nose,  605-607 

of  omentum,  779 

origin  of,  194 

osseous,  200 

ovarian,  1039 

of  ovary,  solid,  1048 

of  palate,  695 

of  parotid,  658 

of  pharynx,  692 

of  rectum,  805 

retro-pharyngeal,  692 

of  scalp,  503 

of  skull,  505 


1226 


INDEX. 


Tumors,  spinal,  560 

of  spinal  conl,  561 

of  spleen,  TS'.i 

of  siil)niaxillary  gland,  059 

of  thyroid,  005 

of  tongue,  073 

of  tonsils,  091 

tooth,  088 

of  trachea,  023 

treatment  of,  196 

of  litems,  1003 

of  vagina,  981 

vascular,  202 

villous,  208 

of  vulva,  971 

warty,  208 
Turpentine  stupe,  1182 
Typhlitis,  700 

Ulcer  and  Ulcers,  48 
acute,  49 
of  anus,  800 
atonic,  49 
callous,  50 

cancerous,  of  skin,  488 
chronic,  49 
erethistic,  49 
exuberant,  49 
of  foot,  perforating,  486 
healthy,  49 
irritable,  49 
of  larvnx,  618 
Marjo'lin's,  618 
neuro  paralytic,  48 
of  nose,  600 
painful,  49 
perforating,  of  foot,  48,  486 

of  nasal  se{Uum,  593 
phagedenic,  50 
rodent,  51,  214,  487 
simple,  of  tongue,  679 
specific,  51 
of  stomach,  713 
strumous,  of  palate,  695 
syphilitic,  of  palate,  695 
of  tongue,  678 
dee[),  677 
tubercular,  of  tongue,  677 
varicose,  49,  220 
Ulceration,  48 

of  new  growths,  210 

of  rectum,  syphilitic,  804 

tubercular,  804 
syphilitic,  of  palate,  695 
of  tongue,  syphilitic,  678 
Uranoplasty,  694 

Uremia,  differential  diagnosis  of,  513 
Ureter,  catheterization  of,  841 

stricture  of,  851 
Uretero-lithotomy,  839 
Ureterotomy,  889 
Uretero- ureterostomy,  850 
Ureters,  835,  067 
diseases  of,  835 
wounds  of,  850,  1022 
Urethra,  diseases  and  injuries  of,  868 
injuries  of,  893 

and  penis,  relative  sizes  of,  988 
rupture  of,  893 
stricture  of,  926 


Urethra,  stricture  of,  annular,  920 
deep,  impassable,  935 

])ermeable  only  to  filiform  bougies,  934 
inllanunatory,  920 
irritable,  927 
of  large  caliber,  929 

behind  the  bulbo-membranous  junction, 

933 
of  pendulous  portion,  930 
linear,  920 

of  meatus  and  fossa  navicularis,  932 
organic,  926 
resilient,  927 
of  small  caliber,  933 

of  small    caliber,    in    advance    of  bulbo- 
membranous  junction,  933 
deei)er  than  bulbo-membranous  junc- 
tion, 933 
spasmoilic,  92<) 
tortuous,  92() 
Urethral  arthritis,  407 
caruncle,  971 
catarrh,  905 

treatment  of,  914 
chancre,  150 
discharge,  chronic,  905 
treatment  of,  914 
persistent,  treatment  of,  914 
fever,  37,  893 
fistula,  936 

injections  in  early  stage  of  gonorrhea,  910 
svnovitis,  903 
Urethritis,  895 
antisepsis  in,  911 
in  female,  922 

treatment  of,  925 
simple,  890 
Urethrotomy,  external,  935 

internal,  934 
Urinar}'  calculus,  860 
deposits,  837 
fever,  893 
Urine,  bloody,  853 
chylous,  470 

examination  of,  before  operation,  1073 
extravasation  of,  857,  894,  936 
incontinence  of,  581,  856 
infiltration  of,  893 
phosphatic,  837 
residual,  859 
retention  of,  855 

treatment  of,  856,  917 
tubercle  bacilli  in,  5 
Uterine  ai)pendages.  ablation  of,  by  abdorainwl 
section,  1038 
removal  of,  ultimate  results  of,  1039 
gonorrhea,  923 
treatment  of,  925 
Utero-ventral  suture,  997 
Uterus,  anteflexion  of,  989 
anteversion  of.  989 
carcinoma  of,  1017 
displacem«nt  of,  989 
fibro-myomata  of,  1003 

treatment  of,  1005 
inflammations  of,  987 
inversion  of,  1002 
myomata  of,  1003 
prolapse  of,  999 
punctured  wounds  of,  984 


INDEX. 


1227 


Uterus,  reposition  of,  Dt'S 
retrolU'xion  of,  {•'••2 
retruvorsion  ot",  '.11)2 
rupture  of,  '.>X4 
sarcoiiKi  III",  1025 
surgery  of,  1025 
tumors  of,  1001^ 
wounds  of,  '.'SH 

Vaccination,  1 1H7 
Vacciuo-sypliilis,  147 
Vagina,  atresia  of,  i'7G 
closure  of,  il7'.) 
foreign  luulies  in,  OSl 
indaiuniation  of,  980 
injuries  of,  977 
malformations  of,  976 
prolapse  of,  981 
surgery  of,  976 
tumors  of,  981 
wounds  of,  977 
Vaginal  hysterectomy,  1020 
Vaginismus,  977 
Vaginitis,  921,  980 
chronic,  922 
treatment  of,  924 
Varicocele,  954 
Varicose  aneurysm,  248 
ulcer,  226 
veins,  225 
of  vulva,  972 
Varix,  225 

arterial,  230,437 
capillary,  505 

of  internal  saphenous  vein,  225 
Vas  deferens,  wounds  of,  959 
Vascular  tumors,  202 
Vein  and  \'eins,  axillary  wounds  of,  262 
complications  of  wounds  of,  261 
diseases  of,  223 
entrance  of  air  into,  1072 
femoral,  wounds  of,  262 
inflammation  of,  224 
jugular,  wounds  of,  262 
subclavian,  wounds  of,  262 
varicose,  225 

of  vulva,  972 
wounds  of,  261 
Vein-stones,  226 
Velpeau's  bandage,  1179 

dressing  for  fracture  of  clavicle,  337 
Velum,  lupus  of,  78 
Venereal  disease,  139 
Venesection,  1184 

Ventricles,  lateral,  surgery  of,  507,  542 
tai)ping  of,  in  hydrocephalus,  507 
puncture  of,  543 
Verruca  necrogenica,  77 
Verrucae,  482 

Vertebra^  tuberculosis  of,  79,  566 
Vertical  sulcus,  496 
Vesical  calculus.     See  Calculus,  Vesical. 

forceps  of  Thompson,  888 
Vesicants,  1182 
Vesico-vaginal  fietula,  977 
Villous  growths  of  rectum,  805 

tumors,  208 
Vision,  cerebral  center  for,  497 
Vitality  of  patient,   relation  ef,  to  operations 
1074 


Volkinann's  sliding  rest,  297 

splint,  294 
Volvulus,  753 
Vomiting  from  ether,  1089 
Von    Hacker's   method    in  intestinal  oljstruc- 

tion,  747 
Vulva,  dermoid  cysts  of,  971 

elephantiasis  of,  972 

inflammation  of,  920,  969 

injuries  of,  "J(J9 

lympliuiliMna  of,  972 

malignant  disease  of,  971 

papilloma  of,  971 

pruritus  of,  970 

sebaceous  cysts  of,  971 

surgery  of,  969 

tuberculosis  of,  970 

tumors  of,  971 

varicose  veins  of,  972 
Vulvitis,  920,  969 

treatment  of,  923,  970 
Vulvo-vaginal  abscess,  920,  971 

Wallerian  degeneration,  369 
Wardrop's  operation  for  aneurysm,  244 
Warts,  208,  482 
of  scalp,  503 
Warty  growths  of  rectum,  805 
tumors,  208 
of  tongue,  674 
Water,  boiling,  as  an  antiseptic,  1077 
Water-cushions,  1091 
Webbed  fingers,  349 
Wens,  475,  503 

Wharton's  duct,  calculi  in,  659 
Wheelhouse's  method  of  perineal  section,  937 
White's  operation,  944 
White  swelling,  80,  398 
Whitehead's  gag,  693 

operation  for  excision  of  piles,  797 
for  removal  of  entire  tongue,  680 
WhiUow,  47,  340 
Wilson's  cyrtometer,  494 
Withering"  scirrhus,  211,  1063 
Witzel's  method  of  performing  gastrostomy,  721 
Wool-sorters'  disease,  128 
Word-blindness,  546 

-deafness,  546 
Wound  fever,  primary,  34 

secondary,  34,  35 
Wounds,  89 

of  abdomen,  701 

arrest  of  hemorrhage  in,  707 
euterectomy  in,  709 
non-penetrating,  701 
omental  grafting  in,  710 
penetrating,  911 
diagnosis  of,  705 
incision  in,  707 
preparation  of  patient  for  operation  in, 

706 
symptoms  of,  704 
treatment  of,  706 
search  for  perforations  in,  708 
treatment  after  operation,  §10 
after-treatment  of,  106 
arrow  ,  121 
aseptic,  91 
cleansing  of,  100 
coaptation  of,  101 


1228 


INDEX. 


Wounds,  complications  of,  10() 
constitutional  treatment  of,  10') 
contused,  !•(),  1](» 

and  lacerated,  1 10 
dissection,  123 

dry  method  of  dressing,  1087 
erysipelas  after,  107 
gangrene  after,  107 
gunshot,  00,  113 

am|)utations  after.  120 

intermediary  jieriod  in,  120 
primiry  period  in,  120 
secondary  })eriod  in,  120 

probing  of,  117 

resections  after,  120 

treatment  of,  118 
healing  of,  25 
hemorrhage  after,  91,  99 
incised,  90,  109 
inflammation  after,  100 
of  intestine,  suturing  of,  709 
lacerated,  90,  110 

and  contused,  amputations  after,  1152 
local  treatment  of,  104 
open,  90 


Wounds,  open,  treatment  of,  118K 

pain  after,  91 

penetrating,  90.     See  Ahdomen,  Cluxi,  i-ic. 

perforating,  90.     See  Abdomen,  Chest,  etc. 

poisoned,  90,  112 

punctured,  90,  112 

repair  of,  97 

septic,  91 

of  sinu.se8  of  brain,  517 

subcutaneous,  90 
healing  of,  29 

suppuration  after,  107 

of  tongue,  732 

treatment  of,  99 
Wrist-drop,  374 
Wrist-joint  disease,  403 
erasion  in,  403 
excision  in,  403 

tuberculosis  in,  403 
Wry-neck,  346 
Wyeth's  amputation  at  hiii-joint,  1109 

A'- Rays,  1191 

ZOOGLKA,  1 


LIST  OF   INSTRUiAIENT-MAKERS'   CUTS. 


Acknowledgment  is  hereby  made  to  the  firms  named  below  for  the  use  of  the 
following  cuts : 

Geo.  Tiemann  »fe  Co.,  New  York  : 

Figs.  250,  251,  253,  254,  255,  263,  264,  265,  266,  347,  348,  350,  352,  354, 
355,  356,  357,  358,  360,  367,  496. 

J.  H.  Gemrig  &  Son,  Philadelphia: 

Figs.  215,  218,  240,  241,  242,  346,  349,  368. 

W.  F.  Ford  &  Co.,  New  York : 

Figs.  41,  42. 
Otto  Flemming,  Philadelphia : 

Fig.  219. 
E.  A.  Yarnall  Co.,  Philadelphia  • 

Fig.  216. 
Lentz  &.  Son,  Philadelphia : 

Fig.  169. 


CATALOGUE 

MEDICAL  PUBLICATIONS 

W.  B.  SAUNDERS, 

No.   925   WALNUT   STREET,   PHILADELPHIA. 


Arranged  Alphabetically  and  Classified  under  Subjects. 


THE  hooks  advertised   in  this  Catalogue  as  heing  sold  by  subscription  are  usually  to  he 
obtained  from  travelling  solicitors,  hut  they  will  he  sent  direct  from  the  office  of  pub- 
lication (charges  of  shipment  prepaid)  upon  receipt  of  the  prices  given.     All  the  other 
books  advertised  are  commonly  for  sale  by  booksellers  in  all  j)arts  of  the  United  States;  but 
books  will  be  sent  to  any  address,  carriage  prepaid,  on  receipt  of  the  published  price. 

Money  may  be  sent  at  the  risk  of  the  publisher  in  either  of  the  following  ways :  A  pos'c- 
ofhce  money  order,  an  express  money  order,  a  bank  check,  and  in  a  registered  letter.  Money 
sent  in  any  other  way  is  at  the  risk  of  the  sender. 

See  pages  30,  31,  for  a  List  of  Contents  classified  according  to  subjects. 


LATEST  PUBLICATIONS. 


American  Text-Book  of  Dis.  of  Eye,  Ear,  Nose,  and  Throat.    Page  3. 

American  Text-Book  of  Genito-Urinary  and  Skin  Diseases,    Page  4. 

American  Text-Book  of  Diseases  of  Children — Rev.  Edition.     Page  3. 

American  Text-Book  of  Gynecology — Revised  Edition.     See  page  4. 

American  Year-Book  of  Medicine  and  Surgery.     See  page  6. 

Anders^  Practice  of  Medicine — Revised  Edition.     See  page  6. 

Vierordt's  Medical  Diagnosis — Fourth  (Revised)  Edition.     See  page  29. 

Van  Valzah  and  Nisbet^s  Diseases  of  the  Stomach.     See  page  28. 

Church  and  Peterson's  Nervous  and  Mental  Diseases.     See  page  8. 

Da  Costa's  Surgery — Revised  and  Enlarged  Edition.     See  page  10. 

Saunders'  Medical  Hand-Atlases.     See  page  2. 

Griffith  on  The  Baby — Revised  Edition.     See  page  12. 

Butler's  Materia  Medica  and  Therapeutics — Revised  Edition.     Page  8, 

De  Schweinitz'  Diseases  of  the  Eye — Revised  Edition.     See  page  JO. 

Vecki's  Sexual  Impotence.    See  page  28. 

Stoney's  Materia  Medica  for  Nurses.     See  page  28. 

Penrose's  Diseases  of  Women — Second  Edition.     See  page  J  8. 

McFarland's  Pathogenic  Bacteria — Revised  Edition.    See  page  17, 

American  Pocket  Medical  Dictionary.     See  page  10. 

Stengel's  Text-Book  of  Pathology.     See  page  26. 

Hirst's  Text-Book  of  Obstetrics.    See  page  13. 

Graf  Strom's  Massage  and  Medical  Gymnastics.     Page  \2. 

Saunders'  Pocket  Formulary— Fifth  ( Revised )  Edition.     See  page  24. 

Stevens'  Practice  of  Medicine— Fifth  (Revised)  Edition.    See  page  27* 


SAUNDERS'  MEDICAL  HAND-ATLASES. 

The  series  of  books  included  under  this  title  consists  of  auiliorized  translations  into 
English  uf  the  world  famous  Lehmann  Medicinische  Handatlanten,  which  for  sci- 
entif  c  accuracy,  pictorial  beauty,  compactness,  ami  cheapness  surpass  any  similar 
volumes  ever  puljlisiied.  Eacii  volume  contanis  from  50  to  100  colored  plates,  executed 
by  the  most  skilful  (lerman  lilhopraphers,  besides  numerous  illustrations  in  the  text.  There 
is  a  full  and  appropriate  description  of  each  plate,  and  each  book  contains  a  condensed 
but  adequate  outline  of  the  subject  to  which  it  is  devoted. 

One  of  the  must  vaiual)le  features  of  these  atlases  is  that  they  offer  a  ready  and  satis- 
factory substitute  for  clinical  observation.  To  those  unable  to  attend  impoit.mt  clinics 
these  books  will  he  absolutely  indispensable. 

In  planning  this  series  ot  books  arrangements  were  made  with  representative  publishers 
in  the  chief  medical  centers  of  nhe  world  for  the  publication  of  translations  of  the  atlases 
into  nine  different  languages,  the  lithographic  plates  for  all  these  editions  being  made  in  Ger- 
many, where  work  of  this  kind  has  been  brought  to  the  greatest  perfection.  The  expense  of 
making  the  plates  being  shared  by  the  various  publi-shers,  the  cost  to  each  one  was  materially 
reduced.  Thus  by  reason  of  their  universal  translation  and  reproduction,  tlie  publish- 
ers have  been  enabled  to  secure  for  these  atlases  the  best  artistic  and  professional 
talent,  to  produce  them  in  the  most  elegant  style,  and  yet  to  offer  them  at  a  price 
heretofore  unapproached  in  cheapness.  The  success  of  the  undertakinjj  is  demon- 
strated by  the  fact  that  the  volumes  have  already  appeared  in  nine  different  languages 
— German,  English,  French,  Italian,  Russian,  Spanish,  Danish,  Swedish,  and  Hungarian. 

In  view  of  the  striking  success  of  these  works,  Mr.  Saunders  has  contracted  with  the 
publisher  of  the  original  German  edition  for  one  hundred  thousand  copies  of  the  atlases. 
In  consideration  of  this  enormous  undertaking,  the  jniblisher  has  been  enabled  to  prepare 
and  furnish  special  additional  colored  plates,  making  the  series  even  handsomer  and  more 
complete  than  was  originally  intended. 

As  an  indication  of  the  practical  value  of  the  atlases  and  of  the  favor  with  which  they 
have  been  received,  it  should  be  noted  that  the  Medical  Department  of  the  U.S.  Army 
has  adopted  the  "  Atlas  of  Operative  Surgery  "  as  its  standard,  and  has  ordered  the  book  in 
large  quantities  for  distribution  to  the  various  rejiiments  and  army  posts. 

The  same  careful  and  competent  editorial  supervision  has  been  secured  in  the 
English  edition  as  in  the  originals,  the  translations  being  edited  by  the  leading  American 
specialists  in  the  different  subjects. 

NOW  READY. 

Atlas  of  Internal  Medicine  and  Clinical  Diagnosis.  By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited 
bv  AuGUSTL'S  A.  KsHNKK,  M.U.,  Piofcssorol  Cliuical  Medicine  in  the  Philadelphia  Polvclinic;  At- 
tending Physician  to  the  Philadelphia  Hospital.  68  colored  plates,  and  64  illustrations  in  the  text. 
Cloth,  ;f3.oo  net. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited  by  Frederick  Peter- 
son. M.U..  Clinical  Professor  of  Mental  Diseases,  Woman's  Medical  College,  New  York;  Chief 
of  Clinic,  Nervous  Dept.,  College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  fig- 
ures on  56  plates,  and  193  beautiful  half-tone  illustrations.     Cloth,  J3.50  net. 

Atlas  of  Diseases  of  the  Larynx.  P.y  Dr.  L.  Grunwald,  of  Munich.  Edited  by  Charles  P. 
(iRAYSON,  M.D.,  i^ecturer  on  Laryngology  and  Rhinology  in  the  University  of  Pennsylvania; 
Physician-in-Charge,  Throat  and  Nose  Department,  Hospital  of  the  Univer-sity  of  Pennsylvania. 
With  107  colored  figures  on  44  plates,  and  25  text-illustrations.    Cloth,  $2.50  net, 

Atlas   of   Operative    Surgery.     Bv  I>r.  O.  Zitckkrkandl,  of  Vienna.     Edited    by  J.  Chalmers 

DaCosi  A,  .M.IJ.,  Clinical  Professor  of  Surgeiy,  Jetterson  Medical  College,  Philadelphia  ;  Surgeon 
to  the  Philadelphia  Hospital.     With  24  colored  plates,  and  217  text  illustrations.     Cloth,  53.00  net. 

Atlas  of  Syphilis  and  the  Venereal  Diseases.  By  Prof.  Dr.  F"ranz  Mrackk,  of  Vienna.  Edited 
by  L.  Bolton  Bangs,  M.D.,  latt  Professor  of  Genito-Urinary  and  Venereal  Diseases,  New  York 
Post-Graduate  Medical  School  and  Hospital.  With  71  colored  plates  from  original  water-colors, 
and  16  black-and-white  illustrations.     Cloth,  I3.50  net. 

IN  PREPARATION. 

Atlas  of  External  Diseases  of  the  Eye.  By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E. 
DE  ScHWEiNiTZ.  M.D.,  Ptofessor  of  Ophthalmology,  JeflFerson  Medical  College,  Philadelphia. 
With  100  colored  illustrations. 

Atlas  of  Skin  Diseases.    By  Prop.  Dr.  Franz  Mra?bk,  of  Vienna.    Edited  by  Henry  W.  Stelwagon, 

M.  D.,  Clinical  Professor  of  Dermatology,  Jefferson  Medical  College,  Philada.    80  colored  plates. 

Atlas  of  Pathological  Histology.  Atlas  of  Operative  Gynecology. 

Atlas  of  Orthopedic  Surgery.  Atlas  of  Psychiatry. 

Atlas  of  General  Surgery.  Atlas  of  Diseases  of  the  Ear. 


THE  AMERICAN  TEXT-BOOK  SERIES. 

AN  AMERICAN  TEXT=BOOK  OF  APPLIED  THERAPEUTICS. 

By  43  Distinguished  Practitioners  and  Teachers.  Edited  by  James  C. 
Wilson,  M.D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical 
Medicine  in  the  Jefferson  Medical  College,  Philadelphia.  One  hand- 
some imperial  octavo  volume  of  1326  pages.  Illustrated.  Cloth, 
^7.00  net;  Sheep  or  Half  Morocco,  $8.00  net.     Sold  by  Subscription. 

"  As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  of 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician." — Chicago  Clinical  Revinv. 

"The  whole  field  of  medicine  has  been  well  covered.  The,  work  is  thoroughly  prac- 
tical, and  while  it  is  intended  for  practitioners  and  students,  it  is  a  better  book  for  the  general 
practitioner  than  for  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpful." — The  Indiatt  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  DISEASES  OF  CHILDREN. 
Second  Edition,  Revised. 

By  65  Eminent  Contributors.  Edited  by  Louis  Starr,  M.  D.,  Con- 
sulting Pediatrist  to  the  Maternity  Hospital,  etc.  ;  assisted  by  Thomp- 
son S.  Westcott,  M.  D.,  Attending  Physician  to  the  Dispensary 
for  Diseases  of  Children,  Hospital  of  the  University  of  Pennsyl- 
vania. In  one  handsome  imperial  octavo  volume  of  1244  pages, 
profusely  illustrated.  Cloth,  ^7.00  net;  Sheep  or  Half  Morocco, 
^8.00  net.     Sold  by  Subscription. 

"This  is  far  and  away  the  best  text-book  on  children's  diseases  ever  published  in  the 
English   language,  and  is  certainly  the  one  which  is   best   adapted  to  American  readers. 
We  congratulate  the  editor  upon  the  result  of  his  work,  and  heartily  commend  it  to  the- 
attention  of  every  student  and  practitioner. ' ' — A/nerican  Journal  of  the  Medical  Sciences. 

AN  AMERICAN  TEXT=BOOK  OF  DISEASES  OF  THE  EYE,  EAR, 
NOSE,  AND  THROAT. 

By  58  Prominent  Specialists.  Edited  by  G.  E.  de  Schweinitz,  M.D  . 
Professor  of  Ophthalmology  in  the  Jefferson  Medical  College,  Phila- 
delphia ;  and  B.  Alexander  Randall,  M.D.,  Professor  of  Diseases 
of  the  Ear  in  the  University  of  Pennsylvania.  Imperial  octavo,  1251 
pages;  766  illustrations,  59  of  them  in  colors.  Cloth,  $7.00  net;  Sheep 
or  Half  Morocco,  $8.00  net.     Sold  by  Subscription. 

Illustrated  Catalogue  of  the  "American  Text-Books"  sent  free  upon  application. 


4  Medical  Publications  of  W.  B.  Saunders. 

AN  AMERICAN   TEXT-BOOK    OF   GENITO-URINARY  AND  SKIN 
DISEASES. 

By  47  Eminent  Specialists  and  Teachers.  Edited  by  L.  Bolton 
Bangs,  M.D.  ,  Late  Professor  of  Genito-Urinary  and  Venereal  Diseases, 
New  York  Post-Graduate  Medical  School  and  Hospital ;  and  W. 
A.  Hardaway,  M.D.,  Professor  of  Diseases  of  the  Skin,  Missouri 
Medical  College.  Imperial  octavo  volume  of  1229  pages,  with  300  en- 
gravings and  20  full-page  colored  plates.  Cloth,  $7.00  net;  Sheep 
or  Half  Morocco,  $8.00  net.     Sold  by  Subscription. 

"This  volume  is  one  of  the  best  yet  issued  of  the  publisher's  series  of '  American  Text- 
Books.'  The  list  of  contributors  represents  an  extraordinary  array  of  talent  and  extended 
experience.  The  book  will  easily  take  the  place  in  comprehensiveness  and  value  of  the 
half  dozen  or  more  costly  works  on  these  subjects  which  have  heretofore  been  necessary  to 
a  well-equipped  library." — A'e-w   York  Polyclinic. 

AN  AMERICAN  TEXT=BOOK  OF  GYNECOLOGY,  MEDICAL  AND 
SURGICAL.     Second  Edition,  Revised. 

By   ID   of  the  Leading   (iynecologists  of  America.      Edited  by  J.    M. 
Baldv,  M.  D.,  Professor  of  Gynecology  in  the  Philadelphia  Polyclinic, 
etc.     Handsome  imperial  octavo  volume  of  718  pages,  with  341   illus- 
trations in  the  text,  and  38  colored  and  half-tone  plates.     Cloth,  $6.00 
net;  Sheep  or  Half  Morocco,  $7.00  net.     Sold  by  Subscription. 
"  It  is  practical  from  beginning  to  end.     Its  descriptions  of  conditions,  its  recommen- 
dations for  treatment,  and   above  all   the   necessary  technique  of  different  operations,  are 
clearly  and  admirably  presented.     .     .     .     It  is  well  up  to  the  most  advanced  views  of  the 
day,  and  embodies  all  the  essential  points  of  advanced  American  gynecology.     It  is  destined 
to  make  and  hold  a  place  in  gynecological   literature  which  will  be  peculiarly  its  own." — 
Medical  Record,  New  York. 

AN  AMERICAN  TEXT-BOOK  OF  LEGAL  MEDICINE  AND  TOXI- 
COLOGY. 

Edited  by  Frederick  Peterson,  M.D.,  Clinical  Professor  of  Mental 
Diseases  in  the  Woman's  Medical  College,  New  York  ;  Chief  of  Clinic, 
Nervous  Department,  College  of  Physicians  and  Surgeons,  New  York ; 
and  Walter  S.  Haines,  M.D.,  Professor  of  Chemistry,  Pharmacy, 
and  Toxicology  in  Rush  Medical  College,  Chicago.     In  Preparation. 

AN  AMERICAN  TEXT=BOOK  OF  OBSTETRICS. 

By  15  Eminent  American  Obstetricians.  Edited  by  Richard  C.  Nor- 
Ris,  M.D.;  Art  Editor,  Robert  L.  Dickinson,  M.D.  One  handsome 
imperial  octavo  volume  of  1014  images,  with  nearly  900  beautiful  colored 
and  half-tone  illustrations.  Cloth,  $7.00  net ;  Sheep  or  Half  Morocco, 
$8.00  net.     Sold  by  Subscription. 

"  Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers." — Alkxander 
J.  C.  Skene,  Professor  of  Gynecology  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  Y. 

"  This  is  the  most  sumptuously  illustrated  work  on  midwifery  that  has  yet  appeared.  In 
the  number,  the  excellence,  and  the  beauty  of  production  of  the  illustrations  it  far  surpasses 
every  other  book  upon  the  subject.  This  feature  alone  makes  it  a  work  which  no  medical 
library  should  omit  to  purchase." — British  Aledical  Journal. 

"  As  an  authority,  as  a  book  of  reference,  as  a  '  working  book  '  for  the  student  or  prac- 
titioner, we  commend  it  because  we  believe  there  is  no  better." — American  Journal  of  the 
Medical  Sciences. 

Illustrated  Catalogue  of  the  ''American  Text-Books  "  sent  free  upon  application. 


Medical  Publications  of  W.  B.  Saunders.  5 

AN  AMERICAN  TEXT-BOOK  OF  PATHOLOGY. 

Edited  by  John  Guitkkas,  M.D.,  Professor  of  General  Pathology  and 
of  Morbid  Anatomy  in  the  University  of  Pennsylvania;  and  David 
RiESMAN,  M.D.,  Demonstrator  of  Pathological  Histology  in  the 
University  of  Pennsylvania.     In  Preparation. 

AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY. 

By  lo  of  the  Leading  Physiologists  of  America.  Edited  by  William 
H.  Howell,  Ph.D.,  M.D.,  Professor  of  Physiology  in  the  Johns  Hop- 
kins University,  Baltimore,  Md.  One  handsome  imperial  octavo 
volume  of  1052  pages.  Illustrated.  Cloth,  $6.00  net ;  Sheep  or  Half 
Morocco,  $7.00  net.     Sold  by  Subscription. 

"  We  can  commend  it  most  heartily,  not  only  to  all  .students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  subjects." — London  Lancet. 

•'  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  status  of  the  science  of  physiology  in  the 
English  language." — American  Journal  of  the  Medical  Sciences. 

AN  AMERICAN  TEXT=BOOK  OF  SURGERY.     Second  Edition. 

By  13  Eminent  Professors  of  Surgery.     Edited  by  William  W.  Keen, 
M.D.,  LL.D.,   and  J.   William   White,  M.D.,   Ph.D.      Handsome 
imperial  octavo  volume  of  1250  pages,  with  500  wood-cuts  in  the  text, 
and  39  colored  and  half-tone  plates.     Thoroughly  revised  and  enlarged, 
with  a  section  devoted  to  "  The  Use  of  the  Rontgen  Rays  in  Surgery." 
Cloth,  $7.00  net;  Sheep  or  Half  Morocco,  $8.00  net.     Sold  by  Sub- 
scription. 
♦'  Personally,  I  should  not  mind  it  being  called  THE  Text-Book  (instead  of  A  Text- 
Book)  ,  for  I  know  of  no  single  volume  which  contains  so  readable  and  complete  an  account 
of  the  science  and  art  of  Surgery  as  this  does." — Edmund  Owen,  F.R.C.S.,  Member  of 
the  Board  of  Examiners  of  the  Royal  College  of  Surgeons,  England. 

"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
London  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  THEORY  AND  PRACTICE 
OF  MEDICINE. 

By  12  Distinguished  American  Practitioners,  Edited  by  William 
Pepper,  M.D.,  LL.D.,  Professor  of  the  Theory  and  Practice  of  Medi- 
cine and  of  Clinical  Medicine  in  the  University  of  Pennsylvania.  Two 
handsome  imperial  octavo  volumes  of  about  1000  pages  each.  Illus- 
trated. Prices  per  volume  :  Cloth,  $5.00  net ;  Sheep  or  Half  Morocco, 
$6.00  net.     Sold  by  Subscription. 

*'  I  am  quite  sure  it  will  commend  itself  both  to  practitioners  and  students  of  medicine, 
and  become  one  of  our  most  popular  text-books." — Alfred  Loomis,  M.D.,  LL.D.,  Pro- 
fessor of  Pathology  afid  Practice  of  Medicine,  University  of  the  City  of  New  York. 

"  We  reviewed  the  first  volume  of  this  work,  and  said  :  '  It  is  undoubtedly  one  of  the 
best  text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the 
second  and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work 
is  in  our  opinion  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see." — New  York  Medical 
Jour7ial. 

Illustrated  Catalogue  of  the  "American  Text-Books^'  sent  free  upon  application. 


6  Medical  Publications  of  W.  B.  Saunders. 

AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SURGERY. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and 
investigators.  Collected  and  arranged,  with  critical  editorial  com- 
ments, by  eminent  American  specialists  and  teachers,  under  the  general 
editorial  charge  of  George  M.  Gould,  M.D.  One  handsome  imperial 
octavo  volume  of  about  1200  pages.  Uniform  in  style,  size,  and 
general  make-up  with  the  **  American  Text-Book"  Series.  Cloth, 
$6.50  net;  Half  Morocco,  $7.50  net.     So/d  by  Subscrip/ion. 

"  It  is  difficult  to  know  which  to  admire  most — the  research  and  industry  of  the  distin- 
guished band  of  experts  whom  Dr.  Gould  has  enhsted  in  the  service  of  the  Vear-Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  .  .  .  It  is  much  more  than  a  mere  compilation  of  abstracts, 
for,  as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the 
advantage  of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers 
fully  qualified  to  perform  these  tasks.  .  .  .  It  is  emphatically  a  book  which  should  find 
a  place  in  every  medical  library,  and  is  in  several  respects  more  useful  than  the  famous 
'  Jahrbiicher '  of  Geraiany. " — London  Lancet. 

THE  AMERICAN   POCKET  MEDICAL  DICTIONARY. 

[See  Do/iaiur s  Pocket  Dictionary,  page  10.] 

ANDERS'  PRACTICE  OF  MEDICINE.    Second  Edition. 

A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  In  one 
handsome  octavo  volume  of  1287  pages,  fully  illustrated.  Cloth, 
$5.50  net;  Sheep  or  Half  Morocco,  $6.50  net. 

"  It  is  an  excellent  book, — concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you  ;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 
James  C.  Wilson,  Professor  of  the  Practice  of  Medicine  and  Clinical  Aledicine,  Jefferson 
Medical  College,  Philadelphia. 

ASHTON'S  OBSTETRICS.     Fourth  Edition,  Revised. 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D.,  Pro- 
fessor of  Gynecology  in  the  Medico-Chirurgical  College,  Philadelphia. 
Crown  octavo,  252  pages;  75  illustrations.  Cloth,  $1.00;  interleaved 
for  notes,  $1.25. 

[See  Saunders'  Question- Coinpends,  page  21.] 

"  Embodies  the  whole  subject  in  a  nut-shell.     We  cordially  recommend  it  to  our  read 

ers." — Chicago  Medical  Times. 

BALL'S  BACTERIOLOGY.     Third  Edition,  Revised. 

Essentials  of  Bacteriology  ;  a  Concise  and  Systematic  Introduction 
to  the  Study  of  Micro-organisms.  By  M.  V.  Ball,  M.D.,  Bacteriol- 
ogist to  St.  Agnes'  Hospital,  Philadelphia,  etc.  Crown  octavo,  218 
pages;  82  illustrations,  some  in  colors,  and  5  plates.  Cloth,  $1.00; 
interleaved  for  notes,  $1.25. 

[See  Smmders'  Question- Compends,  page  21.] 

"  The  student  or  practitioner  can  readily  obtain  a  knowledge  of  the  subject  from  a  perusal 
of  this  book.     The  illustrations  are  clear  and  satisfactory." — Medical  Record,  New  York. 


Medical  Publications  of  W.  B.  Saunders.  7 

BASTIN'S  BOTANY. 

Laboratory  Exercises  in  Botany.  By  EnsoN  S.  Bastin,  M.A., 
late  Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.    Octavo  volume  of  536  pages,  with  87  jjlates.    Cloth,  $2.50. 

"It  is  unquestionably  the  best  text-book  on  the  subject  that  has  yet  appeared.  The 
work  is  eminently  a  practical  one.  We  regard  the  issuance  of  this  book  as  an  important 
event  in  the  history  of  pharmaceutical  teaching  in  this  country,  and  predict  for  it  an  unquali- 
fied success." — Alumni  /Report  to  the  Philadelphia  College  of  Pharmacy. 

"  Tliere  is  no  work  like  it  in  the  pharmaceutical  or  botanical  literature  of  this  country, 
and  we  predict  for  it  a  wide  circulation." — American  Journal  of  Pharmacy, 

BECK'S  SURGICAL  ASEPSIS. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.D.,  Surgeon  to 
St.  Mark's  Hospital  and  the  New  York  German  Poliklinik,  etc.  306 
pages;  65  text-illustrations,  and  12  full-page  plates.     Cloth,  $1.25  net. 

"  An  excellent  exposition  of  the  '  very  latest '  in  the  treatment  of  wounds  as  practised 
by  leadii'ig  German  and  American  surgeons." — Birtningham  (Eng. )  Medical  Review. 

"This  little  volume  can  be  recommended  to  any  wlio  are  desirous  of  learning  the  details 
of  asepsis  in  surgerj',  for  it  will  serve  as  a  trustworthy  guide." — Loiidon  Lancet. 

BOISLINIERE'S  OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND 
OPERATIONS. 
Obstetric  Accidents,  Emergencies,  and  Operations.     By  L.  Ch. 

BoiSLiNiERE,  M.D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis 
Medical  College.     381  pages,  handsomely  illustrated.    Cloth,  ;^ 2. 00  net. 

"  It  is  clearly  and  concisely  written,  and  is  evidently  the  work  of  a  teacher  and  practi- 
tioner of  large  experience." — British  Medical  Journal. 

"  A  manual  so  useful  to  the  student  or  the  general  practitioner  has  not  been  brought  to 
our  notice  in  a  long  time.  The  field  embraced  in  the  title  is  covered  in  a  terse,  interesting 
way." —  Yale  Afedical Journal. 

BROCKWAY'S  MEDICAL  PHYSICS.     Second  Edition,  Revised. 
Essentials  of   Medical   Physics.     By  Fred  J.  Brockwav,  M.D., 
Assistant  Demonstrator  of  Anatomy  in  the  College  of  Physicians  and 
Surgeons,  New  York.     Crown  octavo,  330  pages;   155  fine  illustrations. 
Cloth,  $1.00  net;  interleaved  for  notes,  $1.25  net. 

[See  Saunders'  'Question- Compends,  page  21.] 

"  The  student  who  is  well  versed  in  these  pages  will  certainly  prove  qualified  to  com 
prehend  with  ease  and  pleasure  the  great  majority  of  questions  involving  physical  principles 
likely  to  be  met  with  in  bis  medical  studies." — American  Practitioner  and  News. 

"We  know  of  no  manual  that  affords  the  medical  student  a  better  or  more  concise 
exposition  of  physics,  and  the  book  may  be  commended  as  a  most  satisfactory  presentation 
of  those  essentials  that  are  requisite  in  a  course  in  medicine." — New  York  Aledical  Journal. 

"  It  contains  all  that  one  need  know  on  the  subject,  is  well  written,  and  is  copiously 
illustrated." — Medical  Record,  New  York. 

BURR  ON  NERVOUS  DISEASES. 

A  Manual  of  Nervous  Diseases.  By  Charles  W.  Burr,  M.D., 
Clinical  Professor  of  Nervous  Diseases,  Medico-Chirurgical  College, 
Philadelphia ;  Pathologist  to  the  Orthopedic  Hospital  and  Infirmary 
for  Nervous  Diseases ;  Visiting  Physician  to  St.  Joseph's  Hospital,  etc. 
Jn  Preparation. 


8  Medical  Publications  of  W.  B.  Saunders. 

BUTLER'S  MATERIA  MEDICA,  THERAPEUTICS,  AND  PHAR- 
MACOLOGY. Second  Edition,  Revised. 
A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  i".  Butler,  Ph.G.,  M.D.,  Professor  of  Materia 
Medica  and  of  Clinical  Medicine  in  the  College  of  Physicians  and 
Surgeons,  Chicago ;  Professor  of  Materia  Medica  and  Therapeutics, 
Northwestern  University,  Woman's  Medical  School,  etc.  Octavo,  860 
pages,  illustrated.      Cloth,  $4.00  net ;    Sheep,  ;g5. 00  net. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory 
of  any  single-volume  works  on  materia  medica  in  the  market." — Journal  of  the  American 
Medical  Association. 

CERNA  ON  THE  NEWER  REMEDIES.  Second  Edition,  Revised. 
Notes  on  the  Newer  Remedies,  their  Therapeutic  Applications 
and  Modes  of  Administration.  By  David  Cerna,  M.D.,  Ph.D., 
formerly  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics 
in  the  University  of  Pennsylvania;  Demonstrator  of  Physiology  in  the 
Medical  Department  of  the  University  of  Texas.  Rewritten  and 
greatly  enlarged.     Post-octavo,   253  pages.     Cloth,  ^1.25. 

"  The  appearance  of  this  new  edition  of  Dr.  Cerna's  very  valuable  work  .shows  that  it 
is  properly  appreciated.  The  book  ought  to  be  in  the  possession  of  every  practising  physi- 
cian."— A^ezo  York  Alcdical  Journal. 

CHAPIN  ON  INSANITY. 

A  Compendium  of  Insanity.  By  John  B.  Chapin,  M.D.,  LL.D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane ;  late  Physi- 
cian-Superintendent of  the  Willard  State  Hospital,  New  York ;  Hon- 
orary Member  of  the  Medico-Psychological  Society  of  Great  Britain, 
of  the  Society  of  Mental  Medicine  of  Belgium.  i2mo,  234  pages, 
illustrated.     Cloth,  $1.25  net. 

"  The  practical  parts  of  Dr.  Chapin's  book  are  what  constitute  its  distinctive  merit.  We 
desire  especially  to  call  attention  to  the  fact  that  on  the  subject  of  therapeutics  of  insanity 
the  work  is  exceedingly  valuable.  It  is  not  a  made  book,  but  a  genuine  condensed  thesis, 
which  has  all  the  value  of  ripe  opinion  and  all  the  charm  of  a  vigorous  and  natural  style." — 
Philadelphia  Medical  Journal. 

CHAPMAN'S  MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 
Second  Edition,  Revised. 
Medical  Jurisprudence  and  Toxicology.  By  Henry  C.  Chapman, 
M.D.,  Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence 
in  the  Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55 
illustrations  and  3  full-page  plates  in  colors.     Cloth,  $1.50  net. 

"The  best  book  of  its  class  for  the  undergraduate  that  we  know  of." — Ne^u  York 
Medical  Times. 

CHURCH  AND  PETERSON'S  NERYOUS  AND  MENTAL  DISEASES. 
Nervous  and  Mental  Diseases.  By  Archihald  Church,  M.  D., 
Professor  of  Mental  Diseases  and  Medical  Jurisprudence  in  the  North- 
western University  Medical  School,  Chicago  ;  and  Frederick  Peter- 
son, M.  D. ,  Clinical  Professor  of  Mental  Diseases,  Woman's  Medical 
College,  N.  Y.;  Chief  of  Clinic,  Nervous  Dept.,  College  of  Physi- 
cians and  Surgeons,  N.  Y.  Handsome  octavo  volume  of  843  pages, 
profusely  illustrated.     Cloth,  ;^5.oo  net;   Half  Morocco,  |!6.oo  net. 


Medical  Publications  of  W.  B.  Saunders. 


CLARKSON'S  HISTOLOGY. 

A   Text-Book    of    Histology,    Descriptive   and     Practical.      By 

Arthur  Clarkson,  M.B.,  CM.  Edin.,  formerly  Demonstrator  of 
Physiology  in  the  Owen's  College,  Manchester;  late  Demonstrator  of 
Physiology  in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages; 
22  engravings  in  the  text,  and  174  beautifully  colored  original  illustra- 
tions.     Cloth,  strongly  bound,  ^6.00  net. 

"The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  textbooks, 
and  is  to  be  highly  recommended." — Neiu  York  Aledical  Joiirnal. 

"Tliis  is  one  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the 
book  will  attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 

CLIMATOLOGY. 

Transactions  of  the  Eighth  Annual  Meeting  of  the  American 
Climatological  Association,  held  in  Washington,  September  22-25, 
1891.  Forming  a  handsome  octavo  volume  of  276  pages,  uniform  with 
remainder  of  series.      (A  limited  quantity  only.)     Cloth,  $1.50. 

COHEN  AND  ESHNER'S  DIAGNOSIS. 

Essentials  of  Diagnosis.  By  Solomon  Solis-Cohen,  M.D.,  Pro- 
fessor of  Clinical  Medicine  and  Applied  Therapeutics  in  the  Philadel- 
phia Polyclinic  ;  and  Augustus  A.  Eshner,  M.D.,  Professor  of  Clinical 
Medicine  in  the  Philadelphia  Polyclinic.  Post-octavo,  382  pages;  55 
illustrations.     Cloth,  ^1.50  net. 

[See  Saunders'  Question- Compends,  page  21.] 

"  We  can  heartily  commend  the  book  to  all  those  who  contemplate  purchasing  a  'com- 
pend.'  It  is  modern  and  complete,  and  will  give  more  satisfaction  than  many  other  works 
which  are  perhaps  too  prolix  as  well  as  behind  the  times." — Medical  Review,  St.  Louis. 

CORWiN'S  PHYSICAL  DIAGNOSIS. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur 
M.  CoRWiN,  A.M.,  M.D.,  Demonstrator  of  Physical  Diagnosis  in  Rush 
Medical  College,  Chicago  ;  Attending  Physician  to  Central  Free  Dis- 
pensary, Department  of  Rhinology,  Laryngology,  and  Diseases  of  the 
Chest,  Chicago.    200  pages,  illustrated.   Cloth,  flexible  covers,  $1.25  net. 

"  It  is  excellent.  The  student  who  shall  use  it  as  his  guide  to  the  careful  study  of 
physical  exploration  upon  normal  and  abnormal  subjects  can  scarcely  fail  to  acquire  a  good 
working  knowledge  of  the  subject." — Philadelphia  Polyclinic . 

"A  most  excellent  little  work.  It  brightens  the  memory  of  the  differential  diagnostic 
signs,  and  it  arranges  orderly  and  in  sequence  the  various  objective  phenomena  to  logical 
solution  of  a  careful  diagnosis." — Journal  of  Nervous  and  Mental  Diseases. 

CRAGIN'S  GYN/ECOLOGY.     Fourth  Edition,  Revised. 

Essentials  of  Gynaecology.  By  Edwin  B.  Cragin,  M.  D.,  Lecturer 
in  Obstetrics,  College  of  Physicians  and  Surgeons,  New  York.  Crown 
octavo,  200  pages;  62  illustrations.     Cloth,  ^i.oo  ;  interleaved  for  notes, 

[See  Saunders'  Question- Compends,  page  21.] 

"  A  handy  volume,  and  a  distinct  improvement  on  students'  compends  in  general.  No 
author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the  student's  needs 
so  thoroughly  as  Dr.  Cragin  has  done." — Medical  Record,  New  York. 


10  Medical  Publications  of  W.  B.  Saunders. 

CROOKSHANK'S  BACTERIOLOGY.     Fourth  Edition,  Revised. 

A  Text-Book  of  Bacteriology.  By  Edgak  M.  Ckookshank,  M.B,, 
Professor  of  Comparative  Pathology  and  Bacteriology,  King's  College, 
London.  Octavo  volume  of  700  pages,  with  273  engravings  and  22 
original  colored  plates.     Cloth,  $6.50  net;  Half  Morocco,  §7. 50  net. 

"  To  the  student  who  wishes  to  obtain  a  good  resume  of  what  has  been  done  in  bacteri- 
ologj',  or  who  wishes  an  accurate  account  of  the  various  methods  of  research,  the  book  may 
be  recommended  with  confidence  that  he  will  find  there  what  he  requires.' — London  Lancet. 

Da  COSTA'S  SURGERY.  Second  Ed.,  Revised  and  Greatly  Enlarged. 
Modern  Surgery,  General  and  Operative.  By  John  Ch.\l.\iers 
D.^CosTA,  M.D.,  Clinical  Professor  of  Surgery,  Jefferson  Medical 
College,  Philadelphia;  Surgeon  to  the  Philadelphia  Hospital,  etc. 
Handsome  octavo  volume  of  900  pages,  profusely  illustrated.  Cloth, 
§4.00  net;  Half  Morocco,  $5. 00  net. 

"We  know  of  no  small  work  on  sui^ery  in  the  English  language  which  so  well  fulfils 
the  requirements  of  the  modem  student.'' — Medico-Chiruygical Journal,  Bristol,  England. 

DE  SCHWEINITZ  ON  DISEASES  OF  THE  EYE.      Third  Edition, 
Revised. 
Diseases  of   the  Eye,     A  Handbook   of   Ophthalmic   Practice. 

By  G.  E.  DE  ScHWEiNiTZ,  ^LD.,  Professor  of  Ophthalmology  in  the 
Jefferson  Medical  College,  Philadelphia,  etc.  Handsome  royal  octavo 
volume  of  696  pages,  with  256  fine  illustrations  and  2  chromo-litho- 
graphic  plates.     Cloth,  $4.00  net ;  Sheep  or  Half  Morocco,  $5.00  net. 

"  A  clearlj'  written,  comprehensive  manual.  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering 
upon  the  study  of  this  special  branch  of  medical  science." — British  Medical  Journal. 

"  A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.  I  am  satisfied  that  unusual  success  awaits  it.'" — William 
Pepper,  M.D.,  Professor  of  the  Theory  and  Practice  of  Medicine  and  Clinical  Medicine, 
University  of  Pennsylvania. 

DORLAND'S  DICTIONARY. 

The  American  Pocket  Medical  Dictionary.  Containing  the  Pro- 
nunciation and  Derivation  of  over  26,000  words  and  phrases,  and  a  large 
number  of  useful  tables.  Edited  by  W.  A.  Newman  Borland,  M.  p.. 
Assistant  Demonstrator  of  Obstetrics,  L'niversity  of  Pennsylvania  :  Fel- 
low of  the  American  Academy  of  Medicine.  518  pages;  handsomely 
bound  in  full  leather,  limp,  with  gilt  edges.     Price,  ^1.25  net. 

DORLAND'S  OBSTETRICS. 

A  Manual  of  Obstetrics.  By  W.  A.  Newman  Dorland,  ^LD., 
Assistant  Demonstrator  of  Obstetrics,  University  of  Pennsylvania; 
Instructor  in  Gynecology  in  the  Philadelphia  Polyclinic.  760  pages; 
163  illustrations  in  the  text,  and  6  full-page  plates.     Cloth,  $2.50  net. 

"  By  far  the  best  book  on  this  subject  that  has  ever  come  to  our  notice." — American 
Medieal  Rei'iew. 

"  It  has  rarely  been  our  duty  to  review  a  book  which  has  given  us  more  pleasure  in  its 
perusal  and  more  satisfaction  in  its  criticism.  It  is  a  veritable  encyclopedia  of  knowledge, 
a  gold  mine  of  practical,  concise  thoughts." — American  Medico- Surgical  Bulletin. 


Medical  Publications  of  W.  B.  Saunders. 


11 


FROTHINGHAM'S  GUIDE  FOR  THE  BACTERIOLOGIST. 

Laboratory  Guide  for  the  Bacteriologist.     By  Langdon  Froth- 

Tngham    M  D.V.,  Assistant  in  Bacteriology  and  Veterinary  Science, 

Sheffidd  Scientific  School,  Yale  University.    Illustrated.    Cloth,  75  cts. 

..  It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  neces- 

am  M<;fico-Sii?gic<jl  Bulletin. 

GARRIGUES'  DISEASES  OF  WOMEN.  Second  Edition.  Revised. 
Diseases  of  Women.  By  Henry  J.  Garrigues,  A.M.,  M.D  ,  Pro- 
fc  for  of  Gynecology  in  the  New  York  School  of  Clinical  Medicine ; 
Gy^roloSt  to  St^'Mark's  Hospital  and  to  the  Gern.an  Dispensary 
New  York  City,  etc.  Handsome  octavo  volume  of  728  pages  ^Hus^ 
trated  by  335  engravings  and  colored  plates.  Cloth,  ^4-00  net, 
Sheep  or  Half  Morocco,  $5.00  net. 

..  One  of  the  best  text-books  for  students  and  P-^titioners.^ich  has  been  publ.^^^^^^ 
the  English  language  ;  it  is  condensed    e,ea;,  and  -^^^^^^^^  •„  | 

^t^l^n^dlnSv:  t:^'  t;:::S^^litionersto  who^  expenenced^nsuUants 

GLEASON'S  DISEASES  OF  THE  EAR.  Second  Edition,  Revised. 
Essentials  of  Diseases  of  the  Ear.  By  E.  B  Gleason  S.B., 
MD  Clinical  Professor  of  Otology,  Medico-ChirurgK:al  College 
^;iUdelphia;  Surgeon-in-Charge  of  ^1- Nose  Throat,  and  Ear  Dep^^^^ 
ment  of  the  Northern  Dispensary,  Philadelphia.  208  pages,  ^Mth 
114  illustrations.  Cloth,  $1.00  ;  interleaved  for  notes,  $1.25. 
[See  Saunders'   Question- Compends,  page  21.] 

ramd^:'— Liverpool  Medico- Chi rurgica I  Joicrna I. 

GOULD  AND  PYLE'S  CURIOSITIES  OF  MEDICINE. 

Anomalies  and  Curiosities  of  Medicine.     By  George  M   Gould 
M  D  ,  and  Walter  L.   Pyle,  M.D.     An  encyclopedic  collection  of 
rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an 
xhaXeLearch  of  medical  literaUire  from  its  -gin^o  the  p.esen 
day,  abstracted,  classified,  annotated,  and  indexed.     Handsorne  im 
perial  octavo  volume  of  968  pages,  with  295  engravings  ^^    he  ^ex  , 
and  X 2  full-page  plates.     Cloth,  $6.00  net;  Half  Morocco,  $7-00  net. 
Sold  by  Subscription. 

"  One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is  so  far 
as  we  kn^w  absolutely  unique,  and  every  page  is  as  f--"f ^"^ -.^rrTferenS^o  all  wt 
the  medical  profession  has  this  volume  va  ue:  '^J'^^^Yco  leeal  tol^'-S^^^^^^^  Medical 
are  interested  in  general  scientific,  sociologic,  or  medico-legal  topics.  ^ 


^"7:This  is  certainly  a  most  -arkable  and  in..sth^^oUn^    It  -d.  aU^j^ng 

medical  literature,  an  anomaly  on  anomalies    m  that  there  >s  noumg  n 

medical  literature.     It  is  a  book  full  of  revelations  ^^'Z^J'^.'^ MedS-S^I^^^^^ 

but  interest  and  sometimes  almost  homfy  its  readers.   -American  Meduo  ^tirgic 


12  Medical  Publications  of  W.  B.  Saunders. 


QRAFSTROM'S   MECHANO-THERAPY. 

A  Text-Book  of  Mechano-Therapy  (Massage  and  Medical  Gym- 
nastics i.  I*)y  AxKi.  \'.  ('.KAi-sikoM,  B.  Sc,  M.  I).,  laic  Lieutenant  in 
the  Royal  Swedish  Army  ;  late  House  Physician  City  Hospital,  IJlack- 
well's  Island,  Xew  York.    i2mo,  139  i)ages,  illustrated.    Cloth,  $1.00  net. 

GRIFFITH  ON  THE  BABY.     Second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.D.,  Clini- 
cal Professor  of  Diseases  of  Children,  University  of  Pennsylvania ; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  i2mo,  404 
pages,  with  67  illustrations  in  the  text,  and  5  plates.      Cloth,  $1.50. 

"  The  best  book  for  the  use  of  the  young  mother  with  which  we  are  acquainted.  .  .  . 
There  are  very  few  general  practitioners  who  could  not  read  the  book  through  with  advan- 
tage. ' ' — Archives  of  Pediatrics. 

"The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a 
master  hand.  It  can  be  read  with  benefit  not  only  by  mothers  but  by  medical  students  and 
by  any  practitioners  who  have  not  had  large  opportunities  for  obser\'ing  children." — Ameri- 
can Journal  of  Obstetrics. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D.  , 
Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Penn- 
sylvania, etc.      25  charts  in  each  pad.      Per  pad,  50  cents  net. 

A  convenient  blank  for  keeping  a  record  of  the  child's  weight  during  the  first  two  years 
of  life.  Printed  on  each  chart  is  a  curve  representing  the  average  weight  of  a  healthy  infant, 
so  that  any  deviation  from  the  normal  can  readily  be  detected. 

GROSS,  SAMUEL  D.,  AUTOBIOGRAPHY  OF. 

Autobiography  of  Samuel  D.  Gross,  M.D.,  Emeritus  Professor  of 
Surgery  in  the  Jefferson  Medical  College,  Philadelphia,  with  Remi- 
niscences of  His  Times  and  Contemporaries.  Edited  by  his  Sons, 
Samuel  W.  Gross,  M.D.,  LL.D.,  late  Professor  of  Principles  of  Sur- 
gery and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and 
A.  Haller  Gross,  A.M.,  of  the  Philadelphia  Bar.  Preceded  by  a 
Memoir  of  Dr.  Gross,  by  the  late  Austin  Flint,  M.D.,  LL.D.  In 
two  handsome  volumes,  each  containing  over  400  pages,  demy  octavo, 
extra  cloth,  gilt  tops,  with  fine  Frontispiece  engraved  on  steel.  Price 
per  volume,  §2.50  net. 

"Dr.  Gross  was  perhaps  the  most  eminent  exponent  of  medical  science  that  America 
has  yet  produced.  His  Autobiography,  related  as  it  is  with  a  fulness  and  completeness 
seldom  to  be  found  in  such  works,  is  an  interesting  and  valuable  book.  He  comments  on 
many  things,  especially,  of  course,  on  medical  men  and  medical  practice,  in  a  very  interest- 
ing way." — The  Spectator,  London,  England. 

HAMPTON'S  NURSING.  Second  Edition,  Revised  and  Enlarged. 
Nursing:  Its  Principles  and  Practice.  Py  Isadii,  Adams  Hamp- 
ton, Graduate  of  the  New  York  Training  School  for  Nurses  attached 
to  Bellevue  Hospital ;  late  Superintendent  of  Nurses  and  Principal  of 
the  Training  School  for  Nurses,  Johns  Hopkins  Hospital,  Baltimore, 
Md.    12  mo,  512  pages,  illustrated.     Cloth,  ^2.00  net. 

"  Seldom  have  we  perused  a  book  upon  the  subject  that  has  given  us  so  much  jileasure 
as  the  one  before  us.  We  would  strongly  urge  upon  the  members  of  our  own  profession  the 
need  of  a  book  like  this,  for  it  will  enable  each  of  us  to  become  a  training  school  in  him- 
self"—  Ontario  Medical  Journal. 


Mediciil  Publications  of  W.  B.  Saunders.  13 

HARE'S  PHYSIOLOGY.  Fourth  Edition,  Revised. 

Essentials  of  Physiology.  By  H.  A.  Hark,  M.I).,  Professor  of 
'I'hcrapeutics  and  Materia  Medica  in  tlie  Jefferson  Medical  College  of 
rhilaciclphia.  Crown  octavo,  239  pages.  Cloth,  $1.00  net;  inter- 
leaved for  notes,  $1.25  net. 

[See  Saunders'  Quesiion-Compends,^2igQ  21.] 
"  The  best  condensation  of  physiological   knowledge  we   have  yet   seen."— Metrical 
Record,  New  York. 

HART'S  DIET  IN  SICKNESS  AND  IN  HEALTH. 

Diet  in  Sickness  and  in  Health.     By  Mrs.  Ernest  Hart,  formerly 
Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School 
of  Medicine    for  Women;    with   an    Introduction   by  Sir   Henry 
Thompson,  F.R.C.S.,  M.D.,  London.     220  pages.      Cloth,  $1.50. 
«  We  recommend  it  cordially  to  the  attention  of  all  practitioners ;  both  to  them  and  to 

their  patients  it  may  be  of  the  greatest  service.  "—A^rw   York  Medical  Journal. 

HAYNES'  ANATOMY. 

A  Manual  of   Anatomy.      By  Irving  S.   Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Depart- 
ment of  the  New  York  University,  etc.     680  pages,  illustrated  with  42 
diagrams    in  the    text,  and   134  full-page  half-tone  illustrations  from 
original  photographs  of  the  author's  dissections.      Cloth,  $2.50  net. 
"  This  book  is  the  work  of  a  practical  instructor— one  who  knows  by  experience  the 
requirements  of  the  average  student,  and  is  able  to  meet  these  requirements  in  a  very  satis- 
factory way.     The  book  is  one  that  can  be  coxaxaenAeA.'"— Medical  Record,  New  \  ork. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.D.,  Pro- 
fessor of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 
In  Preparalion. 

HIRST'S  OBSTETRICS. 

A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome 
octavo  volume  of  848  pages,  with  618  illustrations,  and  a  number  of 
colored  plates.  Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  $6.00  net. 
This  work  represents  the  very  latest  teaching  in  the  practice  of  obstetrics  by  a  man  of 

extended  experience  and  recognized  authority.     The  book  emphasizes  especially,  as  a  work 

on  obstetrics  should,  the  practical  side  of  the  subject,  and  to  this  end  presents  an  unusually 

large  collection  of  illustrations,  the  majority  of  them  original. 

HYDE  AND  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES. 
Syphilis  and  the  Venereal   Diseases.     By  James  Nevins   Hyde, 
M.D.,  Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Mont- 
gomery, M.D.,  Lecturer  on  Dermatology  and  Genito-Urinary  Diseases 
in  Rush  Medical  College,  Chicago,  111.    618  pages,  profusely  illustrated. 
Cloth,  $2.50  net. 
"  We  can  commend  this  manual  to  the  student  as  a  help  to  him  in  his  study  of  venereal 
diseases. ' ' — Liverpool  Medico- Ch irurgical  Journal. 

"The  best  student's  manual  which  has  appeared  on  the  subject."— 5/.  Louis  Medical 
and  Surgical  Journal. 


14  Medical  Publications  of  W.  B.  Saunders. 


JACKSON  AND  GLEASON'S  DISEASES  OF  THE  EYE,  NOSE,  AND 
THROAT.  Second  Edition,  Revised. 
Essentials  of  Refraction  and  Diseases  of  the  Eye.  By  I^dward 
Jackson,  A.M.,  M.U.,  Professor  of  Diseases  of  the  Kye  in  the  Phila- 
delphia Polyclinic  and  College  for  Graduates  in  Medicine;  and — 
Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  Bald- 
win CiLEASON,  M.D.,  Surgeon-in-Charge  of  the  Nose,  Throat,  and 
Ear  Department  of  the  Northern  Dis])ensary  of  Philadelphia.  Two 
volumes  in  one.  Crown  octavo,  290  pages;  124  illustrations.  Cloth, 
$1.00;  interleaved  for  notes,  Si-25- 

[See  Saunders'  Question- Compends,  page  21.] 

"Of  great  value  to  the  beginner  in  these  branches.  The  authors  are  both  capable  men, 
and  know  what  a  student  most  needs." — Medical  Record,  New  York. 

KEATING'S  DICTIONARY.     Second  Edition,  Revised. 

A  New  Pronouncing  Dictionary  of  Medicine,  with  Phonetic 
Pronunciation,  Accentuation,  Etymology,  etc.  By  John  M. 
Keating,  M.D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia; Vice-President  of  the  American  Paediatric  Society;  Editor 
"Cyclopaedia  of  the  Diseases  of  Children,"  etc.;  and  Henry 
Hamilton,  Author  of  "A  New  Translation  of  Virgil's  ^neid  into 
English  Rhyme,"  etc.;  with  the  collaboration  of  J.  Chalmers  Da- 
Costa,  M.D..  and  Frederick  A.  Packard,  M.D.  With  an  Appendix 
containing  Tables  of  Bacilli,  Micrococci,  Leucomaines,  Ptomaines; 
Drugs  and  Materials  used  in  Antiseptic  Surgery;  Poisons  and  their 
Antidotes ;  Weights  and  Measures ;  Thermometric  Scales ;  New 
Official  and  Unofficial  Drugs,  etc.  One  volume  of  over  800  pages. 
Prices,  with  Denison's  Patent  Ready-Reference  Index:  Cloth,  S5-oo 
net;  Sheep  or  Half  Morocco,  $6-00  net;  Half  Russia,  S6.50  net. 
AVithout  Patent  Index:  Cloth,  $4.00  net;  Sheep  or  Half  Morocco, 
$5.00  net. 

"  I  am  much  pleased  with  Keating"s  Dictionarj-,  and  shall  take  pleasure  in  recommend 
ing  it  to  my  classes." — Henry  M.  Lyman,  M.D.,  Professor  of  the  Principles  and  Practict 
of  Medicine,  Rush  Medical  College,  Chicago,  III. 

"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient 
in  size  and  sufficiently  full  for  ordinary  use." — C.  A.  Lindsley,  M.D.,  Professor  of  the 
Theory  and  Practice  of  Medicine,  Medical  Dept.   Yale  University. 

KEATING'S  LIFE  INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating, 
M.D.,  Fellow  of  the  College  of  Physicians  of  Philadelphia;  Vice- 
President  of  the  American  Paediatric  Society ;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages;  with  two  large  half-tone  illustrations,  and  a  plate  prepared  by 
Dr.  McClellan  from  special  dissections ;  also,  numerous  other  illustra- 
tions.    Cloth,  1 2. 00  net. 

"  This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination, 
a  subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume 
is  Part  II,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  If  for  these  alone,  the  book  should  be  at  the  right 
hand  of  every  physician  interested  in  this  special  branch  of  medical  science. ' ' —  The  Medical 
News. 


Medical  Publications  of  W.  B.  Saunders.  15 


KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The   Surgical  Complications  and   Sequels  of  Typhoid    Fever. 

By  Wm.  W.  Kkkn,  M.D.,  LL.D.,  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia; 
Corresponding  Member  of  the  Soci^te  de  Chirurgie,  Paris ;  Honorary 
Member  of  the  Societe  Beige  de  Chirurgie,  etc.  Octavo  volume  of 
386  pages,  illustrated.     Cloth,  ^3.00  net. 

"  This  is  probably  the  first  and  only  work  in  the  linglish  language  that  gives  the  reader 
a  clear  view  of  what  typhoid  fever  really  is,  and  what  it  does  and  can  do  to  the  human 
organism.  This  book  should  be  in  the  possession  of  every  medical  man  in  America." — 
Amencan  MeJico-Sitigicii/  Bulhtin. 

KEEN'S  OPERATION  BLANK.  Second  Edition,  Revised  Form. 
An  Operation  Blank,  with  Lists  of  Instruments,  etc.  Required 
in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.D.,  LL.D., 
Professor  of  the  Principles  of  Surgery  in  Jefferson  Medical  College, 
Philadelphia.  Price  per  pad,  containing  blanks  for  fifty  operations, 
50  cents  net. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.D., 
Clinical  Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical 
College,  Philadelphia ;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital ;  Bacteriologist  to  the  Philadelphia 
Orthopedic  Hospital,     hi  Preparation. 

LAINE'S  TEMPERATURE  CHART. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.D.  Size  8  x  13^ 
inches.  A  conveniently  arranged  Chart  for  recordiiig  Temperature, 
with  columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions, 
Food,  Remarks,  etc.  On  the  back  of  each  chart  is  given  in  full  the 
method  of  Brand  in  the  treatment  of  Typhoid  Fever.  Price,  per  pad 
of  25  charts,  50  cents  net. 

"  To  the  busy  practitioner  this  chart  will  be  found  of  great  value  in  fever  cases,  and 
especially  for  cases  of  typhoid.'' — Indian  Lancet,  Calcutta. 

LOCKWOOD'S  PRACTICE  OF  MEDICINE. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lock- 
wood,  M.D.,  Professor  of  Practice  in  the  Woman's  Medical  College 
of  the  New  York  Lifirmary,  etc.  935  pages,  with  75  illustrations  in 
the  text,  and  22  full -page  plates.      Cloth,  ^2.50  net. 

"  Gives  in  a  most  concise  manner  the  points  essential  to  treatment  usually  enumerated 
in  the  most  elaborate  works." — Massachusetts  Medical  Journal. 

LONG'S  SYLLABUS  OF  GYNECOLOGY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An 
American  Text=Book  of  Gynecology."  By  J.  W.  Long,  M.D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of 
Virginia,  etc.      Cloth,  interleaved,  $1.00  net. 

"  The  book  is  certainly  an  admirable  resume  of  what  every  gynecological  student  and 
practitioner  should  know,  and  will  prove  of  value  not  only  to  those  who  have  the  '  American 
Text-Book  of  Gynecology,'  but  to  others  as  well." — Brooklyn  Aledical Journal. 


16  Medical  Publications  of  W.  B.  Saunders. 


MACDONALD'S  SURGICAL  DIAGNOSIS   AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.D. 
Edin.,  F.R.C.S.,  Edin.,  Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery  in  Hamline  University;  Visiting  Surgeon  to  St. 
Barnabas'  Hosi)ital,  Minneapolis,  etc.  Handsome  octavo  volume  of 
800  pages,  profusely  illustrated.  Cloth,  $5.00  net;  Half  Morocco, 
$6.00  net. 

"  A  thorough  and  complete  work  on  surgical  diagnosis  and  treatment,  free  from  pad- 
ding, full  of  valuable  material,  and  in  accord  with  the  surgical  teaching  of  the  day." — The 
Medical  Netcs,  New  York. 

"The  work  is  brimful  of  just  the  kind  of  practical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  commend  the  book  because  of  its  intrinsic 
value  to  the  medical  practitioner." — Cincinnati  Lancet-Clinic. 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work 
in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on 
Post-Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank 
B.  Mallorv,  A.!NL,  ALD.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H.  Wright,  A.^L, 
M.D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston.  Octavo  volume  of  396  pages,  handsomely  illustrated.  Cloth, 
$2.50  net. 

"  I  have  been  looking  forward  to  the  publication  of  this  book,  and  I  am  glad  to  say  that 
I  find  it  to  be  a  most  useful  laboratory  and  post-mortem  guide,  full  of  practical  information, 
and  well  up  to  date." — William  H.  Welch,  Professor  of  Pathology,  Johns  Hopkins  Uni- 
versity, Baltimore,  Md. 

MARTIN'S  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 
DISEASES.  Second  Edition,  Revised. 
Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  Martin,  A.M.,  ^LD.,  Clinical  Professor  of 
Genito-Urinary  Diseases,  University  of  Pennsylvania,  etc.  Crown 
octavo,  166  pages,  with  78  illustrations.  Cloth,  $1.00  ;  interleaved  for 
notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"  A  very  practical  and  systematic  study  of  the  subjects,  and  shows  the  author's  famil- 
iarity with  the  needs  of  students." — Therapeutic  Gazette. 

MARTIN'S  SURGERY.     Sixth  Edition,  Revised. 

Essentials  of  Surgery.  Containing  also  Venereal  Diseases,  Surgi- 
cal Landmarks,  Minor  and  Operative  Surgery,  and  a  complete  de- 
scription, with  illustrations,  of  the  Handkerchief  and  Roller  Bandages. 
By  Edward  Martin,  A.M.,  RLD.,  Clinical  Professor  of  Genito- 
Urinary  Diseases,  University  of  Pennsylvania,  etc.  Crown  octavo,  338 
pages,  illustrated.  With  an  Appendix  containing  full  directions  for  the 
preparation  of  the  materials  used  in  Antiseptic  Surgery,  etc.  Cloth, 
Ji.oo;  interleaved  for  notes,  $1.25. 

[See  Sounders'  Question- Compends,  page  21.] 

"  Contains  all  necessary  essentials  of  modem  surgery  in  a  comparatively  small  space. 
Its  style  is  interesting,  and  its  illustrations  are  admirable." — Medical  and  Surgical  Reporter. 


Medical  Publications  of  W.  B.  iSautiders.  17 

McFARLAND'5  PATHOGENIC  BACTERIA.  Second  Edition.  Re- 
vised and  (jreatly  Enlarged. 
Text-Bool<  upcn  the  Pathogenic  Bacteria,  liy  Jo^kih  McKar- 
i.AN'D,  M.  1).,  I'rolc'ssor  ot"  Pathology  and  Ha(  tcriology  in  the  Medico- 
Chirurgical  College  ot  I'hikulelphia,  etc.  Octavo  volume  of  497  pages, 
finely  illustrated.     Cloth,  $2.50  net. 

"  Dr.  McFarland  lias  treated  the  subject  in  a  systematic  manner,  and  has  succeeded  in 
presenting  in  a  concise  and  readable  form  the  essentials  of  bacteriology  up  to  date.  Alto- 
gether, the  book  is  a  satisfactory  one,  and  I  shall  take  pleasure  in  recommending  it  to  the 
students  of  Trinity  College."  — H.  H.  Andkrson,  M.D.  ,  Professor  of  Patholoj^y  and  BaC' 
teriology.  Trinity  Medical  College,  Toronto. 

MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  Arthur  V,  Meigs,  M.D.  Bound 
in  limp  cloth,  flush  edges,  25  cents  net. 

"This  pamphlet  is  worth  many  times  over  its  price  to  the  physician.  The  author's 
experiments  and  conclusions  are  original,  and  have  been  the  means  of  doing  much  good." — 

Medical  Bulletin. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.D., 
Professor  of  Orthopedics  and  Adjunct  Professor-  of  Clinical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo 
volume  of  356  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

"  A  most  attractive  work.  The  illustrations  and  the  care  with  which  the  book  is  adapted 
to  the  wants  of  the  general  practitioner  and  the  student  are  worthy  of  great  praise." — Chicago 
Medical  Recorder. 

"A  very  demonstrative  work,  every  illustration  of  which  conveys  a  lesson.  The  work  is 
a  most  excellent  and  commendable  one,  which  we  can  certainly  endorse  with  pleasure." — 
St.  Louis  Medical  and  Surgical  Journal. 

MORRIS'S  MATERIA  MEDICA  AND  THERAPEUTICS.  Fifth 
Edition,  Revised. 
Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription- 
Writing.  By  Henry  Morris,  M.D.,  late  Demonstrator  of  Thera- 
peutics, Jefferson  Medical  College,  Philadelphia,  Fellow  of  the  College 
of  Physicians,  Philadelphia,  etc.  Crown  octavo,  288  pages.  Cloth, 
;^i.oo  ;  interleaved  for  notes,  gi.25. 

[See  Saunders^  Question- Comfends,  page  21.] 

"  This  work,  already  excellent  in  the  old  edition,  has  been  largely  improved  by  revi- 
sion." — American  Practitioner  and  News. 

MORRIS,  WOLFF,  AND  POWELL'S  PRACTICE  OF  MEDICINE. 
Third  Edition,  Revised. 
Essentials  of  the  Practice  of  Medicine.  By  Henry  Morris,  M.D., 
late  Demonstrator  of  Therajjeutics,  Jefferson  Medical  College,  Phila- 
delphia; with  an  Appendix  on  the  Clinical  and  Microscopic  Examina- 
tion of  Urine,  by  Lawrence  Wolff,  M.D. ,  Demonstrator  of  Chemistry, 
Jefferson  Medical  College,  Philadelphia.  Enlarged  by  some  300  essen- 
tial formulae  collected  and  arranged  by  William  M.  Powell,  M.D. 
Post-octavo,  488  pages.     Cloth,  $2.00. 

[See  Saunders'  Question- Compends,  page  21.] 

"  The  teaching  is  sound,  the  presentation  graphic  ;  matter  full  as  can  be  desired,  and 
style  attractive." — American  Practitioner  and  News. 


18  Medical  Publications  of  W.  B.  Saunders. 


MORTEN'S  NURSE'S  DICTIONARY. 

Nurse's  Dictionary  of  Medical  Terms  and  Nursing  Treat- 
ment. Containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms  and  Abbreviations ;  of  the  Instruments,  Drugs,  Diseases,  Acci- 
dents, Treatments,  Operations,  Foods,  Appliances,  etc.  encountered 
in  the  ward  or  in  the  sick-room.  By  Honnor  Morten,  author  of 
*'  How  to  Become  a  Nurse,"  etc.     i6mo,  140  pages.      Cloth,  $1.00. 

"  A  handy,  compact  little  volume,  containing  a  large  amount  of  general  information,  all 
of  which  is  arranged  in  dictionary  or  encyclopedic  form,  thus  facilitating  quick  reference. 
It  is  certainly  of  value  to  those  for  whose  use  it  is  published." — Chicago  Clinical  Review. 

NANCREDE'S  ANATOMY.     Fifth  Edition. 

Essentials  of  Anatomy,  including  the  Anatomy  of  the  Viscera. 
By  Charles  B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clini- 
cal Surgery  in  the  University  of  Michigan,  Ann  Arbor.  Crown  octavo, 
388  pages;  180  illustrations.  With  an  Appendix  containing  over  60 
illustrations  of  the  osteology  of  the  human  body.  Based  upon  Gray' s 
Anatomy.  Cloth,  gi.oo;  interleaved  for  notes,  $1.25. 
[See  Saunders'  Question- Compends,  page  21.] 

"  For  self-quizzing  and  keeping  fresh  in  mind  the  knowledge  of  anatomy  gained  at 
school,  it  would  not  be  easy  to  speak  of  it  in  terms  too  favorable." — American  Practitioner. 

NANCREDE'S  ANATOMY  AND  DISSECTION.     Fourth  Edition. 
Essentials  of  Anatomy  and    Manual  of    Practical    Dissection. 

By  Charles  B.  Nancrede,  M.D.  ,  Professor  of  Surgery  and  of  Clinical 
Surgery,  University  of  Michigan,  Ann  Arbor.  Post-octavo ;  500  pages, 
with  full-page  lithographic  plates  in  colors,  and  nearly  200  illustrations. 
Extra  Cloth  (or  Oilcloth  for  the  dissection-room),  ^2.00  net. 

"  It  may  in  many  respects  be  considered  an  epitome  of  Gray's  popular  work  on  general 
anatomy,  at  the  same  time  having  some  distinguishing  characteristics  of  its  own  to  commend 
it.  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students 
in  their  work  in  the  dissecting  room." — Journal  of  the  A7nerican  Medical  Association. 

NORRIS'S  SYLLABUS  OF  OBSTETRICS.  Third  Edition,  Revised. 
Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department 
of  the  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.M.,  M.D.,  Demonstrator  of  Obstetrics,  University  of  Pennsylvania. 
Crown  octavo,  222  pages.     Cloth,  interleaved  for  notes,  $2.00  net. 

"This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in 
calling  attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner." — Medical  Record,  New  York. 

PENROSE'S  DISEASES  OF  WOMEN.     Second  Edition,  Revised. 
A  Text=Book  of  Diseases  of  Women.     By  Charles  B.  Penrose, 
M.D.,  Ph.D.,  Professor  of  Gynecology  in  the  University  of  Pennsyl- 
vania;   Surgeon    to   the   Gynecean    Hospital,    Philadelphia.     Octavo 
volume  of  529  pages,  handsomely  illustrated.     Cloth,  $3.50  net. 

"I  shall  value  very  highly  the  copy  of  Penrose's  'Diseases  of  Women'  received. 
I  have  already  recommended  it  to  my  class  as  THE  BEST  book."— Howard  A.  Kelly. 
Professor  of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore,  Md. 

"  The  book  is  to  be  commended  without  reserve,  not  only  to  the  student  but  to  the 
general  practitioner  who  wishes  to  have  the  latest  and  best  modes  of  treatment  explained 
with  absolute  clearness." — Therapeutic  Gazette. 


Medical  Publications  of  W.  B.  Saunders.  19 


POWELL'S  DISEASES  OF  CHILDREN.     Second  Edition. 

Essentials  of  Diseases  of  Children,  liy  William  M.  Powell, 
M.D.,  Attending  Physician  to  tlie  Mercer  House  for  Invalid  Women 
at  Atlantic  City,  N.  J.  ;  late  Physician  to  the  Clinic  for  the  Diseases  of 
Children  in  the  Hospital  of  the  University  of  Pennsylvania.  Crown 
octavo,  222  pages.  Cloth,  ^i.oo;  interleaved  for  notes,  51.25. 
[See  Saunders'  Question- Compends,  page  21.] 

"Contains  the  gist  of  all  the  best  works  in  the  department  to  which  it  relates." — 
American  Practitioner  and  Ne7vs. 

PRINQLE'S  SKIN  DISEASES  AND  SYPHILITIC  AFFECTIONS. 
Pictorial  Atlas  of  Skin  Diseases  and  Syphilitic  Affections 
(American  Edition).  Translation  from  the  French.  Edited  by 
1.  |.  Pringle,  M.E.,  F.R.C.P.,  Assistant  Physician  to  the  Middlesex 
Hospital,  London.  Photo-lithochromes  from  the  famous  models  in 
the  Museum  of  the  Saint-Louis  Hospital,  Paris,  with  explanatory  wood- 
cuts and  text.  In  12  Parts.  Price  per  Part,  ^3.00.  Complete  in 
one  volume.  Half  Morocco  binding,  $40.00  net. 

"  I  strongly  recommend  this  Atlas.  The  plates  are  exceedingly  well  executed,  and 
will  be  of  great  value  to  all  studying  dermatology."— Stephen  Mackenzie,  M.D. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — New  York  Medical  Journal. 

PYE'S  BANDAGING. 

Elementary  Bandaging  and    Surgical  Dressing.      AVith  Direc- 
tions concerning  the  Immediate  Treatment  of  Cases  of  Emergency. 
For  the  use  of  Dressers  and  Nurses.     By  Walter  Pve,  F.R.C.S.,  late 
Surgeon  to  St.  Mary's  Hospital,  London.     Small  i2mo,  with  over  80 
illustrations.      Cloth,  flexible  covers,  75  cents  net. 
"  The  directions  are  clear  and  the  illustrations  are  good." — London  Lancet. 
"  The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  port- 
able, although  the  paper  and  type  are  good." — British  Medical  Journal. 

RAYMOND'S  PHYSIOLOGY. 

A  Manual  of  Physiology.  By  Joseph  H.  Raymond,  A.M.,  M.D., 
Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in 
the  Long  Island  College  Hospital ;  Director  of  Physiology  in  the 
Hoagland  Laboratory,  etc.  382  pages,  with  102  illustrations  in  the 
text,  and  4  full -page  colored  plates.      Cloth,  ^1.25  net. 

'« Extremely  well  gotten  up,  and  the  illustrations  have  been  selected  with  care.  The 
text  is  fully  abreast  with  modern  physiology." — British  Medical  Journal. 

RONTGEN  RAYS. 

Archives  of  the  Rontgen  Ray  (Formerly  Archives  of  Clinical 
Skiagraphy).  Edited  by  Sydney  Rowland,  M.A.,  M.R.C.S.,  and 
W.  S.  Hedley,  M.D.,  M.R.C.S.  A  series  of  collotype  illustrations, 
with  descriptive  text,  illustrating  the  applications  of  the  new  photo- 
graphy to  Medicine  and  Surgery.  Price  per  Part,  $1.00.  Now  ready: 
Vol.  I  ,  Parts  I.  to  IV.:  Vol.  II.,  Parts  I.,  II. 


Jgp^" 


Saunders' 
Question 
compends 


Arranged  in  Question  and 
Answer  Form, 

npHE  MOST  COMPLETE  AND  BEST 
ILLUSTRATED  SERIES  OF 

COMPENDS  EVER  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature  .... 

with  Students  and  Practitioners  in  every  City  of  the  United  States  and  Canada. 


O- 


OVER  J  65,000  COPIES  SOLD. 


'•<* 
-o 


THE  REASON  WHY. 


They  are  the  advance  guard  of  "Student's  Helps" — that  DO  help.  They  are  the 
leaders  in  their  special  line,  well  and  authoritatively  written  by  able  men,  who,  as  teachers  in 
the  large  colleges,  know  exactly  what  is  wanted  by  a  student  preparing  for  his  examinations. 
The  judgment  exercised  in  the  selection  of  authors  is  fully  demonstrated  by  their  professional 
standing.  Chosen  from  the  ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of 
them  have  become  Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250  pages, 
profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on  fine  paper. 

The  entire  series,  numbering  twenty-three  volumes,  has  been  kept  thoroughly  revised 
and  enlarged  when  necessary,  many  of  the  books  being  in  their  fifth  and  sixth  editions. 

TO  SUM  UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  market,  none  of 
them  approach  the  "Blue  Series  of  Question  Compends  ;"  and  the  claim  is  made  for  the 
following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  nuthors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Quality  of  illustrations,  paper,  printing,  and  binding. 

Any  of  these  Compends  will  be   mailed  on  receipt  of  price  (see  next  page  for  Ltst)» 


Oaunders^  Question-Compend  Series* 

Price,  Cloth,  $J.OO  per  copy,  except  when  otherwise  noted. 


"Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the 
Saunders  Series,  in  our  opinion,  bears  off  the  palm  at  present."— A«c  york  Medical  Record. 


1.  ESSENTIALS  OF  PHYSIOLOGY.     By  II.  A.   Hare,  M.D.    Fourth  edition, 

revised  and  enlarged.      (3l.oo  net.) 

2.  ESSENTIALS   OF   SURGERY.     By  Kdward  Martin,  M.D.      Sixth  edition, 

revised,  with  an  Appendix  on  Antiseptic  Surgery. 

3.  ESSENTIALS   OF    ANATOMY.      By  Charlks   B.    Nancrede,   M.D.     Fifth 

edition,  with  an  Appendix. 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

By  L.wvrence  Wolff,  M.D.     Fourth  edition,  revised,  with  an  Appendix. 

5.  ESSENTIALS  OF  OBSTETRICS.     By  W.  Easterly  Ashton,  M.D.     Fourth 

edition,  revised  and  eidarged. 

6.  ESSENTIALS  OF   PATHOLOGY  AND  MORBID  ANATOMY.     By  C.  E. 

Ak.\l^nd  Semple,  M.D. 

7.  ESSENTIALS  OF  MATERIA  MEDICA,  THERAPEUTICS,  AND   PRE- 

SCRIPTION=WRITING.    By  Henry  Morris,  M.D.       Fifth  edition,  revised. 

8.  9.    ESSENTIALS   OF    PRACTICE    OF    MEDICINE.      By   Henry   Morris, 

M.D.  x\n  Appendix  on  Urine  Examination.  By  Lawrence  Wolff,  M.D. 
Third  edition,  enlarged  by  some  300  Essential  Formulae,  selected  from  eminent 
authorities,  by  Wm.  M.  Powell,  M.D.      (Double  number,  ^2.00.) 

10.  ESSENTIALS  OF  GYN/ECOLOGY.      By  Edwin  B.  Cragin,  M.D.      Fourth 

edition,  revised. 

11.  ESSENTIALS  OF  DISEASES  OF  THE  SKIN.     By  Henry  W.  Stelwagon, 

Jkl.D.      Third  edition,  revised  and  enlarged.      ($1.00  net.) 

12.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.     By  Edward  Martin,  M.D.     Second  ed. ,  revised  and  enlarged. 

13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

By  C.  E.  AR.M.A.ND  Se.mple,  M.D. 

14.  ESSENTIALS  OF   DISEASES  OF  THE   EYE,  NOSE,  AND  THROAT. 

By  Edward  Jackson,  M.D.,  and  E.  B.  Gleason,  M.D.     Second  ed.,  revised. 

15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.     By  William  M.  Powell, 

M.D.     Second  edition. 

16.  ESSENTIALS  OF   EXAMINATION    OF   URINE.     By   Lawrence  Wolff, 

M.D.     Colored  "  VoGEL  Scale."     (75  cents. ) 

17.  ESSENTIALS  OF  DIAGNOSIS.     By  S.  Solis  Cohen,  M.D.,  and  A.  A.  Eshner, 

I\I.D.      (§1.50  net.) 

18.  ESSENTIALS  OF  PRACTICE   OF   PHARMACY.     By   Lucius   E.    Sayre. 

Second  edition,  revised  and  enlarged. 

20.  ESSENTIALS  OF  BACTERIOLOGY.     By  M.  V.  Ball,  M.D.     Third  edition, 

revised. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.     By  John  C. 

Shaw,  M.D.      Third  edition,  revised. 

22.  ESSENTIALS  OF   MEDICAL  PHYSICS.      By   Fred  J.    Brockway,    M.D. 

Second  edition,  revised.      ($1.00  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.    By  David  D.  Stewart,  M.D., 

and  Edward  S.  Lawrance,  M.D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE   EAR.      By  E.  B.  Gleason,  M.D 

•    Second  edition,  revised  and  greatly  enlarged. 


Pamphlet  containing  specimen  pages,  etc  sent  free  upon  application* 


Saunders' 

New  Series 
of  Manuals 


for  Students 
and 
Practitioners. 


'T'HAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading  branches 
of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the  favor  w^ith  which 
the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been  received  by  medical 
students  and  practitioners  and  by  the  Medical  Press.  These  manuals  are  not  merely 
condensations  from  present  literature,  but  are  ably  w^ritten  by  w^ell-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative  American  colleges. 
Each  volume  is  concisely  and  authoritatively  -written  and  exhaustive  in  detail,  without 
being  encumbered  -with  the  introduction  of  "cases,"  which  so  largely  expand  the 
ordinary  text-book.  These  manuals  will  therefore  form  an  admirable  collection  of 
advanced  lectures,  useful  alike  to  the  medical  student  and  the  practitioner:  to  the 
latter,  too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  -v^hat  he 
wants  to  know^,  they  w^ill  prove  of  inestimable  value ;  to  the  former  they  will  afford 
safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be  superior 
to  any  similar  books  now^  on  the  market.  No  other  manuals  afford  so  much  infor- 
mation in  such  a  concise  and  available  form.  A  liberal  expenditure  has  enabled  the 
publisher  to  render  the  mechanical  portion  of  the  w^ork  ^vorthy  of  the  high  literary 
standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page  for  List). 


Saunders^  New  Series  of  Manuals^ 


VOLUMES   PUBLISHED. 

PHYSIOLOGY.  By  Josrph  Howard  Raymond,  A.M.,  M.D.,  Professor  of  Physiology 
and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long  Island  College  Hospital; 
Director  of  Physiology  in  the  Hoagland  Laboratory,  etc.     Illustrated.     Cloth,  J?l.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmkrs  DaCosta,  M.D.,  Clini- 
cal Professor  of  Surgery,  Jelferson  Medical  College,  Philadelphia;  Surgeon  to  the 
Philadelphia  Hospital,  etc.  Second  edition,  thoroughly  revised  and  greatly  enlarged. 
Octavo,  gii  pages,  profusely  illustrated.      Cloth,  ^4.00  net ;   Half  Morocco,  $5.00  net. 

DOSE=BOOK    AND    MANUAL    OF    PRESCRIPTION=WRITINQ.      By   E.    Q. 

Thornton,   M.D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia.    Illustrated.     Cloth,  $1.25  net. 

SURGICAL  ASEPSIS.  By  Car i.  Beck,  M.D.,  Surgeon  to  St.  Mark's  Hospital  and 
to  the  New  York  German  Poliklinik,  etc.     Illustrated.     Cloth,  $1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.D.  Professor  of  Insti- 
tutes of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical  College  of  Phila- 
delphia.    Illustrated.     Cloth,  ^1.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James  Nevins  Hyde,  M.D., 
Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Montgomery,  M.D., 
Lecturer  on  Dermatology  and  Genito-Urinary  Diseases  in  Rush  Medical  College, 
Chicago.     Profusely  illustrated.     Cloth,  $2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.D.,  Professor  of 
Practice  in  the  Woman's  Medical  College  of  the  New  York  Infirmary;  Instructor  in 
Physical  Diagnosis  in  the  Medical  Department  of  Columbia  College,  etc.  Illustrated. 
Cloth,  ^2.50  net. 

MANUAL  OF  ANATOMY,  By  Irving  S.  Haynes,  M.D.,  Adjunct  Professor  of 
Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department  of  the  New  York 
University,  etc.     Beautifully  illustrated.      Cloth,  ^2.50  net. 

MANUAL  OF  OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.D.,  Assistant 
Demonstrator  of  Obstetrics,  University  of  Pennsylvania  ;  Chief  of  Gynecological  Dis- 
pensary, Pennsylvania  Hospital,  etc.     Profusely  illustrated.     Cloth,  $2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant  Surgeon  to 
Middlesex  Hospital  and  Surgeon  to  Chelsea  Hospital,  London;  and  Arthur  E. 
Giles,  M.  D.,  B.  Sc.  Lond.,  P\R.C.S.  Edin.,  Assistant  Surgeon  to  Chelsea  Hospital, 
London.     Handsomely  illustrated.     Cloth,  ^2.50  net. 


VOLUMES  IN  PREPARATION. 

NOSE  AND  THROAT.  By  D.  Braden  Kyle,  M.D.,  Clinical  Professor  of  Laryn- 
gology and  Rhinology,  Jefferson  Medical  College,  Philadelphia  ;  Consulting  Laryngolo- 
gist,  Rhinologist,  and  Otologist,  St.  Agnes'  Hospital;  Bacteriologist  to  the  Philadel- 
phia Orthopedic  Hospital  and  Infirmary  for  Nervous  Diseases,  etc. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.D.,  Clinical  Professor  of  Nervous 
Diseases,  Medico-Chirurgical  College,  Philadelphia;  Pathologist  to  the  Orthopaedic 
Hospital  and  Infirmary  for  Nervous  Diseases ;  Visiting  Physician  to  the  St.  Joseph 
Hospital,  etc. 

***  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully-prepared  works 
on  various  subjects  by  prominent  specialists. 


Pamphlet  containing  specimen  pages,  etc  sent  free  upon  application. 


24  Medical  Publications  of  W.  B.  Saunders, 


SAUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby, 
M.D.  Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and 
of  the  Royal  Medico-Chirurgical  Society  ;  Physician  to  the  General 
Hospital  ;  Consulting  Physician  to  the  Eye  Hospital  and  to  the  Hos- 
pital for  Diseases  of  Women;  Professor  of  Medicine  in  Mason  College, 
Birmingham,  etc.  Octavo  volume  of  434  pages,  with  numerous  illus- 
trations and  4  colored  plates.     Cloth,  §2.50  net. 

"  The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  which  the  views  expressed  are  not  carefully  thought 
out  and  fortitied  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended." — British  Medical  Journal. 

SAUNDERS'  MEDICAL  HAND-ATLASES. 

This  series  of  books  consists  of  authorized  translations  into  English  of 
the  world-famous  Lehmann  Medicinische  Handatlanten.  Each 
volume  contains  from  50  to  100  colored  lithographic  plates,  besides 
numerous  illustrations  in  the  text.  There  is  a  full  description  of  each 
plate,  and  each  book  contains  a  condensed  but  adequate  outline  of  the 
subject  to  which  it  is  devoted.  For  full  description  of  this  series,  with 
list  of  volumes  and  prices,  see  page  2. 

'•  Lehmann  Medicinische  Handatlanten  belong  to  that  class  of  books  that  are  too  good 
to  be  appropriated  by  any  one  nation." — Journal  of  Eye,  Ear,  and  Throat  Diseases. 

"  The  appearance  of  these  works  marks  a  new  era  in  illustrated  English  medical 
works." — The  Canadian  Practitioner. 

SAUNDERS'   POCKET  MEDICAL    FORMULARY.      Fifth   Edition, 

Revised. 

By  William  ^L  Powell,  M.D.,  Attending  Physician  to  the  Mercer 
House  for  Invalid  Women  at  Atlantic  City,  N.  J.  Containing  1800 
formulae  selected  from  the  best-known  authorities.  With  an  Appen- 
dix containing  Posological  Table,  Formulae  and  Doses  for  Hypo- 
dermic Medication,  Poisons  and  their  Antidotes,  Diameters  of  the 
Female  Pelvis  and  Fcetal  Head,  Obstetrical  Table,  Diet  List  for  Various 
Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment 
of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables  of 
Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  flexible  morocco,  with  side  index,  wallet,  and  flap. 
I1.75  net. 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  verj-  useful,  and,  as  the  name  of  the  author  of  each  prescription 
is  given,  is  unusually  reliable." — Medical  Record,  New  York. 

SAYRE'S  PHARMACY.     Second  Edition,  Revised. 

Essentials  of  the  Practice  of  Pharmacy.  By  Lucius  E.  Sayre, 
M.D.,  Professor  of  Pharmacy  and  Materia  Medica  in  the  University  of 
Kansas.  Crown  octavo,  200  pages.  Cloth,  $1.00;  interleaved  for 
notes,  $1.25. 

[See  Saunders'  Question- Compends.  page  21.] 

"  The  topics  are  treated  in  a  simple,  practical  manner,  and  the  work  forms  a  very  useful 
student's  manual." — Boston  Medical  and  Surgical  Journal. 


Medical  Publications  of  W,  B.  Saunders.  25 

SEMPLE'S  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

Essentials  of   Legal    Medicine,  Toxicology,  and  Hygiene.     By 

C.  E.  Armand  Semple,  B.A.,  M.  B.  Cantab.,  M.  R.  C.  P.  Lend., 
Physician  to  the  Northeastern  Hospital  for  Children,  Hackney,  etc. 
Crown  octavo,  212  pages;  130  illustrations.  Cloth,  $1.00;  interleaved 
for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"  No  general  practitioner  or  student  can  afford  to  be  without  this  valuable  work.  The 
subjects  are  dealt  with  by  a  masterly  hand." — London  Hospital  Gazette. 

SEMPLE'S  PATHOLOGY  AND  MORBID  ANATOMY. 

Essentials    of    Pathology    and    Morbid    Anatomy.      By  C.   E. 

Armand  Semple,  B.A.,  M.B.  Cantab.,  M.R.C.P.  Lond.,  Physician  to 
the  Northeastern  Hospital  for  Children,  Hackney,  etc.     Crown  octavo, 
174  pages;  illustrated.      Cloth,  $1.00;  interleaved  for  notes,  $1.25. 
[See  Saundefs'  Question- Cojnpetids,  page  21.] 

"  Should  take  its  place  among  the  standard  volumes  on  the  bookshelf  of  both  student 
and  practitioner." — London  Hospital  Gazette. 

SENN'S  GENITO=URINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female. 

By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of 
Surgery  and  of  Clinical  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  320  pages,  illustrated.      Cloth,  $3.00  net. 

"  An  important  book  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  u[)on  one  of  the 
most  important  subjects  of  the  day." — Clinical  Reporter. 

"  A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged 
in  conformity  with  "  An  American  Text=Book  of  Surgery."    By 

Nicholas  Senn,  M.D.,  Ph.D.,  Professor  of  the  Practice  of  Surgery  and 
of  Clinical  Surgery  in  Rush  Medical  College,  Chicago.     Cloth,  ^2.00. 

"  This  syllabus  will  be  found  of  service  by  the  teacher  as  well  as  the  student,  the  work 
being  superbly  done.  There  is  no  praise  too  high  for  it.  No  surgeon  should  be  without 
it. " — Ne%v  York  Medical  Times. 

SENN'S  TUMORS. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  N.  Senn, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Rush  Medical  College ;  Professor  of  Surgery,  Chicago  Polyclinic ; 
Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief,  St. 
Joseph's  Hospital,  Chicago.  Octavo  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  Cloth,  $6.00  net; 
Half  Morocco,  $7.00  net. 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  suljject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  is  handsomely  illustrated  and  printed,  and  the  author  has  given  a 
notable  and  lasting  contribution  to  surgery." — Journal  of  the  American  Medical  Association. 


26  Medical  Publications  of  W.  B.  Saunders. 


SHAW'S  NERVOUS  DISEASES  AND  INSANITY.  Third  Edition, 
Revised. 
Essentials  of  Nervous  Diseases  and  Insanity.  By  John  C. 
Shaw,  M.U.,  Clinical  rrofessor  of  Diseases  of  the  Mind  and  Nervous 
System,  Long  Island  College  Hospital  Medical  School ;  Consulting 
Neurologist  to  St.  Catherine's  Hospital  and  to  the  Long  Island  College 
Hospital.  Crown  octavo,  i86  pages;  48  original  illustrations.  Cloth, 
$1.00  ;  interleaved  for  notes,  $1.25. 

[See  Saunders'  Question- Compends,  page  21.] 

"Clearly  and  intelligently  written." — Boston  Medical  and  Surgical  Journal. 

"There  is  a  mass  of  valuable  material  crowded  into  this  small  compass." — American 
Medico- Surgical  Bulletin. 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.     By 

Louis  Starr,  M.D.,  Editor  of  "An  American  Text-Book  of  the 
Diseases  of  Children."  230  blanks  (pocket-book  size),  perforated 
and  neatly  bound  in  flexible  morocco.     $1-25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant  life  ;  each 
blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food,  the  latter  directions  being 
left  for  the  physician.  After  the  seventh  month,  modifications  being  less  necessary,  the  diet 
lists  are  printed  in  full.      Formulae  for  the  preparation  of  diluents  and  foods  are  appended. 

STELW AGON'S  DISEASES  OF  THE  SKIN.  Third  Edition,  Revised. 
Essentials  of  Diseases  of  the  Skin.  By  Hknrv  \\ .  Stelwagon, 
M.D.,  Clinical  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia;  Dermatologist  to  the  Philadelphia  Hospital; 
Physician  to  the  Skin  Department  of  the  Howard  Hospital,  etc. 
Crown  octavo,  270  pages;  86  illustrations.  Cloth,  $1.00  net;  inter- 
leaved for  notes,  S1.25  net. 

[See  Saunders''  Question- Compends,  page  21.] 
"  The  best  student's  manual  on  skin  diseases  we  have  yet  seen." — Times  and  Register. 

STENGEL'S  PATHOLOGY. 

A  Text=Book  of  Pathology.  By  Alfred  Stengei,,  M.  D.,  Physician 
to  the  Philadeli)hia  Hospital  :  Clinical  Professor  of  Medicine  in  the 
Woman's  Medical  College;  Physician  to  the  Children's  Hospital; 
late  Pathologist  to  the  German  Hospital,  Philadelphia,  etc.  Handsome 
octavo  volume  of  848  pages,  with  nearly  400  illustrations,  many  of  them 
in  colors.     Cloth,  $4.00  net;   Half  Morocco,  S5.00  net. 

STEVENS'   MATERIA    MEDICA    AND   THERAPEUTICS.      Second 
Edition,   Revised. 
A  Manual  of   Materia   Medica   and  Therapeutics.      By  A.  A. 

Stevens,  A.M.,  M.D.,  Lecturer  on  Terminology  and  Instructor  in 
Physical  Diagnosis  in  the  University  of  Pennsylvania  :  Professor  of 
Pathology  in  the  Woman's  Medical  College  of  Pennsylvania.  Post- 
octavo,  445  pages.      Flexible  leather,  $2. 25. 

"  The  author  has  faithfully  presented  modem  therapeutics  in  a  comprehensive  work, 
and,  while  intended  particularly  for  the  use  of  students,  it  will  be  found  a  reliable  guide  and 
sufficiently  comprehensive  for  the  physician  in  practice." — University  Medical  Magazine. 


Medical  Publications  of  W.  B.  Saunders.  '-^7 


STEVEN5'  PRACTICE  OF  MEDICINE.     Fifth  Edition,  Revised. 

A  Manual  of  the  Practice  of  Medicine.     I.y  A.  A.  Stkvens,  A.  M., 
M.I).,  Lecturer  on  1  crminologv  aiul  Instructor  in   Physical  Diagnosis 
in   the    University   of    Pennsylvania ;     Professor    of    Pathology   in    the 
Woman's    Medical   College  of   Pennsylvania.     Spe(  ially  intended^  for 
students    preparing   for    graduation   and    hosjjital  examinations.      I'osi- 
octavo,  519  pages;    illustrated.      Flexible  leather,  $2.00  net. 
"The  frequency  with  which  new  editions  of  this  manual  are  demanded  bespeaks  its 
Donularilv       It   is  an  excellent   condensation  of   the  essentials  of  medical   practice  ^,r  the 
student,  and  may  be  found  also  an  excellent  reminder  for  the  busy  phy.Mc.an.   -Buja/o 
Medical  Journal. 

STEWART'S  PHYSIOLOGY.      Third  Edition,  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For 
Students  and  Practitioners.  By  G.  N.  Stewart,  M.A.,  M.D., 
U  Sc  lately  Examiner  in  Physiology,  University  of  Aberdeen,  and 
of  the  New  Museums,  Cambridge  University ;  Professor  of  Physiology 
in  the  Western  Reserve  Universitv,  Cleveland,  Ohio.  Octavo  volume 
of  848  pages;  300  illustrations  in  the  text,  and  5  colored  plates. 
Cloth,  $3.75  net. 
«  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.     It  is  one 

of  the  very  best'  English  text-books  on  the  subject.  "—Z.'w^/ow  Lancet. 

"Of  the  many  text-books  of  physiology  published,  we  do  not   know  of  one  that  so 

nearly  comes  up  Jthe  ideal  as  does  Prof.  Stewart's  volume,  "-^r^/^./.  Medual  Journal. 

STEWART  AND  LAWRANCE'S  MEDICAL  ELECTRICITY. 

Essentials  of  Medical  Electricity.  By  D.  D.  Stewari,  M.D., 
Demonstrator  of  Diseases  of  the  Nervous  System  and  Chief  of  the 
Neurological  Clinic  in  the  Jefferson  Medical  College;  and  L.  S. 
Lawrence,  M.D.,  Chief  of  the  Electrical  Clime  and  Assistant  Demon- 
^t?lr  of  bisease's  of  the  Nervous  System  in  the  Jefferson  Medical 
College,  etc.  Crown  octavo,  158  pages;  65  illustrations.  Cloth, 
$i.oo^  interleaved  fornotes,  ^1.25. 

[See  Saunders'  Que  stmt- Comp  ends,  page  21.] 
.<  Throughout  the  whole  brief  space  at  their  command  the  authors  show  a  discriminating 

knowledge  of  their  subject."— ^/^^?V«/  News. 

STONEY'S  NURSING.     Second  Edition,  Revised. 

Practical  Points  in  Nursing.     For  Nurses  in  Private  Practice. 

Bv  Emily  A.  M.  Stoney,  Graduate  of  the  Training-bchool  for  Nurses, 
Tawrence  Mass.;  late  Superintendent  of  the  Iraming-School  for 
Nu™  Carney  Hospital,  South  Boston,  Mass.  456  pages,  illustrated 
with  73  engra^vings  in  the  text,  and  8  colored  and  half-tone  plates. 
Cloth,  $1.75  net. 
"There  are  few  books  intended  for  non-professional  readers  which  can  be  so  cordially 

endorsed  by  a  medical  journal  as  can  this  ox.^.^ -Therapeutrc  Gazette. 

This  is  a  well- written,  eminently  practical  volume,  which  covers  the  entire  range  of 
1  his  is  a  w^'.'  .        •  u' ,1   from  hosnital  nursing,  and    nstructs  the  nurse  how  best  to 

private  nursing  as  distinguished  from  hospital  ""rsing,  everything  ordinarily 

"'T,V;:'l  *aX.  .he  physician  can  p„c.  in  >he  hands  of  his  ,.ri.a,e  nurses  »,.h  ,he 
assurance  of  benefit."— (^/^^c^  Medical  Journal. 


28  Medical  Puhlications  of  W.  B.  Saunders. 


STONEY'S   MATERIA    MEDICA    FOR   NURSES. 

Materia  Medica  for  Nurses.  I^y  I<>mii.y  A.  M.  Stonky,  Graduate  of 
the  'rraining-School  lor  Nurses,  Lawrence,  Mass.  ;  late  Superintendent 
of  the  Training-School  for  Nurses,  Carney  Hospital,  South  15oston,  jMass. 
Handsome  octavo  volume  of  about  300  pages.     C'loth,  $1.50  net. 

The  present  book  differs  from  other  similar  works  in  several  features,  all  of  which  are 
intended  to  render  it  more  practical  and  generally  useful.  The  general  plan  of  the  contents 
follows  the  lines  laid  down  in  training-schools  for  nurses,  but  the  book  contains  much  use- 
ful matter  not  usually  included  in  works  of  this  character,  such  as  I'oison-emergencies, 
Ready  Dose  list,  Weights  and  Measures,  etc.,  as  well  as  a  Glossary,  detining  all  the  terms 
used  in  Materia  Medica,  and  describing  all  the  latest  drugs  and  remedies,  which  have  been 
generally  neglected  by  other  books  of  the  kind. 

SUTTON  AND  GILES'  DISEASES  OF  WOMEN. 

Diseases  of  Women.  By  J.  Bland  Sutton,  F.R.C.S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital, 
London;  and  Arthur  E.  Giles,  M.D.,  B.Sc.  Lond.,  F.R.C.S.  Edin., 
Assistant  Surgeon  to  Chelsea  Hospital,  London.  436  pages,  hand- 
somely illustrated.  Cloth,  $2.50  net. 
"The  text  has  been  carefully  prepared.     Nothing  essential  has  been  omitted,  and  its 

teachings  are  those  recommended  by  the  leading  authorities  of  the  day."— /ourna/  0/  /At 

American  Aleciiail  Association. 

THOMAS'S  DIET  LISTS  AND  SICK=ROOM  DIETARY. 

Diet  Lists  and  Sick=Room  Dietary,  By  Jerome  B.  Thomas, 
M.D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and 
Children  and  to  the  Newsboys'  Home  ;  Assistant  Visiting  Physician 
to  the  Kings  County  Hospital.      Cloth,  $1.50.     Send  for  sample  sheet. 

THORNTON'S  DOSE=BOOK  AND  PRESCRIPTION=WRITING. 

Dose=Book  and  Manual  of    Prescription=Writing.       By   E.    Q. 

Thornton,  M.U.,  Demonstrator  of  Therapeutics,  Jefferson  Medical 
College,  Philadelphia.      334  pages,  illustrated.      Cloth,  $1.25  net. 

"Full  of  practical  suggestions;  will  take  its  place  in  the  front  rank  of  works  of  this 
sort." — Medical  Record,  New  York. 

VAN  VALZAH  AND  NISBET'S  DISEASES  OF  THE  STOMACH. 
Diseases  of  the  Stomach.  By  William  W.  Van  Valzah,  M.D.  , 
Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  York  Polyclinic;  and  J.  Douglas  Nisbet,  M.D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive 
System  and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674 
pages,  illustrated.      Cloth,  ^3.50  net. 

"  Its  chief  claim  lies  in  its  clearness  and  general  adaptability  to  the  practical  needs  of 
the  general  practitioner  or  student.  In  these  relations  it  is  probably  the  best  of  the  recent 
special  works  on  diseases  of  the  stomach." — Chicago  Clinical  Review. 

VECKI'S   SEXUAL  IMPOTENCE. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor 
(J.  Veck.1,  M.D.  From  the  second  German  edition,  revised  and  en- 
larged.    Demi-octavo,  about  300  pages.     Cloth,  $2.00  net. 

The  subject  of  impotence  has  seldom  been  treated  in  this  country  in  the  truly  scientific 
spirit  that  it  deserves.  Dr.  Vecki's  work  has  long  been  favorably  known,  and  the  CJennan 
book  has  received  the  highest  consideration.  This  edition  is  more  tlian  a  mere  translation, 
for,  although  based  on  the  German  edition,  it  has  been  entirely  rewritten  in  English. 


Medical  Publications  of  W.  B.  Saunders.  29 


VIERORDT'S  MEDICAL  DIAGNOSIS.  Fourth  Edition,  Revised. 
Medical  Diagnosis.  By  Dr.  Oswald  Vierordi',  Professor  of  Medi- 
cine at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  fifth  enlarged  German  edition,  with  the  author's  permission, 
by  Francis  H.  Stuart,  A.  M.,  M,  D.  Handsome  royal  octavo  volume 
of  603  pages;  194  fine  wood-cuts  in  text,  many  of  them  in  colors. 
Cloth,  ^4.00  net;  Sheep  or  Half  Morocco,  $5.00  net. 

"  A  treasury  of  practical  information  which  will  be  found  of  daily  use  to  every  busy 
practitioner  who  will  consult  it." — C.  A.  Lindslky,  M.D.,  Professor  of  the  Theory  and 
Practice  of  Medicine,   Yale  University. 

"  Rarely  is  a  book  published  with  which  a  reviewer  can  find  so  little  fault  as  with  the 
volume  before  us.  Each  particular  item  in  the  consideration  of  an  organ  or  apparatus,  which 
is  necessary  to  determine  a  diagnosis  of  any  disease  of  that  organ,  is  mentioned ;  nothing 
seems  forgotten.  The  chapters  on  diseases  of  the  circulatoiy  and  digestive  apparatus  and 
nervous  system  are  especially  full  and  valuable.  The  reviewer  would  repeat  that  the  book  is 
one  of  the  best — probably  the  best — which  has  fallen  into  his  hands." — University  Medical 
Magazine. 

WARREN'S  SURGICAL  PATHOLOGY  AND  THERAPEUTICS. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.D.,  LL.D.,  Professor  of  Surgery,  Medical  Department  Harvard 
University;  Surgeon  to  the  Massachusetts  General  Hospital,  etc. 
Handsome  octavo  volume  of  832  i)ages ;  136  relief  and  lithographic 
illustrations,  33  of  which  are  printed  in  colors,  and  all  of  which  were 
drawn  by  William  J.  Kaula  from  original  specimens.  Cloth,  ;^6.oo 
net;  Half  Morocco,  ^7.00  net. 

"There  is  the  work  of  Dr.  Warren,  which  I  think  is  the  most  creditable  book  on 
Surgical  Pathology,  and  the  most  beautiful  medical  illustration  of  the  bookmaker's  art,  that 
has  ever  been  issued  from  the  American  press." — Dr.  Roswell  Park,  in  the  Harvard 
Graduate  Magazine. 

"  The  handsomest  specimen  of  bookmaking  that  has  ever  been  issued  from  the  American 
medical  press." — American  Journal  of  the  Medical  Sciences. 

"  A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without 
exception,  from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their  coloring 
and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the  barrel 
of  a  microscope  at  a  well-mounted  section." — Annals  of  Surgery. 

WOLFF  ON  EXAMINATION  OF  URINE. 

Essentials  of  Examination  of  Urine.  By  Lawrence  Wolff,  M.D., 
Demonstrator  of  Chemistry,  Jefferson  Medical  College,  Philadelphia, 
etc.  Colored  (Vogel)  urine  scale  and  numerous  illustrations.  Crown 
octavo.      Cloth,  75  cents. 

[See  Saunders^   Question- Compends,  page   21.] 
"  A  very  good  work  of  its  kind — very  well  suited  to  its  purpose." — Times  and  Register. 

WOLFF'S  MEDICAL  CHEMISTRY.     Fourth  Edition,  Revised. 
Essentials    of    Medical    Chemistry,   Organic    and    Inorganic. 

Containing  also  Questions  on  Medical  Physics,  Chemical  Physiology, 
Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Lawrence 
Wolff,  M.D.,  Demonstrator  of  Chemistry,  Jefferson  Medical  College, 
Philadelphia,  etc.  Crown  octavo,  218  pages.  Cloth,  $1.00;  inter- 
leaved for  notes,  $1.25. 

[See  Saunders'  Questio7i-Compends,  page  21.] 

"The  scope  of  this  work  is  certainly  equal  to  that  of  the  best  course  of  lectures  ori 
Medical  Chemistry." — Pharmaceutical  Era. 


CLASSIFIED    LIST 


Medical  Publications 


W.  B.  SAUNDERS, 

925  "Walnut  Street,  Philadelphia. 


ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A  Text-Book  of  Histology,  9 
Haynes — A  Manual  of  Anatomy,  .  .  .  13 
Heisler — A  Text-Book  of  Embryology,  13 
Nancrede — Essentials  of  Anatomy,  .  .  18 
Nancrede — Essentials  of  Anatomy  and 

Manual  of  Practical  Dissection,  ...  18 
Semple — Essentials   of   Pathology  and 

Morbid  Anatomy, 25 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology,  ...      6 
Crookshank — A  Text-Book  of  Bacteri- 
ology,   10 

Frothingham  — I.aboratory  Guide,  .  .  11 
Mallory    and    Wright — Pathological 

Technique, 16 

McFarland — Pathogenic  Bacteria,    .    .    17 

CHARTS,  DIET- LISTS,  ETC. 

Griffith — Infant's  Weight  Chart,     ...  12 

Hart — Diet  in  Sickness  and  in  Health,  .  13 

Keen — Operation  Blank, 15 

Laine — Temperature  Chart,    ...        -15 

Meigs — Feeding  in  Early  Infancy,    .    .  17 

Starr — Diets  for  Infants  and  Children,  .  26 
Thomas — Diet-Lists     and    Sick-Room 

Dietary, 28 

CHEMISTRY  AND  PHYSICS. 

Brock  way — Essentials  of  Medical  Phys- 
ics  7 

Wolff — Essentials  of  Medical  Chemistry,   29 

CHILDREN. 

An  American  Text-Book  of  Diseases 

of  Children,    .    .             3 

Griffith — Care  of  the  Baby 12 

Griffith — Infant's  Weight  Chart,   ...  12 

Meigs — Feeding  in  Early  Infancy,    .    .  17 

Powell — Essentials  of  Dis.  of  Children,  19 

Starr — Diets  for  Infants  and  Children,  .  26 

DIAGNOSIS. 

Cohen  and  Eshner  — Essentials  of  Di- 
agnosis,    9 

Corwin — Physical  FJiagnosis 9 

Macdonald — Surgical  Diagnosis  and 
Treatment 16 

Vierordt — Medical  Diagnosis 29 

DICTIONARIES. 

Borland — Pocket  Dictionary,     ....  10 

Keating — Pronouncing  Dictionarj',    .    .  14 

Morten — Nurse's  Dictionary,     ....  18 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text- Book  of  Diseases 

of  the  Eye,  Ear,  Nose,  and  Throat,  .  3 
De  Schweinitz — Diseases  of  the  Eye, .  10 
Gleason — Essentials  of  Dis.  of  the  Ear,  il 
Jackson  and    Gleason — Essentials  of 

Diseases  of  the  Eye,  Nose,  and  Throat,  14 
Kyle — Diseases  of  the  Nose  and  Throat,  15 

GENITO=URINARY. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 4 

Hyde  and  Montgomery — Syphilis  and 
the  \'enereal  Diseases,  ......    13 

Martin — Essentials    of   Minor   Surgery. 

Bandaging,  and  Venereal  Diseases,  .  16 
Saundby — Renal  and  Urinary  Diseases,  24 
Senn — Genito- Urinary  Tuberculosis,  .  25 
Vecki — S(-xual   Impotence, 28 

GYNECOLOGY. 

American  Text- Book  of  Gynecology,  4 
Cragin — Essentials  of  Gynecology,  .  .  9 
Garrigues — Diseases  of  Women,  ...  11 
Long — Syllabus  of  Gynecology,  ...  15 
Penrose— Diseases  of  Women,  ....  18 
Sutton  and  Giles — Diseases  of  Women,  28 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

An  American  Text-Book  of  Applied 

Therapeutics 3 

Butler — Text-Book  of  Materia  Medica, 

Therapeutics  and  Pharmacology,  ...  8 
Cerna — Notes  on  the  Newer  Remedies,  8 
Griffin — Materia  Med.  and  Therapeutics,  12 
Morris  —  Essentials  of    Materia   Medica 

and  Therapeutics,  .    .  17 

Saunders'  Pocket  Medical  Formulary,  24 
Sayre  —  Essentials  of  Pharmacy,  .    .    24 

Stevens — Essentials  of  Materia  Medica 

and  Therapeutics,  ...  ...    26 

Stoney — Materia  Medica  for  Nurses,  .  28 
Thornton — Dose-Book  and   Manual  of 

Prescription-Writing,    ......    28 

MEDICAL   JURISPRUDENCE    AND 
TOXICOLOGY. 

An  American  Text-Book  of  Legal 
Medicine  and  Toxicology 4 

Chapman — Medical  Jurisprudence  and 
Toxicology,    ..........      8 

Semple — Essentials  of  I^egal  Medicine, 
Toxicology,  and  Hygiene 25 


Medical  Publications  of  W.  B.  Saunders. 


31 


Nervous  and  mental 
diseases,  etc. 

Burr — Nervous  Diseases, 7 

Chapin — Coinpendiuin  of  Insanity,  .  .  8 
Church    and    Peterson — Nervous  and 

Mental  Diseases, 8 

Shaw — Essentials  of  Nervous  Diseases 

and  Insanity 26 

NURSING. 

An  American  Text-Book  of  Nursing,  29 

Griffith — The  Care  of  the  IJaby,    ...  12 

Hampton — Nursing 12 

Hart — Diet  in  Sickness  and  in  Health,  I3 

Meigs — Feeding  in  Early  Infancy,    .    .  17 

Morten — Nurse's  Dictionary 18 

Stoney — Practical  Points  in  Nursing,    .  27 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics,  4 
Ashton — Essentials  of  Obstetrics,  ...  6 
Boisliniere — Obstetric  Accidents,  Emer 

gencies,  and  Operations,  .... 
Borland — Manual  of  Obstetrics,  . 
Hirst — Text-Book  of  Obstetrics,  . 
Norris — Syllabus  of  Obstetrics,  .    . 

PATHOLOGY. 


7 
lo 

13 

18 


Physi- 


An  American  Text-Book  of  Pathology,  5 
Mallory    and    Wright  —  Pathological 

Technique, ....    16 

Semple — Essentials   of    Pathology  and 

Morbid  Anatomy,  .    .         25 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 25 

Stengel — Te.xt-  Book  of  Pathology,    .    .    26 
Warren — Surgical  Pathology  and  Thera- 
peutics,    29 

PHYSIOLOGY. 

An   American    Text-Book    of 

ology, 

Hare — Essentials  of  Physiology,  .  .  .  I3 
Raymond — Manual  of  Physiology,  .  .  19 
Stewart — Manual  of  Physiology,  ...    27 

PRACTICE  OF  MEDICINE. 

An  American  Text-Book  of  the  The- 
ory and  Practice  of  Medicine,  ....      5 

An  American  Year-Book  of  Medicine 
and  Surgery,  6 

Anders — Text-Book  of  the  Practice  of 
Medicine, 6 

Lockwood — Manual  of  the  Practice  of 
Medicine, 15 

Morris — Essentials  of  the  Practice  of 
Medicine, 1 7 

Rowland  and  Hedley  —  Archives  of 
the  Roentgen  Ray, 19 

Stevens — Manual  of  the  Practice  of 
Medicine, 27 

SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 3 


Hyde  and  Montgomery — Syphilis  and 
the  Venereal  Diseases 13 

Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,    .    16 

Pringle — Pictorial  Atlas  of  Skin  Dis- 
eases and  Syphilitic  Affections,    ...    19 

Stelwagon — Essentials  of  Diseases  of 
the  Skin, 26 

SURGERY. 

An  American  Text-Book  of  .Surgery,     5 
An  American  Year-Book  of  Medicine 

and  Surgery, 6 

Beck — Manual  of  Surgical  Asepsis,  .    .      7 
DaCosta — Manual  of  Surgery,  ....    10 

Keen — Operation  Blank, 15 

Keen — The  Surgical  Complications  and 

Sequels  of  Typhoid  Fever, 15 

Macdonald — Surgical    Diagnosis    and 

Treatment, 16 

Martin — Essentials   of    Minor  Surgery, 

Bandaging,  and  Venereal  Diseases,    .    16 
Martin — Essentials  of  Surgery, ....    16 

Moore — Orthopedic  Surgery, 17 

Pye — Elementary  Bandaging  and  Surgi- 
cal Dressing, 19 

Rowland    and    Hedley  — Archives  of 

the  Roentgen  Ray, 19 

Senn — Genito-Urinary  Tuberculosis,      .    25 

Senn — Syllabus  of  Surgery, 25 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 25 

Warren — Surgical  Pathology  and  Ther- 
apeutics,       29 

URINE  AND  URINARY  DISEASES. 

Saundby — Renal  and  Urinary  Diseases,  24 
Wolff— Essentials    of    Examination    of 
Urine, 29 


MISCELLANEOUS. 

Bastin — Laboratory    Exercises   in    Bot- 
any,      7 

Gould  and  Pyle — Anomalies  and  Curi- 
osities of  Medicine, n 

Grafstrom — Massage,     .......     12 

Keating — How   to    Examine    for   Life 

Insurance,       ... 14 

Rowland    and    Hedley — Archives   of 

the  Roentgen  Ray, 19 

Saunders'  Medical  Hand-Atlases,  .  .  2 
Saunders'  New  Series  of  Manuals,  22,  23 
Saunders'  Pocket  Medical  Formulary,  .  24 
Saunders'  Question-Compends,  .  .  20,  21 
Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, -25 

Stewart  and  Lawrance — Essentials  of 

Medical  Electricity 27 

Thornton — Dose-Book  and  Manual  of 

Prescription-Writing, 28 

Van  Valzah  and  Nisbet — Diseases  of 
the  Stomach, 28 


In  Preparation  for  Early  Publication. 


THE  INTERNATIONAL  TEXT-BOOK  OF  SURGERY.     In  two  volumes. 

By  American  ami  liriiish  authors.  Edited  by  J.  Collins  Warren,  M.  D.,  LL.D., 
Professor  of  Surj^ery,  Harvard  Medical  School,  Boston ;  Surgeon  to  the  Massachusetts 
General  Hospital ;  and  A.  Pearck  Gould,  M.  S.,  F.  R.  C.  S.,  England,  Lecturer  on 
Practical  Surgery  and  Teacher  of  Operative  Surgery,  Middlesex  Hospital  Medical 
School ;    Surgeon  to  the  Middlesex   Hospital,  London,  England. 

AN  AMERICAN  TEXT=BOOK  OF  PATHOLOGY. 

Edited  by  John  Guiteras,  M.D.,  Professor  of  General  Pathology  and  of  Morbid 
Anatomy  in  the  University  of  Pennsylvania;  and  David  Riesm.^n,  M.D.,  Demon- 
strator of  Pathological  Histology  in  the  University  of  Pennsylvania. 

AN  AMERICAN  TEXT=BOOK  OF  LEGAL  MEDICINE  AND  TOXICOLOGY. 

Edited  by  Frederick  Peterson,  M.D.,  Clinical  [Professor  of  Mental  Diseases  in 
the  Woman's  Medical  College,  New  York;  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  New  York ;  and  Walter  S.  Hai.nes,  M.D., 
Professor  of  Chemistry,  Pharmacy,  and  Toxicology  in  Rush  Medical  College,  Chicago, 

Illinois. 

AN  AMERICAN  TEXT=BOOK  OF  DIAGNOSIS. 

Edited  by  Alfred  Stengel,  M.  D.,  Physician  to  the  Philadelphia  Hospital;  Professor 
of  Clinical  Medicine  in  the  Woman's  Medical  College ;  Physician  to  the  Children's 
Hospital ;   late  Pathologist  to  the  German  Hospital,  Philadelphia,  etc. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.D.,  Professor  ol 
Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical  Pro- 
fessor of  Laryngology  and  Rhinology,  Jefferson  Medical  College,  Philadelphia;  Con- 
sulting Laryngologist,  Rhinologist,  and  Otologist,  St.  Agnes'  Hospital ;  Bacteriologist 
to  the  Philadelphia  Orthopedic  Hospital  and  Infirmary  for  Nervous  Diseases,  etc. 

PRYOR— PELVIC   INFLAMMATIONS. 

The  Treatment  of  Pelvic  Inflammations  through  the  Vagina.     By  W.  R, 

Pryor,  M.  D.,  Professor  of  Gynecology  in  the  New  York  Polyclinic. 

WEST'S  NURSING. 

An  American  Text-Book  of  Nursing.  By  American  Teachers.  Edited  by 
Roberta  M.  West,  late  Superintendent  of  Nurses  in  the  Hospital  of  the  University 
of  Pennsylvania. 


COLUMBIA   UNIVERSITY    LIBRARIES 


This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  &s 
provided  by  the  Hbrary  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

..4^ 

C2a 1  lO- S3  )  lOOM 

1899 


ERSITY  LIBRARIES  (hsI.sU) 

1899  C.1 


)2144360 


toerioan  text  'i^,^^r'7.j>~f~ 


